Bettina Cox has spent her adult life following the rules. She raised a family. She paid her bills.
Cox always had health insurance coverage, too, until she lost it - with her job - five years ago.
Now she is among the one in four uninsured Texans waiting to see how, or even if, the health insurance reforms upheld last month by the U.S. Supreme Court will change their lives.
Cox would be eligible for the provision's Medicaid expansion, which could take effect in 2014, allowing people who earn up to $14,800 a year - $30,600 for a family of four - to participate in the nation's main health insurance program for the poor.
But the state's leaders haven't agreed to the expansion, worried about the potential cost and about giving the federal government the power to decide who gets to participate.
Cox, however, needs medical help now.
"Most of my life, I've worked. I have had insurance. I didn't use it because I didn't need it," said Cox, 59. "Now I do. Does that mean I have to go untreated?"
She and the other 6.5 million uninsured Texans - at more than 25 percent, the state has the highest rate of uninsured residents in the nation - depend on hospital emergency rooms and a network of public and charity clinics.
She had moved in with her daughter in Richmond, in Fort Bend County, when abdominal pain sent her searching for help in late 2011.
First treated at the Fort Bend Family Health Center, which serves low-income patients at a discounted rate, she was diagnosed with a uterine tumor and later referred to Gateway to Care, a network that can coordinate treatment for more complex cases.
She will see a surgeon later this month, eight months after she began looking for help.
In the meantime, the tumor is growing.
Between 1.5 million and 2 million people in Texas would be covered by the Medicaid expansion, but the Supreme Court allowed states to opt out without jeopardizing their funding for the traditional Medicaid program.
Guidelines for traditional Medicaid vary from state to state; in Texas, children, pregnant women, disabled adults and the elderly are covered.
Under the expansion, anyone with an income no greater than 133 percent of the federal poverty level would qualify. Advocates say that would improve public health.
"There's data that shows children's health improves when their parents are also covered," said Laura Guerra- Cardus, associate director of the Children's Defense Fund Texas office.
"Their parents are healthier, able to be at work more and have more access to health services for the whole family."
Expenses could climb
The federal government would cover all of the expansion's cost for the first three years before phasing in the state's share. By 2020, the state would be required to cover 10 percent.
That's far less than the 40 percent state share of traditional Medicaid, but it's an additional expense for a state that dramatically cut education and other services in 2011. And some state officials fear the federal government would cut back its share in the future.
If the state doesn't opt for the expansion, people who earn at least 100 percent of the poverty level, about $23,000 for a family of four, would qualify for a subsidy to help buy private insurance under the Affordable Care Act. Those who earn less would be out of luck.
Guerra-Cardus calls that a moral issue, as well as a political one.
For people like Danny Harris, it's another reminder that tough choices will remain a way of life.
"You go to the doctor, or you buy food for the week," said Harris, who is 50 and was diagnosed with HIV 15 years ago.
Harris was on Medicaid until two years ago, when a routine cost-of-living raise in his disability payment boosted him beyond the income limits.
He still qualifies for Medicare - a luxury to Texas' uninsured - but that still leaves him responsible for 20 percent of his medical costs, including a $3,000 co-pay for surgery to repair a hand injury earlier this summer.
"I have to weigh my options," he said. "I needed physical therapy for my hand, but I'd rather eat."
Then there are people like Sophia Hernandez, 34, who has held and lost more than a half-dozen jobs since she began having seizures 18 years ago.
Doctors have told her she doesn't have epilepsy, but being uninsured has made consistent follow-up treatment difficult. Without control over the seizures, she said, she has been unable to hold a job.
"Whenever I did get work, I'd get fired," Hernandez said.
Her husband works but does not have health insurance.
Nursing home care
Hernandez receives care, including access to a mental health therapist, at a clinic run by El Centro de Corazón, but she said Medicaid coverage would allow her to see more specialists and improve her chances of getting the seizures under control.
Without the expansion, Medicaid will continue to provide a patchwork of benefits for children, pregnant women, the disabled and elderly.
It currently covers more than half of all births and 70 percent of nursing home bills in Texas.
Nancy Acevedo, 24, is pregnant with her third child and, for now, she and sons Damian, 4, and Matthew, 2, are all covered by Medicaid.
Both boys have allergies, and Acevedo said she just found out they are anemic, as well.
"Now they can go to the dentist and all the things I couldn't do before," she said. She's also hoping to see a therapist for help with postpartum depression, which she experienced after a previous pregnancy.
The baby is due in August, and Acevedo's Medicaid coverage will end two months later, although the children will remain covered.
For Bettina Cox, the debate over the Medicaid expansion has been overshadowed by more immediate concerns.
'A sad commentary'
The tumor continued to grow as she sought help, eventually making it difficult to walk as it pressed on a nerve.
She said she doesn't yet know whether the tumor is malignant, and is worried that it will cut off circulation to her left leg before it is removed.
"My walking is very limited because of the pain," Cox said. "It could have been minor surgery if they had been able to treat it in time. Now it has become major surgery. That's really a sad commentary: Because of not being able to afford insurance, that I could lose a leg."
