The first author discussed an earlier appearing report concerning occupational injury and illness in the United States and expressed surprise that no reference was made to the inefficiencies, waste and fraud that are inherent in the present system for compensating workers for injury and illness. The costs of occupational injury continue to increase progressively and the author shares several reasons for this. Often the compensation to the worker bears no relationship to the actual severity of the injury or illness; instead, it becomes an adversarial contest between the injured worker and the employer. Medical considerations are often sidetracked, and the psychological, social and economic considerations become the determining factors. Another factor is the absence of any well defined standards of care. Significant differences also exist in workers' compensation statues from state to state. While there is no easy solution, close collaboration among workers' compensation insurance carriers, physicians, employers, labor unions, legislators, and employee groups must happen before any meaningful reduction in costs will occur. In a reply, the authors indicate that although waste, fraud and abuse may account for 6% of workers' compensation costs, about 60% of fatal and nonfatal occupational injuries are missed. In addition, perhaps 90% of occupational disease deaths are missed. They conclude that the high cost of occupational injuries and illnesses is not a result of the workers' compensation system, rather it is a result of the great number and severity of these injuries and illnesses.