This story is part of a roundup of the many categories—both good and bad—in which Texas ranks number one.

Royce Reed was once a star shooting guard on the basketball team at Bellaire High School. When he came to see me at the emergency room at Houston’s Ben Taub Hospital last October, he wore red warm-up pants, the kind with snaps on the side so he could tear them off at a moment’s notice and enter the game—or, in this case, change into a hospital gown. I needed only to unfasten the two snaps on the bottom to see what had brought him here. The middle three toes of his right foot had been stripped of their skin and underlying fat, and there was a wound the size of a silver dollar coin on his heel. Royce, who was 44, was suffering from an infection in his foot bones that made it nearly impossible for him to walk.

Royce’s health problems had emerged years earlier. He was diagnosed with type 1 diabetes at the age of seven, but thanks to the health insurance his parents had through their jobs, the family managed to keep his illness largely under control. He played intramural basketball at Sam Houston State University, earned business and computer science degrees, and, when he turned 28, got a job at the post office that provided him with health insurance of his own. 

Royce was, at that point in his life, lucky. According to the latest data, from 2021, Texas has the country’s largest medically uninsured rate; more than five million Texans lack insurance, a number that represents 18 percent of our population. That’s 4.2 percentage points higher than the rate in Oklahoma, the runner-up in this sweepstakes of shame. 

A perhaps even more shocking statistic: In 2021 there were 930,000 uninsured children in Texas—a number destined to exceed one million as the state rolls back the Medicaid coverage the federal government provided during the pandemic. The percentage of uninsured children, 11.8, is the highest in the country, and more than double the national average. 

Not having insurance can be deadly. A 2017 article in the Annals of Internal Medicine mentions one study that found that having health insurance reduced adult mortality by as much as 6 percent. The uninsured are, for instance, far more likely to have cancer diagnosed at later stages and to die at younger ages. And, of course, having insurance can also alleviate many nonfatal forms of suffering caused by crippling chronic illnesses. For many people, Texas is a tough place to get sick.

When Royce was 32, he developed kidney failure and required a transplant. His private insurance didn’t pay for this procedure, so Medicare paid for it and the 36 months of recovery that followed. His private insurance did cover a podiatrist visit after Royce found a small discoloration on his left foot in 2019, as well as continued follow-ups with his kidney doctor, who pushed him to be diligent about his health, fearing that the small diabetic ulcer he had developed on his foot would worsen. “She got on my ass,” Royce noted.

Things began to fall apart in February 2021, when Royce lost electricity during the deep freeze and blackout. Because of the damage diabetes had done to his nerves and blood vessels, Royce was especially vulnerable to frostbite, and his feet turned black. His father took him to the hospital, where doctors noticed a foul smell coming from his left foot. The skin over the wound had started to slough away, and the ulcer had expanded. Royce underwent emergency surgery to remove the infection. Once he was released, specialists advised him to keep off his feet. 

That was pretty much impossible at the post office, where Royce occasionally covered routes when a colleague was absent. Something had to give. He stopped working in early 2021, and though the union made sure he didn’t get fired, the post office eventually stopped paying its part of his insurance. Soon enough, he joined the more than five million Texans who don’t have health coverage.

Royce couldn’t visit his endocrinologists or podiatrists; he did, though, receive insulin and vital medications for his kidney transplant through donations from the American Kidney Fund. But when his right foot began having similar issues, he couldn’t find a way to receive medical care. So it was no surprise that Royce ended up at Ben Taub, a public hospital that teems with the uninsured.

Since our first meeting, Royce has been admitted four times over eight months. He’s spent 45 days in the hospital, visited the ER six other times, and had dozens of clinic visits. Most of this expensive care would have been prevented if he’d had coverage. And he’s just one of many Texans suffering needlessly.

The first time I saw Royce, I told him how much his ailments dispirited me. “You were once a basketball player,” I said. That didn’t matter anymore, he explained. He was focused on keeping his feet and trying to stay alive. He had applied for disability, but that took time. In the meantime, he hopes that at some point his health will improve and he’ll be able to start working at the post office again.

“I still got my job,” he said, noting the difficult nature of his situation. “I just don’t have insurance.”

Ricardo Nuila is a doctor of internal medicine at Ben Taub Hospital, in Houston, and the author of The People’s Hospital: Hope and Peril in American Medicine.

This article originally appeared in the September 2023 issue of Texas Monthly with the headline “Medican’t.” Subscribe today.