Too often missing in the debate about health care are the likely consequences for insurance coverage and costs if nothing changes. In an Oct. 1 paper, we looked at all 50 states to quantify the impact on insurance coverage and spending by government, employers and families if health reforms are not enacted.

The report makes clear that the cost of failure would be substantial and felt across the country. Over the next decade in every state, the percentage of the population that is uninsured will increase, employer-sponsored coverage will continue to erode, spending on public programs will balloon, and individual and family out-of-pocket costs could increase by more than 35 percent.

Using the Urban Institute's Health Insurance Policy Simulation Model, we examined the effects on coverage and costs for three scenarios:

• Worst case -- slow growth in incomes and continuing high growth in health-care costs;

• Intermediate case -- somewhat faster growth in incomes but lower growth in health-care costs;

• Best case -- full employment, faster income growth and even slower growth in health-care costs.

Under any scenario, the analysis shows a tremendous economic strain on individuals and businesses in all 50 states and the District of Columbia if reforms are not enacted. While all income levels would be affected, middle-class working families would be hardest hit. Within 10 years, under the worst-case scenario, we estimate that:

• In 29 states, the number of people without insurance would increase by more than 30 percent by 2019. The number of uninsured would grow by at least 10 percent in every state. The number of uninsured Americans would reach 65.7 million.

• Businesses in more than 27 states would see their premiums more than double. Even in the best-case scenario, 46 states would see employer premium costs increase by more than 60 percent.

• Every state would see a smaller share of its population with employer-sponsored insurance. Half would see the number of people with employer-sponsored insurance fall by more than 10 percent.

• Every state would see its spending for Medicaid and the Children's Health Insurance Program rise by more than 75 percent by 2019. Half would face cost increases of more than 100 percent.

• The amount of uncompensated care in the health system would more than double in 45 states. Even in the best case, uncompensated care would increase by more than 50 percent in 48 states.

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