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.

Thats 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.

Its a complicated decision that can be expensive, and unemployed Texans have a weak record of enrolling in such backup plans. Thats 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.

Its devastating for the families that wont 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.

Its also devastating for health providers, she said. Their patient volumes have declined sharply amid coronavirus fears, and theyve 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.

Its 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? Its 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 Institutes Health Policy Center.

Texas lags in another metric: Just 23% of those eligible for a marketplace plan enrolled in an ACA option. Thats lower than in the U.S. (32%) and far lower than in Florida (47%) even though Florida has a Republican governor and hasnt expanded Medicaid, either.

In Texas, maybe theres 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 thats 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. Theyre 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 whats considered normal and whos considered to be deserving, Hempstead said. This experience could normalize other kinds of health coverage. Theres 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 theres a federal tool we can use, we ought to figure out how to access it.

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The pandemic's next blow: Over 1 million Texans will lose health insurance - The Dallas Morning News