When Texas went to court last year to block President Obama's healthcare overhaul, Gov. Rick Perry pledged to do everything in his power to "protect our families, taxpayers and medical providers." Texas, he said, could manage its own healthcare.
But in the 11 years the Republican presidential hopeful has been in office, working Texans increasingly have been priced out of private healthcare while the state's safety net has withered, leaving millions of state residents without medical care.
"Texas just hasn't proven it can run a health system," said Dr. C. Bruce Malone III, an orthopedic surgeon and president of the historically conservative Texas Medical Assn.
More than a quarter of Texans lack health insurance, the highest rate in the nation, placing a crushing burden on hospitals and doctors who treat patients unable to pay.
Those costs are passed to the insured. Insurance premiums have risen more quickly in Texas than they have nationally over the last seven years. And when compared with incomes, insurance in Texas is less affordable than in every state but Mississippi, according to the nonprofit Commonwealth Fund.
That has taken a toll, as nearly a third of the state's children did not receive an annual physical and a teeth cleaning in 2007, placing Texas 40th in a state ranking by the fund. Over the last decade, infant mortality rates have risen in Texas while declining nationwide, according to the Centers for Disease Control and Prevention.
Seniors, despite guaranteed Medicare coverage, also are suffering, as nearly 1 in 5 ends up back in the hospital within a month of being released, one of the highest readmission rates in the country and a leading indicator of systemwide problems.
Similar healthcare dynamics drove Obama's push for a national overhaul. In Texas, however, elected officials have done little to address the growing crisis, local health leaders say.
"The philosophy has been the less public expenditure, the better," said Dr. Kenneth Shine, who heads the University of Texas health system. "And some people will just have to make do."
For those who can get it, medical care in Texas can compete with the best in the nation. The state is home to internationally renowned medical and research centers.
Perry promotes the state as a model for a private-sector healthcare solution. Low taxes and limited government, he and his allies say, lure businesses that can offer private insurance and empower working people to make their own healthcare choices.
"The governor's primary goal is to create an environment that encourages job creation and provides an environment of independence rather than dependence," said spokeswoman Catherine Frazier. "Texas does provide an adequate safety net to those truly in need … and many individuals simply choose not to purchase healthcare coverage."
Frazier pointed to several initiatives, including medical malpractice limits and a year-old program to subsidize insurance for small businesses. As of August, the program had insured 4,266 people.
But across Texas, health coverage — and health — are eroding even in places where jobs are plentiful.
In San Angelo, a growing city in the cotton and sorghum fields of West Texas not far from where Perry was raised, unemployment is just 7.2%, lower than it is statewide and nationally. But the waiting room at the federally subsidized Esperanza Clinic is filled every day with working people who have no insurance.
Connie Villarreal, who works the night shift at a home for disabled adults, said she scraped enough together to get coverage for her diabetes. But she brought her uninsured 13-year-old daughter to the clinic for a state-mandated physical so she could play soccer this fall.
Buying family coverage wasn't an option, Villarreal said. "It'd be most of my paycheck, so we've been winging it." Villarreal just went to court to force her daughter's father to pick up the tab to get the teenager insurance.
Three-quarters of Esperanza's patients have jobs, said clinic Chief Executive Mike Campbell. But because many businesses don't offer health benefits, demand at the clinic is skyrocketing. Esperanza saw 13,000 patients last year, up from 11,000 the year before. "We are at the breaking point," Campbell said.
At Shannon Medical Center, San Angelo's largest hospital, 30% of patients coming to the ER lack coverage, close to twice the national rate.
And at the San Jacinto Elementary School clinic, exam rooms fill up with the children of working parents who don't have insurance or a regular doctor.
While some of those seeking care are undocumented immigrants, just a sixth of the uninsured in Texas are in the state illegally, according to the nonprofit Center for Public Policy Priorities. "The reality is that is not the big number," said Republican state Rep. John Zerwas.
For years, healthcare leaders here have urged elected officials to act. A 2006 task force of doctors, academic leaders and business executives warned of a "problem of epidemic proportions" that threatened "the economic vitality and health of Texas."
Perry enacted a major overhaul of the medical malpractice system, which helped doctors stay in practice. "We now have much better access to care," said Dr. William Hinchey, past president of the Texas Medical Assn.
But Texas still has among the fewest physicians per capita in the country, according to census data.
This year, the governor and state Legislature slashed funding to train physicians to less than half of what it was a decade ago. Another initiative highlighted by Perry's office to aid community health centers was also cut.
That came atop $800 million in cuts to hospitals and other medical providers that serve poor children, pregnant women and others who rely on Medicaid.
Even before that move, Texas had one of the slimmest Medicaid and Children's Health Insurance Programs in the country, spending less per enrollee than 41 other states and the District of Columbia, according the nonprofit Kaiser Family Foundation.
"The question seems to be how little can we fund and still have a system," said Dr. Jane Rider, a past president of the Texas Pediatric Society. "I always thought they would wake up and see, if nothing else, they need a healthy, educated workforce.... Instead, it seems like we're leading the way into a downward spiral."