By Mitchell Schnurman, Dallas Morning News

Half who lose their jobs and employer health plans are expected to go without coverage — far worse than the rest of the U.S.

The worst is about to get worse. In Texas, where 5 million people already go without health insurance, nearly 1.2 million more are projected to join their ranks — far more than any other state.

That’s the estimated collateral damage from the coronavirus recession, assuming the national unemployment rate hits 20%, according to a recent Urban Institute report. Some believe the real jobless number for April may already be that high.

In that scenario, 25 million adults and children in the U.S. are expected to lose employer-sponsored health insurance. The vast majority — 7 in 10 nationwide — will get coverage elsewhere, the study estimated.

But in Texas, just 1 in 2 are projected to be covered, which would be the lowest share among the states.

The surge in uninsured arrives while COVID-19 is still raging and states are struggling to restart their economies safely. Laid-off workers who lose health insurance generally have a 60-day window to sign up for replacement coverage, usually through their company plan or the federal health exchange.

It’s a complicated decision that can be expensive, and unemployed Texans have a weak record of enrolling in such backup plans. That’s why the report projects such a low take-up in the state.

Losing insurance will greatly compound the health and financial challenges for people, hospitals, doctors and the broader economy.

“It’s devastating for the families that won’t be able to get the care they need,” said Vivian Ho, a Rice University economist who specializes in health issues. “Many are gonna try to tough it out on their own, and they could get really ill.”

It’s also devastating for health providers, she said. Their patient volumes have declined sharply amid coronavirus fears, and they’ve had to ramp up spending on supplies and preparation for COVID-19 cases.

“Providers are already running in the red,” Ho said. “This is gonna turn it blood red.”

Even before the pandemic, hospitals were struggling with a large number of uninsured and underinsured patients in the state, said John Hawkins, senior vice president for the Texas Hospital Association. Facilities in Texas provide billions in uncompensated care, and he said the costs are generally passed on to commercial customers and taxpayers in hospital districts.

Adding more uninsured now will amplify the strain.

“It’s huge,” Hawkins said. “It has a fiscal impact and a quality-of-life impact.”

Every state will see an increase in uninsured, the study shows. But Texas stands apart in both the total number to be added and the share of workers projected to end up without coverage.

Why so bad? It’s no coincidence.

For years, Texas’ statewide elected leaders have rejected efforts to improve access to care. They turned down Medicaid expansion time and again, and resisted programs to help people enroll in the federal marketplace. Texas is leading the legal challenge to overthrow the Affordable Care Act, a case headed to the U.S. Supreme Court.

Thirty-six other states, including some led by Republican governors and legislatures, have expanded Medicaid, a key plank of the ACA. The federal government pays 90% of those costs, and expanding Medicaid would cover nearly 1.6 million working poor in Texas — that was the figure before the pandemic led to millions of layoffs and furloughs.

In Texas’ existing Medicaid program, the state sets the lowest income threshold in the country. If a single mom with two kids earns more than $3,800 a year — or $317 a month — she makes too much to get Medicaid coverage in Texas, said one expert.

“We have the stingiest eligibility in the country,” said Stacey Pogue, a senior policy analyst at the Center for Public Policy Priorities in Austin.

The income cap in Texas is 17% of the federal poverty level for a family of three, which is lower than in Alabama and Mississippi, said the Kaiser Family Foundation. The average income cutoff for the U.S. is 138% of poverty level, which is generally the level in states that expanded Medicaid.

In those states, over half of the people losing employer insurance will get Medicaid coverage.

“This is the purpose of the Medicaid program, to provide a safety net to people in financial distress,” wrote Bowen Garrett and Anuj Gangopadhyaya of the Urban Institute’s Health Policy Center.

Texas lags in another metric: Just 23% of those eligible for a marketplace plan enrolled in an ACA option. That’s lower than in the U.S. (32%) and far lower than in Florida (47%) — even though Florida has a Republican governor and hasn’t expanded Medicaid, either.

