Joel B. Finkelstein

WASHINGTON – Hospitals are getting smart instead of angry about competition from physicians.

“A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities,” Dr. Robert Berenson, a senior fellow at the Washington-based think tank The Urban Institute, said at a press briefing on health care costs sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team. “Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals,” he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on “what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings.”

To counteract such trends, “what we have seen over the last 5-8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it,” he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

“It is really interesting how things come full circle,” said Mr. Feinstein. “Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it.”

There are similarities, but some important differences this time around, Mr. Schaub said. “In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus,” he said.

WASHINGTON – Hospitals are getting smart instead of angry about competition from physicians.

“A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities,” Dr. Robert Berenson, a senior fellow at the Washington-based think tank The Urban Institute, said at a press briefing on health care costs sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team. “Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals,” he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on “what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings.”

To counteract such trends, “what we have seen over the last 5-8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it,” he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

“It is really interesting how things come full circle,” said Mr. Feinstein. “Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it.”

There are similarities, but some important differences this time around, Mr. Schaub said. “In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus,” he said.

WASHINGTON – Hospitals are getting smart instead of angry about competition from physicians.

“A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities,” Dr. Robert Berenson, a senior fellow at the Washington-based think tank The Urban Institute, said at a press briefing on health care costs sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team. “Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals,” he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on “what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings.”

To counteract such trends, “what we have seen over the last 5-8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it,” he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

“It is really interesting how things come full circle,” said Mr. Feinstein. “Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it.”

There are similarities, but some important differences this time around, Mr. Schaub said. “In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus,” he said.

WASHINGTON — Hospitals are getting smart instead of angry about competition from physicians.

“A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities,” Dr. Robert Berenson, a senior fellow at the Washington-based think tank the Urban Institute, said at a press briefing on health care costs that was sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team.

“Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals,” he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on “what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings.”

To counteract such trends, “what we have seen over the last 5–8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it,” he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

“It is really interesting how things come full circle,” said Mr. Feinstein. “Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it.”

There are similarities, but some important differences this time around, Mr. Schaub said.

“In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus, whether it's service-line related or to head off entrepreneurs splitting off or to focus on a particular geography, hospitals in a lot of markets are being more selective than they were 10 years ago,” he said.

WASHINGTON — Hospitals are getting smart instead of angry about competition from physicians.

“A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities,” Dr. Robert Berenson, a senior fellow at the Washington-based think tank the Urban Institute, said at a press briefing on health care costs that was sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team.

“Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals,” he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on “what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings.”

To counteract such trends, “what we have seen over the last 5–8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it,” he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

“It is really interesting how things come full circle,” said Mr. Feinstein. “Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it.”

There are similarities, but some important differences this time around, Mr. Schaub said.

“In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus, whether it's service-line related or to head off entrepreneurs splitting off or to focus on a particular geography, hospitals in a lot of markets are being more selective than they were 10 years ago,” he said.

WASHINGTON — Hospitals are getting smart instead of angry about competition from physicians.

“A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities,” Dr. Robert Berenson, a senior fellow at the Washington-based think tank the Urban Institute, said at a press briefing on health care costs that was sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team.

“Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals,” he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on “what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings.”

To counteract such trends, “what we have seen over the last 5–8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it,” he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

“It is really interesting how things come full circle,” said Mr. Feinstein. “Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it.”

There are similarities, but some important differences this time around, Mr. Schaub said.

“In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus, whether it's service-line related or to head off entrepreneurs splitting off or to focus on a particular geography, hospitals in a lot of markets are being more selective than they were 10 years ago,” he said.

WASHINGTON — Hospitals are getting smart instead of angry about competition from physicians.

"A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities," Dr. Robert Berenson, a senior fellow at the Washington-based think tank of the Urban Institute, said at a press briefing on health care costs sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team.

"Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals," he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on "what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings."

To counteract such trends, "what we have seen over the last 5–8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it," he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

"It is really interesting how things come full circle," said Mr. Feinstein. "Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it."

There are similarities, but some important differences this time around, Mr. Schaub said.

"In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus, whether it's service-line related or to head off entrepreneurs splitting off or to focus on a particular geography, hospitals in a lot of markets are being more selective than they were 10 years ago," he said.

