Joel B. Finkelstein

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 pass rising health insurance premiums on to their employees, said Mary Kay Henry, of 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.

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 raises insurance premiums. The result is that more employers drop coverage because of high premiums and the cycle starts all over again.

What the solution will look like is not clear, but 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,” said Ms. Henry.

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 pass rising health insurance premiums on to their employees, said Mary Kay Henry, of 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.

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 raises insurance premiums. The result is that more employers drop coverage because of high premiums and the cycle starts all over again.

What the solution will look like is not clear, but 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,” said Ms. Henry.

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 pass rising health insurance premiums on to their employees, said Mary Kay Henry, of 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.

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 raises insurance premiums. The result is that more employers drop coverage because of high premiums and the cycle starts all over again.

What the solution will look like is not clear, but 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,” said Ms. Henry.

WASHINGTON — Doctors who have yet to get on the health information technology bandwagon no longer have any excuses, according to members of the National ePrescribing Patient Safety Initiative, a coalition of health insurers and software companies.

The initiative—called NEPSI—is offering physicians' offices access to a secure, easy-to-use system that is compatible with the software in 99% of the nation's pharmacies, coalition members said at a press briefing to announce the launch of the initiative.

“According to [the Institute of Medicine], 1.5 million Americans are injured and more than 7,000 die from medication errors every year. As a practicing physician, I find that unacceptable,” said Dr. Nancy Dickey, a family physician and president of the Health Science Center at Texas A&M University in College Station.

In a report released last year, the IOM identified electronic prescribing as the single most significant step physicians can take to reduce drug-related medical errors.

No More Excuses

Dr. Dickey said time and money have been major barriers for the adoption of electronic prescribing, despite the fact that widespread use could save the U.S. health care system as much as $27 billion, as estimated by the Center for Information Technology Leadership.

“Part of the problem is that the people who are being asked to take the time and to spend the money to put this in their offices—the physicians—aren't necessarily the ones who get the financial benefit,” she said. That's why the coalition has come together to offer physicians an option that is not only free, but takes 15–30 minutes to learn.

“It is a truly easy system,” said Dr. Azar Korby, a family physician in Salem, N.H., who has been testing the software for the past year. Even someone who is not computer savvy should be able to learn the system in under 40 minutes.

There also is a growing incentive to adopt electronic prescribing, Dr. Mark McClellan said at the NEPSI launch.

Part D plans already are required to support electronic prescribing and Medicare Advantage plans are moving toward adoption of similar standards. Even in traditional fee-for-service Medicare, the Centers for Medicare and Medicaid Services is expanding efforts to boost reimbursement to physicians who report quality data, said Dr. McClellan, former CMS administrator and now a senior fellow at the AEI-Brookings Joint Center, a Washington think tank. “It all fits together in supporting the movement toward electronic prescribing to get to better quality care at a lower cost.”

Patient Safety Is the Goal

To that end, the initiative is being wholly funded by the coalition of private stakeholders at an estimated cost of $100 million for the first 5 years. That is in contrast to other free electronic prescribing software that requires physicians to market personal health records or other products to patients.

The companies that are supporting and paying for NEPSI see this as an investment in the future, said Glen Tullman, chief executive officer of Allscripts Inc., which is leading the effort.

“Down the road, we're very hopeful that this encourages adoption of full electronic health records, and Allscripts is a leading provider of those health records,” he said at the briefing. “But I want to make it very clear that our first objective is to equip every physician in the United States with electronic prescribing software that is absolutely free of charge,” in an effort to improve patient safety, he added.

WASHINGTON — Doctors who have yet to get on the health information technology bandwagon no longer have any excuses, according to members of the National ePrescribing Patient Safety Initiative, a coalition of health insurers and software companies.

The initiative—called NEPSI—is offering physicians' offices access to a secure, easy-to-use system that is compatible with the software in 99% of the nation's pharmacies, coalition members said at a press briefing to announce the launch of the initiative.

“According to [the Institute of Medicine], 1.5 million Americans are injured and more than 7,000 die from medication errors every year. As a practicing physician, I find that unacceptable,” said Dr. Nancy Dickey, a family physician and president of the Health Science Center at Texas A&M University in College Station.

In a report released last year, the IOM identified electronic prescribing as the single most significant step physicians can take to reduce drug-related medical errors.

