Anne McQuary for The New York Times
Joyce G. Barr, 59, of Marion, is one of several hundred thousand South Carolinians left without adequate health insurance.
FLORENCE, S.C. — Brenda B. Culick has two stents in her heart and a severe wound in her right leg, injured while she was doing home repairs six months ago. But she cannot afford to see a cardiologist or go to a wound care center.
Her household income is $1,200 a month, but she does not qualify for Medicaid because she has no dependent children and is not disabled. Ms. Culick, 52, is one of several hundred thousand people left behind by South Carolina's refusal to expand Medicaid under President Obama's health care law — a choice made by about half the states.
"If I could get Medicaid, I'd be the happiest person on earth," Ms. Culick said.
In her State of the State speech in January, Gov. Nikki R. Haley, a Republican, said, "South Carolina will not implement the public policy disaster that is Obamacare's Medicaid expansion." And she boasted of her stance at a recent rally announcing her bid for re-election. "When it came to Obamacare," she said, "we didn't just say 'no,' we said 'never.' "
The reality, however, is more complex. South Carolina officials say they welcome the prospect that more than a half-million state residents — out of a population of 4.7 million — could soon gain access to affordable coverage, even without the expansion of Medicaid eligibility. And they are working to remake Medicaid so that it does not just pay claims but produces measurable improvements in the health of poor people.
Even without a change in eligibility rules, enrollment is expected to grow as a result of the new health care law. The law requires most Americans to have coverage, and state officials predict that the mandate will prompt more of those who are currently eligible, but not enrolled, to sign up for Medicaid. Consumers will see many advertisements from the Obama administration and insurers urging them to obtain coverage, and that is also expected to drive Medicaid enrollment.
"If they are eligible for Medicaid, they should get it," said Dr. William R. Jennings Jr., a medical director at the South Carolina Department of Health and Human Services. "If people are eligible for coverage in the exchange, they should get it."
Mr. Obama's health care law was intended to provide coverage in two major ways: by expanding Medicaid eligibility and by setting up an insurance marketplace, or exchange, where people can shop for private insurance.
Ms. Haley and the Republican-controlled Legislature here did neither. But state officials say they recognize that low- and moderate-income residents will get insurance subsidized by the federal government, in a marketplace run by federal officials.
Enrollment in the exchange begins Oct. 1, for coverage starting Jan. 1, but many who apply are likely to be found eligible for Medicaid. State officials are bracing for the impact of the changes, the biggest in decades.
The call center of the state Medicaid program is doubling its staff to answer a flood of calls and questions about the federal law, the Affordable Care Act. It is running a "Medicaid boot camp" to train new employees. And officials are rewiring computers to connect the state Medicaid program to the federal exchange.
State officials say that people who are uninsured — more than one-sixth of South Carolina residents — should get any coverage to which they are entitled.
As a condition of receiving their full allotment of Medicaid money, hospitals in South Carolina will be required to check uninsured patients to see if they might qualify for the existing Medicaid program, for subsidized insurance on the federal exchange or for other coverage.
Anthony E. Keck, who as director of the South Carolina Department of Health and Human Services is also the state's Medicaid director, said: "Our goal is not to insure as many people as Obamacare. Our mission is to purchase the most health for our citizens in need, at the least possible cost to the taxpayer."
State officials predict that 430,000 people could get insurance through the federal exchange in South Carolina. And they say that 170,000 people who are already eligible, but not enrolled, may sign up for Medicaid.
"We will actively go after that population," Mr. Keck said.
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