WASHINGTON — Hospitals are getting smart instead of angry about competition from physicians.

"A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities," Dr. Robert Berenson, a senior fellow at the Washington-based think tank of the Urban Institute, said at a press briefing on health care costs sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team.

"Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals," he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on "what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings."

To counteract such trends, "what we have seen over the last 5–8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it," he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

"It is really interesting how things come full circle," said Mr. Feinstein. "Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it."

There are similarities, but some important differences this time around, Mr. Schaub said.

"In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus, whether it's service-line related or to head off entrepreneurs splitting off or to focus on a particular geography, hospitals in a lot of markets are being more selective than they were 10 years ago," he said.

WASHINGTON — Hospitals are getting smart instead of angry about competition from physicians.

"A lot of care is moving from the hospital to the ambulatory sector, some of which is still under the auspices of the hospital, but increasingly into doctor's offices, into physician-owned ambulatory surgery centers, imaging centers, testing facilities," Dr. Robert Berenson, a senior fellow at the Washington-based think tank of the Urban Institute, said at a press briefing on health care costs sponsored by the Center for Studying Health System Change.

Physicians often set up these centers in part out of frustration with hospital bureaucracy, but also in response to economic pressures, said Adam Feinstein, a managing director at Lehman Brothers where he coordinates the health care facilities research team.

"Physician incomes have been going down. They have been looking to make up for the lost income, and they're competing more aggressively with the hospitals," he said.

Over the past 10 years, the number of ambulatory surgery centers has doubled to approximately 5,000. There are now almost as many surgery centers as there are hospitals in the country. By comparison, there are only about 100 specialty hospitals in the United States, despite all the political attention they get.

Jeff Schaub, who rates acute care hospitals for the international credit rating firm Fitch Ratings, pointed out that when hospital leadership does not focus on "what their physicians are doing and want to do, we have seen dozens of places have their outpatient surgery volumes cut in half because docs have gone out and put up buildings."

To counteract such trends, "what we have seen over the last 5–8 years is tremendous interest on the part of hospitals and systems to do joint ventures with physicians, figuring that they would rather lose half the business than all of it," he said.

Alternatively, some hospitals have tried to integrate physicians into more of the business decisions, hoping to create a more comfortable environment for them to work and minimizing their desire to go off on their own, Mr. Schaub said.

"It is really interesting how things come full circle," said Mr. Feinstein. "Hospitals were letting doctors partner with them back in the mid-1990s, there was a lot of scrutiny over this so everyone stopped doing it, and now here we are again and everyone is doing it."

There are similarities, but some important differences this time around, Mr. Schaub said.

"In the 1990s, everybody was buying practices just because everybody else was buying practices. Now what I see is a much more strategic focus, whether it's service-line related or to head off entrepreneurs splitting off or to focus on a particular geography, hospitals in a lot of markets are being more selective than they were 10 years ago," he said.

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his state of the union address in January.

In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers. Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.

The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.

"The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest. … There is evidence … that we could get more for our money," said Dr. Baicker.

Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.

However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.

"As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable," said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington, D.C.

He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't. But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. "Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning."

Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. "Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow," said Dr. Baicker.

Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at state rather than the national level.

"We are not—let's be honest here—on the verge of a national consensus about which of those models will work, and we are not close to the prospect of being able to get 60 votes in the Senate and a presidential signature," he said. "Health care financing is too vast to be remade in a single bill. It will come gradually and over time."

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his state of the union address in January.

In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers. Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.

The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.

"The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest. … There is evidence … that we could get more for our money," said Dr. Baicker.

Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.

However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.

"As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable," said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington, D.C.

He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't. But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. "Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning."

Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. "Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow," said Dr. Baicker.

Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at state rather than the national level.

"We are not—let's be honest here—on the verge of a national consensus about which of those models will work, and we are not close to the prospect of being able to get 60 votes in the Senate and a presidential signature," he said. "Health care financing is too vast to be remade in a single bill. It will come gradually and over time."

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his state of the union address in January.

In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers. Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.

The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.

"The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest. … There is evidence … that we could get more for our money," said Dr. Baicker.

Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.

However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.

"As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable," said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington, D.C.

He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't. But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. "Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning."

Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. "Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow," said Dr. Baicker.

Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at state rather than the national level.

"We are not—let's be honest here—on the verge of a national consensus about which of those models will work, and we are not close to the prospect of being able to get 60 votes in the Senate and a presidential signature," he said. "Health care financing is too vast to be remade in a single bill. It will come gradually and over time."

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his state of the union address in January. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers. Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families. The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a briefing sponsored by the Alliance for Health Reform.

“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest. … There is evidence … that we could get more for our money,” said Dr. Baicker.

Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms. However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it. As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.

Providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't. But as fewer people can afford coverage, it will become more difficult to accept nonpayers.

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his state of the union address in January. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers. Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families. The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a briefing sponsored by the Alliance for Health Reform.

“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest. … There is evidence … that we could get more for our money,” said Dr. Baicker.

Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms. However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it. As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.

Providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't. But as fewer people can afford coverage, it will become more difficult to accept nonpayers.

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his state of the union address in January. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers. Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families. The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a briefing sponsored by the Alliance for Health Reform.

“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest. … There is evidence … that we could get more for our money,” said Dr. Baicker.

Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms. However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it. As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.

Providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't. But as fewer people can afford coverage, it will become more difficult to accept nonpayers.

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his January state of the union address. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers.

Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.

The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.

“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest,” Dr. Baicker said.

There is evidence “that we could get more for our money,” she added.

Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.

However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.

“As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.

He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't.

But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. “Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning.”

Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. “Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow,” Dr. Baicker said.

Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at the state rather than the national level.

“We are not—let's be honest here—on the verge of a national consensus about which of those models will work, and we are not close to the prospect of being able to get 60 votes in the Senate and a presidential signature,” he said. “Health care financing is too vast to be remade in a single bill. It will come gradually and over time.”

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his January state of the union address. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers.

Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.

The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.

“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest,” Dr. Baicker said.

There is evidence “that we could get more for our money,” she added.

Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.

However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.

“As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.

He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't.

But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. “Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning.”

Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. “Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow,” Dr. Baicker said.

Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at the state rather than the national level.

“We are not—let's be honest here—on the verge of a national consensus about which of those models will work, and we are not close to the prospect of being able to get 60 votes in the Senate and a presidential signature,” he said. “Health care financing is too vast to be remade in a single bill. It will come gradually and over time.”

WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.

Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.

Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.

The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his January state of the union address. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers.

Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.

The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.

The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.

“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest,” Dr. Baicker said.

There is evidence “that we could get more for our money,” she added.

Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.

Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.

More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.

However, there are more fundamental differences in the philosophies that undergird many of these proposals.

Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.

“As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.

He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't.

But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. “Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning.”

Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. “Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow,” Dr. Baicker said.

Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at the state rather than the national level.

“We are not—let's be honest here—on the verge of a national consensus about which of those models will work, and we are not close to the prospect of being able to get 60 votes in the Senate and a presidential signature,” he said. “Health care financing is too vast to be remade in a single bill. It will come gradually and over time.”

WASHINGTON – Companies both large and small are finding it increasingly difficult to afford the health insurance coverage they have traditionally provided to their workers, experts warned at a conference sponsored by AcademyHealth.

Employer-based insurance remains the dominant source of coverage in the American health care system. However, the proportion of companies that provide health benefits dropped from 70% in 2000 to 60% in 2005. Small businesses, those with only a handful of employees, have been especially hard hit by rising premiums, said Todd McCracken, president of the National Small Business Association.

“We have reached a point in the past couple of years where for the first time in memory, most of these companies now do not provide health benefits to their employees,” he said.

Of the small companies that can still offer health coverage, few can give their workers a choice of health plans, and they are often not happy with the plans they can offer. In any given year, 60% of small companies are shopping around for another health plan, but only 24% make a switch, according to data from the Kaiser Family Foundation.

“Small businesses are constantly in the marketplace looking for a better deal, sure that there's something out there for them that can bring prices in line, when in fact, they don't find much or they find choices that are even worse,” he said.

When they come up empty, most companies have few options other than shifting more of the cost of premiums to their workers or reducing benefits, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics. “The share that employees will be asked to bear simply outstrips any realistic ability they may have to pay,” Mr. McCracken said.

