America's health care system is failing. It denies care to many in need and is expensive, error-prone, and increasingly bureaucratic. The misfortune of illness is often amplified by financial ruin. Despite abundant medical resources, care is often inadequate because of the irrationality of our insurance system. Yet our political leaders seem intent on reprising failed schemes from the past, rejecting the single payer national health insurance model that is the sole hope for affordable, comprehensive coverage.

Leading Republicans propose tax incentives to encourage the uninsured to buy coverage, but these subsidies fall far short of the cost of adequate insurance. For cost control, they suggest high co-payments and deductibles. Yet these selectively burden the sick and poor, discourage preventive and primary care, and have little effect on costs, since seriously ill patients - who account for most health spending - quickly exceed their deductibles and are in no position to forego expensive care.

Most leading Democrats offer a mandate model for reform. Under this model, the government would require people (or their employers) to buy private coverage, while offering an expanded Medicaid-like program for the poor and near-poor.

Variants of the mandate model, first proposed by Richard Nixon, were passed with great fanfare in Massachusetts (1988), Oregon (1989) and Washington State (1993). All died quiet deaths. As costs soared, legislators backed off from enforcing the mandates or funding new coverage for the poor. Massachusetts' recent reform, which largely excuses employers from the mandate but imposes steep fines on the uninsured, appears poised to follow a similar path. Of the middle-income uninsured who are required to pay the full premium for coverage, few have signed up. Meanwhile, the state has already announced a $147 million shortfall in funding for subsidies for the poor.

Mandates and tax incentives can add coverage only by increasing costs. They augment the role (and profits) of private insurers, whose overhead is four times Medicare's, and whose efforts to avoid payment impose a costly paperwork burden on doctors and hospitals. The cost cutting measures often appended to such reforms - computerization, care management and medical prevention - have repeatedly failed to yield savings.

In contrast, single payer reform could realize administrative savings of more than $300 billion annually - enough to cover the uninsured, and to eliminate co-payments and deductibles for all Americans. It would also slow cost increases by fostering coordination and planning.

Political calculus favors mandates or tax incentives, which accommodate insurers, drug firms and other medical entrepreneurs. But such reforms are economically wasteful and medically dangerous. The incremental changes suggested by most Democrats cannot solve our problems; further pursuit of market-based strategies, as advocated by Republicans, will exacerbate them. What needs to be changed is the system itself.

We urge our political leaders to stand up for the health of the American people and implement a non-profit, single payer national health insurance system.