ATLANTA Shirley Johnson gets her medical care at Palmetto Health Baptist hospital's emergency room in Columbia. She goes when her back gives out or when a benign tumor near her ribcage swells and throbs. She goes for headaches, heartburn, and spider bites, leaving the hospital a sheaf of unpaid bills.
I owe so much money, said Johnson. The last time I went just for my toe. It cost $1,000.
Johnson, a 49-year-old with no dependents, isn't eligible for Medicaid, the joint state-federal health program for the poor, which covers about 20 percent of the state's residents. And in two years, when President Barack Obama's health-care overhaul allows the expansion of Medicaid to cover 17 million more Americans, she still may be left behind.
Gov. Nikki Haley, a Tea Party-backed Republican, was among the first state leaders to oppose expanding Medicaid after the Supreme Court ruled the federal government can't make states do so. Caught between poverty and pressure to curb government's power, South Carolina illustrates the forces at play in the nation's capitals amid the broadest changes to the health care system since 1965.
In South Carolina, the law would add about 500,000 people to Medicaid, said Tony Keck, whom Haley appointed to head the Health and Human Services Department.
We simply can't support this, Haley and Keck said in a July 3 statement. We are not going to jam more South Carolinians into a broken program, a program that stifles innovation, discourages personal responsibility, and encourages fraud, abuse and overuse of services and that, by the way, costs us billions of dollars.
Republican governors of Louisiana, Florida, Iowa, Mississippi, and Texas also oppose the plan to boost the scale of the health-care program.
States' decisions about Medicaid will determine a key provision of the Obama's plan to extend care to the uninsured, one that would make the program available to everyone earning less than 133 percent of the poverty line $30,657 for a family of four. If they don't, millions of Americans would be left uncovered, without access to the program and unable to qualify for the insurance subsidies available to those with higher incomes.
The federal government would pay 100 percent of the costs for those newly enrolled until 2017, when its share would begin to decrease to 90 percent. Some states are leery of adding enrollees as pressure on federal spending may put those funds at risk, said Matt Salo, the head of the National Association of Medicaid Directors in Washington.
There is an enormous amount of federal dollars that are being put on the table, he said. On the other hand, there are risks associated with this. States are having trouble sustaining the current Medicaid program. Ten percent of a very large number is still a lot of money.
The federal government will pay $931 billion of the cost of the Medicaid expansion through 2022, with states paying $73 billion, according to the Center on Budget and Policy Priorities, a Washington-based group that argues against cutbacks that hurt the poor.
At the end of the day and maybe the end of the day is after the November election I think all or virtually all of the states will agree to participate, said Ron Pollack, executive director of Families USA, a Washington nonprofit that advocates expanded health-care coverage. It is truly fiscal malpractice for them to turn it down.
The effects would be felt broadly in South Carolina, where about 16 percent live below the poverty line. The state ranks as the nation's fifth-least healthy, according to Haley.
The state also long been suspicious of ceding power to the federal government, said Bruce Ransom, a political scientist at Clemson University.
U.S. Sen. Jim DeMint, R-Greenville, is a founder of the Tea Party Caucus. In 2009, then-Gov. Mark Sanford sparred with the Obama administration and his own Legislature, seeking to use $700 million from the stimulus program to pay down debt instead of spending on the economy.
Federal aid, federal programs unless it's for the military are not good things, Random said, summarizing voters' views. That plays here. The conventional wisdom says that's a winning hand.
Keck, South Carolina's top health official, said the state's illnesses are driven by poverty and that money poured into Medicaid would best be used elsewhere. Keck said he and Haley favor block-grant funding that would hold the state accountable for set outcomes, such as lowering obesity.
State Sen. Darrell Jackson, D-Richland, who sits on the finance and medical affairs committee, said he plans to rally support for expanding Medicaid in the Republican-controlled Legislature. He said he's confident lawmakers can be persuaded to buck Haley's position, just as they challenged Sanford's rejection of Obama's stimulus money.
South Carolina is basically a poor state, he said. There are very few legislators' districts that would not be affected by this.
Haley also faces challenges from the state's hospitals, burdened by serving patients too poor to pay. Without more residents on Medicaid, hospitals will suffer, said Allan Stalvey, a lobbyist for the South Carolina Hospital Association. He said his group will press legislators and Haley's administration for the expansion.
We're concerned about it, he said. We're hopeful we can work something out.
Across South Carolina, hospitals offered $1.6 billion in care to uninsured indigents in 2011, according to Chris Finney, program manager for the state's Office of Research and Statistics.