No More Excuses

Dr. Dickey said time and money have been major barriers for the adoption of electronic prescribing, despite the fact that widespread use could save the U.S. health care system as much as $27 billion, as estimated by the Center for Information Technology Leadership.

“Part of the problem is that the people who are being asked to take the time and to spend the money to put this in their offices—the physicians—aren't necessarily the ones who get the financial benefit,” she said. That's why the coalition has come together to offer physicians an option that is not only free, but takes 15–30 minutes to learn.

“It is a truly easy system,” said Dr. Azar Korby, a family physician in Salem, N.H., who has been testing the software for the past year. Even someone who is not computer savvy should be able to learn the system in under 40 minutes.

There also is a growing incentive to adopt electronic prescribing, Dr. Mark McClellan said at the NEPSI launch.

Part D plans already are required to support electronic prescribing and Medicare Advantage plans are moving toward adoption of similar standards. Even in traditional fee-for-service Medicare, the Centers for Medicare and Medicaid Services is expanding efforts to boost reimbursement to physicians who report quality data, said Dr. McClellan, former CMS administrator and now a senior fellow at the AEI-Brookings Joint Center, a Washington think tank. “It all fits together in supporting the movement toward electronic prescribing to get to better quality care at a lower cost.”

Patient Safety Is the Goal

To that end, the initiative is being wholly funded by the coalition of private stakeholders at an estimated cost of $100 million for the first 5 years. That is in contrast to other free electronic prescribing software that requires physicians to market personal health records or other products to patients.

The companies that are supporting and paying for NEPSI see this as an investment in the future, said Glen Tullman, chief executive officer of Allscripts Inc., which is leading the effort.

“Down the road, we're very hopeful that this encourages adoption of full electronic health records, and Allscripts is a leading provider of those health records,” he said at the briefing. “But I want to make it very clear that our first objective is to equip every physician in the United States with electronic prescribing software that is absolutely free of charge,” in an effort to improve patient safety, he added.

WASHINGTON — Doctors who have yet to get on the health information technology bandwagon no longer have any excuses, according to members of the National ePrescribing Patient Safety Initiative, a coalition of health insurers and software companies.

The initiative—called NEPSI—is offering physicians' offices access to a secure, easy-to-use system that is compatible with the software in 99% of the nation's pharmacies, coalition members said at a press briefing to announce the launch of the initiative.

“According to [the Institute of Medicine], 1.5 million Americans are injured and more than 7,000 die from medication errors every year. As a practicing physician, I find that unacceptable,” said Dr. Nancy Dickey, a family physician and president of the Health Science Center at Texas A&M University in College Station.

In a report released last year, the IOM identified electronic prescribing as the single most significant step physicians can take to reduce drug-related medical errors.

No More Excuses

Dr. Dickey said time and money have been major barriers for the adoption of electronic prescribing, despite the fact that widespread use could save the U.S. health care system as much as $27 billion, as estimated by the Center for Information Technology Leadership.

“Part of the problem is that the people who are being asked to take the time and to spend the money to put this in their offices—the physicians—aren't necessarily the ones who get the financial benefit,” she said. That's why the coalition has come together to offer physicians an option that is not only free, but takes 15–30 minutes to learn.

“It is a truly easy system,” said Dr. Azar Korby, a family physician in Salem, N.H., who has been testing the software for the past year. Even someone who is not computer savvy should be able to learn the system in under 40 minutes.

There also is a growing incentive to adopt electronic prescribing, Dr. Mark McClellan said at the NEPSI launch.

Part D plans already are required to support electronic prescribing and Medicare Advantage plans are moving toward adoption of similar standards. Even in traditional fee-for-service Medicare, the Centers for Medicare and Medicaid Services is expanding efforts to boost reimbursement to physicians who report quality data, said Dr. McClellan, former CMS administrator and now a senior fellow at the AEI-Brookings Joint Center, a Washington think tank. “It all fits together in supporting the movement toward electronic prescribing to get to better quality care at a lower cost.”

Patient Safety Is the Goal

To that end, the initiative is being wholly funded by the coalition of private stakeholders at an estimated cost of $100 million for the first 5 years. That is in contrast to other free electronic prescribing software that requires physicians to market personal health records or other products to patients.

