Introduction

With Washington stalled in partisan paralysis and interest-group deadlock, the impetus for universal health care coverage is passing to the states. After ballot initiatives for a single-payer system failed in California in 1994, Massachusetts in 2000, and Oregon in 2002, state leaders there and elsewhere began looking for more viable solutions to the nation's health care crisis. Massachusetts and Vermont have enacted plans to expand coverage, while at least 11 other states have proposed similar reforms.

Ultimately, it will take national legislation to create a truly universal system of coverage. For now, though, state initiatives are yielding a new model for universal health care -- a uniquely American approach based on the principle of shared responsibility rather than the old dream of European-style "national health insurance" provided in top-down fashion by government. The emerging shared-responsibility model, long advocated by the Progressive Policy Institute, rests on three key pillars.

• An individual mandate. Many of the leading state experiments require individuals to purchase private health insurance for themselves and their children if they have the means to do so;

• Financial assistance. Most state plans offer public subsidies for needy families on a sliding scale based on income; and

• Choice and competition. Most plans call for insurance pools based on the Federal Employee Health Benefits system (FEHB). These pools connect individuals and small businesses to the group-insurance market, fostering choice and competition among plans to improve quality and keep costs down.