WASHINGTON -- A growing debate over whether to let states opt out of any government-run health insurance plan overlooks a key facet of the health-care measures being assembled in Congress: When Washington is done, the shape of any new health-care system is likely to be finalized in Lansing and Boise and Baton Rouge.

Along with the opt-out proposal offered last week by Senate leaders, lawmakers on Capitol Hill are drafting health-care legislation that would delegate to state officials a multitude of momentous decisions, from what benefits are offered to low-income families to what hurdles to put in front of private insurance companies before they can raise premiums.

"The fact is that state programs are going to look different," said Judith Solomon, a senior fellow at the Center on Budget and Policy Priorities in Washington. "Where some people might be expecting national health reform, we're facing the real possibility that what you get is going to depend heavily on where you live."

The prospect of state control over the new health system holds both promise and peril, said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who has advised Democrats on health reform. "The plus side is that states are uniquely positioned to reflect the tastes of their residents and market conditions. Plus, we can really learn from the different approaches states take," Dr. Gruber said. The downside "is that states can screw up and not meet the federal desires we have for minimum standards."

The health-care package unveiled by House leaders Thursday comes closer to national reform, health policy experts said. It would create a national marketplace where those who lack insurance could shop for policies, including a plan run by federal health officials. States would play a supporting role.

But the package under development in the Senate is a different story. A bill approved by the Finance Committee would leave virtually every major decision to state officials.

Rather than create a central marketplace for insurance, that measure would permit each state to establish its own "exchange" and decide which insurers would have access to that market. States could let low-income families shop the exchanges or offer them some other kind of coverage, such as policies already offered to state employees.

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