Like a lot of American institutions these days, health care has become most defined by whom it excludes. Part of Utah's health-care reform ambitions include allowing businesses who don't provide employees medical insurance benefits to help individuals buy their own coverage.

One state, Missouri, is the first in the country to approve legislation allowing employers to provide workers an insurance stipend to help purchase plans that are better tailored to each person rather than continuing to carry the burden of traditional group plans that small businesses can't afford.

In Utah, the portion of workers younger than 65 covered by a medical benefit from their employer dropped by 8.9 percent between 2000 and 2006 — the largest rate of decline nationwide, according to the Economic Policy Institute, a nonprofit, nonpartisan economic think tank.

The number of businesses in Utah providing health-care plans is around 46 percent today, down from about 68 percent eight years ago, according to the institute.

The nationwide assumption that full-time work equates to full medical coverage is clearly no longer valid, the report states. Its author, EPI economist Elise Gould, said the rate at which workers are joining the ranks of the uninsured is "alarming."

A story with slight variations in the numbers is the same in nearly every state, said Beverly Gossage, a health-care expert from a Missouri health policy research group in Utah this week to advise lawmakers on how her state is addressing the problem.

"Shopping to determine which single carrier's one or two plans an employer will offer each year to attempt to meet the needs of all employees is every small business owner's nightmare," Gossage told the Deseret News on Wednesday.

It comes down to these basic reasons: The hassle of selecting a plan; employer contribution and employee participation requirements; lack of retention among employees and the high cost of group premiums. The uninsured become uninsured because they can't afford their portion of the premium and they can't take coverage with them when they change jobs.

New legislation in Missouri addresses those concerns, all of which are on the table before a legislative health-care reform task force that has been meeting since April to lay the foundation to a new and improved system in Utah.

Under the Missouri plan, the employee becomes the consumer and purchaser of insurance with the employer merely contributing a defined amount. Group carriers there as well as here require that employers contribute at least half the premium for each employee.

The one-size-fits all approach is often more expensive than individual plans. The big carriers that are group providers are recognizing at least the need if not yet the trend of individuals seeking coverage and are addressing it, she said.