Jose Gallegos' company eliminated employee health insurance to save money, so when his gut started hurting and his skin took on a yellow tinge, he resisted seeing a doctor. When he finally went to the emergency room, physicians diagnosed stomach cancer.
Gallegos made too much money to qualify for Medicaid but not enough to buy his own insurance, so he scraped together what he could, and his wife, Andrea, took on three jobs. Just over a year later, at 41, he died, leaving behind four children.
Two years later, it was Andrea's turn. A crack and sharp pain in her back drove her to the emergency room, where she learned she had breast cancer. It had snapped one of her vertebra. Now 45, she said the cancer remains in several other vertebrae, but at the moment it's not spreading.
Families like the Gallegos stand at the center of a debate over President Barack Obama's health care overhaul, which could have expanded Medicaid coverage to 1.3 million uninsured Texans. But Republican Gov. Rick Perry has said he will not widen the program because it would cost too much.
"It gets me mad," Gallegos said. Perry "made a decision without us."
Nowhere did Obama's health care law hold more promise than in Texas, which leads the nation in the portion of its population that is uninsured. A quarter of Texans have no coverage, many of them families like the Gallegos who are considered the working poor.
Perry was not alone in his decision. Several other GOP governors made the same move or are contemplating doing so, saying they can't afford to expand the joint state-federal program that provides care for the poor and disabled, or that they disagree with it philosophically.
Texas already has one of the nation's most restrictive Medicaid programs, offering coverage only to the disabled, children and parents who earn less than $2,256 a year for a family of three.
Without a Medicaid expansion, the state's working poor will continue relying on emergency rooms — the most costly treatment option — instead of primary care doctors. The Texas Hospital Association estimates that care for uninsured patients cost hospitals in the state $4.5 billion in 2010.
The expansion of Medicaid would cover 17 million uninsured Americans. The rest would be pushed into subsidized private insurance.
For the first 10 years under the new law, the federal government would pitch in about $7 for every $1 the state spends, according to estimates from the Texas Health and Human Services Department. The Center on Budget and Policy Priorities, which studies policies affecting the poor, shows an even higher rate of return.
But Perry wants the federal government to turn over the cash without strings and allow the state to develop its own program, something the Obama administration will not allow.
"I think it is very important for the people of Texas to understand that the current Medicaid program is unsustainable," Perry said. "And to ask, or to demand, that the state of Texas expand a program that is already broken, is just not good public policy."
Perry has said no Texan is going without health care because emergency rooms cannot turn away patients in urgent need. But the system to pay for chronic health problems is underfunded, difficult to navigate and as a result can shorten life expectancies.
Republican state Sen. Dan Patrick of Houston, a member of the Health and Human Services Committee, said he believes the majority of legislators support Perry on the issue.
"I just think the plan is a disaster on every level," Patrick said. He doesn't believe it will improve care or lower costs and instead will increase government spending and wait times for medical treatment.
Texas officials estimate it would cost the state $16 billion over 10 years to fully implement the law. The federal government would pay the full cost for the first three years. After that, the state share would be capped at 10 percent.
Andrea Gallegos said better health care coverage might have saved her husband's life and been cheaper for the government, too.
"The thing is now they're spending even more money because ... we all ended up in the emergency room," Gallegos said. "They're wasting billions and billions of dollars just here in Texas."
Gallegos recalls how Jose had his stomach removed and endured chemotherapy and radiation. He relied on donated medications, crossed the border for cheaper scans in Mexico and sometimes chose between doctors' appointments when there wasn't enough money. One month, while Jose was briefly in remission, he decided to see the cardiologist instead of going for a follow-up MRI.
Andrea wonders if missing that appointment was a "fatal mistake," because the cancer came back. By the time they got the drugs donated for a new round of chemotherapy, it was too late.
Doctors initially gave Andrea three months to live, but she has fared better and got coverage through Planned Parenthood's breast and cervical cancer program. Three years and two rounds of chemotherapy later, she frets about two sisters who also have cancer and no insurance. Neither has had any follow-up monitoring since her initial treatment.
Perry's opposition to the Medicaid expansion has also drawn criticism from hospitals, which complain that they are forced to recover the cost of treating the uninsured by charging more to private insurance companies, which then pass the expense onto consumers as higher premiums.
Jim Valenti, president and CEO of University Medical Center of El Paso, sees it every day in his hospital, where nearly half of patients are uninsured. He hopes Perry reconsiders.
"In essence, the governor is saying no to as much as $112 billion in new federal Medicaid funds over the next ten years," Valenti said. "Those funds will be directed to other states to cover their low-income residents."
One of the hospital's frequent visitors is Henry Austin, who suffers from HIV and epileptic seizures.
"My entire life is going from one doctor to another," Austin said. Bill collectors "call all of the time, and I say: 'I'm sorry, I don't have any money. If I had, I'd give it to you.'"
Now health care executives must go back to the governor and lawmakers to figure out what comes next.
"If not Medicaid expansion, then what?" asked David Lopez, CEO of the Harris County Hospital District, where up to 80 percent of patients at some facilities are uninsured.
Ricardo Garcia, a 55-year-old from Alamo in South Texas, spent four years without insurance — a period that included a second hernia surgery and a diabetes diagnosis. During that time, he bought less expensive medication in Mexico, sought treatment in emergency rooms, relied in part on donated insulin and worked out a payment plan with his surgeon.
Garcia said he likes Perry, but suggested the governor go undercover to experience life without medical insurance.
"If you have cancer and your medication is high, why should we let you die because you don't have the money to pay for it?" he said. "You're human. You should have the same right as anybody else to be taken care of."
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