At a cost of more than $2.5 billion a year in state and federal money, Medicaid is the second largest expense in the state's budget, after public education, which costs more than $3 billion a year in local, state and federal taxes.
Getting Medicaid spending right is a must. There is no other option.
Gov. Tomblin's proposal to use interest from a rainy day fund to help address the program's increasing costs has much merit and deserves serious consideration from lawmakers.
The state has $914 million set aside for hard times in two accounts. The second of these was originally funded with $235 million from the tobacco settlement. With interest and a small amount from the medical malpractice premium tax, the fund has grown to $348 million
Tomblin wants to use interest from that fund to help finance Medicaid. While the $30 million earned in interest last year is barely 1 percent of overall Medicaid spending, every little bit hurts.
West Virginia and 45 other states sued the tobacco companies because of the burden on Medicaid caused by smoking-related illnesses.
The governor also is weighing the expansion of Medicaid, which now covers 420,000 people. The expansion, called for in the federal Affordable Care Act, would cover an additional 130,000 not-quite-so-poor people. The federal law offers the state financial incentives, but it would still be an expansion of state government and its expense.
One way to control the cost of adding people who live above the official poverty level is through co-payments.
Last month, Perry Bryant, executive director of the liberal group West Virginians for Affordable Health Care, said his group would be open to requiring modest co-payments for the 130,000 people who would be added.
Tomblin has not committed to the expansion as he awaits analysis of the cost from an independent consultant.
A state with roughly $10 billion in unfunded pension and health benefits for state workers when they retire must learn from past mistakes in long-term obligations and be very careful with its money.