If comprehensive national health care reform can't pass with overwhelming Democratic majorities in the House and Senate and a strong Democrat in the White House, it is time to face facts. Instead of trying to impose complicated systemic change from above in Washington - as has been tried unsuccessfully in fits and starts for 100 years - it is time to encourage individual states to take up the endeavor.

This idea was first suggested a decade ago by the visionary late Sen. Paul Wellstone. Under this approach, the federal government would offer significant subsidies to kick-start efforts by states to provide affordable, quality, comprehensive health coverage to all their residents. States would have to show how they were going to both provide universal coverage and "bend the cost curve" (something largely absent in the current national health care reform proposals) by changing payment methods, encouraging evidence-based practices and addressing malpractice reforms. If they didn't meet their goals, they would risk losing federal funding. To avoid judicial interference and to ensure that states have maximum flexibility to achieve these goals, Federal ERISA waivers would have to be granted to each state participating in the initiative. (ERISA is a federal law that limits states' ability to regulate employer-based insurance plans.) States could try any approach they wanted as long as it resulted in affordable, comprehensive coverage for all: single-payer systems, public-private collaborations, nonprofit co-operatives, health savings accounts or other tax incentives would all be fair game. To ensure accountability, comprehensive five-year evaluations would be required of each state's approach, looking at health status changes of their populations; potential hospital and emergency room costs averted due to widespread access to preventive and primary care; whether the system slowed the increase in costs of health care; and overall satisfaction among patients and providers alike.

By allowing several participating states to be "incubators for change," citizens and policymakers would be able to see which approaches worked best and could potentially be replicated regionally or nationally. The results of the evaluations of different types of reforms would provide the critical information missing in the current national debate on health care reform; right now, although there is some evidence that certain components of reform are effective, there really is no proof that the current Senate and House bills would improve health and control costs.

With real-life evidence in hand from the various state efforts in the Wellstone approach, proponents of national health care reform would have the ammunition to counter many of the arguments thrown at current proposals, some of which stick because they are given the "benefit of the doubt" - doubt that would be removed if we had good evidence to the contrary. Here in Howard County, we have found exactly that with the Healthy Howard Health Plan - our local comprehensive, affordable health coverage plan for the uninsured. Initial evaluation of the program indicates improved health status and cost effectiveness of our medical home/health coaching model, making it more likely that other localities or states could replicate this approach.

An additional benefit of reforming health care at the state level first is simply getting the debate out of Washington, where any good-faith effort at figuring out what works for everyday Americans is completely overwhelmed by partisan firefights. In contrast, at the state level, the partisan gridlock and rule by lobbyists is less entrenched, and the media glare that brings out excess partisanship is less extreme. Instead of imagining what a proposal might mean, we could see and weigh results, as we've done with Healthy Howard; the country could then follow the lead of "pioneer" states, saving money and time in the process. Maryland is well-positioned to be among those chosen.

Whatever reform of America's broken health care system can be accomplished in Washington over the next few weeks is likely to be meager. We can't allow the failure of comprehensive health care reform at the national level to be the endgame. We can't wait another 15 or 20 years for another grand national campaign to fix the remaining problems. That is not fair to the tens of millions who suffer without any or adequate insurance; nor can our challenged economy sustain the current growth rate of health care expenses.

Let the states lead the way in showing how they can improve care, cover the uninsured and control runaway health costs. The Wellstone approach is a smart way to go about it.

Dr. Peter Beilenson is the Howard County health officer. His e-mail is pbeilen son@howardcountymd.gov. Ken Ulman is the Howard County executive. His e-mail is kulman@howardcountymd.gov.