So achieving comprehensive health care reform is no simple feat, as I learned a decade ago. None of these ideas mean anything if the political will to ensure that they happen doesn't exist.

Some people believe that the only solution to our present cost explosion is to shift the cost and risk onto individuals in what is called ''consumer driven'' health care. Each consumer would have an individual health care account and would monitor his or her own spending. But instead of putting consumers in the driver's seat, it actually leaves consumers at the mercy of a broken market. This system shifts the costs, the risks and the burdens of disease onto the individuals who have the misfortune of being sick. Think about the times you have been sick or injured -- were you able under those circumstances to negotiate for the best price or shop for the best care? And instead of giving individuals, providers and payers incentives for better care, this cost-shifting approach actually causes individuals to delay or skip needed services, resulting in worse health and more expensive health needs later on.

Meanwhile, proposals like those for individual health insurance tax credits, without reforms for the individual insurance market, leave individuals in the lurch as well. We know that asthmatics can have their entire respiratory systems excluded from coverage. Individual insurance companies can increase your premium or limit coverage for factors like age, previous medical history or even flat feet. Those in the individual market cannot pool their risk with colleagues or other members of the group. The coverage you can get and the price you pay for it will reflect individual risk, and you simply don't receive many of the benefits of what we consider traditional insurance when people pool risks. So the proposal to give individuals tax credits to buy coverage in the individual market, without any rules of fair play, won't provide much help for Americans who need health care. In the same way, the recent Medicare bill, which seeks to privatize Medicare benefits, long a government guarantee, threatens to leave the ''bad risks'' without any affordable coverage. With the new genetic information at our disposal, that could mean any one of us could one day be denied health insurance.

When many of those who opposed the Health Security Act look back, they are still proud of their achievement in blocking our reform plan. The focus of that proposal was to cover everybody by enabling the healthier to pool the ''risk'' with others. The plan was to redirect what we currently pay for uninsured care into expanding health coverage.

We could make cosmetic changes to the system we currently have, but that would simply take what is already a Rube Goldberg contraption and make it larger and even more unwieldy. We could go the route many have advocated, putting the burden almost entirely on individuals, thereby creating a veritable nationwide health care casino in which you win or lose should illness strike you or someone in your family. Or we could decide to develop a new social contract for a new century premised on joint responsibility to prevent disease and provide those who need care access to it. This would not let us as individuals off the hook. In fact, joint responsibility demands accountability from patients, employers, payers and society as a whole.

What will we say about ourselves 10 years from today? If we finally act to reform what we know needs to change, we may take credit in building a health care system that covers everyone and improves the quality of all our lives. But if we continue to dither and disagree, divided by ideology and frozen into inaction by competing special interests, then we will share in the blame for the collapse of health care in America, where rising costs break the back of our economy and leave too many people without the medical attention they need.

The nexus of globalization, the revolution in medical technology and the seismic pressures imposed by the contradictions in our current health care system will force radical changes whether we choose them or not. We can do nothing, we can take incremental steps -- or we can implement wide-ranging reform.