AUSTIN, Texas — The booming $1.8 trillion Texas economy rivals that of many countries and puts the state at the top of a host of rankings for its fast-growing cities, low unemployment and job growth.

But the familiar Texas braggadocio disappears when it comes to health care:

Texas has both the largest number (4.7 million) and highest percentage (19 percent) of uninsured residents under age 65 in the country, according to a new Urban Institute analysis. Two-thirds of the uninsured are in families with at least one full- or part-time worker. The state ranks 37th in the “2018 America's Health Rankings,” an annual state-by-state assessment of the nation's health. Thirty-three percent of adult Texans are obese. The state's maternal mortality rate is 34.2 per 100,000 live births, a rate that has increased 9 percent since 2016 and is one of the worst in the country. It ranks 45th in the number of primary care doctors per capita.

Related: Who are America's uninsured?

The state's “Don't Mess With Texas” mantra drives much of its politics and policies, as limited government, low taxes and individual rights have prevailed at the statehouse for almost a quarter-century. That freewheeling formula has worked gangbusters for the economy, including the business of medicine, giving rise to some of the nation's wealthiest hospital systems, as well as hundreds of freestanding emergency rooms and surgery centers.

But it has, ironically, also left citizens struggling to get care and pay bills in health care's wild west. It has allowed and supported entrepreneurial health care practices that are illegal in many states, including freestanding emergency rooms, doctor-owned hospitals and balance billing. Texas has more uninsured residents than any other state, in part because its largely Republican state politicians elected not to expand Medicaid.

“We're not having honest discussions about medical needs,” said Sen. Kirk Watson, a Democrat, a cancer survivor and former Austin mayor. Instead, the discussions focus on health care costs, he added.

'Free rein' for corporate systems

In August, Ken Blankenship, 48, of McKinney, Texas, was suffering from intense headaches, muscle pain and weakness. “I was hanging outside all day. It was hot,” he said, adding that he played basketball and threw around a baseball in the park. His wife forced him to go to an urgent care clinic, which diagnosed him as dehydrated, then referred him to a freestanding emergency room to rule out a stroke. Though the facility was in his insurance plan, his copayment was over $2,300 for fluids and a CAT scan.

“I was shocked. The first thing I thought was, 'That's crazy. It must be a mistake,'” Blankenship said. He got the bill reduced by more than $600 after calling the ER.

“All I know is they have me wanting to be thankful for paying $1,600,” he said.

In many cases, there has been “somewhat more of a free rein,” with corporate entities now involved in the practice of medicine, said economist David Warner, professor emeritus of health and social policy at the LBJ School of Public Affairs at the University of Texas at Austin.

In 2009, Texas was the first state to allow ERs that were independent of hospitals, prompting a rush of highly profitable ERs. At last count, 214 freestanding ERs have popped up across the state, in addition to hundreds of urgent care clinics and surgery centers.

“Basically, they can charge what they like,” Warner said. “They can have a charge scheme that has no relation to cost [of care].'' He adds that the freestanding ERs often mislead patients, telling them that their insurance will pay for everything and then going after the individuals for unpaid balances.

For the most part, the Texas Medical Association — the country's largest state medical group — has championed doctors' business interests and also lobbied against giving nurse practitioners more leeway to practice independently, as they do in neighboring states.

When the Texas Legislature convenes next month, the TMA will focus on “broken issues” including freestanding ERs, Medicaid and overall access to care, said Dr. Douglas Curran, TMA's president and a family physician in East Texas.

Lack of regulatory interest

Without policy changes, Texas' working poor and uninsured will continue to find it almost impossible to access quality care.

The state's failure to expand Medicaid — even in the midst of a robust economy — keeps millions of people in the Lone Star State living without insurance, straining the medical system, driving up costs and compromising public health.

“We can be a state that's wildly economically successful and still have more than one-quarter of our working-age adults uninsured,” said Anne Dunkelberg, associate director of the Center for Public Policy Priorities, a nonpartisan, nonprofit policy institute in Austin.

Health care experts maintain that the political leadership has no interest in reducing the number of uninsured. The chairman and vice chairman of the Texas House Public Health Committee — Reps. Four Price and J.D. Sheffield, both Republicans — declined to be interviewed.

“It's not the cost per Medicaid enrollee that's going up and up,” said Ken Janda, president and CEO of Community Health Choice, a nonprofit HMO for the Houston area. “We have too many poor people. A couple of years ago, there were only 3 million people on Medicaid, and now there's 4 million people,” he added.

The poor are “not immigrants coming over the border. It's people working at jobs that make minimum wage. These are not people sitting on their front porch waiting for their welfare checks,” Janda said.

The poor health outcomes aren't confined to the uninsured. Employers are increasingly reducing or eliminating altogether subsidies for employees to meet monthly premiums and are shifting to high-deductible plans for their workers.

“We all have to be personally accountable for health,” Janda told the audience at a two-day Healthier Texas Summit in Austin in October. “But it's very expensive and it's very difficult if you have people not getting the care they need because they've got a $5,000 deductible.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Everything's bigger in Texas, including its health care problems

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