Laci Crosson’s son doesn’t have pills to manage his attention deficit disorder.

Betty Canales is worried about how she’ll pay for her diabetes medication.

Stevie Smith saw a doctor after she was furloughed — and paid more than double her usual price.

With the U.S. economy flailing as the country contends with the coronavirus pandemic, more than 1 million Texans have likely suffered the double whammy of losing their jobs and their employer-based health insurance. Some have landed in the state’s patchy health care safety net, where advocates say they could be cut off from physical and mental health services while facing the economic strain of a public health crisis.

Researchers estimate that between 25 million and 43 million people in the U.S. will lose health insurance through their employers in the coming months if the unemployment rate grows to 20%. It’s already near 15%, a record high since the Great Depression.

The situation is particularly dire in Texas, where state officials have restricted access to publicly funded health insurance programs for the poor and have led the charge to toss the Affordable Care Act in court.

Already home to more than 5 million uninsured residents — or about 18% of its population, the highest uninsured rate of any state — Texas is in the minority of states that have declined to expand Medicaid coverage to people with incomes near or below the poverty line.

The result: Of 1.6 million Texans who have likely lost employer-sponsored health insurance during the pandemic, 30,000 would be eligible for Medicaid if the state expanded the program, according to recent estimates from the Kaiser Family Foundation.

Instead, they’re uninsured, and many more are expected to join them.

Texas’ approach stands in contrast to the 36 states that have expanded Medicaid to cover adults who earn less than 138% of the poverty line, about $36,000 a year for a family of four.

More than half of the newly uninsured residents in those states will qualify for Medicaid, leaving less than one quarter of unemployed workers without insurance, according to projections from the Urban Institute.

In Texas and the other states that rejected Medicaid expansion, one-third of the newly jobless are estimated to get Medicaid, with 40% becoming uninsured.

Among the affected is Crosson, 35, a stay-at-home mom whose husband was laid off in March from his job as a heavy equipment mechanic.

Crosson hustled to get her two youngest children enrolled in Medicaid. But for the adults, including her eldest son, who has ADHD and takes Adderall, there was nothing, said Crosson, who moved to Fort Worth last fall.

Her son’s been without his medication.

Crosson herself recently had a medical emergency, coming down with a bad bout of pneumonia just weeks after her husband was laid off. Bedridden for days, and with her husband worried she had the coronavirus, Crosson went to the hospital and was quickly asked, “Do you have health insurance?”

She received a flu test, strep test, chest X-ray, electrocardiogram and a bill she fears she won’t be able to pay. The family’s already lost a storage unit because they couldn’t afford the payments, and they are downsizing to a smaller house.

Her husband seemed depressed at first. “I can't blame him. I was like that for a little while myself,” Crosson said.

A lack of options

There are few choices for adults who lose their job-based health insurance.

They can pay the full premium, an expensive option called COBRA that temporarily extends their coverage. The average annual cost is about $7,200 for a single person or $21,000 for a family of four, according to the Kaiser Family Foundation.

If their annual income is above the poverty line — about $26,000 for a family of four — they can purchase a plan on the Affordable Care Act’s health insurance marketplace, which offers a subsidy to offset some of the cost.

And in limited circumstances in Texas, there’s Medicaid.

Texas has the strictest Medicaid eligibility in the country, and adults are unlikely to qualify for the public insurance program unless they are pregnant or have a disability that keeps them from working. A single parent with two kids could not make more than $300 or so a month.

The restrictive criteria have left a gaping health insurance hole for people who aren’t poor enough to qualify for Medicaid but make too little to get subsidies in the federal marketplace.

Before the pandemic, about 761,000 Texans, many of them working, fell into this coverage gap. Another 382,000 could soon join their ranks because of soaring unemployment, according to estimates from the Kaiser Family Foundation.

The impact may not be felt fully for months, when the unemployment benefits that have buoyed Texans’ incomes — in some cases allowing them to get subsidies in the marketplace — expire this year.

But already, health centers have reported hearing more and more from people asking what to do if they’ve lost their job and benefits.

At People’s Community Clinic, which treats underserved and uninsured Central Texans, there’s been an influx of calls from established patients who say they’ve lost insurance and want to talk to a financial counselor, said Chief Executive Officer Regina Rogoff.

“I think we’re beginning to capture the beginning of this unemployment wave,” said Rhonda Mundhenk, chief executive officer of Lone Star Circle of Care, which has clinics in Central Texas and Houston. “We have always existed to catch folks who fall into the uninsured category. But the scale of what the entire nation is experiencing now is what is radically different and requires different solutions, particularly if the economy doesn’t recover quickly.”

Lone Star clinics offer financial screenings to see if patients qualify for federal, state or county health programs — including one in Travis County for low-income residents. Not everyone will be eligible.

Among the newly uninsured is Canales, 52, who hasn’t had coverage since she was laid off from her job as a receptionist for a large Dallas-area restaurant company in late April. She and her partner have an 18-year-old daughter who can likely be covered by Medicaid until her 19th birthday, but Canales has not found an affordable source of coverage for herself.

She is diabetic and typically visits the doctor every three months to get bloodwork and prescriptions for the six medications she takes for various conditions: blood pressure, diabetes, cholesterol, neuropathy.

