Too much of the discussion about Grady Hospital sounds like the old story about the fellow searching for his lost car keys under a street lamp, not because the keys are there, but because the light is better there.

There are real problems at Grady. Better contracting, better management, less waste, stricter controls and professional nonpolitical oversight make sense. We should insist on implementation.

Grady must put its house in order.

But even if we fix problems directly attributable to Grady (and we should), Grady's long-term solvency remains at risk. The biggest problem, dwarfing all the others under discussion in terms of dollars and cents, is the fact that the state of Georgia allows health care coverage to languish.

The state must put its house in order, too.

That means doing something about Medicaid, and that means doing something about the uninsured and the underinsured. The state's lack of initiative impacts every hospital in Georgia, but the impact attains crisis proportions at Grady, given its unique "patient mix" dominated by very large numbers of patients covered by Medicaid or lacking adequate coverage at all.

As detailed by a recent editorial in this newspaper, the Medicaid program administered by the state of Georgia reimburses Grady Hospital for only 85 percent of the costs of caring for patients covered by Medicaid. The hospital wrote off approximately $144 million in charges for Medicaid patients in 2005. That is a lot of money for a hospital funded by only two counties such as Grady.

Grady serves as a safety net for patients who are uninsured or underinsured, a population that is large and growing. The hospital provided at least $70 million in unreimbursed care to uninsured and underinsured patients in 2005. The governor and the General Assembly have failed to extend health care coverage to the uninsured and underinsured comparable to the levels of coverage achieved in many other states. Seventy million dollars a year is a lot of money for a hospital funded by only two counties like Grady.

What the governor and the state Legislature have been doing is outsourcing their health care budget deficit to Grady.

The state of Georgia's inadequate funding of its Medicaid program and of programs to extend health care coverage to the uninsured and the underinsured has undermined Grady Hospital's financial viability. Adequate funding is required for Grady Hospital's long-term solvency.

The state Legislature can fix the Medicaid reimbursement rate and can make a good start on protecting the uninsured when it reconvenes in January. By facing up to their obligations, the governor and the Legislature can save Grady. If they do not, the rest of us cannot save it with those dramatically smaller fixes that are being talked about so much. There is not enough money there.

Grady Hospital faces an immediate fiscal crisis. We need a signal right now from the governor, the lieutenant governor and the speaker of the state House that they are going to act. We need a public commitment to fund state health care coverage programs at levels adequate to ensure the solvency of Grady Hospital. It is time for the governor and the state Legislature to live up to their responsibilities.

We cannot simply look for those missing car keys under the street lamp because the light is better there. We need to look for the keys where they really are.

Given that the state of Georgia costs Grady hundreds of millions of dollars every year by underfunding our state's health care coverage, the keys are in the governor's, the lieutenant governor's and the speaker's hands.

> W. Burrell Ellis Jr. is presiding officer of the DeKalb County Commission.