High unemployment caused an additional 23,000 people to enroll last year in Hawaii’s Medicaid services program for the poor, and the growth can be expected to continue over the next year. The state must be smarter in mining monetary resources left over from this year’s crippled economy and consider joining most other states in charging nominal fees of patients.

The Kaiser Family Foundation reports that the Hawaii enrollment in Medicaid, including the state’s Quest version, grew by 11.4 percent from 203,000 during the year prior to last December and 158,000 the previous year. That amounts to one in five people in Hawaii enrolled in Medicaid, which also reflects the 12.5 percent of residents below the poverty level and 145,000 people using food stamps.

The federal government pays for about two-thirds the cost and has added $87 billion in relief to the states, extending assistance at a reduced level through next June. At that point, states will face an increase of 25 percent or more in their share of costs.

Medicaid now mainly serves children, pregnant women and the many seniors in nursing homes. It will be expanded in 2014 to be made available to able-bodied adults with incomes up to 133 percent of the federal poverty level, now $14,404 for a single adult and $29,326 for a family of four.

The state will need to be prepared to pay a share of the cost greater than the current amount being spent. Hawaii reduced Medicaid-covered dental service in August 2009 to emergency only but it would be unfortunate to scale back other medical services because of the cost.

One avenue of revenue that Hawaii and only five other states have chosen not to use is charging patients a nominal "copayment," generally defined as $3 or less per service, according to the Kaiser report. A 2005 federal law allows states to charge patients more than nominal amounts, but states understandably have been reluctant to do so.

Among the states using copayments is Oklahoma, with inpatient hospital stays of $10 a day up to a total of $90 per stay, $3 for doctor visits and $2 for prescription drugs costing less than $30 and $3 for those costing more.

Providing medical care to those who cannot afford health insurance is "what government is here for," said state Sen. Suzanne Chun-Oakland, chairwoman of the Human Services Committee. "It’s a safety net."

That does not mean, however, that all of those in need of such a net are destitute, as the upcoming federal qualifications make clear. And it is why most states already have developed systems of varying levels of eligibility, according to the Kaiser report, "using copayments as a cost control tool."

At some point not far away, Hawaii should have reason to follow that path.