There are the days Lilia Valadez spends in pain — vomiting, pacing, aching, screaming — and the days she spends anticipating when the pain might come again, keeping her from work and potentially requiring an emergency room visit she can’t afford.

Valadez, a 44-year-old living in the border town of Pharr, Texas, has a recurring intestinal infection and no health insurance. She’s nearly $25,000 in medical debt from visits to the ER — more than she and her husband bring in each year between his disability payments and her part-time job as a caregiver to the elderly.

The rest of her family qualifies for Medicaid, the government’s health care program for the poor and disabled, because her husband has a severe mental illness and her 3-year-old son is autistic. But while Valadez is poor, and sick, she’s neither poor enough nor sick enough to qualify for Medicaid in Texas. So she goes without care.

“I kind of just have to sit here and rot until something happens,” Valadez said through tears. “I’m so scared.”

To get Medicaid in the state, an adult has to be an impoverished parent making a few hundred dollars or less each month, so ill or disabled that the state considers it impossible for the person to work, or pregnant. In many instances, low-income parents or ill adults still capable of bringing in some sort of income are locked out of Medicaid. To qualify, Valadez would have to either lose her job or become devastatingly ill.

This is the case in Texas and the 13 other states that declined, under the 2010 Affordable Care Act, to expand Medicaid to people making up to 138 percent of the poverty level.

Separately, the ACA offers government aid to middle-income Americans to help them purchase private health insurance plans. But because the law was originally written to expand Medicaid nationwide, these subsidies aren’t available to the poorest Americans. That means people like Valadez have no options for affordable health insurance.

This is known as the “Medicaid coverage gap,” and Texas has the largest number of people that fall into it — at least 638,000, according to the Kaiser Family Foundation. And, for a number of reasons — one being that approximately 11 percent of Texas residents are not U.S. citizens — the state also has the highest uninsurance rate in the country, at 19 percent, according to the Urban Institute, a think tank.

“If I’m poor or I work, I still don’t qualify. Whatever it is, I’m undeserving.”

The uninsured status of millions has contributed to a health debt crisis. Credit reports showed 26 percent of Texans had past-due medical debt in collections in 2017, compared to a national rate of 18 percent, according to the Urban Institute. In Hidalgo County, the Rio Grande Valley's most populous county, that rate was about 23 percent, according to the institute.

Valadez lives below the poverty line, but she would have to pay thousands a year for health insurance. Her family’s annual income is barely $21,000. So, she waits for the pain to go away.

Putting off necessary health care due to cost is common in the Rio Grande Valley, the fast-growing, four-county stretch in the southernmost region of Texas, where Valadez lives. The valley is home to nearly 1.4 million people, more than 90 percent of whom are Latino and many of whom are poor. More than a quarter of the residents in the Rio Grande Valley lack health insurance; many of them fall into the Medicaid coverage gap.

And Republicans are pushing to make the rest of the country’s health care look a lot like Texas’.

This week, the Trump administration unveiled a 2020 spending plan that would cut almost $1.5 trillion from Medicaid over a decade, and eliminate funding for Medicaid expansion entirely. Instead, according to the plan, the federal government would allocate $1.2 trillion to block grants or per-person caps — funding arrangements that give states more flexibility to kick poor people off health insurance.

Texas’ attorney general, Ken Paxton, is also leading a coalition of 20 states suing the federal government to unravel the nation’s health care program by arguing the 2010 Affordable Care Act is unconstitutional. A Fort Worth-based judge took Paxton’s side in a ruling in December, although Obamacare is still in effect during the appeals process. If the Texas-led lawsuit wins, Medicaid expansion could disappear across the country.

If the rest of the U.S. were to allow a Texas-style Medicaid coverage gap to fester, “it’d be both a personal crisis for millions of Americans and a systemic crisis for the health-care industry,” said Anne Dunkelberg, associate director at the Austin-based Center for Public Policy Priorities.

That crisis is already too real for Valadez. She has tiny, infected pouches along the wall of her colon, an illness called diverticulitis. When those pouches flare, debilitating pain follows. Valadez waits out the pain for at least three days before she goes to the emergency room. She’s already unable to pay off her existing medical debt, and each visit can cost thousands. But she’s had to go multiple times over the past two years anyway.

The last time she had a flare-up, two weeks ago, she drove across the Mexican border to seek less expensive care. In Nuevo Progreso, a border town in Tamaulipas about 40 minutes from her home, a doctor told her she will likely need surgery. Without health insurance, it’s not an option.

“It doesn’t matter what I do. If I’m poor or I work, I still don’t qualify. Whatever it is, I’m undeserving,” Valadez said.

“It’s exhausting”

The toxic combination of poverty and lack of medical care has led to a health crisis in the Valley. Diabetes and hypertension are common ailments; Lucy Ramirez Torres, the CEO of Nuestra Clinica del Valle, said the vast majority of the people who walk through the doors in her chain of community health clinics have one or both conditions and are uninsured.

When the Affordable Care Act first passed in 2010, advocates working near the Texas-Mexico border hoped it would lead to better health in the community, Torres said. Her clinic geared up to enroll as many people as they could on low-cost health insurance.

