Health care reform runs into another problem even when everyone agrees it is necessary--a lack of vision. Politicians, as well as most policy advisors, tend to see only two possible kinds of reform.

Conservatives, not surprisingly, tend to advocate a quasi-market solution. The absence of thinking in the White House and the abundance of knee-jerk free marketeers there means that the only suggestion we will get out of Bush is a reluctant agreement to a gap-filling insurance system for those 37 million uninsured.

This kind of public/private partnership would require employers to provide insurance and let the federal government pick up everyone else. Like the old Massachusetts plan, small employers would be allowed to buy into a government-sponsored insurance plan that reduces their costs and lets them comply with the law. Even the American Medical Association, that bastion of greedhead doctors, has come out in favor of this kind of reform.

The great advantage of this system is that it makes a lot of smoke while it does absolutely nothing to help correct the systemic rot. Nothing keeps hospitals from being walk-in clinics. Nothing reverses our increasing infant mortality rate. And most important, nothing cuts the skyrocketing insurance costs.

The second option is a nationalized, standardized, state-based, universal health care program similar to Canada's. Such a program would slash administrative costs by centralizing administration within the government. Of course it would cover the uninsured and encourage preventive medicine.

A Canadian-style socialization would be, in a perfect world, a very good idea. But in a world with a powerful Republican party, it is an utter impossibility. (Oddly enough, corporate America will probably back the more radical plan--companies are paying so much for health care that anything that shifts costs from them would be an improvement.)

The wealthy will yell about "socialization" and how that means rationing, and how rationing is a death sentence for old people who need transplants, dialysis and other expensive treatments. Of course, the wealthy will not yell about the rationing which is taking place right now, where the rich live in a medicalized paradise and the poor die in a third-world hell.

THERE IS, however, a way around the legislative bottleneck of the Washington loop. Out in the boonies, innovative states and locales are doing the impossible: They are doing more with less. Here is where America, if it chooses to, will find its medical salvation.

In western Ohio, a radical plan is taking shape. To renew your Medicaid eligibility, you must sign up for a state-sponsored Health Maintenance Organization (HMO). Then you choose a primary care physician. This keeps people out of emergency rooms with anything less than an emergency. The huge reduction in emergency room visits improves the quality of emergency room care for everyone.

And due to the dedication of the people involved, the HMO includes 99 percent of all doctors in the area. That means that the welfare HMO is the best HMO in the region--public or private.

In addition, the Ohio plan includes an aggressive prenatal program. If an expectant mother goes to her prenatal visits she gets free merchandise from a department store. The plan increase birth weights, reduces premie costs and lowers infant mortality. It is the best of public/private partnerships imaginable, and it works because the administrators and the business community want it to.

Finally, the savings have been so great that the organization was able to hire fulltime several people on general relief to be drivers. They drive people without transportation to their doctor visits. They also drive mobile clinics, staffed by doctors and nurses, who run blood pressure checks, give vaccinations, mammograms and bring health care into areas where there has been none.

Such successful systems are bound to proliferate. For a political entrepreneur, they could be models not only for Medicaid, but for a revolution in system of health care administration.

If such a plan were nationalized, states would be required to pick two or three of the biggest HMOs in their borders and grant them a collective monopoly. Employers would stop buying insurance, Medicare and Medicaid would wither away, and everyone would sign up for one of the new plans, funded through tax dollars and administered through the HMOs.

Insurance companies which are not selected to administer state programs will go out of business. It will be, for all intents and purposes, a high-tech, high-flexibility nationalization.