Steve Alvarez started feeling sick in late June. His symptoms were mild at first, but then he developed a fever, chills and shortness of breath. He thought it was a bad cold he just couldn't shake.
"Just when I started to get to feeling better and I would have a couple of good days," Alvarez says. "I felt like I'd backtrack and I was just really run down. This thing lingered and lingered."
Alvarez, a Tejano musician who lives in the San Antonio area, eventually got a free COVID-19 test provided by the city of San Antonio. A week later, he found out he tested positive for the virus.
Alvarez and his wife – who also got infected – never ended up in the hospital, and they feel fine now. But he says there were some scary days – he knows a lot of people who got sick with COVID. A friend his age has been in an ICU, on a ventilator, for weeks now.
But Alvarez wasn't just worried about their health. Financial fears loomed large, too.
"We thought if something happens, and this starts getting much worse, we need to start thinking about how we are going to deal with it, how we are going to pay for it," he says. "It was just abject terror as to what was going to happen and what we were going to do."
Money has been tight ever since the pandemic forced most of his musical gigs to be cancelled. Alvarez also lost his health insurance a year ago, when he was laid off from his day job in construction safety.
While he was sick, he paid out of pocket for everything: remote doctor visits, some prescriptions and over-the-counter medicine.
"I use discount cards for those prescriptions as much as possible," Alvarez says. "If something is not generic, that's just absolutely too expensive, I have to consider doing without it."
Texas' uninsured rate has been climbing along with its unemployment rate as COVID-19 cases surge in the state. Before the pandemic, Texas already had the highest rate and largest number of people without health insurance in the country. And 20 percent of all uninsured children in the U.S. live in Texas.
This year the coverage gap in Texas has only gotten worse: 29 percent of Texas adults under 65 don't currently have health insurance, according to recent data from Families USA, a consumer health advocacy group that supports the Affordable Care Act.
The group found about 659,000 people in the state lost their coverage between February and May, as job losses soared. Texas is one of 13 states that has not expanded Medicaid under the ACA.
"Texans who lose their health insurance that is tied to jobs simply have fewer options for new insurance because we do not have Medicaid expansion," says Elena Marks, the president and chief executive officer of the Episcopal Health Foundation in Houston.
Republican state leaders in Texas have long refused to expand health coverage to more low-income adults through Medicaid, despite the fact that the state has had the highest uninsured rate in the country for years.
Marks says the pandemic has made the state's existing health insurance crisis much worse.
"Everything that's happening now was happening before – it's just on a path of acceleration," she says, because there are "so many more people who are sick and who are getting very sick and the costs are very expensive."
Uninsured Texans could face steep costs for COVID treatment and testing, according to Stacey Pogue, an analyst with Every Texan, a progressive policy think tank in Austin.
While some Texans are able to find free coronavirus testing, others have had to pay as much as a few hundred dollars. For people who are already in financial distress, that's prohibitively expensive, Pogue says.
"We need to do everything we can to make sure people are not afraid to get tested because of cost, or are not afraid to get treatment because of cost," she says. "And states like Texas with such a huge uninsured population, that's a huge barrier to our public health response."
Hospitals also feel the financial pain: When uninsured, poor Texans do have to go to the hospital, those hospitals end up absorbing much of the cost.
Even before the pandemic, the cost of caring for uninsured patients in Texas hospitals was more than $7 billion a year, says John Hawkins, the senior vice president for advocacy and public policy at the Texas Hospital Association.
"We've been able to make it work, frankly, because of the growth in the state," he says. "But as we look at COVID going forward, it really does make the case that we have to look at addressing the coverage piece."
Health care providers can expect some federal relief money in the coming months, Hawkins say, but the long term trend is unsustainable for Texas hospitals. If unaddressed, he says, the financial burden on hospitals could lead to future cuts in services – and some hospitals might have to close.
If state lawmakers don't start fixing the state's coverage problem soon, Hawkins expects it will become a significant issue during the next legislative session, which begins in January.
Even before the pandemic, health care advocates across Texas had begun organizing an effort to make Texas' uninsured rate a political liability for state lawmakers running for reelection in November.
But for millions of Texans, the insurance issue is something they have to face now, and every day. The stress is physical, emotional, and financial.
Alvarez and his wife are already doing everything they can to defer mortgage payments and bring in more money, so they don't lose their house, he says.
"But that bottom is going to fall out soon enough," he says. "That's what I am really dreading right now. And I know that that's not an uncommon thing that's going on."
This story comes from NPR's reporting partnership with KUT and Kaiser Health News.