Cox always had health insurance coverage, too, until she lost it - with her job - five years ago.
Now she is among the one in four uninsured Texans waiting to see how, or even if, the health insurance reforms upheld last month by the U.S. Supreme Court will change their lives.
Cox would be eligible for the provision's Medicaid expansion, which could take effect in 2014, allowing people who earn up to $14,800 a year - $30,600 for a family of four - to participate in the nation's main health insurance program for the poor.
But the state's leaders haven't agreed to the expansion, worried about the potential cost and about giving the federal government the power to decide who gets to participate.
Cox, however, needs medical help now.
"Most of my life, I've worked. I have had insurance. I didn't use it because I didn't need it," said Cox, 59. "Now I do. Does that mean I have to go untreated?"
She and the other 6.5 million uninsured Texans - at more than 25 percent, the state has the highest rate of uninsured residents in the nation - depend on hospital emergency rooms and a network of public and charity clinics.
She had moved in with her daughter in Richmond, in Fort Bend County, when abdominal pain sent her searching for help in late 2011.
First treated at the Fort Bend Family Health Center, which serves low-income patients at a discounted rate, she was diagnosed with a uterine tumor and later referred to Gateway to Care, a network that can coordinate treatment for more complex cases.
She will see a surgeon later this month, eight months after she began looking for help.
In the meantime, the tumor is growing.
Between 1.5 million and 2 million people in Texas would be covered by the Medicaid expansion, but the Supreme Court allowed states to opt out without jeopardizing their funding for the traditional Medicaid program.
Guidelines for traditional Medicaid vary from state to state; in Texas, children, pregnant women, disabled adults and the elderly are covered.
Under the expansion, anyone with an income no greater than 133 percent of the federal poverty level would qualify. Advocates say that would improve public health.
"There's data that shows children's health improves when their parents are also covered," said Laura Guerra- Cardus, associate director of the Children's Defense Fund Texas office.
"Their parents are healthier, able to be at work more and have more access to health services for the whole family."
Expenses could climb
The federal government would cover all of the expansion's cost for the first three years before phasing in the state's share. By 2020, the state would be required to cover 10 percent.
That's far less than the 40 percent state share of traditional Medicaid, but it's an additional expense for a state that dramatically cut education and other services in 2011. And some state officials fear the federal government would cut back its share in the future.
If the state doesn't opt for the expansion, people who earn at least 100 percent of the poverty level, about $23,000 for a family of four, would qualify for a subsidy to help buy private insurance under the Affordable Care Act. Those who earn less would be out of luck.
Guerra-Cardus calls that a moral issue, as well as a political one.
For people like Danny Harris, it's another reminder that tough choices will remain a way of life.
"You go to the doctor, or you buy food for the week," said Harris, who is 50 and was diagnosed with HIV 15 years ago.
Harris was on Medicaid until two years ago, when a routine cost-of-living raise in his disability payment boosted him beyond the income limits.
He still qualifies for Medicare - a luxury to Texas' uninsured - but that still leaves him responsible for 20 percent of his medical costs, including a $3,000 co-pay for surgery to repair a hand injury earlier this summer.
"I have to weigh my options," he said. "I needed physical therapy for my hand, but I'd rather eat."
Then there are people like Sophia Hernandez, 34, who has held and lost more than a half-dozen jobs since she began having seizures 18 years ago.
Doctors have told her she doesn't have epilepsy, but being uninsured has made consistent follow-up treatment difficult. Without control over the seizures, she said, she has been unable to hold a job.
"Whenever I did get work, I'd get fired," Hernandez said.
Her husband works but does not have health insurance.
Nursing home care
Hernandez receives care, including access to a mental health therapist, at a clinic run by El Centro de Corazón, but she said Medicaid coverage would allow her to see more specialists and improve her chances of getting the seizures under control.
Without the expansion, Medicaid will continue to provide a patchwork of benefits for children, pregnant women, the disabled and elderly.
It currently covers more than half of all births and 70 percent of nursing home bills in Texas.
Nancy Acevedo, 24, is pregnant with her third child and, for now, she and sons Damian, 4, and Matthew, 2, are all covered by Medicaid.
Both boys have allergies, and Acevedo said she just found out they are anemic, as well.
"Now they can go to the dentist and all the things I couldn't do before," she said. She's also hoping to see a therapist for help with postpartum depression, which she experienced after a previous pregnancy.
The baby is due in August, and Acevedo's Medicaid coverage will end two months later, although the children will remain covered.
For Bettina Cox, the debate over the Medicaid expansion has been overshadowed by more immediate concerns.
'A sad commentary'
The tumor continued to grow as she sought help, eventually making it difficult to walk as it pressed on a nerve.
She said she doesn't yet know whether the tumor is malignant, and is worried that it will cut off circulation to her left leg before it is removed.
"My walking is very limited because of the pain," Cox said. "It could have been minor surgery if they had been able to treat it in time. Now it has become major surgery. That's really a sad commentary: Because of not being able to afford insurance, that I could lose a leg."
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