PASADENA, Tex. — In an ordinary world, Josh Hebert would have accepted the raises his employer offered.


But in the extraordinary world of the uninsured, he has not only turned down the pay increases at the bank where he works, but has twice asked for a pay cut — so that he and his wife’s ill 7-year-old daughter can qualify for government-sponsored children’s health insurance.


By keeping his income low, he and his wife, Kyla, are able to ensure that their daughter continues to have health coverage. The parents remain uninsured themselves, like thousands of others in this working-class refinery town outside Houston. Thirty-three percent of the population here lacks medical insurance.


Nearby in Houston, hours after the Supreme Court’s ruling on Thursday upheld the core provisions of President Obama’s health care overhaul, Luis Duran hardly paid attention. He and his wife sifted through medical documents stuffed in a paper bag, evidence of his ordeal to survive cancer without health insurance.


A crane operator, Mr. Duran had been covered for years through his employer, but a simple paperwork oversight left him uninsured last year. Months later, he learned he had colon cancer, and spent roughly $7,000 on a colonoscopy and surgery — a reduced rate — using money he received from relatives and from selling some of his and his wife’s jewelry, including a 14-karat gold medallion of Jesus Christ.


“When you don’t have insurance, nobody listens to you,” said Mr. Duran, 51, who had been making about $50,000 annually but is now on disability. “It’s a powerless feeling. You feel like you’re an outcast. You feel that you’re homeless without insurance.”


In Texas — where 25 percent of the population lacks health insurance, the highest uninsured rate of any state, according to the Texas Medical Association — the Supreme Court’s ruling was not quite the partisan victory or defeat it might have been in Washington. Though those without health coverage perhaps had the most at stake, the ruling was one more element of uncertainty in uncertain lives, drowned out by more pressing medical needs and financial pressures.


The uncertainty was intensified by unanswered questions over the state’s efforts to fight the expansion of Medicaid, the government health-insurance program for low-income and sick people. Expanding Medicaid was the major portion of the health care law that the Supreme Court restricted in its decision, allowing states flexibility to opt out of the expansion without penalties. Thomas M. Suehs, the commissioner of the Texas Health and Human Services agency, said he remained concerned that expanding Medicaid without reforming it multiplied the costs the program put on states, adding that Medicaid already consumed a quarter of the state budget.


As a result, many of the uninsured in Texas who would be eligible for coverage under the expansion remain in a state of limbo.


“It’s a big concern,” said Gladys Vasquez, 50, a Houston home health aide who cannot afford private insurance on her $17,000 annual salary and whose employer does not offer her coverage. “Right now, it’s scary to get sick, because if you don’t die from the sickness, you die when you see the bill.”


Mrs. Vasquez takes care of her own medical needs at a local clinic and by relying on her 90-year-old mother’s home remedies. On Thursday, watching the television news coverage of the ruling at her client’s house, she let out a cheer.


“It’s like a dream come true,” said Mrs. Vasquez, a member of the Texas Organizing Project, a community activist group. “It’s something we really needed.”


In Houston and the surrounding suburbs and cities in Harris County, including Pasadena, the number of uninsured people like Mrs. Vasquez is so large — more than one million people — it rivals the total population of Dallas. They defy easy categorization.


Though some are newly arrived illegal immigrants living in extreme poverty, many others, like Mr. Hebert, Mr. Duran and Mrs. Vasquez, are American citizens with mortgages or part-time and full-time jobs. Some work in businesses that do not offer coverage, or they cannot afford private insurance; others are eligible but not enrolled in government programs like Medicaid.