Everything, they say, is bigger in the Texas. So it is with the failure of the health care system. Leading the nation with a jaw-dropping 25% of its residents uninsured, Texas ranked 46th in the Commonwealth Fund's 2009 scorecard of state health care performance. All of which makes Friday's op-ed by Newt Gingrich and Governor Rick Perry touting the mess in Texas all the more puzzling.

Just two days after the CBO dismissed a House Republican plan that would barely dent the rolls of the uninsured, Perry and Gingrich blasted Democratic health care reform in a Washington Post screed titled, "Let States Lead the Way." Besides dredging up Newt's worn out 1990's vintage talking points on unfunded mandates, the duo insist it is the Lone Star State which should be at the front of that vanguard:

Texas, for example, has adopted approaches to controlling health-care costs while improving choice, advancing quality of care and expanding coverage. Consider the successful 2003 tort reform. Fewer frivolous lawsuits have attracted record numbers of doctors to the state as medical malpractice insurance premiums dropped by half. Christus Health, a large Catholic nonprofit system with a significant presence in Texas, spent about $100 million on liability defense payments in 2003. Last year, Christus spent $2.3 million on such payments. Much of that savings has gone into expanding health-care services in low-income neighborhoods.

As the Post's Erza Klein asks, "how's that working out?"

The answer, of course, is quite poorly. While from 2007 to 2009 Texas nudged its way from a horrific 48th to a merely miserable 46th in the Commonwealth Fund rankings, the health care system there remains an ongoing calamity for its residents. Among the poster children for the failure of red state health care, Perry's state brought up the rear across the five indicators measured. When it comes to health care access and equity, Texas is dead last. (See table above.)

While it is predictable that Republicans Gingrich and Perry cite Texas' draconian tort reform law as an example for the nation, the data is far from clear as to its benefits in actually reducing malpractice premiums, lowering costs and attracting physicians to the underserved state.

As I previously noted in "Republican Malpractice Myths," it comes as no surprise that a cavalcade of GOP leaders, including Perry, Sarah Palin, John Cornyn and John Kyl cited the same study showing malpractice awards caps enacted in 2003 in Texas fueled an increase in the number of physicians in the Lone Star State:

According to the Pacific Research Institute, medical licenses in Texas have increased 18 percent in the last four years, with 7,000 new doctors moving to the state.

The actual impact of the Texas law, however, remains in dispute. The state's rising population, its 48th place ranking in physicians per capita, its staggering percentage of uninsured, its lack of an income tax and the 147% jump in malpractice premiums in 2003 alone make gauging the unique contribution of malpractice caps difficult to assess. Regardless, health care costs in Texas have continued their upward spiral.

What seems beyond dispute is that other similar malpractice cap states like Mississippi have not seen an influx of new doctors. The Jackson Free Press took exception to Governor Haley Barbour's claim that tort reform meant that physicians "have quit leaving the state and limiting their practices to avoid lawsuit abuse":

But non-partisan facts show that doctors were never really leaving the state in the first place. A 2003 Government Accountability Office report, "Medical Malpractice: Implications of Rising Premiums on Access to Health Care," took a hard look at five medical "crisis" states--Mississippi, Nevada, Pennsylvania, West Virginia and Florida--and dismissed reports of doctor emigration from states.

Information compiled by the American Medical Association--which supports tort reform and President Obama's vision of health reform--shows that the number of physicians in Mississippi rose steadily in years leading up to tort-reform legislation in 2004, and even slowed its increase following 2004.

From 2004 to 2005, the state actually recorded no increase over the 5,872 doctors counted in 2004, and added only 18 new physicians in 2006. The year 2007 reflected an increase of 71 physicians--still less than the 145-increase between 2000 and 2001 and the 99-doctor increase between 1998 and 1999. Even the time between 2002 and 2003--arguably the years of the worst tort abuse, according to tort-reform proponents--experienced a growth in the state doctor population of 140.

Ironically, to the degree that Texas and other red state bastions of medical misery have made minor improvements in recent years, the credit in large part goes to the federal government and the expansion by Democrats of initiatives like the State Children's Health Insurance Program (SCHIP). As the Commonwealth Fund concluded its 2009 study:

The 2009 State Scorecard paints a picture of health care systems under stress, with deteriorating health insurance coverage for adults and rising health care costs. On a positive note, there were gains in children's coverage as a result of national reforms, and improvement in some measures of hospital and nursing home care following federal efforts to publicly report quality data.

In a final irony, as Klein suggests, there is a Republican Governor with whom Gingrich could have partnered to make the case for the states as the laboratories of health care reform: Mitt Romney. Thanks to its own insurance mandate passed during Mitt's tenure, the percentage of uninsured in 6th ranked Massachusetts has dropped to 3%. But as Klein muses:

Romney, however, disowned his bill after he realized the Republican base didn't like health-care reform.

Regardless, when it comes to a model for reforming the U.S. health care system, don't mess with Texas.

(This piece also appears at Perrspectives.)