“In Texas, maybe there’s less of a culture of coverage,” said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, which helped support the Urban Institute report.

That could be related to the type of households, family income, immigration status and other factors. All that’s in addition to public policies from lawmakers, along with ideology and politics.

She believes the dynamic could change, perhaps with the new wave of workers who lose health plans during the pandemic. They’re accustomed to having coverage and may prioritize it more highly than the uninsured in the past.

They could pressure elected leaders to expand Medicaid and push for other ways to help residents navigate the marketplace. Such efforts are underway in other states.

“Sometimes a catastrophe can reshape what’s considered normal — and who’s considered to be deserving,” Hempstead said. “This experience could normalize other kinds of health coverage. There’s so much financial strain right now, and Texas is passing on a huge source of federal money.”

For years, Texas hospitals have fallen short in pushing for Medicaid expansion, which could be worth $100 billion in federal funding over a decade. The picture has changed, Hawkins said, because of the coronavirus and the energy bust.

“These are extraordinary times,” he said, “and if there’s a federal tool we can use, we ought to figure out how to access it.”

By Erica Grieder, The Houston Chronicle May 13, 2020 Updated: May 17, 2020 1:36 p.m.

State Sen. Carol Alvarado, shown in 2018, is among 12 members of the Texas Senate Democratic Caucus who have called on Gov. Greg Abbott to expand Medicaid via executive action, as governors in several states have done.

Photo: Elizabeth Conley, Houston Chronicle / Staff photographer

——————————-

There’s nothing like a pandemic to make Texans reflect on the wisdom of our collective failure to provide for those who lack access to reliable health care.

The state notoriously has the highest uninsured rate in the country, at nearly 18 percent of the population — roughly double the national average. That figure has come down a bit since passage of the Affordable Care Act in 2010, but not as much as it might have. Texas is one of the states that has opted against expanding Medicaid, and its Republican leaders have brooked little debate on that subject. Indeed, Attorney Gen. Ken Paxton is leading a push to overturn the ACA — or “Obamacare” — at the Supreme Court.

With nearly 42,000 confirmed COVID-19 cases in the state and 1,153 deaths, Democratic lawmakers believe it’s time revisit the question of expanding health care access.

Last month, the 12 members of the Texas Senate Democratic Caucus, chaired by Sen. Carol Alvarado of Houston, called on Gov. Greg Abbott to expand Medicaid via executive action, as governors in several states have done. All told, 36 states — including Republican-led states such as Ohio — have opted into the expansion.

“As governor, you have the power to break the political inertia that presently blocks successful implementation,” they write.

That’s true, but there’s no indication that Abbott, a Republican who frequently sued the Obama administration when he was attorney general, is inclined to use that power. So the Democratic senators have also taken their case to the public, in an op-ed that reflects a hard-won understanding of how arguments are won or lost in the Texas Legislature.

The dozen Democrats point to the state’s high uninsured rate, as well as the financial toll that this takes on hospitals and families, particularly in rural areas. They argue that absent Medicaid expansion, Texas taxpayers are missing out on an opportunity to recapture billions of the dollars that we send to Washington, D.C. each year. Under the ACA, the federal government covers 90 percent of the costs of Medicaid expansion, with states covering the rest.

That being the case, Democrats say expanding Medicaid would provide the state with an economic stimulus of sorts as well as improve public health.

“As we contend with the troubles of the oil industry, coupled with those caused by the pandemic, it doesn’t make sense for state leaders to refuse billions of our own federal tax dollars,” they write.

They continue, “The double whammy significantly will reduce the state’s ability to pay for other essential obligations and ultimately reduce our ability to afford any tax cuts.”

There’s something poignant about this argument, isn’t there?

The bit about the tax cuts would seem like a non sequitur, unless you’ve spent some time around the Republicans who have controlled both chambers of the Legislature for over a decade.

