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Immediate concerns over swine flu might be waning, but public health and government officials continue their fight against the illness, directing people with flu symptoms to see their doctor. But advice like this takes for granted a well-functioning health care system. Many Americans don't have a doctor to contact, either because they don't have health insurance or because primary-care physicians are in seriously short supply.

Automated enrollment strategies have achieved remarkable results with many public and private benefit programs, dramatically increasing program participation while lowering administrative costs and reducing erroneous eligibility determinations. The recently passed Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) should make such steps much easier for states to take in covering eligible but uninsured children. Following CHIPRA's enactment, states have both new tools and new incentives to use automated strategies in fulfilling four key functions: identifying uninsured children; determining their eligibility for health coverage; enrolling eligible children into coverage; and retaining eligible children.

Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008. This was below the general rate of inflation, resulting in a reduction in real fees. Only primary care fees grew at the rate of inflation--20 percent between 2003 and 2008. However, because of slow growth in Medicare fees, Medicaid fees closed a small portion of their ongoing gap relative to Medicare--growing from 69 percent to 72 percent of Medicare. The increase in Medicaid fees relative to Medicare fees resulted from relative increases for primary care and obstetrical services, but not for other services.

Current health insurance markets suffer from many shortcomings. Comprehensive health care reform will be necessary to address them. Insurance market reforms and subsidies to make coverage affordable for the modest-income population within the context of a more organized health insurance market are essential strategies. A health insurance exchange can be developed to organize the insurance market and to provide guidance and oversight in achieving reform goals. Making a public health insurance plan option available to purchasers can further promote competition in insurance markets and could be an effective strategy for slowing health care cost growth.

A health insurance exchange can make it possible to organize health insurance markets more efficiently and effectively than takes place today. Because so many different problems must be addressed in the insurance marketplace in order for all to have meaningful and affordable coverage, an entity like an exchange is needed to coordinate tasks and guide markets to comply with consumer protections and compete in cost-efficient ways. While not a panacea for all that ails the health system, carefully designed, an exchange can be a vehicle that facilitates and monitors the movement of the system toward many national health reform goals.