Large companies also face rising health insurance premiums and are passing them on to their employees, said Mary Kay Henry, who leads the health systems division of the Service Employees International Union.

The union represents 700,000 workers worldwide. About half have no health coverage and the other half are being asked to share more of the cost of their health insurance. Over the past few years, SEIU has increasingly found itself in difficult negotiations with employers over health benefits at both the level of collective bargaining and that of individual workers.

“Beyond the bargaining problem, we also had a crisis happening for individual workers, which was [that] they were, by virtue of no coverage, having to face not getting the medical care they needed in order to live,” she said.

Every physician has a horror story about some uninsured patient who should have come in sooner, said Dr. Eduardo Sanchez, director of the Institute for Health Policy at the University of Texas Health Science Center in Houston.

“My horror story involves a gentleman, a laborer who came in to see me for a 'blister.' When we got his shoe off, he actually had a through-and-through diabetic ulcer on one of this toes. He went straight to a hospital and had a couple of toes amputated. … Had this gentleman been diagnosed with diabetes 5 years earlier, it would have cost a whole lot less money with a whole lot less trauma,” he said.

The uninsured end up with a greater level of need for care, which is often uncompensated. That cost is passed on to those who can pay, which in turn causes insurance premiums to rise. The result is that more employers drop coverage because of high premiums and the cycle starts all over again. That cycle needs to be broken, he said.

Although the solution is not clear, there does seem to be a movement for everyone to come to the table, the experts said.

“We're not going to stand on the sidelines of a political debate, we're going to engage the debate in our mutual interest and figure out a solution for everyone in this country,” Ms. Henry said.

WASHINGTON – Companies both large and small are finding it increasingly difficult to afford the health insurance coverage they have traditionally provided to their workers, experts warned at a conference sponsored by AcademyHealth.

Employer-based insurance remains the dominant source of coverage in the American health care system. However, the proportion of companies that provide health benefits dropped from 70% in 2000 to 60% in 2005. Small businesses, those with only a handful of employees, have been especially hard hit by rising premiums, said Todd McCracken, president of the National Small Business Association.

“We have reached a point in the past couple of years where for the first time in memory, most of these companies now do not provide health benefits to their employees,” he said.

Of the small companies that can still offer health coverage, few can give their workers a choice of health plans, and they are often not happy with the plans they can offer. In any given year, 60% of small companies are shopping around for another health plan, but only 24% make a switch, according to data from the Kaiser Family Foundation.

“Small businesses are constantly in the marketplace looking for a better deal, sure that there's something out there for them that can bring prices in line, when in fact, they don't find much or they find choices that are even worse,” he said.

When they come up empty, most companies have few options other than shifting more of the cost of premiums to their workers or reducing benefits, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics. “The share that employees will be asked to bear simply outstrips any realistic ability they may have to pay,” Mr. McCracken said.

Large companies also face rising health insurance premiums and are passing them on to their employees, said Mary Kay Henry, who leads the health systems division of the Service Employees International Union.

The union represents 700,000 workers worldwide. About half have no health coverage and the other half are being asked to share more of the cost of their health insurance. Over the past few years, SEIU has increasingly found itself in difficult negotiations with employers over health benefits at both the level of collective bargaining and that of individual workers.

“Beyond the bargaining problem, we also had a crisis happening for individual workers, which was [that] they were, by virtue of no coverage, having to face not getting the medical care they needed in order to live,” she said.

Every physician has a horror story about some uninsured patient who should have come in sooner, said Dr. Eduardo Sanchez, director of the Institute for Health Policy at the University of Texas Health Science Center in Houston.

“My horror story involves a gentleman, a laborer who came in to see me for a 'blister.' When we got his shoe off, he actually had a through-and-through diabetic ulcer on one of this toes. He went straight to a hospital and had a couple of toes amputated. … Had this gentleman been diagnosed with diabetes 5 years earlier, it would have cost a whole lot less money with a whole lot less trauma,” he said.

The uninsured end up with a greater level of need for care, which is often uncompensated. That cost is passed on to those who can pay, which in turn causes insurance premiums to rise. The result is that more employers drop coverage because of high premiums and the cycle starts all over again. That cycle needs to be broken, he said.

Although the solution is not clear, there does seem to be a movement for everyone to come to the table, the experts said.

