Healthcare — or perhaps the lack of healthcare — is rapidly becoming the No. 1 domestic issue for voters.

The federal government has taken little substantive action, but the states have moved in impressive ways. Last year it was Massachusetts that adopted plans to provide health coverage for its residents. This year, California has come up with a comprehensive plan of its own. With several other states considering expanding healthcare coverage for their uninsured residents, now is the time for the federal government to assist the almost 47 million Americans who lack health insurance.

Two bipartisan bills designed to expand healthcare coverage to millions of uninsured Americans while improving quality and efficiency were recently introduced in the U.S. Senate and House.

In an unusual show of both houses and both parties, Sens. Jeff Bingaman, D-N.M., and George Voinovich, R-Ohio, as well as Rep. Tammy Baldwin, D-Wis., and Rep. Tom Price, R-Ga., and Rep. John Tierney, D-Mass., introduced the bills at a news conference in mid-January. The bills are similar and both use the term "Health Partnership."

How does the legislation work? It allows states to apply for renewable federal five-year grants that must target four areas: coverage, quality, efficiency and health information technology infrastructure.

States can use a variety of mechanisms to reduce the number of uninsured by using the private system. These include offering tax credits or Health Savings Accounts, creating purchasing pools, and expanding public programs such as Medicaid or the State Children's Health Insurance Programs.

Why should the more than 200 million Americans who have some form of healthcare insurance or coverage support the Health Partnership Act? The growing number of uninsured and their families affect the financial well-being of everyone.

The size of this rapidly mushrooming group and the way it currently accesses and receives medical treatment already costs the country more than $200 billion a year — much of it currently paid by those who are insured through cost-shifting.

Lacking coverage, the uninsured receive about half as much healthcare as the insured. They get almost no preventive care. Because they wait much longer before seeking medical attention, they have much larger tumors when cancer is diagnosed; they suffer more heart attacks because initial warning signs aren't discovered. As a result, they die earlier.

The situation is getting worse as employers shift premium costs to employees or eliminate healthcare benefits for employees and retirees altogether. Also, the costs employees must pay for their part of health premiums increased 126 percent between 2000 and 2004.

The political reality is a discussion of national health insurance is off the table in this country. Experience teaches us that in America, centrally planned programs run by distant bureaucracies don't work. What does work are programs that empower the states to find and implement solutions.

By empowering states to reduce the rate of increasing healthcare costs, we will foster state "laboratories" where states can try out one or more programs to increase access to healthcare for the uninsured.

But that's not all. Targets will be set for quality indicators to ensure states are using best practices in assisting the uninsured. Goals will be developed for improving efficiency, allowing more funds to go for patient coverage.

Finally, use of information technology can greatly reduce administrative costs and repetitive tests. Every year, participating states would meet to review their outcomes and outline ways they could all work — individually or collectively — to improve their state plans. States could modify their plans as they learn from others but could not change their goals.

Ultimately, an increasing number of states will have these grants with the eventual goal of a few well-tested systems emerging as models. Imposing a one-size-fits-all program will not work since all states face different challenges in reducing the number of uninsured residents.

Massachusetts and California captured headlines with their initiatives, and seven other states began discussions on solutions. The trend is beginning to snowball. One state at a time may well be the best way to move toward improving our healthcare system.