For Uninsured in Texas, Supreme Court Ruling Adds to Uncertainty

PASADENA, Tex. — In an ordinary world, Josh Hebert would have accepted the raises his employer offered.

But in the extraordinary world of the uninsured, he has not only turned down the pay increases at the bank where he works, but has twice asked for a pay cut — so that he and his wife’s ill 7-year-old daughter can qualify for government-sponsored children’s health insurance.

By keeping his income low, he and his wife, Kyla, are able to ensure that their daughter continues to have health coverage. The parents remain uninsured themselves, like thousands of others in this working-class refinery town outside Houston. Thirty-three percent of the population here lacks medical insurance.

Nearby in Houston, hours after the Supreme Court’s ruling on Thursday upheld the core provisions of President Obama’s health care overhaul, Luis Duran hardly paid attention. He and his wife sifted through medical documents stuffed in a paper bag, evidence of his ordeal to survive cancer without health insurance.

A crane operator, Mr. Duran had been covered for years through his employer, but a simple paperwork oversight left him uninsured last year. Months later, he learned he had colon cancer, and spent roughly $7,000 on a colonoscopy and surgery — a reduced rate — using money he received from relatives and from selling some of his and his wife’s jewelry, including a 14-karat gold medallion of Jesus Christ.

“When you don’t have insurance, nobody listens to you,” said Mr. Duran, 51, who had been making about $50,000 annually but is now on disability. “It’s a powerless feeling. You feel like you’re an outcast. You feel that you’re homeless without insurance.”

In Texas — where 25 percent of the population lacks health insurance, the highest uninsured rate of any state, according to the Texas Medical Association — the Supreme Court’s ruling was not quite the partisan victory or defeat it might have been in Washington. Though those without health coverage perhaps had the most at stake, the ruling was one more element of uncertainty in uncertain lives, drowned out by more pressing medical needs and financial pressures.

The uncertainty was intensified by unanswered questions over the state’s efforts to fight the expansion of Medicaid, the government health-insurance program for low-income and sick people. Expanding Medicaid was the major portion of the health care law that the Supreme Court restricted in its decision, allowing states flexibility to opt out of the expansion without penalties. Thomas M. Suehs, the commissioner of the Texas Health and Human Services agency, said he remained concerned that expanding Medicaid without reforming it multiplied the costs the program put on states, adding that Medicaid already consumed a quarter of the state budget.

As a result, many of the uninsured in Texas who would be eligible for coverage under the expansion remain in a state of limbo.

“It’s a big concern,” said Gladys Vasquez, 50, a Houston home health aide who cannot afford private insurance on her $17,000 annual salary and whose employer does not offer her coverage. “Right now, it’s scary to get sick, because if you don’t die from the sickness, you die when you see the bill.”

Mrs. Vasquez takes care of her own medical needs at a local clinic and by relying on her 90-year-old mother’s home remedies. On Thursday, watching the television news coverage of the ruling at her client’s house, she let out a cheer.

“It’s like a dream come true,” said Mrs. Vasquez, a member of the Texas Organizing Project, a community activist group. “It’s something we really needed.”

In Houston and the surrounding suburbs and cities in Harris County, including Pasadena, the number of uninsured people like Mrs. Vasquez is so large — more than one million people — it rivals the total population of Dallas. They defy easy categorization.

Though some are newly arrived illegal immigrants living in extreme poverty, many others, like Mr. Hebert, Mr. Duran and Mrs. Vasquez, are American citizens with mortgages or part-time and full-time jobs. Some work in businesses that do not offer coverage, or they cannot afford private insurance; others are eligible but not enrolled in government programs like Medicaid.

Nearly 40 percent are Hispanic, 21 percent are black, and another 21 percent are Asian, according to the Texas Medical Association. The Harris County Hospital District provided $1.1 billion to care for the uninsured and underinsured last fiscal year, about half of which was financed by county property taxes. Mr. Duran, for example, pays a subsidized fee for his chemotherapy treatments at a district hospital.

In Pasadena, the Heberts have been struggling to care for their daughter, Katie, who had brain lesions and is being evaluated for mitochondrial disease, a genetic disorder primarily affecting children that damages cells of the brain, heart, liver and respiratory systems, among others.

Mr. Hebert earns roughly $45,600 annually, but declined the health insurance offered by his employer, not only because of its expense, but because it would not cover all of Katie’s needs.

 They tried to enroll Katie and their healthy 10-year-old son, Nathan, in the government-sponsored Children’s Health Insurance Program, which provides coverage to children whose families cannot afford private insurance but have incomes too high to qualify for Medicaid.

Mr. Hebert’s annual salary initially put them $3,100 a over the limit, so he asked for a pay cut so Katie could qualify for the children’s program, and asked once more after the children were enrolled because he received an automatic cost–of-living raise.

“I’m thankful that we were able to take a pay cut and get Katie what she needs, because it was truly our only option, but it should not be this way,” said Mrs. Hebert, 28, a stay-at-home mother and a University of Houston student. “I think very few Americans truly want to be uninsured, and if health insurance becomes something that the majority of Americans can afford, then very few people will choose to go without it. I know that I would love to have that safety net.”

Yet Mrs. Hebert said she was uncertain how the provision of the health care law that was upheld requiring virtually all Americans to buy health insurance or else pay a fine would affect her.

If they were required to be insured and had to use the plan offered by Mr. Hebert’s employer, they could not survive, because the cost would amount to 25 percent of his income, she said. Under the law, it is likely that they would qualify for a federal subsidy to offset some of that cost, since their share comes to more than 9.5 percent of their income, a detail they had not realized. For the couple, there are more questions than answers.

Because Katie remains undiagnosed for mitochondrial disease, one of her specialists has ordered a genetics test costing $17,000. The children’s program declined to pay for the procedure, but an appeal is pending. The day after the ruling on Friday, Mrs. Hebert took her daughter to an occupational therapy appointment, and when they returned home, they walked past Katie’s IV pole at the bottom of the stairs.

“People are hypothesizing about what it’s going to mean two years down the road,” Mrs. Hebert said of the Supreme Court decision. “But we kind of deal with today, and where we are today.”