“We're not going to stand on the sidelines of a political debate, we're going to engage the debate in our mutual interest and figure out a solution for everyone in this country,” Ms. Henry said.

WASHINGTON – Companies both large and small are finding it increasingly difficult to afford the health insurance coverage they have traditionally provided to their workers, experts warned at a conference sponsored by AcademyHealth.

Employer-based insurance remains the dominant source of coverage in the American health care system. However, the proportion of companies that provide health benefits dropped from 70% in 2000 to 60% in 2005. Small businesses, those with only a handful of employees, have been especially hard hit by rising premiums, said Todd McCracken, president of the National Small Business Association.

“We have reached a point in the past couple of years where for the first time in memory, most of these companies now do not provide health benefits to their employees,” he said.

Of the small companies that can still offer health coverage, few can give their workers a choice of health plans, and they are often not happy with the plans they can offer. In any given year, 60% of small companies are shopping around for another health plan, but only 24% make a switch, according to data from the Kaiser Family Foundation.

“Small businesses are constantly in the marketplace looking for a better deal, sure that there's something out there for them that can bring prices in line, when in fact, they don't find much or they find choices that are even worse,” he said.

When they come up empty, most companies have few options other than shifting more of the cost of premiums to their workers or reducing benefits, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics. “The share that employees will be asked to bear simply outstrips any realistic ability they may have to pay,” Mr. McCracken said.

Large companies also face rising health insurance premiums and are passing them on to their employees, said Mary Kay Henry, who leads the health systems division of the Service Employees International Union.

The union represents 700,000 workers worldwide. About half have no health coverage and the other half are being asked to share more of the cost of their health insurance. Over the past few years, SEIU has increasingly found itself in difficult negotiations with employers over health benefits at both the level of collective bargaining and that of individual workers.

“Beyond the bargaining problem, we also had a crisis happening for individual workers, which was [that] they were, by virtue of no coverage, having to face not getting the medical care they needed in order to live,” she said.

Every physician has a horror story about some uninsured patient who should have come in sooner, said Dr. Eduardo Sanchez, director of the Institute for Health Policy at the University of Texas Health Science Center in Houston.

“My horror story involves a gentleman, a laborer who came in to see me for a 'blister.' When we got his shoe off, he actually had a through-and-through diabetic ulcer on one of this toes. He went straight to a hospital and had a couple of toes amputated. … Had this gentleman been diagnosed with diabetes 5 years earlier, it would have cost a whole lot less money with a whole lot less trauma,” he said.

The uninsured end up with a greater level of need for care, which is often uncompensated. That cost is passed on to those who can pay, which in turn causes insurance premiums to rise. The result is that more employers drop coverage because of high premiums and the cycle starts all over again. That cycle needs to be broken, he said.

Although the solution is not clear, there does seem to be a movement for everyone to come to the table, the experts said.

“We're not going to stand on the sidelines of a political debate, we're going to engage the debate in our mutual interest and figure out a solution for everyone in this country,” Ms. Henry said.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy.

“For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government,” he added.

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse. Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation. However, that aspect of the plan should not be interpreted as a code word for social Darwinism, or as survival of the healthiest, wealthiest, and luckiest members of society, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures. Aspiring states are not only studying these models for the lessons they hold, but also for the encouragement they provide, experts said.

“A lot of people feel if California as a state can make meaningful inroads in terms of our coverage and cost challenges, then that offers some hope and promise for other states, just given the size and the magnitude of our challenges,” said Ms. Belshe.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy.

“For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government,” he added.

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse. Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation. However, that aspect of the plan should not be interpreted as a code word for social Darwinism, or as survival of the healthiest, wealthiest, and luckiest members of society, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures. Aspiring states are not only studying these models for the lessons they hold, but also for the encouragement they provide, experts said.

“A lot of people feel if California as a state can make meaningful inroads in terms of our coverage and cost challenges, then that offers some hope and promise for other states, just given the size and the magnitude of our challenges,” said Ms. Belshe.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy.

“For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government,” he added.

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse. Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation. However, that aspect of the plan should not be interpreted as a code word for social Darwinism, or as survival of the healthiest, wealthiest, and luckiest members of society, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures. Aspiring states are not only studying these models for the lessons they hold, but also for the encouragement they provide, experts said.