The companies that are supporting and paying for NEPSI see this as an investment in the future, said Glen Tullman, chief executive officer of Allscripts Inc., which is leading the effort.

“Down the road, we're very hopeful that this encourages adoption of full electronic health records, and Allscripts is a leading provider of those health records,” he said at the briefing. “But I want to make it very clear that our first objective is to equip every physician in the United States with electronic prescribing software that is absolutely free of charge,” in an effort to improve patient safety, he added.

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.

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 onto their workers or reducing the benefits they are willing to pay for, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics.

Employers at small businesses will be forced to ask employees to pay a share of their health coverage that is so large it far exceeeds the workers'ability to afford, 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 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,'” he recalled.

“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.

“Do the math and you can figure out that 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, he said.

What the solution will look like is not clear, but 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,” said Ms. Henry.

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.

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 onto their workers or reducing the benefits they are willing to pay for, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics.

Employers at small businesses will be forced to ask employees to pay a share of their health coverage that is so large it far exceeeds the workers'ability to afford, 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 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,'” he recalled.

“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.

“Do the math and you can figure out that 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, he said.

What the solution will look like is not clear, but 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,” said Ms. Henry.

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.

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 onto their workers or reducing the benefits they are willing to pay for, a trend that will continue over the next 5 years, according to projections by the Bureau of Labor Statistics.

Employers at small businesses will be forced to ask employees to pay a share of their health coverage that is so large it far exceeeds the workers'ability to afford, 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 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,'” he recalled.

“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.

“Do the math and you can figure out that 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, he said.

What the solution will look like is not clear, but 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,” said Ms. Henry.

WASHINGTON — What was a trend is looking more like a tidal 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 shepard 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,” according to Ms. Belshe.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community. Reformers need to show that uncompensated health care was leading to higher health insurance premiums, overuse of emergency departments was resulting in 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 adopting any single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Programs, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for experiments in health care coverage 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.

“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 tidal 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 shepard 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,” according to Ms. Belshe.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community. Reformers need to show that uncompensated health care was leading to higher health insurance premiums, overuse of emergency departments was resulting in 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 adopting any single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Programs, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for experiments in health care coverage 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.

“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 tidal 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 shepard 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,” according to Ms. Belshe.

In California, this meant demonstrating that the uninsured were having a significant impact on others in the community. Reformers need to show that uncompensated health care was leading to higher health insurance premiums, overuse of emergency departments was resulting in 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 adopting any single-payer approaches. Instead they are building on public programs, including the Medicaid and State Children's Health Insurance Programs, which together provide states with substantial, if still insufficient, federal funds.

If the states are to serve as laboratories for experiments in health care coverage 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.

“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 — The 110th Congress is fertile ground for health care legislation, from expanding coverage to fixing physician pay, according to Capitol Hill insiders and observers speaking at a conference sponsored by AcademyHealth.

“You can feel it in the air, not just in Washington but all across the country. The season is changing,” said Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. “The season is for real debate on health-care reform. And it is long overdue.”

“Having run vigorously against a 'do-nothing' Congress, Democrats … now have to show that they are the do-something Congress,” said Dr. Norman J. Ornstein, a resident scholar at the American Enterprise Institute, a conservative think tank in Washington.

There is also a sense that America's employers are ready to support health care reform, said Sen. Ron Wyden (D-Ore.). “In 1994, the business community said, 'We can't afford health care reform.' In 2007, the business community is saying, 'We can't afford not to fix American health care,'” he said.

Democrats' first focus has been and still is on covering the uninsured, said Sen. Wyden.

“You cannot fix American health care unless you get everybody covered,” he said. “And the reason that's so important is not only is it morally the right thing to do, which it clearly is, but if you don't get everybody covered, what we all know is the costs of people who don't have coverage get passed on to people who do.”

“What we have done is target our efforts on children. And trying to make sure that we improve on the coverage that is there today and certainly try to find those children who would qualify for the public programs that we have and who yet aren't enrolled,” said a Democratic congressional staffer speaking at the briefing.

About 25% of children in the United States have health coverage through either Medicaid or the State Children's Health Insurance Program (SCHIP). However, 9 million children currently have no health insurance, and two-thirds of those are actually eligible for public coverage. States have been increasing their outreach efforts, but they have been stymied by shortfalls in federal matching funds for SCHIP. This year, 14 states are expected to run out of federal funds by May.