Then a 2012 Supreme Court decision threw the decision to expand Medicaid to the states. Texas, along with some other conservative-leaning states including Alabama and Florida, decided not to.

“There are a lot of us that still haven’t given up hope that maybe the lightbulb will turn on and they’ll do some sort of coverage expansion — even if they don’t like the word Medicaid — just do something,” Torres said. Her physicians do as much as they can to stem the illnesses plaguing residents of the community, but many of their patients can’t afford to go to the emergency room or access specialty care, like colonoscopies or minor surgeries, and grow sicker as a result.

“It’s exhausting,” she said.

Since Texas didn’t expand Medicaid through the Affordable Care Act, the requirements to access the government’s health care program for the poor remain as restrictive as ever — an adult in Texas essentially has to be a drastically poor parent, disabled or near death to qualify.

And to get government subsidies for a marketplace plan, a family of four has to earn between the poverty line — $25,100 — and $100,400.

These subsidies, which often come in the form of a tax credit on monthly premiums, were meant to ensure that a person who didn’t qualify for Medicaid wouldn’t owe a prohibitive percentage of their income on insurance.

When the subsidies were created, the assumption was that everyone below the poverty line would get Medicaid coverage due to expansion. But the failure of 14 states to expand left 2.2 million people below the poverty line in the coverage gap.

One of them was Juan Chavez, a 43-year-old deejay from McAllen. He only makes $120 in a good week, doing odd jobs like cleaning cars and cutting yards. But because he doesn’t have dependent kids, he can’t qualify for Medicaid. He’s too poor to get subsidies.

Chavez wants to work more, partly so he can qualify for the insurance subsidies, but he’s struggled to find work because he has a felony record from transporting undocumented immigrants three years ago. So he’s uninsured.

Chavez is diabetic and hypertensive. Last year, a heart problem forced him into emergency surgery to have a pacemaker implanted. Now, between the surgery and the fainting spells that preceded it, he’s more than $25,000 in debt and can’t afford follow-up visits with a cardiologist.

“I would black out from a lack of oxygen to the brain — that happened all of last year,” Chavez said. Debt collectors now send letters to the hotel where he has a room in exchange for doing maintenance tasks.

“I would have died’’

In the years since Texas failed to expand Medicaid, partisan sentiments in some states have changed in favor of the public health program. Voters in three deep-red states — Idaho, Nebraska and Utah — opted to expand Medicaid through ballot initiatives this past November. A survey carried out last year by the Kaiser Family Foundation and the Episcopal Health Foundation found 64 percent of Texans wanted to see Medicaid expanded to cover more poor people. If that were to happen, an estimated 1.2 million people in Texas would gain coverage, and the gap would be eliminated.

Earlier this month, health care advocates and Democratic lawmakers gathered on the steps of the Texas Capitol to plead for change. Texas Rep. Garnet Coleman, a Democrat from Houston, authored a bill that would expand Medicaid., if it's approved by the state’s legislature and governor. And the state’s growing progressive wing has made Medicaid expansion a rallying cry for hyping up young voters. Beto O’Rourke, the Democrat who nearly unseated Republican Sen. Ted Cruz in the midterm elections, made health care a large part of his shockingly successful campaign.

“I think if would’ve continued that way, just staying in the Valley, I would have died.”

Samantha Orduna, a 29-year-old working in customer service living in San Antonio, said she doesn’t understand “what the big issue is on giving people health care.” After what she’s gone through, she said she will never vote for a candidate who denies people access to health care.

Orduna said she believes she would have died if she had stayed in the Valley. In 2013 she was diagnosed with ulcerative colitis, a chronic inflammatory bowel disease that prevented her from working full-time. Three years later, when she turned 26, she aged out of being covered by her mother’s health plan. She was too poor to qualify for Obamacare subsidies, not sick enough for Medicaid, and there wasn’t adequate public assistance nearby.

To keep flare-ups at bay, her disease required expensive therapies and medications she couldn’t afford. But like many poor patients, Orduna would just go to the emergency room when she was critically ill — because it was the only place where she wasn’t forced to pay for care up-front.

So in early 2016, she moved four hours away from her hometown of Los Fresnos to San Antonio, where she knew no one, to access care through a financial assistance program through University Health Systems called CareLink.

In the time she wasn’t seeing a doctor regularly, her condition had worsened, and in San Antonio her large intestine had to be removed.

Orduna is now nearly $40,000 in medical debt, and just qualified for health insurance through her employer about 10 months ago.

“I think if would’ve continued that way, just staying in the Valley, I would have died from infection or my colon rupturing,” said Orduna.

Valadez, the 44-year-old mother in Pharr, Texas, cannot afford the move out of the Valley to a city with a public hospital, although she’s considered it. She wakes up early every day to take online college classes in the hope she can one day get a job that provides health insurance.

Sometimes she feels her state wants the poor to “die off,” she said.

“The only way I can beat the system is to get a good job, get an education, get insurance, so hopefully I can have surgery within the next two years,” she said. “I’m kind of hoping that at some point, some doctor will have mercy on me. That’s really what I’m praying for.”