“A lot of people feel if California as a state can make meaningful inroads in terms of our coverage and cost challenges, then that offers some hope and promise for other states, just given the size and the magnitude of our challenges,” said Ms. Belshe.

WASHINGTON — Companies both large and small are finding it increasingly difficult to afford the health insurance coverage they have traditionally provided to their workers, experts warned at a conference sponsored by AcademyHealth.

Employer-based insurance remains the dominant source of coverage in the American health care system. However, the proportion of companies that provide health benefits dropped from 70% in 2000 to 60% in 2005. Small businesses, those with only a handful of employees, have been especially hard hit by rising premiums, said Todd McCracken, president of the National Small Business Association.

“We have reached a point in the past couple of years where for the first time in memory, most of these companies now do not provide health benefits to their employees,” he said.

Of the small companies that can still offer health coverage, few can give their workers a choice of health plans, and they are often not happy with the plans they can offer. In any given year, 60% of small companies are shopping around for another health plan, but only 24% make a switch, according to data from the Kaiser Family Foundation.

“Small businesses are constantly in the marketplace looking for a better deal, sure that there's something out there for them that can bring prices in line, when in fact, they don't find much or they find choices that are even worse,” he said.

When they come up empty, most companies have few options other than shifting more of the cost of premiums to their workers or reducing benefits, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics.

“The share that employees will be asked to bear simply outstrips any realistic ability they may have to pay,” Mr. McCracken said.

Large companies also face rising health insurance premiums and are passing them on to their employees, said Mary Kay Henry, who leads the health systems division of the Service Employees International Union.

The union represents 700,000 workers worldwide. About half of them have no health coverage and the other half are being asked to share more of the cost of their health insurance. Over the past few years, SEIU has increasingly found itself in difficult negotiations with employers over health benefits at both the level of collective bargaining and that of individual workers.

“Beyond the bargaining problem, we also had a crisis happening for individual workers, which was [that] they were, by virtue of no coverage, having to face not getting the medical care they needed in order to live,” she said.

WASHINGTON — Companies both large and small are finding it increasingly difficult to afford the health insurance coverage they have traditionally provided to their workers, experts warned at a conference sponsored by AcademyHealth.

Employer-based insurance remains the dominant source of coverage in the American health care system. However, the proportion of companies that provide health benefits dropped from 70% in 2000 to 60% in 2005. Small businesses, those with only a handful of employees, have been especially hard hit by rising premiums, said Todd McCracken, president of the National Small Business Association.

“We have reached a point in the past couple of years where for the first time in memory, most of these companies now do not provide health benefits to their employees,” he said.

Of the small companies that can still offer health coverage, few can give their workers a choice of health plans, and they are often not happy with the plans they can offer. In any given year, 60% of small companies are shopping around for another health plan, but only 24% make a switch, according to data from the Kaiser Family Foundation.

“Small businesses are constantly in the marketplace looking for a better deal, sure that there's something out there for them that can bring prices in line, when in fact, they don't find much or they find choices that are even worse,” he said.

When they come up empty, most companies have few options other than shifting more of the cost of premiums to their workers or reducing benefits, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics.

“The share that employees will be asked to bear simply outstrips any realistic ability they may have to pay,” Mr. McCracken said.

Large companies also face rising health insurance premiums and are passing them on to their employees, said Mary Kay Henry, who leads the health systems division of the Service Employees International Union.

The union represents 700,000 workers worldwide. About half of them have no health coverage and the other half are being asked to share more of the cost of their health insurance. Over the past few years, SEIU has increasingly found itself in difficult negotiations with employers over health benefits at both the level of collective bargaining and that of individual workers.

“Beyond the bargaining problem, we also had a crisis happening for individual workers, which was [that] they were, by virtue of no coverage, having to face not getting the medical care they needed in order to live,” she said.

WASHINGTON — Companies both large and small are finding it increasingly difficult to afford the health insurance coverage they have traditionally provided to their workers, experts warned at a conference sponsored by AcademyHealth.

Employer-based insurance remains the dominant source of coverage in the American health care system. However, the proportion of companies that provide health benefits dropped from 70% in 2000 to 60% in 2005. Small businesses, those with only a handful of employees, have been especially hard hit by rising premiums, said Todd McCracken, president of the National Small Business Association.

