HOUSTON - Nationally, more than 15% are uninsured. In Texas it's nearly 24%, the Census Bureau says, the highest percentage among the states. In Harris County, it's 30%, according to state figures, the highest rate among the nation's top 10 metropolitan areas.

As the Houston area struggles to deal with a rising tide of uninsured, it offers a lesson for the nation: Let the problem get out of hand, to a point where nearly 1 in 3 people have no coverage, and you won't just have a less healthy population. You'll have an overwhelmed health care system.

The problems there, as elsewhere, are many. Small employers are dropping health coverage. Federal and state subsidies don't make up the difference. Illegal immigrants represent 21% of the county's public caseload, even though they represent only about 6% of the area's population.

Compounding the problem, insurers are slashing hospitals' reimbursement rates, often leading the hospitals to reduce unprofitable services such as emergency rooms.

The huge number of uninsured residents here means that health officials make tough decisions every day about who gets treated and when.

Some states are trying to tackle the problem. The broadest solutions have been advanced in Massachusetts, Vermont.  Maine, California, Illinois and Pennsylvania may not be far behind. Other states are trying to insure all children as a first step toward insuring all residents. In most of those states, proposals range from increasing government subsidies to mandating that either employers offer or consumers buy coverage.

Then there's Texas, where the insurance crisis has multiple causes:

Small businesses dominate the economy, but only 31% of those with 50 or fewer employees offer insurance in Texas, compared with 43% nationally. As a result, 48% of Texans are covered by employers, compared with 53% nationally.

Income limits to qualify for Medicaid, the federal-state health insurance program for the poor and disabled, are among the lowest in the nation here. Texas has set a limit of $4,822 per year for a family of three, compared with nearly $10,000 in Florida, $18,000 in California and $25,000 in New York. Texas has no subsidized health insurance program for childless adults; 19 states and the District of Columbia offer some coverage.

The state has forfeited more than $900 million in federal money under the Children's Health Insurance Program (CHIP) during the past six years because it wouldn't put up 28 cents for each 72 cents in federal aid. Restrictions put in place in 2003 cut about 200,000 children from the program in a state with the highest percentage of uninsured children, nearly twice the national average.

State officials say the biggest problem in Texas is a surging population: about 23.5 million in 2006, up 12.7% from 2000, about twice the national growth rate. Texas' increase has continued to be fueled by immigrants who cross the nation's longest border with Mexico.

This reflects a tremendous population growth that is only growing bigger, with fewer medically insured.

The state's Medicaid program has doubled in cost in 10 years despite its low-income limits, CHIP money was left on the table because the program started late and could not be fully funded during a 2003 budget shortfall.

The growth of the nation's uninsured population has stretched hospital emergency departments to the breaking point.

Nationally, ER visits rose from 93 million to 110 million from 1994 to 2004, an 18% jump, according to the Centers for Disease Control and Prevention. Texas experienced a 33% increase; in the Houston area, it was more than 50%, according to the Texas Hospital Association. The number of hospital emergency departments dropped by more than 12% in the USA in the same period.

Emergency rooms here are routinely overcrowded.  Patients routinely wait overnight.

About half of the people going to the emergency rooms just seek primary care, a percentage that's similar elsewhere. 

Many of the patients haven't seen a doctor in years,
Packed emergency rooms also are caused by overcrowded hospitals in general. At one hospital they gets calls from area business leaders and politicians trying to sneak a maid or a nanny in the backdoor. Doctors, frustrated by long delays for surgeries, try getting their patients ahead in line.

Some of the hospitals are trying to handle one-third of a population.

Crowding leads hospitals to send patients elsewhere.
In the Houston area, hospitals divert patients about 20% of the time. Ambulances pile up outside emergency rooms, often waiting an hour or two to get their patients in for treatment.  The area record is six hours. The situation is so bad that patients have called 911 from one ER to get to another.

Nurses and doctors both cite horror stories, such as the patient who died after being diverted by helicopter from a Houston hospital to one in Austin. They all say that diversion kills.

The greatest demand for health care isn't in emergency rooms. It's at the clinics and health centers designed to relieve them.

You can see corridor in many clinics with as many as 350 people waiting.

The clinics try to fill the gap between primary and hospital care with its own specialists, but the wait can take months.  Some have only one specialist, and they're booking appointment 6 months in advance.

The large numbers of uninsured and overburdened health care system have consequences. Studies done during the past 25 years indicate that being uninsured is hazardous to your health.

The uninsured are more likely to have high infant mortality rates. They are more likely to develop high blood pressure and hypertension. They are less likely to get treatment for trauma. They are less likely to receive timely cancer diagnoses. They are more likely to die from heart attacks.

Among the states, Texas has the highest percentage of uninsured adults, 27.6%, who say they are in poor or fair health, rather than good or excellent health, according to the American Hospital Association.

One woman waited about a year after noticing a lump on her breast because she was poor, uninsured, and busy. Eventually she went to a women's diagnostic center. She has since had chemotherapy, surgery and radiation, but her long-term prognosis is questionable.

Faced with the onslaught of uninsured patients, Texas is taking steps to rework some of its policies.

Late last month, the Legislature changed its rules to add more than 127,000 children to the 300,000 now covered by the Children's Health Insurance Program. Asset tests were eased, enrollment periods extended and waiting periods eliminated for many clients. The Legislature also paved the way for a new program that will subsidize insurance for 200,000 adults.

Still, there is nothing being proposed on the scale of Massachusetts' fledgling program to insure all residents. To do that would cost Texas $6 billion.

For all their efforts, Houston-area health officials have been unable to reduce the numbers of uninsured.