As Congress considers the reauthorization of SCHIPthis year—its mandate expires Sept. 30—some Democrats have suggested it's time to make the program an entitlement. (SCHIP currently is funded on a pay-as-you-go basis, meaning that any increased funding must be offset by a cut somewhere else in the federal budget.)

When it comes to decreasing physician pay under the sustainable growth rate formula, both Democrats and Republicans have expressed interest in finding a solution. However, no one has come up with a remedy that fits into the current budget outlook.

“In order to get the physicians back to zero, we're talking costs of probably approximately $22 billion. And that isn't addressing the longer-term problem that Medicare's current payment formula is going to call for cuts for an additional 5 years beyond that,” the Republican congressional staffer said.

Recent proposals to fix the SGR have ranged in cost from $4 billion in the short-term to $250 billion in the long term.

Democrats speaking at the conference said they hope to make refinements to the Medicare Part D drug benefit, such as improvements in the low-income subsidies and a reassessment of the higher payments that Medicare Advantage plans currently receive. Several proposals have already been introduced to allow the government to negotiate drug prices.

Republicans are expected to oppose significant changes to the program. “From our perspective this program has been wildly successful beyond any estimation that we could have made back in 2003 when we passed the Medicare Modernization Act. [In light of this], why are we talking about making fundamental changes to this program?” said the Republican congressional staffer.

While action on these and other health care issues seem likely this year, there is a short window of opportunity to complete them before election politics come into play, said Dr. Ornstein.

“The conventional wisdom is that in a presidential election year where there's an open contest in the final 2 years of a two-term president, you have about an 8-month window to move things along. That doesn't mean you have to finish everything, but … you better be pretty close to field goal range at the end of that 8 months,” he said. That seems likely to hold true now this year given that at least 26 members of Congress have announced or are considering announcing a run for the White House, he said.

WASHINGTON — The 110th Congress is fertile ground for health care legislation, from expanding coverage to fixing physician pay, according to Capitol Hill insiders and observers speaking at a conference sponsored by AcademyHealth.

“You can feel it in the air, not just in Washington but all across the country. The season is changing,” said Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. “The season is for real debate on health-care reform. And it is long overdue.”

“Having run vigorously against a 'do-nothing' Congress, Democrats … now have to show that they are the do-something Congress,” said Dr. Norman J. Ornstein, a resident scholar at the American Enterprise Institute, a conservative think tank in Washington.

There is also a sense that America's employers are ready to support health care reform, said Sen. Ron Wyden (D-Ore.). “In 1994, the business community said, 'We can't afford health care reform.' In 2007, the business community is saying, 'We can't afford not to fix American health care,'” he said.

Democrats' first focus has been and still is on covering the uninsured, said Sen. Wyden.

“You cannot fix American health care unless you get everybody covered,” he said. “And the reason that's so important is not only is it morally the right thing to do, which it clearly is, but if you don't get everybody covered, what we all know is the costs of people who don't have coverage get passed on to people who do.”

“What we have done is target our efforts on children. And trying to make sure that we improve on the coverage that is there today and certainly try to find those children who would qualify for the public programs that we have and who yet aren't enrolled,” said a Democratic congressional staffer speaking at the briefing.

About 25% of children in the United States have health coverage through either Medicaid or the State Children's Health Insurance Program (SCHIP). However, 9 million children currently have no health insurance, and two-thirds of those are actually eligible for public coverage. States have been increasing their outreach efforts, but they have been stymied by shortfalls in federal matching funds for SCHIP. This year, 14 states are expected to run out of federal funds by May.

As Congress considers the reauthorization of SCHIPthis year—its mandate expires Sept. 30—some Democrats have suggested it's time to make the program an entitlement. (SCHIP currently is funded on a pay-as-you-go basis, meaning that any increased funding must be offset by a cut somewhere else in the federal budget.)

When it comes to decreasing physician pay under the sustainable growth rate formula, both Democrats and Republicans have expressed interest in finding a solution. However, no one has come up with a remedy that fits into the current budget outlook.

“In order to get the physicians back to zero, we're talking costs of probably approximately $22 billion. And that isn't addressing the longer-term problem that Medicare's current payment formula is going to call for cuts for an additional 5 years beyond that,” the Republican congressional staffer said.

