WASHINGTON – Health care reform may be dead in Washington, but a growing number of states – under both Republicans and Democrats – are taking steps to expand medical insurance coverage.

Faced with a problem they find increasingly hard to ignore, governors and legislators in at least 20 states have hammered out agreements to expand access to health care by squeezing money from existing health programs and taking other politically difficult steps, including some tax hikes.

In Illinois, Democratic Gov. Rod Blagojevich is about to sign a bill providing affordable health coverage for uninsured children of working parents. Massachusetts has taken on a much bigger challenge. There, Republican Gov. Mitt Romney and the Democratic Legislature are negotiating over competing plans to cover all of the state’s half-million uninsured residents.

“The fact that nothing is happening in Washington is not deterring states,” said Alan R. Weil, executive director of the National Academy for State Health Policy. “The lack of action in Washington is not because of the lack of a problem. It’s because of a lack of agreement and, frankly, a lack of consequences for failing to address the issue. At the state level, if you have a Medicaid budget problem or a growing number of uninsured, you have to tackle the issue.”

Given the seemingly intractable economics of health care, it is not clear whether the states will be able to sustain the efforts they have launched. Controlling costs continues to be difficult. States’ revenues can fluctuate. And many are legally barred from running deficits.

But traditional employer-based coverage, the cornerstone of the old system, continues to shrink as the average cost of a family plan approaches $11,000 a year. And some experts think the modest but growing efforts by states could help jump-start a national debate.

“If any of these states succeeds, it could provide impetus for a national debate in later elections,” said Robert Blendon, a public opinion analyst at the Harvard School of Public Health. “If the Iraq war and terrorism were to go away, health care issues are going to pop right up because they just bother a lot of the public and voters.”

The renewed interest in expanding coverage is unexpected.

Earlier this year, headlines focused on Medicaid cutbacks in Tennessee and Missouri, which are expected to leave tens of thousands without coverage. And Florida’s experiment with managed care for its poor is being watched warily by liberals.

But a study by the Kaiser Commission on Medicaid and the Uninsured, released in October, found that 20 states increased access to health care in the 12 months that ended in July. In nine states, those expansions reversed previous cuts. For example, Texas rescinded premium increases that had contributed to 149,000 low-income children losing coverage.

By comparison, 14 states took action that had the effect of limiting health care access, in most cases by raising premiums for programs covering low-income kids.

The Kaiser study found that more states are expanding coverage because budgetary pressures have eased somewhat.

States have not shied away from controversial proposals.

Romney of Massachusetts backs a proposal requiring that individuals obtain health insurance, much as they are required to have automobile insurance. Individuals could enroll in an employer or government plan, or purchase a policy. Subsidies would be provided for those with low incomes.

“The fact that a Republican is supporting a mandate is a huge leap,” Blendon said. Some conservatives see such an insurance mandate as tantamount to a tax increase, and at the national level President Bush has remained aloof from the idea.

Romney is also at odds with many Democratic lawmakers, who believe employers should be the ones required to provide coverage. The Massachusetts debate may extend into next year, but activists on both sides say chances for a deal appear to be good.

“I think it is likely that we are going to do something here, even though nothing is happening in Washington,” said Richard C. Lord, president of Associated Industries of Massachusetts, a business federation trying to stop an employer mandate.

“Most people think something significant is going to happen,” agreed John E. McDonough, executive director of Health Care for All, a consumer group.

“Washington needs to wake up and smell the coffee,” said McDonough, a former college professor. “Employer-based coverage is melting away like the Arctic ice cap. It is stunning and alarming. The basic underpinnings of the health care system are badly eroding.”

Other states have opted for a more limited strategy than the one being pursued in Massachusetts, focusing on small businesses that employ low-wage workers.

Oklahoma recently started to enroll small companies and their employees in a program that will subsidize premiums for private health insurance. The effort is largely financed by a tobacco tax increase that state voters approved last year.

“We should be able to cover 50,000 to 70,000 individuals,” said Cindy Roberts, associate director of Oklahoma’s Medicaid program. “Based on the response we’ve been getting, my fear is we’ll fill up the slots and have to have a waiting list.”

Maine approved a program aimed at small businesses two years ago, but its complexity has made it a target for critics. Financing for the initiative depends substantially on achieving savings through greater efficiency in the operation of the state’s overall health care system, savings that are difficult to estimate. Interest in signing up for the plan has been lukewarm.

Illinois is hoping its All Kids plan will be a model of simplicity. The idea is to make affordable insurance available to more than 125,000 children whose parents make too much to qualify for existing state and federal programs. A family of four making $40,000 to $59,999 a year would pay a monthly premium of $40 per child, well below the going rate for private coverage.

Annette Akey, a real estate broker from the Chicago suburb of Carol Stream, said the program would allow her to obtain coverage for a 6-year-old daughter who suffers from a kidney problem and a mild form of autism.

“It’s to the point where the insurance companies say, ‘Sorry, she is uninsurable,'” Akey said. “Health care has just gotten completely out of range for most middle class people. If you are self-employed or own a small business, you cannot get discounted insurance.”