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When Susan Peake moved to Austin from Denver in 2018, she traded one kind of safety net for another.

In Colorado, she’d received state-funded health insurance coverage, which she credits with saving her from financial ruin after she suffered a heart attack requiring double-bypass surgery. In Texas, though she did not qualify for free health insurance, she had a room at her sister’s house, where she hoped to save some money while she recovered.

But after a disagreement with her brother-in-law, things spiraled out of control for Peake, 52. She moved out of her sister’s house, she said, and began staying on friends’ couches. Before long, she was camping in parks and sleeping on bus stop benches.

Now Peake lives at Gov. Greg Abbott’s temporary campsite for people experiencing homelessness, in a tent pitched on an unmarked patch of asphalt between parking spots 61 and 62 at a state-owned lot.

“I feel safe out here,” she said on a recent cloudless day. But losing out on health insurance coverage under Medicaid was “a big challenge” for Peake, who said she takes medication for bipolar disorder, post-traumatic stress disorder and anxiety, in addition to problems associated with her heart and gastrointestinal tract. Often, while camping, “I didn’t take as much medicine to try to make it last longer,” she said.

Peake’s experience illuminates the challenges of finding health care for the homeless in Texas, which is among the least generous states when it comes to offering publicly funded health coverage to the poor.

For years, Abbott has opposed expanding Texas Medicaid, the state-federal insurance program, to cover poor adults as most other states do. But President Donald Trump’s administration recently announced that states with expanded coverage will have greater flexibility to cut costs in Medicaid, an idea long championed by Republicans. A spokesman for the governor said this week that Abbott is exploring options with the federal government.

Since Austin’s City Council relaxed ordinances last year that prohibited lying and camping in public areas, Abbott has hurled criticism at city leaders for promoting “lawlessness.” On Twitter this month, Abbott said fixing homelessness was “easy” and involved, among other interventions, providing mental health and drug addiction help.

Advocates for the poor were quick to point out that Medicaid could help pay for those services for nearly a million Texans, including many experiencing homelessness.

The dispute over who should receive Medicaid coverage is more than a decade in the making. When a Democrat-controlled Congress passed the Affordable Care Act in 2010, then-President Barack Obama’s signature law sought to extend insurance coverage options to a majority of Americans.

The middle class could purchase private health insurance plans on an online marketplace and receive federal tax credits to offset some of the cost. And the poor — defined as anyone who earns less than 138% of the federal poverty level, or about $25,750 for a family of four — would receive free coverage under Medicaid, the joint state-federal insurance program.

But in 2012, the U.S. Supreme Court ruled that the federal government could not force states to expand their Medicaid programs to cover the poor, though states could opt into it.

In the years since, 36 states and Washington, D.C., have expanded Medicaid to cover the poor, but Texas, which has the highest number of uninsured residents in the country, is not among them. The result is what advocates call a “coverage gap” — a single mother earning minimum wage may be too poor to qualify for an Affordable Care Act tax credit, for example, but if she is not pregnant or does not have a disability, she likely earns too much to qualify for Medicaid under Texas’ strict eligibility criteria.

Childless adults who do not have a disability generally cannot qualify, and parents in a family with two children must earn less than $400 per month, according to the left-leaning Center for Public Policy Priorities.

“Very few adults in Texas can get disability-related Medicaid, so you have to either be diagnosed as being within 12 months of death, or you have to be completely unable to work,” said Anne Dunkelberg, a health policy expert for the think tank. “As a result, there are hundreds of thousands of Texas adults who have mental health diagnoses and are struggling to get the care they need.”

Abbott has vehemently opposed expansion, calling Medicaid a bloated government program and arguing that states should have more say over how to cap its spending. Last month, in a major policy shift, the Trump administration appeared to agree. Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, told states that had expanded Medicaid they would have more flexibility to cut costs and reduce health benefits under a block grant system that would apply only to poor adults covered under Medicaid expansion.

A spokesman for the governor this week did not rule out the idea of a coverage expansion under a block grant, saying that Abbott is discussing options with the federal government.

“Governor Abbott has long advocated for Medicaid block grants and is exploring grant options with the Trump administration,” John Wittman, the spokesman, said in an email. “He has also followed through on his commitment to help the homeless in Austin.”

Wittman noted that state lawmakers included $382 million in the two-year budget passed in 2019 for local mental health providers who care for poor Texans.

“Texas will continue in its efforts to provide for the mental and behavioral health of the homeless,” he said.

Roughly 1.5 million Texans would immediately qualify for Medicaid if the state expanded coverage, according to the Kaiser Family Foundation. A report published by the U.S. Department of Health and Human Services in 2016 estimated there were more than 400,000 uninsured Texans in the Medicaid gap who had mental illnesses or substance use disorders.

