In passing their sweeping health care law, Washington Democrats ordered the states to extend Medicaid coverage to tens of millions more people.
The U.S. Supreme Court upheld the constitutionality of that enormous law on the basis of Congress' power to levy taxes. But the court said Congress cannot compel states to expand Medicaid.
Which presents states like West Virginia, which can't afford the Medicaid program they already have, with difficult decisions.
The costs of the program are borne in part by the federal government, but fall upon state taxpayers as well. The program has been a budget-buster all over the nation.
West Virginia's Medicaid program now covers about 420,000 low-income people. The state is now asked to give Medicaid coverage to people who make as much at 138 percent of the federal poverty level - or about $32,000 for a family of four.
As Daily Mail Capitol Bureau Chief Ry Rivard noted, the administration of Gov. Earl Ray Tomblin must make a decision - in or out - soon. Enrollment of new beneficiaries is to begin in October, and coverage is to begin in January 2014 - an election year.
Tomblin does not yet have an estimate of how much expanding the program might cost West Virginians, but it will be material to taxpayers who are asked to fund many other needs as well.
So it was good news that even strong supporters of expanded health insurance are willing to consider requiring at least some Medicaid recipients to pay a small fee when they seek services.
It costs health care providers money to take money, and asking people who don't make much money to part with a few dollars may seem draconian.
Unfortunately, co-pays are essential to discouraging frivolous use of medical services - and thus to controlling costs.