The diabetes medications alone cost more than $1,000 for a 90-day prescription, an out-of-pocket cost Canales said she can’t afford.

Her medicine cabinet is stocked for about a month.

“I worry, because where am I going to get the money to get my medicine?” she said. “People like me, [who] work and lose what they had, we need something to be able to fall back on until we can get back on our feet and regain everything.”

Effect on mental health services

Mental health professionals and advocates worry the loss of insurance will further hurt Texans already grappling with depleted incomes, home schooling and other demands brought on by the pandemic.

The cost to buy treatments and services out of pocket can be prohibitively expensive without insurance — and losing access to that medical care can be devastating, said Greg Hansch, executive director of the National Alliance on Mental Illness Texas.

Hansch spoke with one man who has a schizoaffective disorder, was furloughed and might not be able to afford a medication, Latuda, which can cost upwards of $1,300 for 30 tablets.

He “expressed extreme distress, frustration and worry. The medication that he was receiving through his health insurance plan is fundamental for his recovery,” Hansch said. “All of a sudden, the rug is swept out from under his feet, and he's not just worried about his quality of life. He's worried about his life itself — it’s a matter of life and death for him.”

Hansch is trying to help him find prescription assistance programs.

The man, a Pflugerville resident, said he has enrolled in an insurance plan on the federal marketplace that kicks in next month. In the meantime, he worries he’ll end up in a psychiatric ward. He’s already called several in Austin to see what precautions they’re taking to prevent the spread of COVID-19.

The rising unemployment rate and loss of job-based insurance could also deter Texans from seeking mental health services like therapy or counseling, said Alison Mohr Boleware, government relations director for the Texas chapter of the National Association of Social Workers.

“When people lose jobs or part of their household income, mental health treatment can be seen as a luxury that ‘can wait,’” she said.

There are free counseling services available, including through employers.

Some newly uninsured people have paid out of pocket for medical care they don’t want to postpone.

Smith, for example, spent $73.50 for a telehealth visit to keep a prescription filled, well above the price she paid while insured.

Before the pandemic, she worked in two bars and a coffee shop. When she was furloughed in March, one of her bosses gave her paperwork to help her enroll in a new health plan. But when Smith saw the options would cost between $174 and $250 a month, she thought, “I can’t pay that,” and declined.

She quickly applied for unemployment, food stamps and Medicaid, listing her income as $0. She was rejected for Medicaid.

“The fact that the better plans are only available through work, but then they’re precarious because of that, doesn’t make any sense,” Smith said.

Medicaid expansion

Texans who’ve lost health insurance this year have fewer options than their neighbors in states like Louisiana and New Mexico, said Anne Dunkelberg, a health policy expert for the left-leaning Center for Public Policy Priorities.

“Essentially everyone in the health care world sees [Medicaid expansion] as essential for a million reasons,” she said.

For adults covered by the expanded program authorized under former President Barack Obama’s signature health law, the federal government pays 90% of costs. In Texas, the federal government pays about 60% of the costs of the more limited program, which mainly covers low-income children, pregnant women and adults with disabilities.

Supporters of expanding Medicaid say the state’s share of the program would pay for itself by creating new health care jobs, boosting tax collections and reducing state spending on other safety-net health programs that many uninsured Texans rely on. And many counties in Texas already raise property taxes to fund health programs for the poor and uninsured.

But Medicaid expansion has been a tough sell for Texas Republicans since 2012, when the U.S. Supreme Court ruled that the federal government could not require states to opt into the program. With the pandemic tanking Texas sales tax collections, the state’s conservative leadership may be even less keen to spend new funds to cover 10% of the program’s costs.

Abbott has mostly remained mum on the subject since the virus reached Texas this spring. A spokesman for the governor did not respond to emailed questions for this story.

A porous safety net

Even Texans who should have qualified for Medicaid have struggled to get coverage and are buckling under the added strain of the pandemic.

Deborah Durst, a single mom with two daughters, one with a heart defect, has been out of work since September. Her unemployment benefits ran out in February. Although she was able to get both her children on Medicaid, her application for the same program has been held up for months. In the meantime, she’s struggled to find work, homeschool her kids and navigate the state’s meager safety net.

The stress began to affect her health, Durst feared. She paid out of pocket to see a cardiologist in March after she began convulsing one night, feeling tingling in her extremities and having heart palpitations.

“It’s on top of looking for work, on top of dealing with medical issues or trying to deal with insurance, on top of dealing with unemployment. It’s on top of dealing with this virus — it's so many stress factors, all at once,” Durst said. “That's what I think caused me to have a heart issue … and being a single mom being on my own. There's no partner; there's no break.”

How to get help

Disaster Distress Helpline: Call 800-985-5990, text "TalkWithUs" to 66749, or visit disasterdistress.samhsa.gov or facebook.com/distresshelpline

National Suicide Prevention Lifeline: 800-273-8255

Texas COVID-19 Mental Health Support Line: 833-986-1919

This story was produced in part with funding from the Ravitch Fiscal Reporting Program at the Newmark Graduate School of Journalism and is part of a national project on how adequate state safety nets are for the pandemic recession.

Disclosure: The Center for Public Policy Priorities has been a financial supporter 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.