In the four years since Congress rejected President Clinton’s health-care reform, the number of uninsured Americans has increased by 5 million to 43 million, the number of restrictions on those lucky enough to be covered has increased and the cost of health care has again headed skyward. Yet Congress seems just barely aware of the extent of this crisis.

The problem is simple: Lack of access and the inability to contain costs makes health care unavailable for millions of Americans, and contributes to insurance premiums and medical costs that are crippling businesses and exhausting the public purse.

Solving this problem requires not so much the elaborate formulas for patients’ rights devised in the Republican and Democratic health plans to be debated next week; it requires courage. It requires courage to say what a Maine legislative committee studying health care recommended six years ago: “Make health coverage a right of citizenship rather than an employer obligation.”

The bills in Congress try to address the individual problems of access, portability, physician choice, legal protections and others. Sen. Olympia Snowe included in the Republican plan a thoughtful proposal that would bar the use of genetic information to discriminate against patients. Nothing wrong with any of these except that they try to cure the symptoms of an inadequate system rather than going after the illness itself.

The United States and South Africa remain the only industrialized nations that do not provide universal access to health care. The U.S. medical system, such as it is, is often called the best in the world and, indeed, there is much to be proud of. But the country’s delivery of health care never can be considered at that same level while it continues to exlude more than 15 percent of the population — or includes them only in what might be called America’s emergency room primary care system.

Canada’s sometimes-maligned single-payer system in 1995 spent just under 7 percent of its gross domestic product on health, compared with 6.6 percent of GDP that came from tax dollars in the United States. The difference is that Canada covers everyone; the tax-supported U.S. health-care system supports less than 30 percent of the citizenry. Why? Administration may be one reason. Canada’s simpler system of payment means fewer records, fewer bills, fewer collection problems. Hospital administrators in Canada don’t have fret over being able to take care of charity cases because there are none. Preventive care is stressed and no one need use an expensive emergency room for what should be a quick trip to a general practitioner.

Comparing outcomes of the two health-care systems is difficult given the number of other factors that have to be considered, but it is noteworthy that Canada has a lower infant-mortality rate and longer life expectancies for both men and women compared with the United States. The Canadian system isn’t perfect — its waiting times for non-critical surgery would be unacceptable here — but it does offer a model to follow as the need to recast the U.S. system becomes increasingly apparent.

Trouble is, almost no one in Washington is talking about it. Rather, just one senator is. Paul Wellstone of Minnesota has introduced the Healthy Americans Act, which allows states to create their own plans for covering the uninsured, with Washington picking up 70 percent of the cost. The qualifying income levels in the Wellstone bill are high enough so that just about everyone in Maine could fall under the voluntary coverage.

Sen. Wellstone would require participating states to offer residents at least the same level of coverage the members of Congress receive, ensuring solid coverage and portability among states. States could also work together to provide similar coverage in a region. The bill is real attempt to restart a serious debate on health care.

So, naturally, the legislation isn’t going anywhere. Instead, Democrats and Republicans will argue about whether a patient can sue an HMO (Why this industry should get special legal protections is a mystery.) and whether individuals should get a tax break on accounts used for medical expenses. Interesting, but of marginal use to millions of Americans who can’t afford to set up the accounts in the first place.

The way the debate is framed in Congress ensures that in a year or two, the nation will return to issue of health care coverage. Only next time, a few million more people will be without coverage, businesses will be even more burdened by costs they cannot support and patients may be wondering whether having the best medical system in the world is good for their health.