Illustration by Ruth Gwily

Geronimo Oregón was wheeled out of the intensive-care unit at Houston’s Ben Taub Hospital on April 17, 2016, his body wired with electrodes and his mother at his side. He had arrived in the emergency room six days earlier, complaining of confusion, stomach pain, and shortness of breath. Physicians had drained nearly half a gallon of fluid from around his right lung, corrected his sodium imbalance (a cause of his confusion), and relieved the worst of his pain. Now Oregón was being transferred to the step-down unit, a kind of limbo between the I.C.U. and the general ward. His new room had a vacuum pump on the wall. When the suction was on, a bright yellow fluid drained out of a tube in his nose and into a clear cannister. Every part of his body—his belly, his face, his eyes—was the same vivid shade. He had jaundice, the result of old red blood cells leaking into his tissues rather than being cleared from his body as waste. In medicine, this is known as a stigmata, a physical mark of illness. Oregón was dying of liver failure. A calculation made using his blood work showed that, unless he received a liver transplant, he had only an eighteen per cent chance of surviving the next ninety days.

I have been an internist at Ben Taub for the past six years. In that time, I have rarely seen patients who lack health insurance, like Oregón, make it to the transplant list. The hospital is part of Harris Health, a county-funded network that provides care for the indigent, but as with most safety nets it does not cover organ transplantation, which can cost hundreds of thousands of dollars. This may be why, when I took over Oregón’s care, I fixated on the tube in his nose. Rather than prolonging his life with invasive equipment, shouldn’t my colleagues and I gear our treatment toward helping him die comfortably? Normally, we would have recommended against resuscitation efforts, such as shocking his heart if it stopped or connecting him to a ventilator. But when we explained this to Oregón and his mother, Emma, she put a stop to the conversation. Her son, she pointed out, was only thirty-six years old—much too young to die. The medical team decided that addressing Oregón’s breathlessness would be a top priority, even if it meant performing more procedures.

Then a medical student noticed something in Oregón’s history that the rest of us had missed: he used to have Medicaid, but it was taken away. The second part of the revelation was not so surprising. Texas is perhaps the worst state in the union to live in as someone who is poor and terminally ill—a direct result of the political bickering surrounding the Patient Protection and Affordable Care Act, also known as Obamacare. In its original form, the legislation would have helped Oregón. It was designed to insure that all Americans—particularly those who worked but did not have employer-sponsored health care—received basic coverage. As part of this goal, the law mandated that states extend Medicaid to any adult under the age of sixty-five who earned as much as a hundred and thirty-eight per cent of the federal poverty level (F.P.L.). Oregón made only six hundred dollars a month, or sixty-one per cent of the F.P.L. at the time, working as a gas-station attendant. But after the U.S. Supreme Court struck the mandate down, in 2012, some states—including mine—chose to reject the Medicaid expansion and the federal dollars that came with it. Texas now has the strictest Medicaid qualifications in the country. According to a 2015 report from the Kaiser Family Foundation, for an adult in a family of three to receive coverage, his household income must be less than four thousand dollars per year, just nineteen per cent of the F.P.L. In most cases, childless adults, no matter how little they earn, cannot receive coverage at all.

My colleagues and I had assumed, from experience, that Texas would not fund a transplant for Oregón. But the first part of the medical student’s discovery—that he had ever had coverage to begin with—gave us hope. How, we wondered, did Oregón qualify for Medicaid in the first place? Could he again?

Oregón was born in Mexico City, raised in the state of Michoacán, and brought to Houston illegally when he was nine. His father had largely abandoned the family years earlier, leaving Emma to make ends meet by working night jobs. The money was enough at first, but then, when Oregón was thirteen, he began having seizures in school. Emma took him to Ben Taub, where he was diagnosed with epilepsy. Medication brought his convulsions under control, but he never returned to school. His father, believing that Oregón would receive better treatment in Mexico, demanded that he be sent to live with his grandparents in Michoacán. Emma eventually relented out of fear of her ex-husband, who had been abusive toward her in the past. Back in Mexico, Oregón’s grandparents put him to work tending their livestock. He didn’t return home to Houston until the age of twenty, this time as a legal U.S. resident. He had only a sixth-grade education, but he was bilingual; he joined the Job Corps, a federal career-training program, and found employment immediately.

Oregón worked low-paying jobs—as a dishwasher, a cook, and at the gas station—for most of his adult life, always making enough to pay his portion of the rent that he shared with his mother. He received affordable medical care, including treatment for his epilepsy, through Harris Health. In December of 2010, Oregón’s primary-care doctor detected early signs of liver damage—the beginning of a condition called cirrhosis—in his blood work, diagnosing it as a result of hepatitis C infection. Hep C, a virus, can be transmitted through contact with infected blood or, more rarely, through unprotected sex, and is a common cause of liver disease. According to the World Health Organization, hundreds of thousands of people die of complications from the virus annually, and as many as thirty per cent of patients with chronic hep C infection develop cirrhosis within twenty years. Since Oregón was young and never drank—alcohol abuse aggravates liver damage—the specialists at Harris Health decided not to treat his hep C, out of concern that mixing antiviral medications with his epilepsy drugs would worsen the damage. They monitored his health consistently for years.

On June 9, 2014, Oregón went to his night shift at the gas station feeling a little tired. A few hours in, he experienced a wave of nausea, suddenly vomited a large quantity of blood, and passed out. An ambulance brought him to Ben Taub, where doctors admitted him to the I.C.U. Oregón’s liver disease, they discovered, was progressing much faster than expected. He would need new medications and, eventually, a transplant. The liver specialist, aware that Harris Health could not cover the procedure, referred Oregón to a hospital social worker, who recommended that he enroll in Social Security Disability Insurance, a program for workers who have reliably paid Social Security taxes but become disabled before they reach retirement age. S.S.D.I. would give Oregón enough money for rent and food, and it would also help him recoup some of his mounting health-care costs. More important, it would change his Medicaid status: in Texas, if you’re disabled, you can qualify for the program as long as you have less than two thousand dollars in assets and earn less than seven hundred and thirty-three dollars per month. Oregón seemed to fit the state’s narrow standards.