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In a state that spurned Medicaid expansion, the recently unemployed fall through the cracks Date: 03/01/17

Jenny Deam

By Jenny Deam

After returning from my first trip to the tiny town of Cuero, Texas I wandered over to my editor and said I had good news and bad news. The bad news was I didn’t get the story I thought I would. The good news was I got something better.

I was well into a yearlong 2016 series called "The Uncovered," which looked at how politics and an unhappy insurance industry had collided, leaving millions of people falling through the cracks. In my regular duties as a health care reporter I had just written about Blue Cross and Blue Shield of Texas, the state’s largest insurer, asking for a 60-percent rate hike on the heels of United HealthCare announcing it would leave the exchange in Texas. (Later Cigna and Humana also fled.) I knew BCBS was the only insurer in about one in three Texas counties and wondered what the rate hike without competition would mean to people trying not just to get coverage – but to get care. This story was not originally planned as part of the series but I thought it could be an important addition based off the news.

After calling around to ACA advocacy groups and rural health networks, someone suggested I visit Cuero, a community on the oil patch in one of the counties with only one insurer on the exchange. Presumably the oil and gas workers would turn to the exchange after losing jobs in the energy collapse. But on my first interview at the regional hospital the CFO looked at me blankly and said he didn't know of any patients using “Obamacare” so the rate hike didn’t affect them. The next two people I interviewed said the same thing. This is a bright red corner of a red state so I thought maybe they were just slamming the president. Then they said that most of the oil workers already had left town. I discovered the story I came for did not exist. But another one awaited.

The main talk in Cuero was that two weeks before, a textile factory that had been a fixture for more than 100 years had shut down. Not only did 275 people in a town of 6,000 abruptly lose jobs, they also lost health insurance. These were $10- and $12-per hour workers with little hope of finding another job with such benefits.

And that is how I saw what Texas’ coverage gap looked like up close. The resulting story, No job. No insurance. No chance at 'Obamacare.' No safety net in Texas. Welcome to Cuero, ran on August 8.

Texas is tied with Alabama as having the strictest Medicaid threshold in the country. A parent in a family of three can make no more than $3,628 per year. But if they made less than $20,000 they would not qualify for subsidies through the ACA (because Texas had chosen not to expand Medicaid under the ACA once the Supreme Court gave states that option) That was the situation facing nearly every one of the laid-off workers. Even if they knew to sign-up for the exchange (they didn’t because enrollment outreach never arrived in Cuero) they still would have to pay full freight on premiums at hundreds of dollars per month. The factory, I realized, held the key to the story.

I learned the hospital’s nursing supervisor once had a side job at the factory’s employee clinic. I asked her to contact former patients. She said she was scared for her town. She talked about running into people who no longer could get their medication and begged her to write a prescription. She had to tell them no.

I still wasn’t quite sure what I had, but it felt like something big and hidden.

I needed the former workers. Where do people who lose jobs go? I found a week-old flier for an emergency community meeting and began calling everyone who had a booth. The woman who answered the phone at a food pantry said her son played football with a boy whose single mother lost her job. That's how I met Tyra Franklin. She mentioned in passing she was running out of her migraine medication. The headaches were starting to come more often from the stress of not having a job. She said she only had 24 pills left and no insurance to get more. I knew I had my lead.

Another woman said she was fine, except she worried about paying for all the costs that went with her daughter being named a local beauty queen. When she left the room I asked her daughter how her mom was really doing. The teenager said her mother had an unexplained growth, possibly a tumor, on her neck that she was trying to ignore because they were uninsured.

People were proud and didn’t want to complain. In nearly every case of those interviewed, when their stories were double-checked with someone who knew them, the situation was almost always worse than they had let on.

This was a story about working your hunches, circling back and working them some more. I went to Cuero twice, for a total of three days. I interviewed nearly 30 people, from clergy, hospital billing clerks, motel workers and waitresses to the towns beleaguered economic development director – and then everyone they pointed me to.

At its core, Cuero was a business story about a gap in the nation's insurance system. I approached it as a narrative feature. The statistics on the coverage gap had been reported but were just numbers. It became important to me to show that behind the numbers were real people in crisis.

Jenny Deam (@jennydeam) has been a reporter for the Houston Chronicle since March 2015. Before that, she was a special correspondent for the Los Angeles Times.