THE NUMBER OF Americans who are uninsured has continued its long-term rise despite a wide range of state coverage initiatives over several decades. As Emily Friedman notes, the problem has recently become more acute because of the combined effects of a weak economy and the escalating costs of healthcare and coverage. Previous coverage expansions have not solved the uninsured problem because they tried to shape publicly financed patches to fill in the coverage gaps left by narrow categorical programs, a counterproductive relationship between publicly financed and private, employer-financed coverage, and a Byzantine labyrinth of cross-subsidies and counterincentives. Previous efforts have neither established nor conveyed a coherent vision of the mutual and individual responsibilities needed to achieve both affordable access for and participation by all Americans. Friedman is right to decry excessive hospital charges to low-income, uninsured patients as a moral failure. Such patients are hapless victims of our collective decision not to extend them the coverage and financial access they need. Charitable hospitals should make sure they do not further abuse such patients through unconscionable billing practices. But the court cases brought against not-for-profit hospitals bear vivid testimony to the schizophrenic views that underlie America's uninsured problem. We expect that everyone should be provided medical care when they urgently need it but that no one should be required to participate in or contribute to the insurance coverage needed to undergird the health delivery system. Previous coverage expansions have focused on the very real need to cover vulnerable low-income populations. But, as Chollet notes, where such expansions extend substantially above poverty levels, they often substitute publicly financed coverage for employerfinanced coverage. Thus, such expansions often cost states more than expected and are too much to sustain when the economy and state revenues decline. GETTING REAL ABOUT WHAT THE PROBLEMS ARE Previous cover-the-uninsured proposals and campaigns have emphasized the negative effects of being uninsured. The widely supported Cover the Uninsured Week heralds the need for all Americans to have access to coverage. But many nonpoor uninsured people are, and perceive themselves to be, relatively low risk; they expect-quite reasonably-that in the unlikely event they do suffer a traumatic injury, the system is obliged to care for them. What such campaigns tend not to convey to the majority who do participate in coverage are other insights about how the system is already unfair to them, such as the following: 1. Insured people ultimately pay for uncompensated care provided to uninsured individuals. 2. As the uninsured population has grown, many hospitals' capacity to provide trauma care and other services has been stretched to the breaking point. 3. Where emergency care providers are forced to close their doors, critical services will not be available where and when lives may literally be at stake. Many Americans might be motivated to support reforms that ensure broad participation in coverage if they understood in such concrete terms how current coverage policies are fundamentally unfair to them and dysfunctional for the medical care system on which they rely. While a broad range of approaches is available for achieving coverage of the uninsured, any real solution must include two basic ingredients: (1) government needs to somehow ensure that coverage is readily available and affordable for everyone and (2) individuals need to participate in that coverage. Addressing Healthcare Costs and the Uninsured Despite concerns over real and pressing cost problems, it would be both unfortunate and counterproductive to hold the uninsured problem hostage to the healthcare cost problem. Achieving accountability for costs is the essential prerequisite for any form of cost discipline. …