HOUSTON At Ben Taub General Hospital in the rich U.S. oil hub of Houston, 52 people wait in a holding room designed for 26, in beds crammed so close together that patients can touch one another.
"They can't even go to a doctor, most of these people," because they lack health insurance, said Angela Siler Fisher, an associate medical director there. "We are their doctor."
The Texas Medical Center -- which is the size of Chicago's downtown Loop and has its own distinct skyline -- draws patients from around the world to its private rooms and specialized, cutting-edge treatments.
Houston, the fourth-largest American city, is a case study in the extremes of the U.S. healthcare system.
It boasts the immense medical center that offers top-notch care at its 13 hospitals, but also has a higher ratio of uninsured patients than any major U.S. city: about 30 percent. Cancer patients can get advanced radiation treatment, yet others need an emergency room just to fill a prescription.
"We've got wonderful access to high-technology procedures -- the best around -- if you are insured," said Guy Clifton, neurosurgery professor at the University of Texas Health Science Center.
President Barack Obama's top domestic priority is to overhaul the U.S. healthcare system and expand coverage to most of the 46 million uninsured Americans. That would mean nearly 6 million Texans, including the one in six U.S. uninsured children who live there, could get health insurance for the first time if the plan is enacted.
The president's $1 trillion healthcare reform bill faces opposition in Congress, as well as in Texas, which has the highest uninsured rate in the nation - about 25 percent. Polls show many Americans are skeptical it will succeed.
While debate rages on, the problems remain.
EXPENSIVE SAFETY NET
In recent years, the emergency room at Ben Taub has become the safety net for the nearly one in three people -- or 1.7 million -- in the Houston area who lack health insurance.
The hospital's holding room is where the "less sick" wait to see doctors. On any given day, patients could include diabetics waiting for dialysis, the mentally ill seeking psychiatric medicines and women with complications from pregnancy. The room is almost always packed.
"You see this guy sitting in a gown in his boxers?" said Fisher, associate medical director of Ben Taub's emergency room. "That's the level of privacy."
Uninsured patients are a huge financial burden for the U.S. healthcare system. They accounted for nearly 20 percent of 120 million U.S. emergency room visits in 2006, the most recent year tracked by the U.S. government.
While public emergency rooms are legally bound to care for critically ill patients, emergency treatment is expensive -- especially when you factor in ailments that could have been avoided with proper primary care.
Even without national action, several U.S. states are moving toward universal health coverage on their own -- including Connecticut, Vermont, Maine and Massachusetts.
But comprehensive coverage is unlikely to come to Texas without federal action. Texas Gov. Rick Perry opposes what he calls "Obamacare" as a federal intrusion on his state's right to set healthcare priorities.
In the meantime, local officials have no choice but to seek their own solutions.
Houston's Harris County Hospital District -- which operates the largest public primary health care network in Texas -- has built community clinics to relieve pressure on its crowded emergency rooms. The clinics are open to the uninsured and others who can't foot the bill for their treatment.
"We are already the model for health reform," said David Lopez, the district's chief executive officer. "Our incentive is to integrate to provide care at a reasonable cost."
The county is opening two new health clinics this year that will provide primary care to 137,000 people annually.
The additions will bring the its facilities to 13 community healthcare centers, 13 clinics in homeless shelters and eight in public schools, in addition to three hospitals.
In May, it opened the gleaming 66,000-square-foot (6,000 square meter) El Franco Lee Health Center in a densely populated area with a high percentage of Latinos and immigrants from China and Vietnam.
The center offers an array of services including prenatal, psychiatry, podiatry, dental care, optometry and radiology.
"We're catching up with a lot of unmet demand," said center director Ricci Sanchez. "A lot of them were crowding the emergency rooms. A lot of them were not seeking care at all."
Houston's economy has been resilient through the U.S. recession, with the help of record oil prices last year, a boon to energy companies like ConocoPhillips headquartered there.
But that prosperity has not trickled down to working class Texans or the illegal immigrants who make up about 8 percent of the state's workforce, according to the Pew Hispanic Center.
Some Texans point to illegal immigrants -- Texas has the second-highest undocumented population next to California -- as the main reason behind crowded emergency rooms and soaring costs. But Lopez said the facts don't support that. He cited a study that found undocumented patients accounted for 10 percent of his hospital district's annual $1.1 billion budget.
Health officials blame soaring costs partly on the lack of primary care. The district pays $174 per patient visit in its clinics, versus $11,700 for an average 6-day hospital stay.
"These clinics easily save our hospital system millions of dollars a year in costs," said John Martinez, a spokesman for the hospital district. Overall savings are hard to estimate but the health centers provide patients with a "medical home."
"The cost of taking care of them is a lot more efficient than waiting for them to get sick and admitting them to the hospital," Martinez said.
In Ohio last week, Obama touted the Cleveland Clinic as a model for the kind of low-cost, high-quality care he wants to offer through his 10-year plan to create a government-run insurance program to compete with private insurers.
Harris County's clinic-building effort is "exactly the right move," and statistics indicate that such efforts have spurred a decline in emergency room usage, said Clifton, who has studied the politics of health policy in Washington.
"To make ERs work and primary care work you have to get them covered," he said. "But if we don't deal with cost, and we are not dealing with costs, this is going to end very badly."
(Editing by Doina Chiacu)