Expanding health care coverage to more Americans is a debate that goes on and on both nationally and at the state level.

And, it continues with good reason. The latest statistics on the uninsured place the number of those who hold their breath and hope that they don’t become seriously ill at approximately 45 million.

It is a debate that the National Association of Insurance Commissioners has taken on over the years. In fact, at the June meeting in Washington, a public hearing was held to gather viewpoints of commissioners, regulators, health insurance trade groups and consumer advocates.

But it was at the fall meeting in St. Louis earlier this month that living proof of why the conversation is a critical one became clear.

This occurred blocks away from the technical policy discussions that are so endemic to regular NAIC dialogue. At a table of dining NAIC attendees, a middle-aged waitress spelled it out in simple terms.

It started with some friendly joking about how I should be interviewing someone. Those gathered at the table then started asking our waitress about what she thought about insurance.

Her response surprised us, both for its bluntness and decisiveness. “It [stinks.]” Her opinion must have been pretty heartfelt to risk offending her table and cutting into her tip.

“Why?” we wanted to know. She had our attention now. She narrowed her problem with insurance down to health insurance. Or, in her case, lack of health insurance.

As our waitress explained, she is a 45-year-old single woman working hard to make a living in a job that doesn’t offer health coverage. She said that her fear is that if some huge health problem comes along, both her health and her simple finances will be ruined.

Why the fear? Well, common sense may be one answer. But the experience of a friend, also without health insurance, brings it home. This friend had had heart surgery and she ended up with a humongous health care tab that is threatening to push her into bankruptcy.

The waitress had a question of her own. What should she and others like her do? Suddenly the question-and-answer session seemed more difficult. As the June NAIC hearing suggested, there are no simple fixes for a complex issue.

But, certainly, there are good places to start. As Oregon Administrator Joel Ario, NAIC Health Insurance and Managed Care “B” Committee chairman, said in an interview, using the states as a “laboratory” to create solutions is a productive use of the state regulatory system that can produce measurable results. He cited health programs in Massachusetts, Montana and New York as evidence of what states can do.

But, as was also noted during the June hearing, different states have different needs. So, solutions will vary.

During the hearing, insurers offered some ideas of their own. For instance, Karen Ignagni, president and CEO of America’s Health Insurance Plans, cited several possible solutions. Those include offering improving enrollment in public programs, using tax incentives to promote private coverage and offering bridge loans for workers between jobs.

Improved enrollment and tax incentives are ideas offered by Mary Nell Lehnhard, a senior vice president with the Blue Cross and Blue Shield Association. She also suggested providing lower cost products and greater transparency about health care costs.

Health care expert Mila Kaufman, an NAIC funded consumer and an associate research professor at the Georgetown University Health Policy Institute, Washington, urged state regulators at the NAIC to develop a model of what health insurance should look like. Kaufman also urged them to oppose federal preemption of existing state initiatives and consumer protections such as Association Health Plans.

Small business and chambers of commerce support these plans as ways of expanding coverage.

The answer may be one, none, or a combination of many of the ideas being discussed. Or it may be an idea yet to be created.

But for living proof that work on this is critical, one need look no further than to the waitress standing over you taking your order.