After a decade of relative silence, politicians are again broaching the issue of universal health care.

The debate can't come too soon for Stephanie Patrick, who's been denied health insurance because she has cerebral palsy.

Ms. Patrick, who's 37 and lives in Denton, used to be covered under a group plan through her former employer, at a cost to her of $125 a month. But when she left that job to start a public relations firm, she went shopping for individual insurance for herself and her son.

"Most insurance agents wouldn't even write up an application once I told them about my medical history," she said. "This whole experience has been frustrating and frightening. At least I've been fortunate not to have any emergencies."

She's been without coverage since August. She expects to wind up with a plan from the state's high-risk insurance pool at a cost of $366 a month.

Ms. Patrick's experience in the individual insurance market is at the heart of the decades-old problem of uninsured Americans. But politicians have largely avoided the issue since Hillary Rodham Clinton, as first lady, led a task force whose wide-ranging proposal for universal health care crashed and burned in 1994.

Today, President Bush, several 2008 presidential candidates and some governors are proposing solutions. Unlikely coalitions of Republicans and Democrats, insurers and consumers, business and labor are proposing reforms.

"For the first time in more than 10 years, I sense momentum behind this issue," said Karen Davis, president of the Commonwealth Fund, which studies the nation's health care system. "It's finally becoming a priority."

America provides arguably the best health care in the world for those with insurance through their employers

But costs have been rising sharply for years, and many companies are trimming benefits. And those who are unemployed, self-employed or work for small businesses that don't offer health insurance are left to navigate the individual insurance market, where costs are sharply higher and insurers can reject applicants, such as Ms. Patrick, with existing medical conditions.

Since 2000, premium costs have soared 72 percent for single coverage and 78 percent for family coverage. The number of uninsured Americans has increased by 7 million.

People without health insurance often go without care or delay seeking help. An estimated 18,000 Americans die each year because they're uninsured and can't get appropriate treatment, according to the Institute of Medicine.

The uninsured have also become an enormous problem for the governments and businesses that end up paying their bills. The Kaiser Family Foundation puts the tab at $41 billion a year.

"When the uninsured get treated, their care is paid for with higher taxes on taxpayers and higher insurance rates on the insured," said Nina Owcharenko, a senior policy analyst at the Heritage Foundation.

Employer-sponsored insurance, the backbone of the health care system, is showing signs of strain, said Fred Brock, author of Health Care on Less Than You Think. Sixty-one percent of businesses offered health benefits in 2006, down from 69 percent in 2000.

"Small businesses in particular are opting out, while companies that continue to insure their workers complain the higher costs make it harder to compete in a global marketplace," Mr. Brock said.

The worsening situation has caused some political shifts.

"After the Clintons were pilloried for their failed reform efforts in the 1990s, extending coverage to the uninsured became a forbidden subject," said Peter Cunningham, a senior fellow with the Center for Studying Health System Change. "Now, there's a common belief that something needs to be done. The situation has gotten so bad it can't be ignored anymore."

Fueled by polls showing that 80 percent of Americans want universal access to affordable health insurance, comprehensive health care reform has shaped up as one of the biggest domestic issues in the nascent 2008 presidential race.

All three of the likely major Democratic contenders – Mrs. Clinton, John Edwards and Barack Obama – have declared that enactment of universal health care coverage should be a priority of the next president.

Mr. Edwards became the first to propose a detailed plan this week. It includes a requirement that businesses provide insurance to their workers or pay 6 percent of their payroll into a government fund to buy coverage for them.

Not about to be upstaged by the new Democratic majority in Congress, Mr. Bush used his State of the Union speech last month to recommend tax breaks that would help pay individuals' insurance premiums.

Some states aren't waiting for Washington to act, however. Massachusetts is rolling out a plan that will cover nearly all of its residents. Politicians in California, New York and Pennsylvania are talking about doing the same.

In Texas, Gov. Rick Perry and other officials are discussing ways to reduce the ranks of the uninsured. About 25 percent of Texans – 5.6 million people – lack coverage, a higher proportion than in any other state.

People who don't get insurance through their jobs can enter the maze of the individual insurance market, which often leads to less protection and higher out-of-pocket expenses than a group plan.

Many who do buy a policy end up joining the 16 million Americans who are "underinsured."