Some of the more rowdy members of the GOP caucus may even push for tax cuts during the next regular session, in 2021, although their more experienced colleagues are anticipating the kind of session that will see lawmakers looking for loose change in a desperate bid to blunt the impact of likely budget cuts.

The grim revenue forecasts they’re receiving from Comptroller Glenn Hegar explain why it’s unlikely the Legislature will have a serious discussion about expanding Medicaid next year even if Democrats retake the Texas House. Sales tax receipts — which make up more than half of the state’s tax collections — have plunged as a result of the shutdown necessitated by the new coronavirus. And though Abbott has initiated a phased re-opening, Hegar is warning, rightly, that we shouldn’t expect the economy to swiftly bounce back.

“We don’t think the recovery in the economy will be a V-shaped recovery — in other words, a very rapid recovery,” he said Monday in an appearance in Temple, explaining that the globalization of the state’s economy means we’re bound to experience adverse impacts until the pandemic subsides around the world. “It’s going to be more of a U-shaped recovery — a long recovery.”

Under those circumstances, the state’s budget-writers are going to have precious little latitude for expanding state spending in any area — even if Republicans such as Abbott and Paxton suddenly have a change of heart about expanding health care access. Which they probably won’t. Republican leaders in some states have been pragmatic rather than ideological in considering the question. But as it stands, state Rep. Sarah Davis of Houston, is the only Republican serving in Austin who supports Medicaid expansion.

Still, Democrats are right to raise the issue. According to the Kaiser Family Foundation, Medicaid expansion would extend health care coverage to an additional 1.5 million adults in Texas. The state’s share of the tab would be roughly $10 billion over the next decade, with the federal government supplying an estimated $100 billion in funds. And a majority of Texans would like to take this step: in a 2019 poll from the Episcopal Health Foundation, 64 percent of respondents expressed support for the idea of Medicaid expansion.

That was before the pandemic itself offered a powerful reminder that the health of our neighbors affects all of us.

erica.grieder@chron.com

]]> https://sickofittx.lisagoodgame.com/sen-nathan-johnson-we-need-to-expand-medicaid-in-texas-now/ Wed, 08 Apr 2020 22:40:00 +0000 http://sickofittx.lisagoodgame.com/index.php/2020/04/08/sen-nathan-johnson-we-need-to-expand-medicaid-in-texas-now/ Link to original article

Public opinion now supports the shift, and there’s federal money to pay for it.

By Nathan Johnson, 1:30 AM on Apr 8, 2020

The conventional political wisdom has been the same for Republicans and Democrats: Don’t say Medicaid expansion. I suppose that explains the nervous chuckling I used to hear when I kept giving the same answer to different questions: How can we help our millions of uninsured citizens? Expand Medicaid. What can we do to stimulate the Texas economy? Expand Medicaid. How do we raise state revenue without raising taxes? Expand Medicaid.

Much has changed in the past few years. Medicaid expansion is now politically popular in Texas, and a time-tested success across the nation. But the political inertia persists, and Texas remains one of only 14 states that haven’t implemented some form of Medicaid expansion.

COVID-19 brings a new urgency to the matter. Medicaid expansion would not only provide care to those most in need but would also help us combat the contagion and provide powerful economic stimulus when we need it more than ever.

It’s time for Gov. Greg Abbott to use his executive authority to expand Medicaid in Texas, now.

Consider the need even before COVID-19. Among the 50 states, Texas has the highest number and percentage of uninsured citizens. Some 1.5 million of the uninsured fall into the expansion gap, earning too much to qualify for Medicaid but too little to qualify for federal insurance subsidies. Their lack of access to health care harms all of us, by increasing the burden of uncompensated care, driving up health care costs, overcrowding emergency rooms, and lowering the state GDP. On the fiscal side, starting next year Texas stands to lose billions of (our own) federal tax dollars when our current non-expansion deal expires and new federal regulations drastically undercut the patchwork system we use to pay for indigent health care.

