Katonya Price, 26, couldn't buy health insurance at work even if she could afford it. As a contract employee at a building supply company, she is not eligible. So she tries to buy some peace of mind by constantly cleaning and dusting her Houston home to control germs and allergens.

Austinite Susan Hammack, 59, lost her state job in 2003 and didn't have health insurance when she needed surgery for breast cancer three years later. When she got insurance again, she was afraid to use it to pay for chemotherapy because she was worried she'd lose her job — and insurance — again if the drugs made her unable to work.

David Grose, 39, a Paris, Texas, welder, had a cancerous growth on his nose but couldn't get treatment without insurance. In desperation last fall, he took a bus 300 miles to one of the country's premier cancer centers in Houston, only to be turned away because he didn't have insurance.

These are just three of the 5.7 million people in Texas who did not have health insurance in 2006. Many Texans may know that their state has the nation's highest portion of residents without insurance, 25 percent, a figure that has remained constant for several years.

But the stories of Price, Hammack and Grose illustrate some common characteristics of the uninsured that might seem surprising:

Most are employed. Two-thirds of uninsured Texas adults younger than 65 have jobs, according to the U.S. Census Bureau.

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"It's not an issue of not working," said Anne Dunkelberg, associate director of the Center for Public Policy Priorities, which speaks for low- and middle-income Texans. "For many folks, it is simply just completely unaffordable."

Most are of working age. Thirty percent of Texans ages 19 to 64 have no insurance, compared with 3 percent of those 65 and older and 22 percent of children.

Most are U.S. citizens. Even if all noncitizens — legal and undocumented — were not considered at all, Texas would still have the country's highest portion of uninsured residents, 20 percent, Dunkelberg said.

Being uninsured is not a static condition. Texans cycle on and off insurance with changes in jobs, incomes and marital status. Insurance status varies not only within neighborhoods but within households.

Some people, for example, are covered by employers' plans but can't afford to add their children to the coverage. Others, like Price, go without insurance, while their children are covered by government programs.

"Without it," Price said of her family, "we're playing with fire."

Texans aren't alone in worrying about health care: It's one of Americans' top concern, polls indicate. Nationwide, 47 million people are without health insurance, according to the U.S. Census Bureau, up from 40 million in 2001.

"Increasingly, this is becoming a matter of self-interest, because they or a family member or a close friend has experienced (being uninsured); it may have been for a short period of time, but they've experienced it," said Ron Pollack, executive director of Families USA, a Washington-based nonprofit that advocates making high-quality, affordable health care available to all Americans. "This is not just about somebody else; this is now about me and my family, and that's changing some of the political dynamic."

Democratic presidential candidates mostly talk about insuring everyone; Republicans tend to talk about improving the current system.

Families USA attributes the growing number of uninsured Americans to rising health insurance premiums, changes in the labor market and underfunded government programs.

Several states are working to extend health care coverage to more people. Three states — Massachusetts, Maine and Vermont — have enacted universal coverage plans and 12 others — including California — are considering them, according to the Kaiser Commission on Medicaid and the Uninsured. Texas is not among them.

Why does Texas have a higher percentage of uninsured people than other states?

Workers here are less likely than those in other states to get insurance from their jobs, Dunkelberg said.

Compared with other states, Texas has a higher percentage of people who want full-time jobs but are working part time, a lower percentage of unionized workers and a lower share of manufacturing jobs, which makes workers in the Lone Star State less likely to have job-based coverage. That is according to federal labor, economics and census statistics cited in a report from the Center for Public Policy Priorities.

"Our employer-sponsored coverage has never been as broad as you find in other states because we have not just more small businesses but more people who work in small businesses," said Albert Hawkins, Texas' health and human services executive commissioner.

Another thing that sets Texas apart is the way it runs Medicaid, the federal-state health insurance program for low-income people.

"Historically, the Texas Medicaid program has focused on the poorest of the poor adults and poor children," Hawkins said. "For low-income adults, the principal strategy has been to provide health care, not coverage, through safety-net systems" including hospital emergency rooms.

