COLUMBIA — The director of South Carolina’s Medicaid agency told state senators today that whether they support or oppose federal health care reform, they need to get ready for costs associated with the government health insurance program to increase rapidly.

Department of Health and Human Services Director Tony Keck said his agency estimates the changes mean about 200,000 more people will join the 1 million adults and children in the state already using Medicaid. And he warned lawmakers that he can’t guarantee the numbers won’t be higher.

To make his point, Keck asked last month for an additional $194 million for his agency. He knows he won’t get all that money because it is several million dollars more than all the extra revenue the state is projected to get next budget year, but he wanted to make a point.

“We’re going to have a very, very difficult time managing all those new people, getting them quality health care and not sending costs through the roof,” Keck told the Senate Medical Affairs Committee.

One decision lawmakers will have to make is whether to expand Medicaid to more low-income adults. The new health care law gives states that option, and offers to pay for it through 2016, then pick up 95 percent of the cost through 2019 and 90 percent thereafter.

Keck and Gov. Nikki Haley, who appointed him, are against the move, saying it would eventually cost the state billions of dollars. Keck said uninsured residents will have plenty of help getting private coverage before requirements kick in by 2014 and he thinks the money is better spent on figuring out ways to help people stay healthy and reduce health care costs rather than going toward insurance and the mechanics of paying for care.

“Just because folks have an insurance card doesn’t mean they are going to all the sudden be healthy,” Keck said.

The state also refused to create its own state health insurance exchange, instead relying on the federal government to set up the online marketplaces for households and businesses to find coverage. Keck mirrored language Haley used sending a letter to the federal government, saying a South Carolina exchange would just be like the federal model with a different label.

Democratic senators questioned Keck about whether it was a smart idea not to take money the federal government was offering. Sen. Brad Hutto of Orangeburg suggested the state would lose health care jobs by not offering more people insurance, while Sen. Darrell Jackson of Columbia pointed out state residents won’t pay less taxes or save the U.S. money by not expanding Medicaid eligibility.

On the other side was Sen. Shane Martin, R-Spartanburg, who asked Keck if he could promise not to expand Medicaid rolls at all. Keck said he couldn’t, in part because federal law likely would make more people eligible, and in part because there might be situations where it saved the state money to ensure poor and rural residents get better access to health care.

“What I will pledge is we should not do it unaccountably,” Keck said.