Recent proposals to fix the SGR have ranged in cost from $4 billion in the short-term to $250 billion in the long term.

Democrats speaking at the conference said they hope to make refinements to the Medicare Part D drug benefit, such as improvements in the low-income subsidies and a reassessment of the higher payments that Medicare Advantage plans currently receive. Several proposals have already been introduced to allow the government to negotiate drug prices.

Republicans are expected to oppose significant changes to the program. “From our perspective this program has been wildly successful beyond any estimation that we could have made back in 2003 when we passed the Medicare Modernization Act. [In light of this], why are we talking about making fundamental changes to this program?” said the Republican congressional staffer.

While action on these and other health care issues seem likely this year, there is a short window of opportunity to complete them before election politics come into play, said Dr. Ornstein.

“The conventional wisdom is that in a presidential election year where there's an open contest in the final 2 years of a two-term president, you have about an 8-month window to move things along. That doesn't mean you have to finish everything, but … you better be pretty close to field goal range at the end of that 8 months,” he said. That seems likely to hold true now this year given that at least 26 members of Congress have announced or are considering announcing a run for the White House, he said.

WASHINGTON — The 110th Congress is fertile ground for health care legislation, from expanding coverage to fixing physician pay, according to Capitol Hill insiders and observers speaking at a conference sponsored by AcademyHealth.

“You can feel it in the air, not just in Washington but all across the country. The season is changing,” said Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. “The season is for real debate on health-care reform. And it is long overdue.”

“Having run vigorously against a 'do-nothing' Congress, Democrats … now have to show that they are the do-something Congress,” said Dr. Norman J. Ornstein, a resident scholar at the American Enterprise Institute, a conservative think tank in Washington.

There is also a sense that America's employers are ready to support health care reform, said Sen. Ron Wyden (D-Ore.). “In 1994, the business community said, 'We can't afford health care reform.' In 2007, the business community is saying, 'We can't afford not to fix American health care,'” he said.

Democrats' first focus has been and still is on covering the uninsured, said Sen. Wyden.

“You cannot fix American health care unless you get everybody covered,” he said. “And the reason that's so important is not only is it morally the right thing to do, which it clearly is, but if you don't get everybody covered, what we all know is the costs of people who don't have coverage get passed on to people who do.”

“What we have done is target our efforts on children. And trying to make sure that we improve on the coverage that is there today and certainly try to find those children who would qualify for the public programs that we have and who yet aren't enrolled,” said a Democratic congressional staffer speaking at the briefing.

About 25% of children in the United States have health coverage through either Medicaid or the State Children's Health Insurance Program (SCHIP). However, 9 million children currently have no health insurance, and two-thirds of those are actually eligible for public coverage. States have been increasing their outreach efforts, but they have been stymied by shortfalls in federal matching funds for SCHIP. This year, 14 states are expected to run out of federal funds by May.

As Congress considers the reauthorization of SCHIPthis year—its mandate expires Sept. 30—some Democrats have suggested it's time to make the program an entitlement. (SCHIP currently is funded on a pay-as-you-go basis, meaning that any increased funding must be offset by a cut somewhere else in the federal budget.)

When it comes to decreasing physician pay under the sustainable growth rate formula, both Democrats and Republicans have expressed interest in finding a solution. However, no one has come up with a remedy that fits into the current budget outlook.

“In order to get the physicians back to zero, we're talking costs of probably approximately $22 billion. And that isn't addressing the longer-term problem that Medicare's current payment formula is going to call for cuts for an additional 5 years beyond that,” the Republican congressional staffer said.

Recent proposals to fix the SGR have ranged in cost from $4 billion in the short-term to $250 billion in the long term.

Democrats speaking at the conference said they hope to make refinements to the Medicare Part D drug benefit, such as improvements in the low-income subsidies and a reassessment of the higher payments that Medicare Advantage plans currently receive. Several proposals have already been introduced to allow the government to negotiate drug prices.

Republicans are expected to oppose significant changes to the program. “From our perspective this program has been wildly successful beyond any estimation that we could have made back in 2003 when we passed the Medicare Modernization Act. [In light of this], why are we talking about making fundamental changes to this program?” said the Republican congressional staffer.