Advocates say most uninsured adults in the Texas coverage gap have stable housing and jobs in industries that don’t offer benefits: retail, food service, construction. But a significant portion of the homeless population would also be eligible for coverage under a Medicaid expansion, including a large share of people with complex health problems.

A 2019 survey estimated there were more than 25,000 homeless Texans, including 2,255 in the Austin area. In the Austin survey, 594 reported severe mental illness, 376 reported chronic substance use, and 45 said they had HIV or AIDS.

“We could have better health care”

Abbott’s campsite abuts a highway in Southeast Austin, far from amenities. A nearby bus stop with infrequent service is the only connection to the city for Peake, who does not own a car. She qualifies for locally funded health care programs and free clinics, which have helped her pay for some dental work and physical therapy. But traveling to her appointments can last up to four hours round trip.

In Colorado, Peake’s health insurance covered far more comprehensive benefits, including a program that provides transportation for low-income people to their medical appointments. “I miss having transportation,” she said.

A 30-year-old woman at the campsite who identified herself only as Mouse said she was familiar with the Medicaid gap. She had state-funded coverage in 2018 when she was pregnant with her son. At the time, she said, she spent some nights couch surfing and other nights camping on sidewalks near the University of Texas campus.

Medicaid paid for her to receive prenatal care, and it covered a host of other benefits that she lost access to after the birth of her son, who she said is living with her husband’s family in San Antonio. Pregnancy-related Medicaid coverage in Texas expires for mothers two months after birth.

Mouse’s most immediate health need, she said, is glasses. But even after a friend gave her a gift card, she’s working to come up with the remaining $43 she needs to cover the cost of frames.

“We could have better health care, like Medicaid,” she said in an interview at the campsite this week. She was using a cane, which she’d borrowed from a friend at the campsite for what she believed was a sprained ankle.

Choosing health care or lunch

Without insurance coverage, a person experiencing homelessness is most likely to access health care in a hospital emergency room or in jail, said Will Francis, executive director of the Texas chapter of the National Association of Social Workers.

“The guy on the street who’s 35 and sleeping in a tent is probably not likely to get care until some type of emergency happens,” he said.

In 2016, the Austin-based Ending Community Homelessness Coalition studied the 250 most “expensive” utilizers of emergency health care in the Austin area and found that each person racked up an average annual cost to taxpayers of $222,603.

The bulk of those costs were related to health care. On average, each person visited the emergency room 22 times, spent 37 days in inpatient hospital beds and was transported by EMS teams nine times in a year.

Matt Mollica, the group’s executive director, said people experiencing homelessness are focused on basic needs ahead of health care.

“Do I go down to this lunch at Caritas, or do I go get this wound looked at at CommUnityCare? A lot of times it’s lunch,” he said.

For that reason, Darilynn Cardona-Beiler advocates a housing-first approach to help the homeless. The idea goes that people have a much better chance of improving their health if they have a stable place to live.

Cardona-Beiler is the director of adult behavioral health systems for Integral Care, the local mental health authority in Austin, which recently built 50 apartments for people experiencing homelessness. The building features an on-site clinic and has 24-hour staff.

“If they don’t have a place to go after they get care, you’re spinning a wheel,” Cardona-Beiler said. She praised Texas lawmakers for increasing state funding for mental health care in recent years.

Integral Care also employs a specialized team to help homeless people determine if they qualify for publicly funded benefits like Medicaid and Social Security.

Having insurance is one of the best indicators that a person will be able to access care. Studies show that adult Texans who have health insurance are up to 50% more likely to receive treatment for mental illness or substance abuse than their uninsured peers.

And some states are exploring agreements with federal health officials to spend Medicaid funds on helping the homeless and people at risk of being homeless pay for housing. North Carolina received permission from the Trump administration to spend up to $650 million to help Medicaid enrollees with housing, food and transportation through 2024.

Poll results published this week by the Houston-based Episcopal Health Foundation found that roughly 4 in 10 Texans report difficulty finding affordable housing. Of those, 46% said the challenges they faced finding housing damaged their health.

Low-income, uninsured Texans may qualify for services from county health providers and local mental health authorities, but the options vary greatly across the state. In Austin, a local health care district collects property taxes to fund health care for the uninsured, including free or reduced-cost clinics and a quasi-insurance program with limited benefits.

“If I am uninsured, my access to care is going to be totally dependent on where I live in Texas,” Dunkelberg, of the Center for Public Policy Priorities, said.

At the homeless camp, Peake invited Abbott to visit to better understand its residents’ health needs.

“I would like for the governor to be camped here for one night and see how he likes it and see what issues he may or may not face,” she said. “At least one night.”

Correction: A previous version of this story incorrectly reported a Kaiser Family Foundation estimate of the number of uninsured Texans who could receive coverage under a Medicaid expansion.

Disclosure: The Center for Public Policy Priorities, the University of Texas at Austin and the Episcopal Health Foundation 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.