Senator Eliot Shapleigh - El Paso, Texas

But in his nine years in office, Perry has been able to offer few remedies for a state in which one in four residents doesn't have health insurance, health care costs have doubled to $22 billion since he became governor, and where one-third of the budget now goes toward health and human services.

Perry's health care emphasis has been on other issues. TheRepublican championed a billion-dollar initiative to bring the state to the forefront of cancer research. And his press secretary, Allison Castle, argued that through wellness programs, increased children's immunizations and lawsuit limits, the governor "led efforts to keep doctors and other health care professionals in the exam room instead of the courtroom."

"We'll continue to improve the health and wellness across the state while assuring accountability to taxpayers," Castle said.

Others on the front line of health care policies believe this area, unlike economic growth and transportation issues, has not made the list of the governor's top priorities.

"His priority has been to remove support for people trying to get health care coverage," said Rep. Garnet Coleman, D-Houston, an expert in public health policy.

He said Perry has emphasized tax cuts and limited government, resulting in "draconian" cuts in health services.

As Perry seeks a third full term, the nation is focused on health care policy. The budget cuts and tough eligibility rules might serve him well in his primary battle against Kay Bailey Hutchison, as conservative voters are expected to dominate the Republican primary. But if Perry wins and faces a Democrat in November, his record could face more scrutiny.

Under Perry, state health coverage took one of its biggest hits in 2003. Because health costs drive so much of the state budget, programs went under the meat cleaver when the state needed to slash $10 billion to balance the 2003 budget.

Perry and Republican legislative leaders insisted on closing the gap without raising taxes. One of the biggest cuts was in the Children's Health Insurance Program.

Among the things lost were dental, vision, mental health and hearing services for the children of working-poor families. The eligibility rules to get into the CHIP program also were tightened.

In the next three years, the state discontinued subsidizing insurance coverage for 230,000 children, cutting the program almost in half.

In his campaign stump speech, Perry touts the 2003 budget and the "tough decision-making" of the time. And while the Legislature has since restored most of the benefits and tweaked eligibility criteria, the enrollment of 491,000 children is below what it was six years ago – even though the state's population has climbed more than 2 million people since then. Hundreds of thousands of eligible children are not enrolled.

Also cut in 2003 were Medicaid reimbursement rates to doctors and hospitals. As a result, many doctors have refused to treat Medicaid patients and hospitals have struggled.

In a 1990 Texas Medical Association survey, 90 percent of primary care doctors accepted Medicaid patients. Last year, 38 percent did.

Health care is a sprawling, complicated area, experts note, and even a longtime officeholder such as Perry isn't solely responsible for it.

"The health care problems plaguing Texas today did not occur overnight," said Tom Banning, chief executive officer for the Texas Academy of Family Physicians. "They've built up over years and have been around long before Governor Perry's term in office."

On the good side, he said, the most effective way to improve health is through child immunizations and prenatal care.

"Texas has improved on both of these fronts," Banning said.

In 2002, 65 percent of children were immunized, but that reached 77 percent last year, with much of the growth occurring after Perry signed an executive order prompting the state health agency to improve.

Two of the other areas Perry has stressed in health care achievements were the $250,000 cap placed on medical malpractice lawsuits, making it impractical for lawyers to pursue most lawsuits against doctors.

This achievement was one of the primary reasons cited by the political arm of the Texas Medical Association when it endorsed Perry's re-election last month.

Perry has cited the lawsuit caps as a national model, pointing to the 27 percent cut in malpractice premiums that doctors pay and the 57 percent increase in doctors applying for a Texas medical license.

The idea was with less threat of lawsuits, cheaper insurance premiums for both doctors and hospitals and the addition of more doctors and greater marketplace competition, health care costs would decrease.

But a study just released by the liberal-leaning national group Public Citizen shows that lawsuit limits have not led to any savings for consumers.

"There is no evidence that any of the savings has been passed on to patients or taxpayers," the study found.

Citing state and federal agency statistics, the study shows Texas insurance premiums for individuals getting health coverage through their employer grew about 114 percent to an average of $4,205, which is about the same rate as national figures.

Another major initiative that Perry cites is his request to the federal government last year for flexibility in using federal money to insure more Texans.

Under the plan, some of the millions in Medicaid money that now goes to hospitals to help defray the cost of treating indigent and uninsured Texans would be diverted to pay for insurance policies.

The congressional plan under consideration – which Perry deplores – implements the idea, albeit on a much grander scale. Perry's waiver was never approved under the Bush administration and has even less chance now, those familiar with the plan said.

The Texas waiver would cover only a small portion of the millions of uninsured; it included high out-of-pocket expenses for those covered; and it would cover a maximum of just $25,000 in medical needs a year, said Anne Dunkelberg, a health policy analyst for the low-income advocating Center for Public Policy Priorities.

The governor has been trying to tailor pilot programs for Texas and limit hospital and emergency room care, the most expensive option in most cases, spokeswoman Castle said.

"The availability of affordable, quality medical care is important to all Texans," she said.

Health care initiatives supported by Gov. Rick Perry:

•Flexible health care plans that allow small businesses to form cooperatives to buy cheaper insurance.

•A "Healthy Texas" program that uses public funds to reinsure private insurance policies against catastrophic costs from providing services to small businesses.

•$3 billion in research bonds, approved by voters, for cancer prevention and research.

•An order, later negated by the Legislature, to require inoculation of girls against the human papillomavirus that causes cervical cancer.

•Creation of the Governor's Advisory Council on Physical Fitness and the Texas Round-Up statewide race.