In contrast, numerous studies have shown that expansion states have seen improved health, increased use of primary care, decreased use of emergency care, lower smoking rates, higher employment rates, improved family financial stability and sustained operation of rural hospitals. On the fiscal side, economist Ray Perryman estimates that expansion would bring about $8 billion into the Texas economy annually, increase gross state product by $29.4 billion over just the first two years, generate a 331% return on investment over 10 years, and have a net positive effect on the state budget.

The COVID-19 crisis has magnified both the needs and the benefits associated with expansion. Workers in the service sector have lost their jobs and as a result lost their insurance. Many among our essential workforce — front-line health care workers, grocery store clerks, drivers and many others — have never been able to afford health coverage in the first place. We should all take pride in providing them with access to care. Meanwhile, social restrictions aimed at protecting life and preserving hospital capacity show the need to accelerate deployment of telemedicine services, and to be able to track, treat, quarantine and isolate. Medicaid expansion serves these ends.

As the 37th state to expand Medicaid, Texas wouldn’t be venturing into uncharted territory. In fact many Republican-led states have expanded Medicaid. Indiana did under then-Gov. Mike Pence. Ohio, Arizona, Indiana and others were able to use expansion to reform and improve their existing Medicaid programs, adding conservative favorites such as health savings accounts, behavior incentives and changes to delivery systems.

There’s no avoiding the expansion conversation any longer. It can’t be brushed aside by saying, “I’m waiting for a block grant.” The Trump administration just offered block grants. (Many, including me, believe that a block grant isn’t the best vehicle, but it’s still Medicaid expansion.)

And early conservative questions and doubts have been answered and dispelled by the positive results in the 36 other states that expanded Medicaid by standard means. Although differences between states do matter, the federal government has made clear that Texas will enjoy unprecedented flexibility in crafting a plan that accommodates its unique needs.

Supporting expansion now is not flip-flopping; it is altering strategy in response to better information and different circumstances. Today we have overwhelming public and business support, successful conservative models, greater flexibility, an even higher level of need, profound urgency and, as part of the federal COVID-19 crisis response, billions of federal dollars that can be employed to ensure that Medicaid expansion in Texas is a fiscal and health care success.

Only the governor can expand Medicaid immediately. Successful implementation over the long term, however, will require both Republicans and Democrats to recognize that Medicaid expansion is a vital and effective means to address our most urgent economic and health care challenges. And that it’s OK to say it.

Nathan Johnson is a Democrat representing Dallas in the Texas Senate. He wrote this column for The Dallas Morning News.

Editorial Board

Published 7:00 a.m. CT April 8, 2020

Now, during the coronavirus pandemic, is a good time to remind you that Texas is one of 14 states saying no to billions in federal dollars because it won’t expand Medicaid coverage.

Now is also a good time to point out a few other things while this pandemic makes more and more Texans eligible for benefits if Medicaid were expanded:

• Texas is the state with the largest uninsured population — about 5 million of our people. We’re the second-largest state, which begs the question why we have more uninsured than California, the largest. (Answer: We’re notoriously stingy with state funding for health care.)

• More than 1.5 million Texans would become eligible if Texas were to expand Medicaid. That number may expand in a hurry with so many people out of work right now.

• By 2024, we Texans will have paid $36.2 billion in federal taxes that will go to other states, assuming our elected officials continue to refuse Medicaid expansion. Ask yourself how you feel about supporting the health care expenses of Massachusetts but not Texas.

• A study released last year by the University of Michigan estimated that 730 Texans die each year because Texas hasn’t expanded Medicaid.

•  It’s estimated that Texas is saying no to $100 billion — billion with a “b” — in a decade’s span.

HOW CAN WE CHANGE THIS?

Gov. Greg Abbott has the authority to do it unilaterally, as did his predecessor, Rick Perry. The expansion program started in 2014 and Abbott has been governor since 2015. It also could be done by the Legislature. Attempts thus far have failed. 

WHY SAY NO TO BILLIONS?