But Texas is trying to shift resources away from emergency room visits and toward prevention. Hawkins has asked federal officials to approve a plan to redirect federal Medicaid dollars toward a pool to help low-income people pay for health insurance. He said he expects the plan to reduce the number of uninsured, but key details have to be worked out.

Mary Katherine Stout, vice president of the Texas Public Policy Foundation, said the national focus on the uninsured is misguided because insuring everyone wouldn't guarantee they'd get great health care. Instead, the debate should be about how to create a robust, competitive marketplace for health care and health insurance, said Stout, whose group supports limited government.

She said state and federal regulations should be scaled back to allow more choices and better quality.

"When you address those things, you take care of the uninsured," she said.

cmaclaggan@statesman.com; 445-3548

Additional material from staff writer Mary Ann Roser

By the numbers

47 million: About 16 percent of the population of the United States is uninsured.

5.7 million: About 25 percent of the population of Texas is uninsured, a higher percentage than any other state.

$11,500: Average annual health insurance premium cost for family coverage in Texas

KATONYA PRICE

Katonya Price, 26, works 8 to 5 Monday through Friday as an office manager for a building supply company. But because she's a contract worker, the job she's had for more than four years does not include health insurance. And she says she can't afford to buy any.

"The cost of health insurance these days is more than a person can actually make," said the mother of three. Price bought health insurance on the individual market two years ago but dropped it just a month later because of the expense: about $300 a month for her and currently unemployed fiancé Nick Williams, 27.

Price earns $16 an hour. But without benefits like sick days or maternity leave, she earned nothing when she took six weeks off after giving birth to son Corey last year.

Corey, now 5 months old, and son Cameron, 7, and daughter Kennedy, 2, are now covered under Medicaid. But for stretches of several months they've been without insurance, such as when a raise put Price over the eligibility limit for the Children's Health Insurance Program a year ago. While the children were uninsured, Price struggled to pay for her son's asthma medication and her daughter's emergency room visit for a hip problem. Price has not paid the hospital bill. "That's money I just don't have," she said.

The two older children's Medicaid coverage, which is free, will expire in February, and the baby will no longer qualify in August. She hopes to get all the kids on CHIP. But she'll skip preventive doctor visits for herself, she said. Too expensive.

Instead, Price said, she constantly cleans and dusts her apartment to cut down on germs and allergens. "I do a lot to at least try to prevent. If something were to happen to me, my children would have nothing."

SUSAN HAMMACK

Austin technical writer Susan Hammack had been working for the state for more than a dozen years when she was laid off from her $40,000-a-year job at the Texas Department of Health during a state budget crunch in 2003. That left her without health insurance.

Hammack, 59, a breast cancer survivor, said she was always diligent about getting mammograms. But working temporary jobs and living on credit cards, she skipped some screenings. So by the time she learned in late 2006 that she had breast cancer again, it had spread to her lymph nodes. Her doctor told her she needed surgery immediately.

By then, Hammack had landed a full-time editing job she still holds at the Texas Historical Commission, but her health insurance hadn't kicked in yet. She now owes tens of thousands of dollars in bills.

Her doctors told her she needed chemotherapy, she said, but she declined, afraid that it would leave her too weak to work, that she'd lose her job and be uninsured again.

Her cancer is in remission. But she said doctors have told her she's at high risk for the disease returning. "I'm not going to live as long as I would have," Hammack said, fighting back tears in the light-filled living room of her house off Cuernavaca Drive.

Hammack, who was born in Vienna, Austria, to "a G.I. Joe and a Viennese fräulein," has lived in the United States since she was a toddler and has bachelor's and master's degrees from the University of Texas. She said she marvels at the difference between her life and that of her relatives in Austria, where insurance is mandatory for workers.

"My cousin doesn't have any degrees, and she gets taken care of with top medical care," Hammack said. "I'm sitting here in America with a master's degree and dying."

DAVID GROSE

David Grose of Paris, Texas, was desperate: He had a cancerous growth on his nose, his doctor said he needed surgery right away, and he had no health insurance.

