It's not that Tony Keck doesn't want people to have health care, it's more like he wants to ensure they have healthy lives.
As the S.C. Medicaid director considers how and whether to take advantage of $30 million of federal dollars for uncompensated care, he says there's a lot more to consider.
Many hospitals have tax-exempt status; in return, they're expected to deliver community benefits equal to their tax exemption.
"Is putting your name on the back of a running club T-shirt for a local 5k a community benefit," Keck said, "or is lowering your prices more of a community benefit?"
Ouch. That stings a little.
That's why 10 percent of the state's existing $464 million Disproportionate Share Hospital budget, or DSH, will be tied to the Healthy Outcomes initiative, designed to reduce the frequency of habitual ER patients and treat their root problems instead of focusing only on critical symptoms.
So as Keck ponders what to do with the extra money, which he rightly points out is temporary, he has to ask himself, what's the best use?
Because even though most of the talk is in big round numbers, the money is used to pay for individual services, for individual people.
"In general what we're trying to do with DSH is bring more accountability for it," Keck said.
And Keck applies that thought process to all the money flowing through his department.
Treating the whole problem
What could be done with the DSH windfall depends on whether the state gets a waiver from the feds. One idea is to give the money to the hospitals to set up programs that would help treat people before they need to make those repeated, multiple visits to the ER. At least a few hospitals are already on board with that idea, Keck said - and why wouldn't they be?
"What we really need to do is spend the money on the outcome we want," Keck said.
In other words, if a patient can't read his prescription, or has no transportation to the pharmacy to fill it, or doesn't have anyone in her life to remind her why it's important to take her medication as prescribed, the money that's spent on patient care is being flushed down the drain.
So for Keck, health care is just as much about improving the community, with things that extend far beyond what we think of as health care: education, job training, sufficient transportation infrastructure.
Because if he uses his money wisely, maybe differently than it has been in the past, there might be some leftover for some of those other things. And those things all tie directly to health and well-being.
"A lot of state agencies don't do the most with their money. I consider one of our biggest jobs to be as efficient with our dollars as possible so more of those dollars can go back to the treasury to figure out how to spend it. My job is to get all the waste out of the system to decide what to do with the taxpayers' money."
Food for thought
It's no secret the system is broken, and both parties bear responsibility.
Listen to Keck long enough and some of his ideas - making sure the poorest among us have access to quality education, good jobs, good transportation - sound more like the drumbeat of the Democrats than the Republicans, a comment he's heard before. But he disagrees.
"Republicans care about people and communities as much as Democrats do, they just have much different solutions," he said. "I think the Republican strategy is setting priorities, understanding where government has a role to play, if it's going to play a role."
Unfortunately, he said, government makes a lot promises it can't keep.
So when he says throwing more money at the problem isn't the answer, it's not a knee-jerk reaction.