No job. No insurance. No chance at 'Obamacare.' No safety net in Texas. Welcome to Cuero

CUERO - Today there are 24 pills left, little pink triangles tucked into paper wrappers, the only thing that blunts the pain when one of Tyra Franklin's migraines hits.

The doctor said take as needed. Lately she's been needing them a lot.

"With the stress of not having a job, they won't last too long," the newly unemployed 40-year-old single mother said of her prescription for Imitrex.

Eight pills cost $180, an impossibility without insurance. And that's where she is, without insurance.

Six years after President Barack Obama's health care law passed with its sweeping mandate for nearly universal coverage, Texas still leads the nation in the number of uninsured. More than 4.5 million Texans are without coverage, without consistent medical care.

The story of the uninsured is told in political ideology and unmet promises - unfolding still, one town, one family, at a time.

More than three-quarters of a million Texans now have no realistic entry to health insurance because of the state's vow not to expand Medicaid. One of the basic pillars of the Affordable Care Act, also known as Obamacare, was that states expand Medicaid programs to scoop up the poor and near-poor and guarantee the access to care. Texas said no.

Those left behind are hard-pressed to find relief in the state's existing system.

Texas is tied with Alabama as having the toughest threshold in the nation for parents to qualify for Medicaid. They can earn no more than 18 percent of the federal poverty level, which means a family of three cannot make more than $3,628 per year. Childless adults in the state do not qualify at all, according to an analysis by the Kaiser Family Foundation.

The problem deepened when a troubling gap in the law was exposed. Under the ACA, Medicaid would take care of lower-income people while those with more means, including the middle class, would benefit from federal subsidies to lower premiums. But the subsidies come with a minimum income requirement and no bridge to help anyone stuck in between.

There are 766,000 Texans, the most in any state in the country, making too much money to qualify for Medicaid but not enough to get a subsidy that would make the price of plans on the federal exchange practical, Kaiser said. So they do without.

"So many people are just one accident or bad thing away from being there," said Tiffany Hogue, policy director for Texas Organizing Project, an advocacy group for the state's poor.

It happened in Cuero.

In June, Mount Vernon Mills, a collection of aging metal buildings near the center of town, closed its doors for good after offering a century of employment to the town of 6,000.

Two hundred seventy-five people, including Franklin, lost their jobs in one day, sending a second shudder through this land of hot sun and wind perched atop an oil patch. During the boom, some left the mill for more lucrative jobs in the Eagle Ford shale fields only to return when they lost those jobs in the crash of crude prices. Mill workers talk of working elbow to elbow with friends, parents, grandparents, cousins, aunts and uncles.

When their $10- and $12-per-hour shift jobs disappeared in an unexpected poof, so, too, did their company-sponsored health plans.

So they roll the dice, ignore their ailments and hope to find work somewhere, someday that gives them benefits again.

On a recent Wednesday, Franklin sat inside the Dairy Queen at 10 a.m. wishing she was at work instead. She was just back from dropping off an application at the H-E-B grocery store. Next she'd try Wal-Mart. She tries not to think of all the others in town who have the same idea.

"I'm a true believer in God," she said, fiddling with her soft drink cup. "I'm living on prayer right now."

***

For 16 years, Franklin had clocked in at Mount Vernon Mills, working a 7  a.m.-to-3 p.m. shift, making $12.42 per hour. She bought a house through Habitat for Humanity a few years back and raised three kids, two still at home. She takes college classes 30 miles away in Victoria, dreaming of a degree in criminal justice. On a good year she made about $26,000, before taxes.

This is not a good year.

The mill had already reduced workers' hours to 32 per week as it struggled to remain open. The pay cut stung, but she loved the job that gave her health insurance and even an on-site clinic where employees could get treatment and prescriptions filled.

Franklin has now applied for unemployment. The best guess, without a new job, is her income for the year will slip to around $17,000.

Texas Medicaid said she makes too much money. Most of her last paycheck went to her $180 electric bill. She rushed to the dentist and the pharmacy before her insurance ran out.

She is now one of the Texas uninsured.

She knows virtually nothing about the ACA.

"I think my sister tried that," she said, struggling to place the law.

Katrice Jackson, her sister, logged on to the healthcare.gov website but abandoned it after becoming confused by the maze of questions: "I just don't understand the plans."

Jackson works on call for $10 per hour at a motel laundry, but since the oil workers left, there haven't been many calls. She, too, has no insurance.

Both women dwell in the Texas coverage gap. If Franklin made $20,000, she probably would qualify for a subsidy so she could buy a silver plan on the federal exchange. The premiums after subsidy would be between $18 and $50 a month. But since she doesn't, she would pay about $265 per month out of pocket, according to a calculation on healthcare.gov.

Next year it could be even more out of reach. Cuero is in DeWitt County, one of 58 counties in the state with only one insurance company offering plans on the exchange, the Center for Public Policy Priorities said. The insurer, Blue Cross and Blue Shield of Texas, has asked for a 60 percent rate increase for some of its 2017 exchange plans, which could raise her cost to $424 a month.

"People are going to leave town," Franklin said. "They don't have a choice.

***

At a recent emergency community gathering in Cuero, there were information tables about food pantries and help to keep the lights on but nothing about getting health insurance.

"To the best of my knowledge, there has been no education about the ACA here," said Patrick J. Kennedy, executive director of Cuero Development Corp.

