“The central question is, how much will we tolerate? We get the system we put up with.”

George Stevens

president of the Coastal Community Foundation of South Carolina

Tony Keck glanced out a window from his high-rise office above downtown Columbia. From here the fall line that separates the Upstate from the coastal plain can be seen.

Until the completion of canals in the early 1800s, this was as far inland as river boats could navigate, making it an inland transit point for cargo. That played into the Legislature's creation of the town of Columbia in 1786 and its designation as the state capital.

Keck also can see the Capitol dome from his office, where he serves as director of the state Department of Health and Human Services.

In that role, he sees himself as a liberal conservative.

“I care about people and money at the same time,” he said.

That might seem surprising to those who know he refused to accept an extension of Medicaid to some 500,000 South Carolinians who don't have medical insurance.

Keck and his boss, Gov. Nikki Haley, wrote an opinion column that appeared in newspapers across the state last summer to explain why they rejected the Medicaid expansion.

They see Medicaid as inefficient and a waste of money that leads to higher medical costs.

Haley and Keck would accept the federal money for the extension only if the government gave it to the state to handle in its own way to improve health.

Keck contends that Medicaid doesn't make people healthier. Most poor children in the state have Medicaid, he said, “but we don't have healthier children.”

Keck would focus the money on preventive care, such as obesity reduction, to head off expensive hospital treatments.

He envisions placing specially trained medical people around the state, perhaps in retail clinics at drug stores, to provide routine treatment and preventive care.

They would work under the supervision of a primary-care doctor or hospital, and Keck enrolled Midland Technical College to develop a curriculum similar to the EMS and paramedic training the school already offers.

People could then drop by the neighborhood drug store to receive care. Keck predicts huge savings, and would work with the governor to pass that money along to schools to improve education. He sees education as the best long-term way to improve the state's overall health.

“There's a lot of evidence showing that just giving people a Medicaid card is not what drives health care,” Keck said. “Getting more kids in early childhood education is it.”

Keck said his office continues to work with the federal government to see if it will agree to let South Carolina spread Medicaid to more people in the way he envisions.

If Keck fails, there's a good possibility that the state Legislature will ignore him and Haley and vote sometime over the next few months to accept the Medicaid extension offered through the federal government's Patient Protection and Affordable Care Act.

The amount of money at stake is huge:

Haley and Keck estimate that extending Medicaid to the state's uninsured would cost the state between $1.1 billion and $2.3 billion over the first six years of the program, money they say the state doesn't have.

Those arguing in favor of the extension say it's a win-win deal.

Not only would 500,000 South Carolinians get better health care, but the federal government would fully pay for the program for the first three years, then never less than $9 for every $1 spent by the state.

Using the cost estimates for the state provided by Haley and Keck, if the state rejects the extension, it will lose billions of federal dollars, possibly more than $20.7 billion.

The figure would almost cover the state's entire discretionary annual budget for four years.

Those in favor of the extension argue that such an infusion of federal dollars directly in South Carolina would not only make the state healthier but work as a massive stimulus for the state's lethargic economy.

Keck concedes, “It's an attractive argument,” but said the nine federal dollars for every one South Carolina dollar spends as a good deal only on three conditions:

What you are buying works.

You don't have to borrow the money to buy it.

There's not a better alternative.

Janice Probst doesn't see it as a matter of money.

She's a professor at the University of South Carolina's School of Public Health, and directs the South Carolina Rural Health Research Center.

In 2011 she co-authored a study that determined, in part, that providing health insurance to the rural poor “would go a long way toward eliminating the disparities in health.”

Extending Medicaid to 500,000 uninsured South Carolinians would “clearly” improve health in the state, she said. If a person has a doctor “you keep them out of the hospital. You save a lot of money and, over time, you save a life.”

Probst paraphrases Otto von Bismark, the 19th century Prussian who united the German Empire: “The health of the people is the health of the state.”

Refusing to extend Medicaid could be cheaper for the state but very short-sighted for the health of 500,000 South Carolinians, Probst said.

She said her study showed that “people who lacked insurance were more likely to die. ... Heck yes, we can save a lot of money in the short run ... the cheapest option is always death.”

Unfortunately, in South Carolina's politics, it won't work to argue that the state should extend health care simply because it's the right thing to do, Probst said. “But doing it to help improve the workforce might.”