While action on these and other health care issues seem likely this year, there is a short window of opportunity to complete them before election politics come into play, said Dr. Ornstein.

“The conventional wisdom is that in a presidential election year where there's an open contest in the final 2 years of a two-term president, you have about an 8-month window to move things along. That doesn't mean you have to finish everything, but … you better be pretty close to field goal range at the end of that 8 months,” he said. That seems likely to hold true now this year given that at least 26 members of Congress have announced or are considering announcing a run for the White House, he 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 in ferrying 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, states 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, Mr. Leddy said. “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.

“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,” Ms. Belshe 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 in ferrying 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, states 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, Mr. Leddy said. “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.

“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,” Ms. Belshe 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 in ferrying 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, states 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, Mr. Leddy said. “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.

“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,” Ms. Belshe 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. But 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.

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 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. Do the math and you can figure out that 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 needing higher-level 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: More employers drop coverage because of high premiums and the cycle starts over again. That cycle needs to be broken, he said.

What the solution will look like is not clear, but 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. But 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.

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 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. Do the math and you can figure out that 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 needing higher-level 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: More employers drop coverage because of high premiums and the cycle starts over again. That cycle needs to be broken, he said.

What the solution will look like is not clear, but 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. But 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.

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 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. Do the math and you can figure out that 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 needing higher-level 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: More employers drop coverage because of high premiums and the cycle starts over again. That cycle needs to be broken, he said.

What the solution will look like is not clear, but 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 senator from Vermont who had 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 effect 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 existing public programs, including Medicaid and the 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, Mr. Leddy said.

“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 said.

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,” Mr. Leddy said.

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.

“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,” Ms. Belshe 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 senator from Vermont who had 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 effect 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 existing public programs, including Medicaid and the 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, Mr. Leddy said.

“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 said.

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,” Mr. Leddy said.

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.

“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,” Ms. Belshe 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 senator from Vermont who had 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 effect 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 existing public programs, including Medicaid and the 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, Mr. Leddy said.

“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 said.

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,” Mr. Leddy said.

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.

“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,” Ms. Belshe said.

WASHINGTON — The 110th Congress is fertile ground for health care legislation, from expanding coverage to fixing physician pay, according to Capitol Hill insiders and observers speaking at a conference sponsored by AcademyHealth.

"You can feel it in the air, not just in Washington but all across the country. The season is changing," said Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. "The season is for real debate on health care reform. And it is long overdue."

In the last election, Democrats won new seats in the House and Senate without losing any of their own by pointing to Republicans' lack of accomplishment, said Norman J. Ornstein, Ph.D., a resident scholar at the American Enterprise Institute, a conservative think tank in Washington.

"Having run vigorously against a do-nothing Congress, Democrats … now have to show that they are the do-something Congress," said Dr. Ornstein.

There is also a sense that America's employers are more than ever ready to support health care reform, said Sen. Ron Wyden (D-Ore.).

"In 1994, the business community said, 'We can't afford health care reform.' In 2007, the business community is saying, 'We can't afford not to fix American health care,'" he said.

Democrats' first focus has been and still is on covering the uninsured. "You cannot fix American health care unless you get everybody covered," he said, drawing applause. "And the reason that's so important is not only is it morally the right thing to do, which it clearly is, but if you don't get everybody covered, what we all know is the costs of people who don't have coverage get passed on to people who do."

However, a Democratic congressional staffer speaking at the briefing pointed out that the tight federal budget means compromises and choices will have to be made.

"What we have done is target our efforts on children. And trying to make sure that we improve on the coverage that is there today and certainly try to find those children who would qualify for the public programs that we have and who yet aren't enrolled," she said.

Approximately 25% of children in the United States have health coverage through either Medicaid or the State Children's Health Insurance Program (SCHIP). However, 9 million children currently have no health insurance, and two-thirds of those are actually eligible for public coverage. States have been increasing their outreach efforts, but have been stymied by shortfalls in federal matching funds for SCHIP. This year, 14 states are expected to run out of federal funds by May.

As Congress considers SCHIP reauthorization this year—its mandate expires Sept. 30—some Democrats have suggested it's time to make the program an entitlement. (SCHIP currently is funded on a pay-as-you-go basis, meaning that any increased funding must be offset by a cut somewhere else in the federal budget.)

