There is an underground war going on. It is the quiet struggle of small businesses to maintain adequate health insurance for their employees at an affordable price.

	Eileen Anderson is designer at Red Clay Tile Works, based in Bellevue (redclay@city-net.com). She is a member of the SMC Business Councils and serves on its Government Relations Committee. She was on the board of directors of Suburban General Hospital from 1996 to 2004.

Because of the rapid rate of increase of small-group health insurance premiums, we seem to be well on our way to creating a whole new group of underinsured and uninsured middle-class small-business owners and employees. There seems to be no end in sight to the ever-rising costs of health care.

I am an artist turned activist for health care reform. I tired of watching my insurance premiums increase each year by 50 percent, 30 percent and then 40 percent, so last October I joined SMC Business Councils and President Cliff Shannon in the battle for affordable health care for small businesses.

If I had it my way, all small-business owners would become activists: They would visit, write and call their legislators, delivering the message that health care costs are killing small business. The reality is that most small-business owners are so overwhelmed by the daily challenges of running their enterprises that they do not have the time to look up. I have chosen to speak and fight for them.

My husband and I have always been covered by health insurance. Now that we are fifty-somethings and because insurers are permitted by law to use medical underwriting and demographic rating to set premium rates, we now find ourselves being squeezed out of the insurance market. If we were to buy guaranteed-issue small-group insurance we would be paying over $1,800 per month. If you add onto that the 15.3 percent self-employment tax of $3,304, $2,000 for vision and dental, that brings the total to $26,904, or $13 per hour. For us that is an impossible expense.

We have "solved" our "health insurance" problem by purchasing the least expensive policy we could find, which translates into the highest deductible. We have become gamblers betting on good health. We each have a $10,000 deductible to satisfy annually before our insurance pays anything. We have abandoned the traditional concept of insurance and instead insure our assets against catastrophe.

While our case may be extreme, it gives you a glimpse of the battle that small businesses are fighting. We exhibited at the Pittsburgh Home & Garden Show and I took that opportunity to speak with many small-business people while gathering 600-plus signatures on petitions that I took to Harrisburg in April with SMC Business Councils. The petitions protested the rising costs of health care for small business.

Many business people have either already given up covering their employees or they are fast approaching that point. I could hear the frustration in their voices as they told stories of escalating premiums, denying raises, passing on more costs, etc. Big businesses experience some of the same problems, but for small businesses insurance has become a much more acute problem. It is a documented fact that small businesses pay on average 20 to 30 percent more for identical coverage. Small business is the engine of job growth and produces 60 to 80 percent of net new jobs annually.

Unfortunately, we are not doing much to preserve the engine. If the current rate of premium increases continues for the next five to six years, the average cost of family coverage for a small-business employee will roughly equal the average wage of $30,000.

Many people mistakenly think that the uninsured don't pay anything for health care received. While the truly indigent may get charity care, creditors pursue the uninsured with a vengeance. Others think that many of the uninsured make over $50,000 per year and just simply choose not to buy insurance. I wish that were the case. The middle-class uninsured occupy a no-man's land where not only can they be shut out of the insurance market and have all their assets exposed to medical bills, but they also pay list price for the same hospital services that are deeply discounted to insurers.

It is a sobering thought and has become even more frightening with the recent changes in bankruptcy laws.

Unfortunately it seems to be the new reality for many entrepreneurs who are now literally risking everything to create jobs and provide needed services and products.

What am I fighting for? What do I propose as solutions to this awful mess? I knew at the beginning of this battle that I would not solve my own insurance problems. Instead I am focusing on the larger fight for health care reform. There are no simple answers to the problems of health insurance and our health care system. Instead there are a number of improvements that can be pursued. The most important thing is to acknowledge that our health care system is a mess, and start working on solutions.

I support the four-point agenda that SMC Business Councils is pursuing on the state and federal level aimed at restraining the growth of the underlying cost structure of health care:

* Medical malpractice reform.

* Rein in the cost of prescription drugs.

* Insurance market reform on the state level

* Pay for performance -- the pursuit of quality in the delivery of health care. In practice it means that providers get paid when they do things right. Currently they get paid, right or wrong, removing all incentives for improvement. It is estimated that waste, inefficiency and ineffectiveness account for one third of all health care expenditures. That cost is passed onto employers in the form of higher premiums. Quality in the delivery of health care is the giant step we need to take to improve our current system.

We often think that solutions to problems lie in the hands of our legislators. Some solutions are legislative, but others are not. In Pittsburgh, the decision to pursue quality in the delivery of health care resides with our top health care leaders: Dr. Kenneth Melani, Jeffrey Romoff and Jerry Fedele, who represent Highmark, UPMC and West Penn Allegheny Health System, respectively.

I challenge them to sit down at the table and begin discussing how they can jointly pursue quality in the delivery of health care. These gentlemen have the power to make health care reform a reality in Pittsburgh thereby benefiting the entire region for years to come.

In spite of what pessimists think, it is not too late; our health care system is not too far-gone. It can be transformed by quality but we must act now. Our health care leaders have the opportunity to shape the future. The exercise of power is a matter of political will. Let's hope that they have the courage and the vision to do so.