cerned about the link between health coverage, health status, and worker well-being and uninterested in efforts to improve assessments of the cost-effectiveness of specific medical services and health care providers. Because workplace and community health promotion programs, local health care initiatives and institutions, and other health-related activities have attracted employees' and employers' support for reasons beyond any specific tie to their health benefit programs, continued support can be expected and fostered.

Given the creativity shown by both public and private sectors in the past and the considerable accomplishments of employment-based health benefits, there is reason to be optimistic that decisionmakers—if they can agree on a basic framework for reform—can find a positive role for employers. That role may be larger or smaller than it is today, but in either case it should be designed to support the country's broad objective of securing broader and more equitable access to more appropriate health care at a more reasonable cost.

John K. Roberts, Jr.

Health insurance is based on the concept of risk sharing. If individuals are allowed to wait until they get sick or injured to purchase insurance, then there is no risk sharing and the insurance mechanism breaks down. This is a concern, particularly in the individual and small group markets, where the insurance buying decision is more likely to be based on current needs for medical care. Individual underwriting and pre-existing condition limitations serve as incentives for individuals to purchase insurance while they are still healthy. If these tools are to be eliminated, they must be replaced by other means of assuring a broad spread of risk. Further, the result of the recommendations as outlined would be to increase the cost of insurance protection for many. This, in turn, will likely result in fewer people—not more—being able to afford insurance coverage, producing a result exactly opposite that intended by the recommendations.