There's a dagger at the heart of any solution to the crisis in health care costs--but it's not the skyrocketing price of prescription drugs. Rather, it's the uninsured: the 41 million Americans--one in seven-- who can't afford, aren't offered or choose not to carry health insurance.

A recent report from the Kaiser Commission on Medicaid and the Uninsured found that $35 billion was spent on uncompensated care for the uninsured, with the public sector picking up 85 percent of that tab. But the uninsured are not just a government problem. This situation threatens the entire health care system--from the effect on hospital rates (which increase to cover uncompensated care) to the impact on insurance premiums (which are pressured for similar reasons).

This has been going on for years, but now several health insurance companies have stepped up to say they intend to promote universal health coverage--suspect heroes though they may be. In December, the chairman of Blue Shield of California proposed a public-private insurance program that would require employers to provide health care to workers, mandate that individuals without employer coverage buy their own policies and develop a new tax to subsidize premiums for those unable to afford coverage.

Meanwhile, Montana's Blue Cross Blue Shield executives lined up bipartisan support in the legislature to raise the cigarette tax to subsidize basic health insurance coverage for those who can't afford to buy it. And in Florida, 30 insurers, working with the state insurance commissioner, outlined plans to introduce several lower-cost standard and basic policies to attract individuals and small-business employers who have been dropping coverage because of high costs.

This is not business as usual. It's rare for private insurers to go out on a limb and propose constructive solutions to what's been an intractable public policy problem. Not only that, but the companies also are offering to do some of the legwork. Blue Shield of California, for instance, has commissioned an independent study to examine various ways of raising the revenue to subsidize premiums.

The insurers' overall approach--building universal coverage around private insurance plans--is, of course, self-serving: It would sell more insurance policies. And that's raised some hackles in public policy circles. But the calls to action may run deeper than immediate sales and profits. Insurance executives are concerned that the problem of the uninsured could tip the health insurance business into a death spiral: Premiums could rise so high that healthier people drop out, leaving insurance companies with a comparatively sicker base of patients who are in need of expensive care and more of it. That, in turn, would force premiums even higher until few could afford them.

At present, the uninsured comprise not just the near-poor but also twenty-somethings who are no longer covered by family policies and don't have coverage through work or college. Their absence from the insurance market weakens the health profile of the insurance base. That's one reason why the insurance company proposals would mandate universal participation.

This is not the first time universal coverage has been tried. The state of Washington set up a program a decade ago, and both Colorado and New Jersey tried similar approaches a few years ago. None have been particularly successful. In New Jersey and Colorado, enrollment has been dwindling in their programs, with mostly high-risk patients attracted to the coverage. The Washington State program, which did not have insurance company buy-in, ran into political interference when insurers and private-sector employers disliked the program and got key requirements rolled back.

However, some health policy experts, such as Alan Weil of the Urban Institute, point to a key lesson from these failures: Basic, bare- bones coverage (in case of a disastrous illness or accident) is not appealing to the less affluent--particularly if the plans have, as they usually do, high co-payments or deductibles for doctor visits.

Past experience doesn't necessarily mean reliance on employee-based insurance can't work as a base for universal coverage. Although the insurance companies may not be operating entirely with a do-the-right- thing mindset, they have a financial interest in crafting an effective solution. If they can collaborate with lawmakers in developing coverage that is both affordable and of value to the working poor, the plan could work. There's nothing wrong with the profit motive as an incentive for much-needed reform.