“We have reached a point in the past couple of years where for the first time in memory, most of these companies now do not provide health benefits to their employees,” he said.

Of the small companies that can still offer health coverage, few can give their workers a choice of health plans, and they are often not happy with the plans they can offer. In any given year, 60% of small companies are shopping around for another health plan, but only 24% make a switch, according to data from the Kaiser Family Foundation.

“Small businesses are constantly in the marketplace looking for a better deal, sure that there's something out there for them that can bring prices in line, when in fact, they don't find much or they find choices that are even worse,” he said.

When they come up empty, most companies have few options other than shifting more of the cost of premiums to their workers or reducing benefits, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics.

“The share that employees will be asked to bear simply outstrips any realistic ability they may have to pay,” Mr. McCracken said.

Large companies also face rising health insurance premiums and are passing them on to their employees, said Mary Kay Henry, who leads the health systems division of the Service Employees International Union.

The union represents 700,000 workers worldwide. About half of them have no health coverage and the other half are being asked to share more of the cost of their health insurance. Over the past few years, SEIU has increasingly found itself in difficult negotiations with employers over health benefits at both the level of collective bargaining and that of individual workers.

“Beyond the bargaining problem, we also had a crisis happening for individual workers, which was [that] they were, by virtue of no coverage, having to face not getting the medical care they needed in order to live,” she said.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy. “For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government.”

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse. Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation, but that should not be interpreted as a code word for social Darwinism, or survival of the healthiest, wealthiest, and luckiest, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures, not only for the lessons they hold, but also for the encouragement they provide, experts said.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy. “For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government.”

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse. Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation, but that should not be interpreted as a code word for social Darwinism, or survival of the healthiest, wealthiest, and luckiest, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures, not only for the lessons they hold, but also for the encouragement they provide, experts said.

WASHINGTON — What was a trend is looking more like a wave as an increasing number of states, no longer content to wait on the seemingly glacial pace of national politics, are seeking their own comprehensive solutions to the growing ranks of the uninsured, state health care reformers said at a conference sponsored by AcademyHealth.

“Can state innovations work on a national problem? It's somewhat of a rhetorical question. There's a growing sense of insecurity among our people that more and more of our citizens … are losing access to affordable health care. It's becoming more like a lottery with more losers,” said Jim Leddy, a former Vermont senator who helped ferry through a sweeping health care reform law in that state.

States are coming to realize that the uninsured are a shared problem, said Kim Belshe, secretary of California's Health and Human Services Agency.

“We've seen in California that when we can draw a connection between a problem that affects a minority of people, relatively speaking, and how it relates to the broader California, that it creates a policy environment where we have a greater potential to affect meaningful reform,” she said.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community such as uncompensated care, leading to higher health insurance premiums, overuse of emergency departments leading to closures, and high rates of uncontrolled chronic disease leading to lost productivity, she said.

Although states are taking this problem on themselves, they have, so far, shied away from single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Program, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for reform they will need to be empowered, not abandoned by the federal government, said Mr. Leddy. “For too long, the laboratories have been bankrupt in terms of ability of states to address problems of their citizens because we fundamentally have not had the support of our national government.”

Some state reform plans also include provisions to enable and even encourage companies to continue providing coverage for their workers.

“The erosion of employer-sponsored insurance plans must not be allowed to become a collapse. Whether we agree philosophically with it, we simply cannot afford a collapse of what is the foundation for what we have now,” Mr. Leddy said.

Beyond expanded access, state health care reformers are focusing on prevention and wellness.

“We not only have to treat chronic conditions better, we also have to have strategies that deal with the incidence and the prevalence of these conditions, in particular diabetes and obesity,” said Mr. Leddy.

Personal responsibility has to be an important component of that equation, but that should not be interpreted as a code word for social Darwinism, or survival of the healthiest, wealthiest, and luckiest, he said.

While there remains a lot of variability between states and their ability to undertake such broad reforms, an increasing number are turning to the examples set by Vermont, California, and a dozen other states in the process of passing reform measures, not only for the lessons they hold, but also for the encouragement they provide, experts said.