With reauthorization also comes the chance to make other changes to the program. Republicans have suggested that states may need even more flexibility in how they spend their SCHIP funds to make them go as far as possible. "It has helped a lot of families. But like any program now, we have the opportunity to take a look at it, see what's working, what's not, what needs to be improved," a Republican congressional staffer said at the meeting.

SGR Fix

Both Democrats and Republicans have expressed interest in finding a solution to decreasing physician pay under the sustainable growth rate formula. However, no one has yet to come up with a remedy that fits into the current budget outlook.

"To get the physicians back to zero, we're talking costs of probably approximately $22 billion. And that isn't addressing the longer-term problem that Medicare's current payment formula is going to call for cuts for an additional 5 years beyond that," the Republican congressional staffer said.

Recent proposals to fix the SGR have ranged in cost from $4 billion in the short term to $250 billion in the long term.

Refining Medicare Part D

Democrats at the conference said they hope to make refinements to the Medicare Part D drug benefit. Several proposals have already been introduced to allow the government to negotiate drug prices.

Republicans are expected to oppose significant changes to the program.

"From our perspective this program has been wildly successful beyond any estimation that we could have made back in 2003 when we passed the Medicare Modernization Act. [In light of this], why are we talking about making fundamental changes to this program?" said the Republican congressional staffer.

WASHINGTON — The 110th Congress is fertile ground for health care legislation, from expanding coverage to fixing physician pay, according to Capitol Hill insiders and observers speaking at a conference sponsored by AcademyHealth.

"You can feel it in the air, not just in Washington but all across the country. The season is changing," said Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. "The season is for real debate on health care reform. And it is long overdue."

In the last election, Democrats won new seats in the House and Senate without losing any of their own by pointing to Republicans' lack of accomplishment, said Norman J. Ornstein, Ph.D., a resident scholar at the American Enterprise Institute, a conservative think tank in Washington.

"Having run vigorously against a do-nothing Congress, Democrats … now have to show that they are the do-something Congress," said Dr. Ornstein.

There is also a sense that America's employers are more than ever ready to support health care reform, said Sen. Ron Wyden (D-Ore.).

"In 1994, the business community said, 'We can't afford health care reform.' In 2007, the business community is saying, 'We can't afford not to fix American health care,'" he said.

Democrats' first focus has been and still is on covering the uninsured. "You cannot fix American health care unless you get everybody covered," he said, drawing applause. "And the reason that's so important is not only is it morally the right thing to do, which it clearly is, but if you don't get everybody covered, what we all know is the costs of people who don't have coverage get passed on to people who do."

However, a Democratic congressional staffer speaking at the briefing pointed out that the tight federal budget means compromises and choices will have to be made.

"What we have done is target our efforts on children. And trying to make sure that we improve on the coverage that is there today and certainly try to find those children who would qualify for the public programs that we have and who yet aren't enrolled," she said.

Approximately 25% of children in the United States have health coverage through either Medicaid or the State Children's Health Insurance Program (SCHIP). However, 9 million children currently have no health insurance, and two-thirds of those are actually eligible for public coverage. States have been increasing their outreach efforts, but have been stymied by shortfalls in federal matching funds for SCHIP. This year, 14 states are expected to run out of federal funds by May.

As Congress considers SCHIP reauthorization this year—its mandate expires Sept. 30—some Democrats have suggested it's time to make the program an entitlement. (SCHIP currently is funded on a pay-as-you-go basis, meaning that any increased funding must be offset by a cut somewhere else in the federal budget.)

With reauthorization also comes the chance to make other changes to the program. Republicans have suggested that states may need even more flexibility in how they spend their SCHIP funds to make them go as far as possible. "It has helped a lot of families. But like any program now, we have the opportunity to take a look at it, see what's working, what's not, what needs to be improved," a Republican congressional staffer said at the meeting.

SGR Fix

Both Democrats and Republicans have expressed interest in finding a solution to decreasing physician pay under the sustainable growth rate formula. However, no one has yet to come up with a remedy that fits into the current budget outlook.

"To get the physicians back to zero, we're talking costs of probably approximately $22 billion. And that isn't addressing the longer-term problem that Medicare's current payment formula is going to call for cuts for an additional 5 years beyond that," the Republican congressional staffer said.