The doctor, Richard Swint, told him to go 300 miles to the University of Texas M.D. Anderson Cancer Center in Houston for the complicated surgery and the reconstruction he needed. But Grose, 39, said he couldn't even get an appointment.

Grose rode the bus for eight hours from Paris to Houston on Oct. 19, arriving at 3:30 a.m, with his medical records, pathology slides and money his doctor gave him for the trip. But no doctor would see him, and Grose said he had no choice but to get back on the bus.

The hospital has a procedure, said Wendy Gottsegen, a spokeswoman for M.D. Anderson. "Before you get the appointment ... you need to understand your options for financial aid," Gottsegen said. "We are not a charity hospital."

Grose, who had worked until October when he left his job as a welder to take care of his cancer, wasn't eligible for Medicaid. But that changed when his 16-year-old son moved in. The son had been staying with his mother, from whom Grose is divorced. Once he became Grose's dependent, Grose qualified for Medicaid, and then M.D. Anderson accepted him.

Grose had his first surgery Nov. 28, he said. He faces more operations but is grateful. He praised the hospital for the care it provides but says he found the experience unsettling.

"It was pretty upsetting," he said. "Before they would even look at my slides, they wanted to know how much money I had. It makes you feel all alone out there."

CYNTHIA PACHECO

At 3:30 p.m. each school day, nearly nine hours after she arrives at Houston's Herrera Elementary School, teaching assistant Cynthia Pacheco begins her second shift. Year-round, she stays at an after-school program until 6:30 p.m.

The 55-year-old with 18-year-old twin sons said she works the overtime shifts to pay her bills. But those extra hours put her family's income — which includes her husband's disability payments — just over the limit to qualify for the Children's Health Insurance Program, she said. The limit for the program — which costs $50 a year or less per family — is $41,300 a year for a family of four.

"I have to (work overtime) just to make ends meet in order to live," said Pacheco, who has health insurance through her job. She said she can't afford the $360 a month it would cost for a plan that includes her sons. That's about what she pays for her electricity in the summer. Her husband is covered through Medicare.

Pacheco's sons, John and Ruffino, haven't had health insurance since they were cut from CHIP two years ago. If her boys got really sick, she said, she'd take them to a doctor, though that might mean being late on a car payment.

"They're strong children," she said of the high school seniors. "So far, everything's been OK."

Pacheco, whose family attends Lakewood Church, the megachurch led by televangelist Joel Osteen, said she relies on her faith to get by. Before she sends her boys to school each morning, she blesses them, praying that God will keep them strong and healthy.

"We have insurance, we're blessed; we don't have insurance, we're still blessed," she said. "I consider myself very blessed. At least I have a job."

RALPH ROMERO

In 1997, El Paso firefighter Ralph Romero, then 36, was helping carry a hose during a house fire when he slipped on some tile and landed on his back.

A decade later, he said, he made the difficult decision to retire because of lingering back problems from the fall.

Because he's not working, he fell behind on his mortgage payments and learned last year his house was in foreclosure, he said. And although worker's compensation pays for health care related to his accident, he said he doesn't have money for health insurance to cover anything else.

"If I go outside and slip and break a leg," he said, "hello!

"I'll just be real careful."

When he was sick with a cold recently, going to the doctor wasn't an option. "I just stayed home, really nursed myself big time, and I got over it," he said.

Romero, 46, said he wonders how he could have ended up in this situation.

"There's something wrong with the system," said Romero, who was with the El Paso Fire Department for 19 years. "How can someone get hurt as a firefighter on duty and later, from the same injury, end up almost losing his house? It's incredible."

Meanwhile, he counts his blessings. He recently got approved for disability retirement, meaning he gets a pension. And with that income, he was able to modify his home loan. The house is no longer in foreclosure. He said he hopes that with physical therapy paid for by worker's compensation, he'll be healthy enough to work a desk job — ideally, with health insurance.

"I actually have decent luck," he said in late 2007. "Just this year has not been my year."

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