Thirteen years after television ads from the insurance industry featuring the fictional middle-class couple helped kill the Clinton health-care plan and make universal coverage politically radioactive, comprehensive proposals for expanding coverage to millions of uninsured Americans are flowering again inside the Beltway and around the country.

And this time, advocates hope, the political climate is right for the best ideas to grow, in large part because many business groups that opposed earlier efforts now agree that rising health-care costs and increasingly tougher access to insurance are unsustainable trends.

Whether Washington will do more than talk about the problem, however, remains to be seen. Money is tight, and some experts say major shifts in federal policy are unlikely until after the 2008 presidential election, in which health care is expected to be a major focus.

Many are not willing to wait. Karen Ignagni, president of America's Health Insurance Plans -- the same industry association that once funded the "Harry and Louise" ads -- was among representatives of 16 business, medical and consumer groups that last week called for Congress to spend $45 billion over five years to extend health coverage to most of the nation's uninsured children. After that, the groups said, lawmakers should direct billions more toward covering uninsured adults, mostly through a mixture of tax breaks and expanded federal programs.

"On this issue, the polls show that Democrats, Republicans and independents want progress," Ignagni said. "The most expensive course is to do nothing."

John J. Castellani, president of the Business Roundtable, an association of chief executives of 160 U.S. companies, issued a similar call at a separate news conference last week with leaders of AARP, the politically powerful seniors organization, and the Service Employees International Union (SEIU). "Our soaring health-care costs put American goods and services at a significant competitive disadvantage, and they slow economic growth," Castellani said. "Policymakers must act."

In recent weeks, proposals for dramatically expanding coverage have been floated by Ignagni's industry group, the Children's Defense Fund and Sen. Ron Wyden (D-Ore.). Sen. Edward M. Kennedy (D-Mass.) and Rep. John D. Dingell (D-Mich.), who lead important congressional committees, plan to pursue legislation to allow Americans under 65 to enroll in Medicare or in the health coverage enjoyed by Congress. And a bipartisan group of two senators and three House members introduced legislation last week to help states fund innovative ways to cover more people.

"Health care has been poked and prodded for years," said Wyden, who wants to replace employer coverage with a centrally financed system of private insurance for all Americans. "I believe it is time for diagnosis and treatment."

Much of the activity in Washington is being spurred by a wave of experiments at the state level, particularly Massachusetts's decision last year to require all residents to obtain health insurance, through state-subsidized policies if necessary. This month, California Gov. Arnold Schwarzenegger (R) proposed a similar plan for all 36 million Californians, funding its $12 billion cost partly through fees on employers, hospitals and doctors.

In Pennsylvania, Gov. Edward G. Rendell (D) last week proposed creating a program of state-subsidized private insurance to help many of the 767,000 uninsured people in his state. The plan would impose taxes on tobacco and on businesses that do not offer coverage, and it would phase in a requirement that people earning more than 300 percent of the poverty level (about $60,000 for a family of four) obtain insurance.

"It is no longer a question of whether we can afford to act," Rendell said, noting that treating Pennsylvania's uninsured costs $1.4 billion annually. "The cost of inaction is far greater in terms of individual health consequences and from the increasing burden on taxpayers."

Vermont enacted legislation last year that seeks to expand coverage so that at least 96 percent of residents will have insurance by 2010. Illinois began a major expansion of coverage for children in 2005. That same year, Maine began implementing a plan whose goal is to cover all of the state's 130,000 uninsured residents by 2009.

Other states considering expanding coverage include Connecticut, Indiana, Iowa, Louisiana, Minnesota, Missouri, New Hampshire, New Jersey, New Mexico, North Carolina and Wisconsin, according to the National Conference of State Legislatures.

All the state activity is adding pressure on politicians in Washington to act on a problem that grows worse year by year. Recent census figures show that a record 46.6 million Americans, including 8.3 million children, had no health insurance in 2005, up from 39.7 million in 1994. Employer coverage is more expensive and less available.

"As usual, Washington is behind the rest of the country," said Andy Stern, president of the SEIU. "We're ready to have a very bipartisan solution. What you are seeing now that you didn't see in 1994 is that everyone is on the same side saying, 'We want universal coverage.' The only question is, 'How?' "

Ah, yes, "how" -- and how to pay for it.

Expanding coverage is a costly proposition, and Democrats, in control of Congress for the first time since 1994, have pledged not to pass major new spending proposals unless other programs are cut to avoid increasing the federal deficit.

While there is bipartisan support for reauthorizing the decade-old state-federal Children's Health Insurance Program, which covers more than 4 million children at a cost of $5 billion a year, experts say at least $12.7 billion more is needed over the next five years just to keep covering the same number of kids.

Moreover, President Bush has given no sign of departing from his advocacy of special tax-favored savings accounts and changes in the tax code as the best ways to make health insurance more affordable. In his State of the Union speech this week, Bush plans to propose more such changes and to announce a new initiative to help states get more residents into private insurance.

"We must address these rising costs so that more Americans can afford basic health insurance," the president said Saturday in his weekly radio address. "And we need to do it without creating a new federal entitlement program or raising taxes."

Despite the new enthusiasm, in the short run, most attempts to expand coverage will probably continue to happen at the state level, some lawmakers said. Federal efforts will be largely incremental and devoted to helping the states find their way.

"The states become laboratories," said Rep. Frank Pallone Jr. (D-N.J.), chairman of the House Energy and Commerce subcommittee on health. "Politically that's necessary. If we tried to adopt a universal health-care plan on the federal level, we probably wouldn't have the votes."

Sen. George V. Voinovich (R-Ohio), a member of a bipartisan group that wants to steer new grants to states, called health care "the greatest domestic problem" but also said that "the truth of the matter is that dealing with this problem between now and the election is not realistic."

"Congress is not going to act in a major way to deal with this access problem in the next couple of years," said Sen. Jeff Bingaman (D-N.M.), another member. "That's the unfortunate reality that we're facing. And so we're saying most of the effort that is possible is at the state level and at the local level. And we want to encourage it and we want to provide assistance."

But ultimately, Washington will have to do more, said Charles N. Kahn III, president of the Federation of American Hospitals.