When the ACA arrived in the state, Republican leaders pulled the welcome mat, calling it both unneeded and, more pointedly, a federal intrusion in Lone Star sovereignty.

In 2012, the U.S. Supreme Court ruled that states had the right to choose if they wanted to expand Medicaid. First, former Gov. Rick Perry and now Gov. Greg Abbott steadfastly said they do not.

"Thank God and our nation's founders that we have the right to do so," Perry wrote in a blistering letter to the U.S. Department of Health and Human Services about his refusal to expand Medicaid or to set up a state exchange to access ACA insurance plans.

Texas is one of 19 states that have not expanded Medicaid despite assurances that the federal government would pay all or most of the cost. By some estimates, Texas has left $100 billion in federal money on the table over the next decade by its decision.

The law's advocates are quick to accuse Republicans of neglect, but those same advocates often are missing from small-town Texas, where the need is great and the awareness of the law's possibilities are all but nonexistent. Despite a mission to educate and enroll, the nonprofit and community groups who fan out during enrollment season complain of a lack state backing, tight budgets and the difficult logistics of reaching remote areas. It is easier to sign up people in the big cities, they said.

While the state's leadership has made no secret of its disdain of the ACA, it has been less vocal on how to help the uninsured.

Previously, Abbott has said Medicaid is undeserving of expansion. His office declined to comment for this story.

Perry, during his 2012 bid for the White House, said the government should have a limited role in providing health insurance, a stance applauded by small-government forces. Since hospital emergency rooms are required by law to treat all patients regardless of ability to pay, the poor and uninsured could go there for medical care, he said.

This brought howls of protest from many in the medical community who argued that hospital emergency room care is many times more expensive, and costs fall back on hospitals and taxpayers if the bills go unpaid. Texas hospitals were stuck with $6.4 billion in unreimbursed care in 2014, the last year figures were available, according to the Texas Hospital Association.

In January, the number of Cuero patients receiving indigent care at its 42-bed community hospital was 80. In July there were 156, hospital officials said.

Over at LifeWay Baptist Church, Glenn Moore, the affable Republican pastor in a Motley Crue T-shirt, preaches inclusiveness. He is disgusted by the politics swallowing health insurance. One side wants the law to fail, the other won't address its problems.

"The left wing and the right wing are attached to the same bird," he said. "But these days we see everything through the political lens and how it will benefit your side."

***

The morning of April  13, Rebecca Johnson felt a wave of happiness as she sat at her desk at Mount Vernon Mills. She was in charge of sending out employee announcements and was told there was news.

Johnson was sure the company was bumping workers back to 40 hours. She composed a message. Then her supervisor tapped her on the shoulder and said to hold off sending it. Instead, her department was to meet in the conference room.

"I'm sorry to announce the plant will be closing," one of the managers began. As part of the human resources team, Johnson was hearing it first. Other employees would find out soon enough. She felt suddenly queasy.

"What am I going to do?" the single mom thought. "This is how I pay my bills. This is how I support my daughter."

Two months later, the factory, founded in 1903, was deserted. A chain-link fence surrounding the property was padlocked and a sign on the front door read: "No applications accepted." The building and its contents are for sale.

Now the ripples of unemployment flow through town for a second time.

Johnson's daughter, Te'Era, waited until her mom left the room before she spoke: "She doesn't like to seem sad in front of me, but I know she's stressed," the 14-year-old confessed. Nodding at the refrigerator plastered with schedules and calendars held by magnets, she said, "I think it's my fault because I'm in so much stuff."

Nonsense, her mother said, re-emerging from a bedroom, wearing a smile.

But in truth, the money is disappearing like vapor. In May, Te'Era was crowned Junior Miss Cuero. Most weekends are filled with trips to events in neighboring towns, often with required outfits. Then there are the sports teams. Family is helping as they can; so are pageant organizers and coaches. No one wants Te'Era to give up all she has achieved.

The teenager sees more than she lets on. What scares her most is her mother has no insurance. A year ago, Johnson, 37, found a mass on her neck, just below her ear. Tests at Houston's University of Texas MD Anderson Cancer Center were inconclusive.

"Sometimes it feels like it may be coming back because it hurts a little. But I just ignore it," Johnson said. She puts olive oil in her ear to dull the ache.

***

Not so long ago, townsfolk were complaining about traffic and the big 18-wheelers roaring through town. Back then, it was impossible to get a motel room, as they were booked months in advance for the energy workers flooding in during the boom on the shale.

The out-of-towners came with wads of money in their pockets, and the locals looked to the future. Long-delayed dreams to rebuild the schools went forward. The town of 6,000 made plans for six motels.

Then the price of oil plummeted. Then the mill closed.

DeWitt County is the second-largest oil producer in the state, but the workforce has been decimated. Industry figures show that at the beginning of 2015 there were 27 rigs, each with roughly 100 jobs attached. By the start of 2016 it had slipped to 13. Recently there were three.

Mount Vernon Mills was the third-largest employer in Cuero, behind the hospital and the school district. There is now talk of layoffs at the schools and a hiring freeze at City Hall.

Sales tax revenue in Cuero this summer was down 50 percent from 2015.

Judith Krupala, the nursing administrator at the hospital, also worked as a nurse practitioner at the mill's clinic taking care of employees. She thinks of them as family.

"The thing that breaks my heart is I go to H-E-B or Wal-Mart and people come up to me and ask me to fill their prescription," she said. "I tell them I can't do that anymore. And they say, 'But I really, really need my medicine.' "