Perry refused expanded Medicaid, saying the entire Medicaid program was unsustainable. You could say that about any number of government programs and services, including the defense budget. We could try doing without them and see how sustainable that turns out. Abbott said the federal government was being “coercive” trying to force Medicaid expansion upon Texas.

But if you want to know their real reason, look no further than whose plan it was — President Barack Obama’s. That name alone was enough for them to oppose it with every fiber of their beings, despite the guaranteed losses of life that these two pro-life politicians had to have seen coming.

CAN ABBOTT BE CONVINCED?

We are trying to be optimistic. It’s why we broached the subject in the first place — because we think coronavirus is the tipping point. We worry what it’ll do to the uninsured poor people who don’t qualify for Medicaid if Texas doesn’t take the expansion. They are at huge risk because they avoid doctor visits they can’t afford and because they’re willing to risk exposure to keep their low-paying jobs. 

We’re also curious, and frightened, about how the University of Michigan would recalculate its 730-deaths estimate to account for coronavirus.

We’d like to think that Abbott would swallow his pride to save lives and that he’d act quickly, since coronavirus already is here killing Texans.

But that’s a lot of pride to swallow. When Abbott was attorney general, he took the lead in the lawsuit by Republican-led states against the federal government, winning states’ rights to refuse Medicaid expansion. It happened at the Supreme Court level in 2012 and could be considered Abbott’s crowning achievement as a lawyer.

So you can see how significant an about-face it would be for Abbott to accept Medicaid expansion. It would be up there with Jesse Helms’ reversal of his stance against funding programs to combat AIDS after Bono lobbied him. (Willie Nelson, are you listening?)

In other words, it’s unlikely but possible.

By Gwendolyn Wu , April 6, 2020 Updated: April 6, 2020 5:16 p.m.

More than 50 Texas health policy and industry groups are urging Gov. Greg Abbott to expand the state’s Medicaid program to cover more than 1 million people as a way to slow the spread of the coronavirus and the illness it causes, COVID-19.

The federal law known as Obamacare allows states to extend eligibility for Medicaid, the government health insurance for the poor, to greater numbers of low-income families. Texas, which leads the nation in both the number and percentage of uninsured, has refused to do so even though the federal government will pay for nearly all of the additional costs.

Expanding Medicaid would open access to medical care, allowing low-income workers who might otherwise put off seeing doctors to get tested and treated for COVID-19 because of costs, health care advocates say. Quickly identifying, isolating and treating people with the disease could slow its spread, advocates said.

“The smartest thing to do would be to go ahead and do the expansion,” said Anne Dunkelberg, a health policy expert at the progressive Center for Public Policy Priorities in Austin.

About 5 million Texans, or nearly 1 in 5, are without health insurance, according to the U.S. Census. Expanding Medicaid would cover an additional 1.5 million people in the state, according the Kaiser Family Foundation, a health policy think tank in San Francisco.

Calls to broaden Medicaid are nothing new. But as increasing numbers of Texans test positive for COVID-19, health care providers, associations and advocates, including the Harris Health System, Texas Hospital Association and Center for Public Policy Priorities, say it’s clear something must be done to slow the spread of the virus before the state’s hospitals are overwhelmed by patients.

How expansion works

Under the Affordable Care Act, a Medicaid expansion would increase the income eligibility cap to cover all who earn up to 138 percent of the federal poverty level, or less than $18,000 a year for an individual.

Annually, the federal government would pay 90 percent of the cost of the Medicaid expansion and the state would pony up the other 10 percent, according to the Kaiser Family Foundation. Gov. Greg Abbott, however, has balked at expanding Medicaid, arguing the system is too broken to permanently expand.

The governor’s office did not respond to a request for comment.

RURAL PREPARATIONS: In rural Texas, precautions are their best protection from coronavirus

Texas’ Medicaid program is the safety-net insurance for children, seniors over 65 and disabled Texans who are under the federal poverty line. Roughly 4 million residents are enrolled in the program.

