Legislators are trying mightily to address problems in the health sector at the state level, but many of the forces driving their problems come from federal policy so they are continually frustrated.

In fact, Harvard's Steffie Woolhandler and David Himmelstein, two policy experts with whom I seldom agree on policy, have an important analysis in the latest International Journal of Health Services that explains how frustrating state-level changes can be.

They cite seven states that have undertaken major health reform initiatives since 1987, from Massachusetts to Tennessee to Washington State, only to see uninsured rates virtually unchanged, if not rising, by 2005, despite their massive and expensive reform efforts. (The authors, of course, are arguing for a government-run, single-payer system, but that's another story...)

State leaders feel compelled to take action. And the public is watching. Four local TV stations and several major newspapers covered my talk in Oklahoma. Legislators, like many others in the health sector, are watching and waiting for the result of the November presidential election, which will be hugely influential in setting the tone and direction for health reform initiatives next year.