CHARLESTON, W.Va. -- Gov. Earl Ray Tomblin has some questions he needs answered before he can make a decision about Medicaid expansion.

To that end, Tomblin on Thursday sent a letter outlining those questions about expanding Medicaid to Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, according to a statement from Tomblin.

While the Supreme Court late last month largely upheld the Affordable Care Act, the court threw out a provision requiring states to expand Medicaid to 138 percent of the federal poverty line.

States now have the option about whether to expand. The federal government will fully fund the expansion for the first three years, should the state so chose.

Tomblin called the decision "significant."

"On the one hand, the expansion would cover well over 100,000 hard-working West Virginians and would in turn allow them to begin receiving appropriate diagnosis and treatment at a much earlier stage," Tomblin said in a prepared statement. "In a state where heart disease, diabetes, and other chronic health conditions occur at levels far too high, this type of access to health care could provide meaningful improvements to the health of our citizens.

"It also has the potential to reduce health-care costs in the future, saving taxpayer dollars and keeping insurance premiums and co-pays lower."

Tomblin also must decide whether the state can afford the expansion in the long run, he said, adding that the federal government's fiscal path is not sustainable.

"I am very cautious in relying on their future funding promises," Tomblin said. "Before a final decision is made, West Virginia must have a plan for the long-term sustainability of any type of Medicaid expansion. Right now, we don't have the information necessary to make the decision."

Bill Maloney, the Republican candidate running against Tomblin for governor, issued a statement after Tomblin's announcement.

"Like a typical, career politician, Earl Ray Tomblin spent the largest budget in state history, and now Earl Ray and Barack Obama are working together to grow government even more," Maloney said. "He supports ObamaCare, the largest tax increase in history, and he will burst our state budget to pay for it.

"I will work to repeal ObamaCare, and I will work to improve accessibility and affordability in our health care system through private-sector, patient-centered solutions."

Still, Tomblin has not said publicly that he supports the health-care reform law.

Like U.S. Sen. Joe Manchin, D-W.Va., Tomblin has sought to distance himself from Obama. Tomblin has not said whether he would vote to re-elect the president and does not plan to attend the Democratic National Convention in Charlotte in September.     

Tomblin's spokeswoman, Amy Shuler Goodwin, rejected the notion that by not deciding on Medicaid expansion, the governor is seeking to separate himself from a president that's unpopular in West Virginia.

"The governor is asking questions to make sure he does the right thing for West Virginia, period," she said. "It's a very big decision. It's the most responsible thing he can do. That's what people expect him to do. This is going to impact a lot of people for a very long time."

Tomblin's letter to Sebelius contains 16 questions. For instance, he asked: "As a result of the Supreme Court ruling, what changes to Medicaid expansion will occur regarding exchange implementation, and when will the United States Department of Health and Human Services provide updated guidance in this regard?"

In the letter, he also asked: "Will West Virginians with incomes between 100 percent and 138 percent of the federal poverty level be eligible for cost sharing subsidies and tax credits to purchase coverage through an exchange?"

West Virginia is required to have its insurance exchange up and running by October 2013. That would include the Medicaid expansion, should the state so choose.

Perry Bryant, executive director of West Virginians for Affordable Health Care, said Tomblin is right to carefully decide on the issue. The governor should ask questions of DHHS but should also take advantage of reports that have already been written on the matter, he said.

"When I read Tomblin's letter, he seemed to be more concerned about the financial effects and not concerned with the people," Bryant said. "I think it's important to look at the costs and the benefits of expanding."

Expanding Medicaid would impact hospitals and businesses significantly, he said. Businesses pay a huge amount of the cost of treating the uninsured through "cost shift," he said. Hospitals shift the cost of treating the uninsured to those with commercial insurance, he said.

Bryant said he supports measures that allow those in West Virginia who suffer from chronic illnesses to get the treatment they need, but that does not mean the state should "blindly" expand Medicaid, he said.

"We should do it with a thorough analysis of the costs and benefits," Bryant said.

Joe Letnaunchyn, president and CEO of the West Virginia Hospital Association, said hospital officials he has spoken with are in support of the expansion, though the association's board has not met to decide on it. Letnaunchyn commended the governor for taking his time and asking questions about expansion.

"The implementation wouldn't [take place] until 2014, so there's no rush to make a decision," he said. "I think it's certainly prudent to take the time to make the decision ... I think it would be irresponsible to make a quick decision without having that information."

Reach Lori Kersey at lori.ker...@wvgazette.com or 304-348-1240.