As Medicaid stands, it leaves out 1.5 million Texans who would make too much to qualify, but too little for federal tax credits to buy a health insurance plan on the marketplace, said Elena Marks, president of the Episcopal Health Foundation, a nonprofit health policy advocacy group in Houston.

Many of the low-income workers who could qualify are essential workers at grocery stores, fast food joints, home health aides and shipping warehouses. Their work puts them at higher risk of exposure, but unstable financial situations and lack of access to adequate medical care could keep working even when feeling sick.

One in five uninsured people Americans in 2018 went without necessary medical care due to the cost, according to the Kaiser Family Foundation.

CORONAVIRUS UPDATES: Stay informed with accurate reporting you can trust

“If we can expand health care access to those people, if we can encourage them if they’re feeling sick to get tested and get treatment,” said Tina Tran, director of AARP Texas, “that is really for the public safety for Texans.”

Fixes, not expansion?

Health care researchers who say Medicaid doesn’t need to be expanded agree with Abbott’s assertion that the program is broken.

Medicaid participants may have difficulties finding a doctor who accepts their insurance, and before the state explores expansion, it needs to fix access to care by expanding the number of providers who accept the safety-net insurance, said David Balat, a health policy expert at the conservative Texas Public Policy Foundation.

“Why put more people on a system that is already strained?” he said.

Instead, Balat said, the state should renew its eligibility for a federal program that provides $25 billion over four years to improve Texas’ safety-net health care programs and hospitals. The program is set to expire next year.

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Extending it by just one year means $3 billion in funding that can be used to develop COVID-19 care programs at hospitals.

Turning point

The virus has sickened more than 1,000 people in the greater Houston area. Economic fallout has caused hundreds of thousands of Texans to file for unemployment. And the complications that come with testing, paying for care and hospitals’ ability to care for COVID-19 patients are illustrating the shortfalls of a system not well-equipped to deal with a pandemic.

An expansion, if the state opts for one, could be done quickly as long as the state does not impose additional work requirements or other conditions, Episcopal Health Foundation’s Marks said.

But some advocates, like Marks, are optimistic this could be the turning point to improve health care in Texas.

“What COVID-19 is doing is bringing attention to the importance of access to affordable preventive and sick care,” Marks said.

gwendolyn.wu@chron.com

twitter.com/gwendolynawu

Texas has the highest share of uninsured residents of any state, with nearly 18% of people lacking health coverage, and many are unable to take paid sick leave from work. Experts say that makes it harder to contain an outbreak.

BY EDGAR WALTERS, MARCH 10, 202012 AM

For Christian Gutierrez, preparing for a coronavirus outbreak is as much a financial consideration as it is a health one.

At what point should the Houston-area Latin dance instructor cancel his classes and forego his bread-and-butter income? If he feels sick with flu-like symptoms, should he take the over-the-counter cough medicine he’s stocked up on, or should he pay out of pocket to see a doctor about COVID-19 testing?

Gutierrez, 40, is one of roughly 5 million Texans who don’t have health insurance. Texas has the highest share of uninsured residents of any state, with nearly 18% of people lacking health coverage, according to the U.S. Census Bureau.

“People, sometimes, when they cannot afford health care or access to health care, they most likely are wanting to treat themselves at home or not go see the doctor because of the cost itself,” Gutierrez said. “You’ve still got to pay the mortgage, you’ve still got to pay the car bill and all the other things just associated with living.”

Public health experts say the state’s uniquely large uninsured population is complicating efforts to contain the disease because financial constraints could prevent millions of people from seeing doctors to get tested or treated — or could make it difficult for them to stay home from work even if they feel ill.

With the number of known cases of coronavirus infection in the U.S. surpassing 500 this weekend, a growing chorus of experts is warning about the vulnerability of millions of Americans who lack health care and are unable to take paid sick time off of work. Texas, where Republican leaders have for years opposed expanding state-funded health insurance coverage to the poor, is home to a disproportionate share of them.

