A study by the American College of Emergency Physicians on emergency care across the U.S. paints a bleak picture of the nation as a whole.

The report card shows the overall grade went from a C- to a D+. Texas ranked 38th with a grade of D+.

“Texas didn't do so well,” said Dr. Jon Mark Hirshon, the report card chair. “Last time they got a C and this time they got a D+. They were 38th overall in the nation."

He said the biggest problems in Texas are uninsured patients and low Medicaid reimbursements.

“Health insurance for people -- they need to be able to access care. But on top of that, make sure there are enough physicians and enough specialists to take care of the patients that do come to the Emergency Department," Hirshon said.

He said changes must come from top Texas leaders.

"It's important that people tell their policy makers that this is an important component of healthcare and that they really need to spur their politicians to take action before the system totally degrades," Hirshon said.

In specific emergency care areas, Texas ranked 47th for access to emergency care and received a grade of F.

In quality and patient safety, Texas ranked 42nd and received a grade of F.

In public health and injury prevention, Texas ranked near the bottom at 49th and scored another grade of F.

The state’s best results were disaster preparedness, where the state ranked 21st with a grade of C, and medical liability, a 2nd place ranking with a grade of A.

Officials at University Hospital were not surprised that Texas ranked so low in emergency care.

Dr. Bruce Adams, University Hospital Emergency Medicine chair, said at least care in the ER at University Hospital is going to improve beginning in April. The hospital is doubling the size of the emergency room.

"In Texas, language it is 100,000 square feet, or the size of two high school football fields," Adams said.

Hirshon was glad to hear about the improvements coming to University.

“I think they should really be complimented and that type of (improvement) should be a model for the rest of the state,” Hirshon said.

But he warned that a bigger ER may not solve all problems.

“When you build it, people will come,” Hirshon said. “So they're going to have increased volumes in their large emergency department. It's going to be increased demand and decreased resources and it really is going to be a struggle to make sure that people can access emergency care when they need it.”

Meanwhile, Adams said he is unhappy with the Texas scores.

“It was disappointing to see,” Adams said. “Texas, in my mind, is the greatest state in the country and we ended up with a D. And Texas doesn't do Ds.”

He said state leaders need to make improvements like those that have been done in Bexar County.

"Texas as a whole went from a C to a D,” Adams said. “But I'd have to say San Antonio and University Hospital have gone from a D to a B and we're very proud of that."

He said the ER residency program at University is also helping by enlarging the supply of emergency room physicians.

Adams said University Hospital has also cut waiting time in the ER in half. Adams said with a sometimes empty waiting room, things were revealed that hadn’t been seen before.

“One of the executives came down and saw that we had some cracks and some rips in the chairs and said boy you've got to get these chairs replaced,” Adams said. “The truth was we hadn't seen the bottom of those chairs in years.”