Texas' healthcare system ranks among the worst in the nation, in large part because so many Texans go without health insurance.

That's a key finding of a "scorecard" released today by researchers at a unit of The Commonwealth Fund who examined each state's performance on 32 separate measures focused on healthcare quality, cost and access to care.

Overall, Texas ranked No. 49 -- third from the bottom -- in the study that included all 50 states and Washington, D.C.

The bottom line: Healthcare varies widely across the country. Even the best-performing states have lots of room for improvement. And those that spend the biggest bucks don't necessarily get top-notch healthcare for their money.

"The scorecard indicates that where you live in the United States matters," said Cathy Schoen, a senior vice president at The Commonwealth Fund who co-authored the report. "The wide variation and gaps between leading and lagging states add up to substantial human and economic costs."

Although no single state excelled across all the categories, states in the Northeast and Upper Midwest generally scored well.

The states that fared poorly include many with high percentages of uninsured residents.

In Texas, for example, just seven out of 10 adults under age 65 have health insurance. And fewer than 80 percent of children have coverage.

"Coverage is very tightly associated with other quality indicators, including hospitals meeting established guidelines," said Joel Cantor, a Rutgers University professor who was among the report's authors. "There's something about having coverage that leads to a healthcare system that is reasonably well-financed and that's able to tackle quality issues broadly. And it's not just access to the right services. It goes well beyond that."

David Tesmer, who is a senior vice president at Arlington-based Texas Health Resources, said the state's large uninsured population creates an uphill battle for healthcare providers, who often see patients with chronic conditions that have gone untreated for too long.

"When people have access to and can obtain healthcare coverage, they're more likely to seek medical care when it's needed and be healthier," said Tesmer, whose hospital chain operates Arlington Memorial and the Harris Methodist hospitals.

Still, hospitals and doctors can achieve marked improvements with the right training and incentives -- even when their patients have scant health coverage, said Dr. David Ballard, chief quality officer at Baylor Health Care System, which runs three Tarrant County hospitals.

"It doesn't absolve us in Texas of responsibility to provide the best care possible for our patients," he said.

Dr. Ladon Homer, a Fort Worth pathologist who is past president of the Texas Medical Association, said the state's system could make strides soon. That's because Texas lawmakers took steps this year to extend health benefits to more low-income families and funneled extra money to Medicaid and the Children's Health Insurance Program.

"Going forward, I'm hoping Texas won't be third from the bottom," Homer said. "It's not acceptable."

Potential for improvement

The Commonwealth Fund estimates that patients would see big changes if all states could match the top performers.

Specifically:

Almost 90,000 lives would be saved each year nationwide.

About half the country's uninsured people -- 22 million adults and children -- would get health coverage.

Almost 9 million older adults and almost 4 million diabetics would get recommended preventive care.

If states with high healthcare spending could bring their costs down to the typical rates, $22 billion to $38 billion would be saved.

In Texas, more than 3.6 million adults and children would have health insurance, and 7,505 premature deaths could be avoided.

Third from the bottom

In a ranking of the 50 states and the District of Columbia, Texas fares among the nation's worst in numerous categories.

Ranking Category

51 Access to healthcare

46 Quality care

48 Avoidable hospital spending

49 Equity among various groups

24 Healthy lives

49 Overall ranking

Ranked highest

1 Hawaii

2 Iowa

3 New Hampshire

3 Vermont

5 Maine

Ranked lowest

46 Louisiana

46 Nevada

48 Arkansas

49 Texas

50 Mississippi

50 Oklahoma

Source: The Commonwealth Fund Commission on a High Performance Health System