The failure of a single malpractice insurer cost the state of Pennsylvania fully one-quarter of its 1998 malpractice coverage, and when others left as well, prices for remaining coverage rose, creating insurance problems that rank among the nation's worst. One cause is the general downturn in the insurance cycle, but state-specific problems are more important, including Pennsylvania's underfunded social coverage for "catastrophically" expensive cases, and its high rates of claims and amounts of claims payments. To fix problems, lawmakers should look beyond conventional tort reforms to consider systematic changes to how medical injuries are identified, compensated, and prevented. (New York: Columbia University, The Project on Medical Liability in Pennsylvania, for The Pew Charitable Trusts, June 2003.)