“One of the greatest challenges ahead is to make sure that the burdens of COVID-19, and our response measures, do not fall unfairly on people in society who are vulnerable because of their economic, social, or health status,” nearly 800 scientists, doctors and lawyers recently wrote in an open letter to the Trump administration.

It is “critical for policymakers to ensure comprehensive and affordable access to testing, including for the uninsured,” the experts wrote. “Control efforts will be less effective if some fail to seek appropriate diagnosis or care due to large out-of-pocket costs or copays.”

That complicates public officials’ and health care workers’ ability to respond to an infectious disease epidemic in several ways. Most immediately, people without health insurance appear less likely to get tested.

“As the coronavirus spreads, health coverage, access, and affordability issues are going to become more pronounced,” Larry Levitt, the Kaiser Family Foundation’s executive vice president for health policy, wrote Saturday.

“How do people who are uninsured or underinsured afford not only testing, but treatment too?” he wrote. “It will expose the inadequacies and inequalities in our health system.”

Testing capacity limited in Texas

Ten public health labs in Texas are operational or soon coming online to test nose and throat swabs for the presence of genetic material from the new strain of the coronavirus, known as SARS-CoV-2. (COVID-19 is the disease caused by the virus.) The U.S. Centers for Disease Control and Prevention has said that anyone can receive a test for the virus as long as a doctor agrees.

A problem for Texas, experts said, is that a significant portion of its massive uninsured population likely does not have a primary care doctor to make that call.

And the state’s testing capacity is limited. Texas officials said last week that the largest public health lab could handle a maximum of 26 tests per day. Federal guidance recommended that doctors “use their judgment” when deciding if a patient merits testing and said they should consider symptoms as well as travel history and the possibility of close contact with people who tested positive for the coronavirus disease.

In San Antonio, where hundreds of cruise ship passengers and other travelers have been sent for quarantine at Lackland Air Force Base, Mayor Ron Nirenberg said this week that his city “needs a heck of a lot more testing, and we’re requesting that ASAP.”

Vice President Mike Pence, picked by President Donald Trump to lead the federal government’s response to the disease, has said it will be “weeks” before testing becomes widely available to the public, as it is in other affected countries such as South Korea.

Insufficient testing — particularly among uninsured Texans — could hamper the government’s understanding of the scope of an outbreak.

“Any social, political, health-related pressure that makes people less likely to talk to people in charge about the fact that they might be infected significantly reduces the effectiveness and efficiency of an outbreak investigation,” said Dennis Perrotta, a former Texas state epidemiologist.

And then there are challenges for public health officials working to contain the spread of the virus, especially when it comes to convincing people to stay home if they’re possibly infected with the virus. State leaders have said there is not yet evidence of person-to-person COVID-19 spread within Texas but that it is likely to happen in the coming weeks.

“Can they afford to lose five days at work, or do they just not tell anybody about it and hope that they’re not sick? That’s an integral part and a bad part of what we face in outbreak investigations,” Perrotta said.

Rodney Rohde, an infectious disease expert at Texas State University, said that the strategy of infectious disease containment can only be effective at the beginning of an outbreak. “If you don’t get it done in the first 30 days or less, you’re just not going to contain it,” he said. “This is not abnormal. This is what [viruses] do.”

Another challenge, according to health care workers, is that people without health insurance are more likely to get medical care in the emergency room. Public health experts expect that, in the event of widespread outbreak, the nation’s emergency hospital care system will be spread extremely thin, as has happened in Wuhan, China.

And if significant numbers of health care workers fall ill, it will tax emergency department resources even further. An early study of Chinese data found that roughly 4% of coronavirus cases occurred in health care workers, with 15% of those infected workers having cases classified as “severe or critical,” including five deaths.

Asked last week what steps uninsured people should take to confront the coronavirus, Texas Department of State Health Services Commissioner John Hellerstedt said they should avoid going to the emergency room for non-urgent care and encouraged them to call a help line to find nearby free or reduced-cost clinics.

