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. Culick, 52, is one of several hundred thousand people left behind by South Carolina’s refusal to expand Medicaid under President Barack 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," 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."

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.

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 state 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," Keck said.

If South Carolina expanded eligibility as envisioned in the federal law, state officials said, 344,000 people, including some who now have private insurance, would become newly eligible for Medicaid. One-third of state residents could then be on Medicaid.

State Sen. Darrell Jackson Sr., a Democrat from Columbia, said: "Of all the years I’ve been in politics, including 20 years in the Senate, I’ve never been more disappointed or embarrassed than when we rejected the expansion of Medicaid. And I’ve never seen a more foolish decision. This was all about politics."

Health care providers are preparing for a surge of interest.

"Young adults will be bombarded with ads," said Patrick Caster, the president of Advicare, a managed care plan for Medicaid patients in South Carolina. "That will boost our Medicaid enrollment."

Officials here defy some preconceptions about conservatives. They are disciples of Dr. Donald M. Berwick, a former administrator of Medicare and Medicaid under Obama, and they embrace his three-part vision: to improve the care of individual patients, to improve the overall health of the population and to reduce per-capita costs.

Medicaid here is changing in big ways. The state automatically enrolls children in Medicaid if their families receive food stamps or cash assistance – an option allowed by the new health care law and a separate 2009 law signed by Obama.

Bruce Lesley, the president of First Focus, a child advocacy group, said: "I would not have expected South Carolina to take up that option. It’s really great that the state did."

To increase access to primary care, state officials recently certified walk-in clinics in 28 CVS drugstores as Medicaid providers. And they increased payment rates for doctors who provide services to Medicaid patients in the evening and on weekends and holidays.

Keck, the state health director, said that insurance was less important than "social determinants of health" like income, education, race and housing conditions. He is prodding hospitals to help arrange social services for Medicaid patients, even as he opposes the expansion of eligibility.

State Sen. Kevin L. Bryant, a Republican from Anderson, said he opposed expanding Medicaid for fiscal and policy reasons.

"The ‘free money’ from Washington is really borrowed from China, or from future generations," said Bryant, a pharmacist. "We don’t need to increase the culture of dependency on government. And the costs of the current Medicaid rolls are unsustainable. Until we rein in those costs, it does not make mathematical sense to expand Medicaid."

Like Culick in Florence, Joyce G. Barr, 59, of nearby Marion, is waiting. Barr has intense arthritic pain in her right hip and has difficulty walking or climbing stairs. Lacking health insurance, she cannot get diagnostic imaging studies or see an orthopedist who might perform hip replacement surgery.

It was for adults like Barr that Congress tried to expand Medicaid. But the U.S. Supreme Court converted the federal mandate to a state option.

"A lot of people have to die because they cannot get any help," Barr said. "I hope I’m not one of them."

© 2013 The New York Times Company