Recent proposals to fix the SGR have ranged in cost from $4 billion in the short term to $250 billion in the long term.

Refining Medicare Part D

Democrats at the conference said they hope to make refinements to the Medicare Part D drug benefit. Several proposals have already been introduced to allow the government to negotiate drug prices.

Republicans are expected to oppose significant changes to the program.

"From our perspective this program has been wildly successful beyond any estimation that we could have made back in 2003 when we passed the Medicare Modernization Act. [In light of this], why are we talking about making fundamental changes to this program?" said the Republican congressional staffer.

WASHINGTON — The 110th Congress is fertile ground for health care legislation, from expanding coverage to fixing physician pay, according to Capitol Hill insiders and observers speaking at a conference sponsored by AcademyHealth.

"You can feel it in the air, not just in Washington but all across the country. The season is changing," said Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. "The season is for real debate on health care reform. And it is long overdue."

In the last election, Democrats won new seats in the House and Senate without losing any of their own by pointing to Republicans' lack of accomplishment, said Norman J. Ornstein, Ph.D., a resident scholar at the American Enterprise Institute, a conservative think tank in Washington.

"Having run vigorously against a do-nothing Congress, Democrats … now have to show that they are the do-something Congress," said Dr. Ornstein.

There is also a sense that America's employers are more than ever ready to support health care reform, said Sen. Ron Wyden (D-Ore.).

"In 1994, the business community said, 'We can't afford health care reform.' In 2007, the business community is saying, 'We can't afford not to fix American health care,'" he said.

Democrats' first focus has been and still is on covering the uninsured. "You cannot fix American health care unless you get everybody covered," he said, drawing applause. "And the reason that's so important is not only is it morally the right thing to do, which it clearly is, but if you don't get everybody covered, what we all know is the costs of people who don't have coverage get passed on to people who do."

However, a Democratic congressional staffer speaking at the briefing pointed out that the tight federal budget means compromises and choices will have to be made.

"What we have done is target our efforts on children. And trying to make sure that we improve on the coverage that is there today and certainly try to find those children who would qualify for the public programs that we have and who yet aren't enrolled," she said.

Approximately 25% of children in the United States have health coverage through either Medicaid or the State Children's Health Insurance Program (SCHIP). However, 9 million children currently have no health insurance, and two-thirds of those are actually eligible for public coverage. States have been increasing their outreach efforts, but have been stymied by shortfalls in federal matching funds for SCHIP. This year, 14 states are expected to run out of federal funds by May.

As Congress considers SCHIP reauthorization this year—its mandate expires Sept. 30—some Democrats have suggested it's time to make the program an entitlement. (SCHIP currently is funded on a pay-as-you-go basis, meaning that any increased funding must be offset by a cut somewhere else in the federal budget.)

With reauthorization also comes the chance to make other changes to the program. Republicans have suggested that states may need even more flexibility in how they spend their SCHIP funds to make them go as far as possible. "It has helped a lot of families. But like any program now, we have the opportunity to take a look at it, see what's working, what's not, what needs to be improved," a Republican congressional staffer said at the meeting.

SGR Fix

Both Democrats and Republicans have expressed interest in finding a solution to decreasing physician pay under the sustainable growth rate formula. However, no one has yet to come up with a remedy that fits into the current budget outlook.

"To get the physicians back to zero, we're talking costs of probably approximately $22 billion. And that isn't addressing the longer-term problem that Medicare's current payment formula is going to call for cuts for an additional 5 years beyond that," the Republican congressional staffer said.

Recent proposals to fix the SGR have ranged in cost from $4 billion in the short term to $250 billion in the long term.

Refining Medicare Part D

Democrats at the conference said they hope to make refinements to the Medicare Part D drug benefit. Several proposals have already been introduced to allow the government to negotiate drug prices.

Republicans are expected to oppose significant changes to the program.

"From our perspective this program has been wildly successful beyond any estimation that we could have made back in 2003 when we passed the Medicare Modernization Act. [In light of this], why are we talking about making fundamental changes to this program?" said the Republican congressional staffer.

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.

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. Do the math and you can figure out that 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.

"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," said Ms. Henry.

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.

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. Do the math and you can figure out that 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.

"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," said Ms. Henry.

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.

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. Do the math and you can figure out that 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.

"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," said Ms. Henry.