“If you’re not clinically ill, there ought to be ways to arrange in advance to get people seen at a variety of resources that exist all over the state,” he said.

Patrik Hornak, a resident in internal medicine at the University of Texas Medical Branch who signed on to the expert letter to the Trump administration, said he’s worried that financial pressures on low-income, uninsured patients may keep them from seeking health care or self-isolating if they become contagious.

“Those are patients that are likely to have a lower-paying job and might have other economic stressors at home, they have kids they need to get food on the table for,” he said. “Imagine somebody who’s working at a drive-through window at a fast food restaurant and they come down with coronavirus, they’re coming in contact with 1,000 people a day.”

Gutierrez considers himself lucky; he has some savings he can dip into if he has to briefly shut down his small business. “But for me it’s of course scary because I don’t want to be in a situation where I’m infected and I have to really deal with it,” he said. “In the worst-case scenario, I’ll have to go to the hospital no matter what the cost is.”

Who pays?

As of Monday, 13 people in the general Texas population had tested positive for the virus. An additional 11 people repatriated from overseas were quarantined at Lackland Air Force Base in San Antonio and tested positive. Texas health officials have urged people so far to take individual preventive measures such as hand-washing, covering coughs and sneezes, and staying home when sick. Government-imposed quarantines and other interventions have been limited so far.

But experts say the number of cases will likely grow exponentially as community transmission becomes a reality in wide swaths of the country.

“As the trajectory of the outbreak continues, many people in the U.S. will, at some point in time, either this year or next, be exposed to this virus, and there’s a good chance many will become sick,” Nancy Messonier, a respiratory disease expert for the U.S. Centers for Disease Control and Prevention, told reporters Monday. “But again, based on what we know about this virus, we do not expect most people to develop serious illness.”

Hornak said he’d like to see the state take a more aggressive approach to make flu vaccines and tests widely available. It’s peak flu season, and both COVID-19 and seasonal flu are respiratory illnesses that present similarly and strain hospital capacity, he said.

“A lot of flu patients end up in the ICU,” he said. “If ICU beds are going to be at a premium, and ventilators and staffing, the more that we can do to keep other preventable diseases at bay I think is a really wise strategy.”

That presents another important consideration for policymakers: Who pays when uninsured patients need emergency coronavirus treatment?

The Wall Street Journal, citing an anonymous official, reported last week that the Trump administration is considering using a national disaster program to pay doctors and hospitals for their care of uninsured patients with COVID-19. The payments would be at 110% of the rate that Medicare pays.

“We are going to look at the uninsured because they have a big problem,” Trump said last week.

Texas hospitals say they’re still waiting on specifics but are bracing for “one of the heaviest lifts of our time,” a trade association spokeswoman said.

“We want to give people the peace of mind that we’re here for all Texans, but this is going to require an incredible amount of resources,” said Carrie Williams, a Texas Hospital Association spokeswoman. “With the uninsured, the tone from the federal government seems to be that these costs will be covered, but it’s unclear exactly how that’s going to work, and we’re encouraging hospitals to closely track their COVID-19 costs.”

U.S. lawmakers passed an $8 billion emergency funding package to help pay for vaccine development, among other priorities, but it did not appear to specifically address hospital payments.

Dana Hendrick of Colorado City in West Texas became uninsured after she retired from her job at a nearby prison. She said she is unable to afford routine medical care and does not know what she would do if she contracted the virus.

“I have a barely livable retirement wage,” she said. “It’s just not nearly enough to pay for decent insurance coverage.”

Her parents, who live nearby, are in their 80s — Hendrick, 58, said her mother “falls a lot” — and they depend on her for regular help. She’s worried about what would happen to them if she needed to self-quarantine.

“I don’t know that we’re handling it as a country as effectively as we should be,” she said.

Disclosure: Texas State University, the University of Texas Medical Branch at Galveston and the Texas Hospital Association have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.