Senator Eliot Shapleigh - El Paso, Texas

Over 60 percent of uninsured Americans live in families with children.

George Hernández keeps a crystal ball of sorts in his University Hospital office. And the future he sees in it is a precarious one.

Hernández's prognosticator is a single demographic chart showing Texas' rapid population growth over the next several decades — an indicator, he believes, of the challenges on health care's horizon. Meanwhile, Texas, at 25.1 percent, now has the highest percentage in the nation of its population without health insurance.

The state's most rapidly expanding ethnic group, Hispanics, are the most likely to be uninsured or underinsured. That combination could amount to a disaster unless bold steps are taken soon, Hernández warned.

"You hear the phrase that people are 'falling through the cracks,' but 'cracks' seems to indicate it's somehow a small problem," he said. "When 25 percent don't have access to health care right now, these are holes, not cracks. And it's only going to get worse."

Sirens have been sounding for years about the issue, its human toll and its costs to society. Reports and recommendations abound on how to fix things, but significant change has yet to occur.

Six times in the past century, major efforts have been made to introduce some type of universal health insurance in the United States, but each was rejected. The first came during World War I; the last try happened during the Clinton years.

The lack of a comprehensive approach to the problem has resulted in a complicated patchwork of charity care that serves some and effectively shuts out others. Meanwhile, the gulf continues to widen between the haves and the have-nots:

Studies show the death rate in any given year for someone without health insurance is 25 percent higher than for someone with coverage.

Up to 2,500 in Texas die each year as a consequence of not having health insurance.

The leading cause of bankruptcy in the country is unpaid medical bills.

Half of those without insurance owe money to hospitals and a third are being pursued by collection agencies.

The significance of such statistics isn't lost on Kenneth Shine. Over the past year, Shine, the University of Texas system's executive vice chancellor for health affairs, has been crisscrossing the state handing out copies of a recent report that provides unique insight into the growing problem.

"Code Red: The Critical Condition of Health in Texas" is an evidence-based look at the statewide implications of inadequate access to health care. Sponsored by Texas' academic health centers, it provides 10 recommendations that its 19-member task force believes the state should consider, including universal access and increased health care funding.

Shine served as senior adviser to the task force, which consisted locally of University Health System's Hernández and Elaine Mendoza, CEO of Conceptual MindWorks, which provides medical, technical and scientific support to clients such as the Department of Defense.

The report's primary recommendation is that everyone in Texas should have access to adequate levels of health care.

"It's not that everyone should have health insurance," Shine stressed. "It's access to adequate care that we think is important."

Changing the way indigent health care is delivered would be a major step toward that goal, he said. A statewide system of care by regional and multi-county programs would be more efficient and fair, he said.

The current county-based system for the poor is inadequate, the report concluded.

The state's large urban counties, such as Bexar with its tax-supported hospital district, now shoulder most of the burden of the uninsured. Outside counties are only required to compensate medical providers when a patient's income is 21 percent of the federal poverty level, which is less than $4,000 a year for a family of four.

That leaves countless others searching for care. Many with serious health conditions often move into larger counties seeking treatment.

CareLink is the primary gateway into local indigent medical care, but currently it covers only 50,000 of the total 350,000 uninsured residents in Bexar County. Members pay reduced medical bills and get access to the University Health System, or UHS; the Cancer Therapy & Research Center; and several other local clinics.

To qualify, a person must be a resident of Bexar County and cannot have moved here just for medical reasons, said Steve Enders, UHS senior vice president.

Enders acknowledged it's difficult to monitor that requirement of CareLink. And it's also heartbreaking to turn away people with chronic, often life-threatening illnesses just because they don't live in the county, he said.

So within the last year, UHS set up a program designed to flag patients with serious medical needs who don't qualify for CareLink. At any given time, up to 40 people are on the list, and the staff works to try to get them both medical care and access to some sort of assistance program, be it local, state or federal, he said.

UHS is compiling statistics of the effort and wants to share them with legislators and county commissioners in surrounding areas that have little to no access to indigent care, Enders said.

"It argues for some kind of system where everyone has some sort of baseline coverage," he said.

Places that do large amounts of indigent care, such as UHS and the CTRC, say they're struggling under the weight of having to provide increasing amounts of uncompensated care to Bexar County's uninsured. There's also an overall shortage of doctors, which affects wait times for appointments for the indigent and can strain the overall efficiency of the system, Hernández said.

Last year, UHS performed $330 million in uncompensated care and CTRC provided $2 million. Texas hospitals in general do about $9 billion a year, said Richard Bettis, president of the Texas Hospital Association.

"Over time, that's unsustainable," he said. "The safety net is coming apart at the seams."

Several studies on Bexar County's safety net for the poor have noted that while CareLink is a unique program that benefits residents without insurance, it is severely limited. Because of funding restrictions, it enrolls only a fraction of the area's uninsured population, leaving a considerable gap in access for care, according to "Code Red."

CareLink relies on local hospital district taxes. Expanding the program to cover everyone would require a major tax hike, something citizens and politicians are unlikely to support, Hernández said.

Private doctors who treat patients with health insurance aren't immune, either. Since many Americans, Bettis said, are "just one incident away from indigency," doctors and hospitals often see patients who are insured one day, only to have lost coverage the next. Physicians are constantly faced with trying to decide how much uncompensated care they can shoulder without bankrupting their businesses, he said.

Dr. Karen Fields, president and CEO of the CTRC, noted that such goodwill often helps individual patients, but fails to make a system-wide impact.

"I'm happy there are doctors like (that), but it can't just be built on good people doing good things," she said. "But if we don't start saying that as a society we need to solve this problem, we'll have to keep piecing things together. And that's not working for anyone."