The way to fix our health-care system is to stop trying to make insurance the solution, and focus instead on getting people the health care they need.

The number of people in the United States who have no way to pay for health care continues to grow, even as costs continue to rise. Absent a national approach, states have begun experimenting with initiatives that encourage more employer coverage, require individuals to purchase private policies, and expand public programs. These initiatives cannot succeed because they are based on a failed model: the same insurance system that got us into trouble in the first place.

What's wrong with insurance? Let me answer that.

First, insurance is temporary. Whether for a home, a car, fine art, or "health," insurance contracts are written for a brief, defined period - a year or less. If you have a private policy, and you cost your company too much or otherwise look undesirable at the end of that period, you'll either pay a lot more or you'll lose coverage altogether. Government insurance for the poor is also temporary. If at the end of your approved period your income has risen only a few dollars, or if you moved and didn't receive your renewal papers, you'll find yourself with no coverage. Finally, if you're one of the shrinking number of Americans lucky enough to be offered insurance through work (and you can afford to pay the co-premiums), you know that your benefits and even the doctors you can use might change from every year. Oh, and don't quit your job, or move out of state, because then you may never get coverage.

Second, insurance is based on minimizing risk and maximizing profit - concepts incompatible with protecting the health of individuals and the public at large. The insurance business depends on building reserves, limiting services, minimizing pay-outs, and refusing to cover people or situations that threaten to cost too much. This model doesn't work for live human beings, who need preventive care, who have babies, who change jobs and move from place to place, who get sick, who age.

This is why the plans under way in Massachusetts, California, and (it appears) soon New York, will not work: they propose to include ever more people in a system that provides temporary coverage, is bureaucratically unwieldy, and does nothing to control costs. Each member of a family could end up with a separate policy - with its own distinct benefits and expiration date. Doctors and hospitals will be even more confused than they are today, trying to figure out how and whom to bill, which services are covered and - worst of all - whether the patient's policy will be in effect long enough to complete her chemotherapy for cancer.

I recently met a Canadian fellow in his forties who told me about his work, caring for an older man disabled from a neurological disease. "Dave" said that he was employed by the government - that the job didn't pay much but he enjoyed the work, and it gave him time to read, do other volunteer work, and tend a garden. I chimed in, "Yes, and you don't have to worry about your insurance." Dave gave me a bewildered look. "Medical insurance," I clarified. He still looked confused. "Your health insurance," I said. "Because Canada has universal coverage." "Oh!" he exclaimed, finally understanding my point. "Yes, we all get health care."

Health care, not "insurance." Health care, not "coverage."

We have a model for this in the United States, and though it might be imperfect, it's a great start. It's called Medicare. Medicare is permanent (once you qualify, you can't lose it). It's universal (everybody over 65 can get it). And it's portable, uniform and consistent (you can move anywhere in the country, doctors and hospitals know what it covers, and they know how and whom to bill). Using Medicare as a model, we can put everybody into one big pool. We can use insurance companies for their networks, their claims-payment systems, and (in some cases) their expertise in disease management. We can cut out the profiteering on people's bodies and lives. And we can start talking about which health-care services are basic and necessary for all people, and set about making sure that everybody can get them.

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