Workers' compensation reform efforts respond to the competing interests of business, labor and insurers. Early reforms expanded programs in response to inadequate benefits and coverage while in the 1980s and 1990s states responded to increasing costs by tightening fee schedules, limiting physician choice, restricting eligibility,lowering benefits, and integrating managed care into workers' compensation. Although managed care has resulted in significant medical savings, the cost of workers' compensation is again rapidly increasing in some states, where workers' compensation legislation is again at the center of debate. Increasing the use of treatment guidelines, placing limitations on use of services, developing more objective criteria for determining level of disability, and streamlining dispute resolutions have been offered as solutions. Controlling costs alone, however, cannot solve other problems of workers' compensation. Future reform efforts will need to focus not only on the costs of the system but also its inclusiveness and support of the workers and their families it was intended to protect.