A federal push for more transparency in how states run their Medicaid programs is pitting patient advocates and medical providers against state officials who fear being hamstrung. The transparency effort comes as states seek ever greater flexibility in how they manage their Medicaid programs to cope with historic budget woes. Federal regulators have expressed sympathy for states' concerns, but they are also required to answer Congress' calls for more public information about what states are up to. "The idea that Washington has to control everything because states can't be trusted to act in the interest of their own citizens frankly is an insult to the states," said Dennis Smith, secretary of the Wisconsin Department of Health Services. Advocates, however, say a dearth of rules has allowed states to get away with major changes to programs millions of vulnerable people depend on with very little oversight.