After five years in which the concerns of people who already have health insurance through private health plans or Medicare has dominated the political debate on health care, we are finally seeing a renewed interest in doing something about the 44 million Americans who have no insurance at all.

Moreover, there is a new consensus emerging in both parties that would make public subsidies for purchase of private health insurance the centerpiece of universal coverage, rather than any Canadian-style, "single-payer" system, where government supplies health insurance to everyone. Both Democratic candidates for President have proposed tax credits as a way to help people buy health insurance who are not covered by employers or by existing government programs like Medicare, Medicaid, or CHiP. The President, last week, proposed similar tax credits for both small businesses and for people nearing, but not reaching, retirement. Tax credits for the uninsured enjoy impressive bipartisan support in Congress.

Much of this year's debate on the uninsured revolves around the pace and cost of covering the uninsured within the context of maintaining a balanced budget. That is indeed a critical question, but even if you are committed to an incremental approach to universal access to care, it's important to have a vision of how the overall system should work when fully in place.

Next month, Blueprint magazine will lay out a comprehensive set of proposals for health care reform addressing all the big issues, including access, cost, and quality of care, and specifically dealing with big challenges like modernizing Medicare and providing long-term care for the baby boom generation. Here's a preview of our basic take on how to get to universal coverage while ensuring quality care at a reasonable cost.

The first step is to provide tax credits to give buying power to the self-employed, workers in small enterprises, and the unemployed. This would eliminate the gross inequity in our tax system which gives workers a large tax break only if they obtain insurance through employer plans. It would also empower citizens to make their own choices about health insurance, while instilling greater competition among health plans on the basis of both quality and cost.

The second step is to give Americans an opportunity to obtain the same purchasing power as big employers, by encouraging a wide array of voluntary group purchasing pools through private non- profit organizations, labor unions, consumer "cooperatives," and state and local governments.

The third step is to harness the power of information to give all consumers greater choice in health plans and knowledge of health outcomes. Credible report cards on health plans and providers are an important place to start. Competition among health plans can produce improvements in quality while holding down costs if, and only if, consumers have the resources to make informed choices.

And the fourth step is to create a truly universal health insurance market (thus expanding choices and dampening costs) by requiring everyone to obtain health insurance, just as we require everyone to obtain automobile insurance. This will help eliminate the many hidden subsidies associated with uncompensated care at hospitals, while greatly expanding the reach of preventative medicine.

This approach couples the opportunity of being able to obtain insurance with the responsibility of having to get it. Universal coverage, coupled with consumer empowerment, is the strong medicine we need to make our health care system healthy.