If West Virginia expands its Medicaid program to cover 130,000 more people, unknown thousands of them might be asked to pay modest fees to visit the doctor.That would be a first for the state Medicaid program, the state and federal program that already provides health care to about 420,000 low-income West Virginians.Right now, the program covers West Virginians making about 30 percent of the federal poverty level.But Gov. Earl Ray Tomblin is deciding whether the state will join a federal effort to expand the Medicaid program to insure people making up to 138 percent of the federal poverty level. That's roughly $32,000 for a family of four.That would add about 130,000 people to the state's Medicaid rolls, according to one commonly cited estimate.Tomblin is awaiting a study of how much that will cost or save the state and the whole health care system.But health care advocates and a top lawmaker are already thinking about what happens if Tomblin approves the expansion.Even expansion advocates support a plan to make some new Medicaid enrollees pay a fee."We're likely to propose that the people between 100 and 138 percent not have as rich a benefit and pay modest co-pays," said Perry Bryant, the executive director of West Virginians for Affordable Health Care.Bryant said he recently told state Medicaid officials his group would be open to the payments, known as co-pays."I think they were surprised," Bryant said.Bryant's group generally supports generous government benefits, so Bryant's remark signals a brewing debate over the future of the program and what kinds of benefits it will offer. Bryant said his idea was talked about internally but had not yet been approved by his board.Tomblin hired Pa.-based Public Works LLC to review ways to shore up the program, which will cause several hundred million dollars in budget shortfalls in coming years.There are basically only three options: Get more money for Medicaid; cut benefits to Medicaid recipients; and find some way to control costs.One of Bryant's underlying goals is to keep the tens of thousands of new Medicaid recipients from unnecessarily overwhelming state doctors. Nationally, roughly 16 million newly insured Americans are expected to further strain already busy doctors and nurses.Bryant also said making some of the better-off Medicaid recipients pay can shape the image of the entitlement program."We think this should look more like a commercial health insurance product than an entitlement," Bryant said. "It will still be an entitlement; you can't get away from that."The co-pays also may make some Medicaid recipients more responsible and keep them from making unnecessarily trips to the doctor. Bryant said the fees should be only a few dollars per visit, which is roughly what the state makes some Medicaid recipients pay for prescription drugs.He also proposes penalizing some Medicaid recipients for missing doctor appointments without notice."We want people to have health insurance, and we want them to use health insurance wisely," Bryant said. "Nobody benefits when people don't use the health care system wisely."Bryant said he did not want people making less than the federal poverty level paying those penalties or being forced to pay to visit the doctor.Still, Bryant's proposals could be the opening bid in one of the most important health policy decisions state officials ever make.House Health and Human Resources Committee Chairman Don Perdue, D-Wayne, said the Legislature is likely to look at ideas that will make some new, better off Medicaid recipients pay more than current recipients."You certainly can argue that's appropriate," Perdue said. "If everybody is sharing in that, I think that's something the public would find very attractive."A lot now depends on Tomblin.The governor is awaiting reports from MIT professor Jonathan Gruber, who advised former Massachusetts Gov. Mitt Romney and President Barack Obama; Maryland-based CCRC Actuaries and Pennsylvania-based consultant Mike Madalena.Gruber has advised more than a half dozen states on health care reform. He was a key architect of Massachusetts reforms when Republican Mitt Romney was governor. Afterward, he helped crafted Democratic President Barack Obama's health care reform law.While Obama's law was intended to expand Medicaid to everyone making 138 percent of the poverty level, top state officials had been eyeing an effort to expand the program to only 100 percent of the poverty level.In December, the federal government said states were not allowed to do that. Now, Tomblin faces an all-or-nothing choice.Bryant said officials need to act fairly quickly: enrollment in an expanded Medicaid program begins in October for other states, and coverage begins next January.Contact writer Ry Rivard at email@example.com or 304-348-1796. Follow him at www.twitter.com/ryrivard.