After Sarona Winfrey, who's 45 and lives in Little Elm, left her corporate job, she began shopping for insurance for herself and her family.

"Reading the fine print became a full-time job," she said. "I felt like the human resources director for my family."

She found a policy for what she considered a fair price, $377 a month. But she had to settle for a high deductible – $5,100 for an individual – and a plan that excluded coverage for her son's allergies.

Many people get turned down because of pre-existing conditions that range from a cancer diagnosis or heart problems to high blood pressure and diabetes, said Walt Parker, an insurance agent in Wylie who sells individual policies.

For those who are denied, Texas and other states have high-risk pools where someone can purchase insurance for 20 percent to 30 percent more than most individual insurance premiums, with comparable benefits, Mr. Parker said.

"If you've got the money, it's an answer," he said. "But not everyone does."

The difficulty in buying individual insurance is giving a lot of would-be entrepreneurs second thoughts about leaving their corporate jobs, Mr. Brock said.

"That hurts the economy," he said. "It stymies small business start-ups, and it creates job gridlock as workers, especially older ones, stay put simply for the health coverage. That stifles younger workers trying to move up."

Despite the growing consensus that something needs to be done, proposed cures vary widely.

Some advocate a government-run system. Democrat Edward Kennedy, the Senate's new health committee chairman, calls for expanding Medicare beyond the elderly and the disabled. He'd start with children and people between 55 and 64.

"The best argument for this proposal is that Medicare is very efficient," Mr. Brock said. "Its administrative expenses total only about 2 percent of its budget, compared to 12 percent to 18 percent for some private insurers."

Also, most seniors say they're satisfied with their coverage, he said.

Still, few analysts see the Kennedy plan as politically viable, because they doubt the powerful insurance industry would stand by and let it happen.

Other reform ideas put the onus on individuals and the private market.

Mr. Bush would give a tax deduction to everyone who purchases coverage, whether through a job or outside the workplace.

Critics say the deductions would work better as refundable credits, which put cash in everyone's pocket regardless of income. The deductions would favor people in higher tax brackets.

Ms. Davis of the Commonwealth Fund fears Mr. Bush's proposal would chip away at employer-based insurance and push more people into the individual market.

"It's important to keep our employer-based system. More than 170 million Americans are satisfied with it," she said. "If we didn't have it, there'd be far more than 47 million uninsured people."

Policy analysts say the most realistic plans will rely on both the public and private sectors and build on what exists. The best examples, they say, can be found in states already tackling the issue.

"The states are definitely the catalyst right now," Mr. Cunningham said. "They'll be the laboratories where ideas are tried. At some point, Washington will step in, draw from the states' experiences and shape a national strategy."

Massachusetts' innovative approach has attracted the most attention.

Its health plan, crafted by a Republican governor and Democratic lawmakers a year ago, requires residents to obtain insurance by July 1 or suffer a tax penalty. It also imposes an assessment on employers who don't provide coverage.

The state already barred insurers from denying coverage or charging higher premiums to people with pre-existing conditions.

The universal coverage plan is projected to cost the state $1.2 billion over three years, according to the Kaiser Family Foundation.

"Massachusetts is the best model we have for health insurance reform," said John Holahan, director of health policy research for the Urban Institute. "Other states could copy all or parts of it, assuming they're willing to pay the price."

Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Austin, predicts Texas will take a number of incremental steps to covermore of the uninsured before it considers reform as sweeping as that in Massachusetts.

"There is no shortage of solutions to the uninsured. The problem is that too many people want all of these plans to cost nothing," she said.

The Texas Health Institute, an independent think tank in Austin, proposed last week a far-reaching plan to help 2.7 million Texans obtain insurance and cut in half the state's number of uninsured.

Its recommendations include broadening Medicaid, expanding the Children's Health Insurance Program, requiring college students to have health coverage and creating tax credits for employers to cover lower-income workers.

The plan would cost the state $1.6 billion a year. The federal government would kick in $1.7 billion.

Institute president Camille Miller said covering the uninsured shouldn't be seen as a drain on state coffers but an investment, because it would promote a healthier, more productive workforce.

"There are economic benefits to consider," she said. "We estimate that cutting the number of uninsured in half would increase Texas' total economic activity by $9.4 billion a year and produce $162 million in new state revenue."

"It's not all one-sided," she said.