GOV. Earl Ray Tomblin awaits a report from CCRC Actuaries of Maryland before committing to a major expansion of the Medicaid program, which now covers 420,000 people.
Under Obamacare, the state could expand the program by another 150,000 people, bringing the total number of West Virginians covered by the program to almost one in three.
That's on top of other taxpayer obligations for health insurance such as the Public Employees Insurance Agency, which covers 100,000 government employees, retirees and their dependents.
Getting an actuarial report is prudent, especially considering that to meet next year's obligations of this $2.5 billion annual program, Tomblin had to make budget cuts elsewhere.
After exempting schools, prisons and other basic services, the cuts were 7.5 percent for the other agencies.
The federal government would cover 100 percent of the extra Medicaid cost for three years and 90 percent after that.
To pay for the program, the federal government would "borrow" the money from the Federal Reserve, which is now buying the bulk of new federal debt. The Fed simply prints more money, which waters down the value of all U.S. currency.
The state of West Virginia does not have such a printing press. That means the state has to balance its books and pay its 10 percent of the cost of expansion with real dollars.
Every dollar spent on a Medicaid expansion is a dollar not spent elsewhere. Whose budget gets cut - a family's through a tax increase or another state service through a budget cut?
"I have not kept up with the actuaries or asked them what is taking them time to do it," said Rob Alsop, Tomblin's chief of staff.
"But when you're talking about looking at six years of projections of the state Medicaid program and you really go down in the weeds, that can take some time to get it right."
Tomblin deserves credit for moving slowly and carefully on this issue. He will no longer be governor when the higher state tab comes due.
Proponents argue there will be savings when more people have access to health care. The thought is they'll seek care before small problems turn into big ones and there will be less cost shifting of free care for the uninsured to others.
This is hopeful thinking that won't translate to state budget savings for years to come, if ever.