A lot of Texans are quite proud of the Lone Star State's medical establishment and were annoyed at last week's report that Texas ranks 46th among the states in providing health care to all of its citizens.

You might expect that from a system that employs 234,000 people, with an annual payroll of $11.8 billion, just in the Dallas-Fort Worth area.

The ranking by researchers with the New York-based Commonwealth Fund, a private foundation focused on improving quality and access to health care, put Texas near the bottom largely because of the high number of uninsured and the state's limits on helping poorer adults who seek medical care.

Arlene Wohlgemuth, a senior fellow at the Texas Public Policy Foundation, faulted this result as a scorecard "weighted toward measurements of big government intervention."

"When it comes to measurements from the Fund's own data of actual health – including rates of cancer, infant mortality, suicide, and smoking – Texas ranks in the top half of states," she said in a prepared statement.

What happens if we leave things the way they are?

Chicago health care investment banker Dave Johnson thinks the triumph of the status quo would mean the rest of the nation soon looks like Texas does today – pockets of excellence, but high and rising costs, large numbers of uninsured and growing public health problems.

"Texas has all of the aspects of the U.S. health care system, for good and for bad, on steroids," Johnson said.

Johnson serves on the audit committee of Christus Health system, a Catholic charities group with more than 50 hospitals and long-term care facilities in Mexico, Texas and five other states.

What he sees in Texas is a health care system that operates with more market competition than the rest of the nation. Anyone can build a hospital, an imaging center or a clinic. Several hospital chains and insurance companies compete for patients.

But this competition occurs in a system where the focus is on more treatment rather than doing what's necessary to get the patient well – and keeping them that way.

"If we don't somehow change the incentive structures to do preventive care and disease care, then the current incentives as they work will continue to give us the health system we have, which produces a lot of activity and does some remarkable things but is exceptionally costly and has a lot of coverage gaps," he said.

Christus has made a big push recently into northern Mexico, and Johnson said such facilities may soon give Texas hospitals a new sort of competition based on price.

"If it were possible to go to Mexico to get the same procedure for a third or half the cost, with equal or better quality, that will be attractive to some segment of [the] marketplace," he said.

Many Texans trace their health care system's ills back to Mexico because it is the source for so many of the immigrants who make their way into the state. Yet only a fourth of the uninsured who live in Texas are immigrants, legal or otherwise, according to the U.S. Census Bureau's latest estimates.

Less than half the state's residents now get employer-provided health insurance. Almost one third of the working-age population (age 18 to 65) doesn't have health insurance.

As medical costs rise, Texas companies have raised premiums, co-pays and deductibles for their employees – or quit offering insurance. The same trend is evident nationwide – but it's not as acute as it is in Texas.