Having pushed the national debt past the $16 trillion mark, the Obama administration and congressional Democrats passed the Patient Protection and Affordable Care Act.
Now it's up to West Virginia to make it work financially.
A key provision of the act offers states three years' worth of subsidies if they expand their Medicaid programs to cover more people. After that, more costs will rest on West Virginia taxpayers.
Gov. Earl Ray Tomblin's administration, after some study, took the deal. A state in which 350,000 people depend on Medicaid will enroll about 91,500 more.
A Maryland-based firm estimated that the federal government will pay $5.2 billion for the expansion over the next 10 years, with the state responsible for an additional $375 million in costs.
West Virginia taxpayers will pay about $5 million a year in the first three years, but the consultant estimated that state residents will need to put in about $65 million a year to support the program by 2020.
State officials said that with offsetting efficiencies, the state can afford that.
And although the state isn't really paying for the Medicaid program it has now - its reimbursement rates are notoriously low - health care providers welcomed the addition of more people to the program as better than nothing. West Virginia hospitals now face about $800 million a year in uncompensated care.
Backers of the expansion believe that by enabling more people to get routine health care, more people will seek care earlier - and that, in turn, will improve health care outcomes and lower health care costs.
That may prove too optimistic.
A study of a trial program in Oregon showed that a group with Medicaid coverage used about 35 percent more health services than the uninsured group, but showed "no significant improvements in measured physical health outcomes" over the uninsured group.
Republican Attorney General Patrick Morrisey is probably closer to the truth.
Nothing in life is free, and a federal government that is $16 trillion in the hole is headed for an even bigger deficit and will have to pressure states to bear more of the cost, even if it doesn't appreciably change health.