To many people, Texas has a strong reputation for quality health care.

Retirees who move to the state cite good hospitals as a key attraction. Dallas' Baylor University Medical Center and UT Southwestern Medical Center are renowned for churning out top-notch doctors. The University of Texas M.D. Anderson Cancer Center in Houston attracts patients from around the world.

But among the 50 states, Texas' health care system ranges from average to poor, according to two reports released this week.

Industry experts say the low rankings are explained largely by the widening gap between Texans who have health insurance and those who don't.

The large immigrant population and a high number of small businesses that don't offer health benefits to employees make Texas highest in the nation in the percentage of uninsured residents.

That helped rank Texas 49th out of 50 states and the District of Columbia for the overall performance of its health care system, in a study by the Commonwealth Fund, a nonprofit health care advocacy group. The study measured access to health care, quality of health care, avoidable hospital costs and deaths per 100,000 residents.

"We have too much pride in this state, and too much good economy, for us to sit back and tolerate this kind of rating," said Ladon W. Homer, immediate past president of the Texas Medical Association.

If Texas improved to the level of Hawaii, the best-performing state in the Commonwealth study, 2.7 million adults and 900,000 children would be insured, and the state would save $250.3 million a year, the study's researchers concluded.

A study released Monday by the U.S. Department of Health and Human Services pegged the state as average for health care quality, based on 129 indicators.

The department began publishing the annual study in 2005 as a way to help state health leaders better recognize their strengths and weaknesses in providing quality care.

"Texas on overall quality is about average," said Ed Kelley, supervisor of the department's study. "There are some things Texas is doing well and challenges that can be improved."

For example, the study found that Texas scored strongly for early colorectal cancer diagnoses and having a low percentage of nursing home residents who are depressed or anxious but poorly in areas such as full vaccination of children and avoidable hospitalizations for diabetes.

In both studies, Midwestern and Northeastern states such as Wisconsin, Minnesota, New Hampshire, Vermont and Maine performed the best. Those states have higher percentages of residents with health insurance and don't have the same impact from immigration as Texas does.

In a state with 23.5 million people, more than 5.5 million – including 1.4 million children – lack health insurance, according to the Texas Medical Association. Texas' uninsured rates are about 1.5 times the national average.

Texas stands out for the ethnic makeup of its uninsured, said Anil Kumar, an economist with the Federal Reserve Bank of Dallas.

Hispanics make up a third of the state's population – much larger than the 13 percent for the U.S. as a whole. More than half of the uninsured in Texas are Hispanic, compared with 25 percent for the nation.

Many Hispanics, particularly laborers, work at small businesses, said Roger C. Rocha Jr., state director of the League of United Latin American Citizens.

"Low-income people who cannot afford health insurance are in jobs that don't offer health insurance," he said. "And then with CHIP programs being cut or not being funded adequately, there is a big segment out there not covered."

Only 55 percent of Texans have access to employer-sponsored insurance, below the national average of 63 percent, according to the Texas Medical Association. For small businesses – which provide about half the state's nonfarm, private-sector jobs – coverage drops to 37 percent.

Tony Hartl, who founded Planet Tan in Dallas in 1995, said providing health insurance is a challenge for many small businesses. "Not in the beginning," he said. "You can't afford it."

For Planet Tan, it took four years of building up the business before the economics worked, he said.

Today, Planet Tan offers insurance to employees who work 32 hours or more, with the company paying 75 percent of the premium. Still, he said, making it affordable for both the company and employees continues to be a challenge.

The strain of supporting uninsured Texans pressures hospitals financially and in the quality of care, experts say.

Total uncompensated care – including bad debt from people who can't pay their bills and charity care that hospitals agree to provide – increased 78 percent, from $5.6 billion in 2001 to $10.1 billion in 2005, according to the Texas Hospital Association.

Uninsured patients are more likely than their insured counterparts to forgo or delay treatment for acute illnesses or injuries, to go without needed treatment for chronic conditions or illnesses and to die prematurely.

Besides the dangers to those who go without insurance, the situation also creates a drag on the state's economy, said Nancy Williams, president of the Health Industry Council of the Dallas-Fort Worth Region. Uninsured patients create higher health care costs for everyone as a result of the inherent cost shifting.

"The uninsured is an issue because the insured can't handle it," Williams said.

A study by Families USA, a Washington-based nonprofit group that advocates for universal health care, found in 2005 that employer-sponsored family coverage in Texas costs $1,551 more per year as a result of the uninsured.

The problem of the uninsured is again getting attention from politicians. Presidential candidates are floating proposals to increase the ranks of insured Americans and even to provide universal health coverage.

Massachusetts is rolling out a plan that will cover nearly all of its residents. Politicians in California, New York and Pennsylvania are talking about doing the same.

In Texas, solutions have come in a more piecemeal fashion.

In the recent legislative session, lawmakers restored many of the funding cuts made in 2003 to the Children's Health Insurance Program. CHIP is designed for children of families who earn too much for Medicaid but not enough to buy private health insurance.

Since the cuts, CHIP enrollment had dropped from a high of 529,000 in May of 2002 to 300,800 this month, according to the Texas Health and Human Services Commission.

Lawmakers also agreed to settle a Medicaid-related lawsuit by spending $707 million to increase dentists' payments by 50 percent and physicians' 25 percent, and to dispatch up to 40 mobile labs into inner-city neighborhoods and impoverished colonias.

Homer, the former TMA president, said the state was funding two-thirds of the actual cost of Medicaid – "which means many physicians opt out of this program, which means more people don't have access to health care."