With one of the leading presidential candidates having unsuccessfully championed health-care reform in her husband's first term in the White House, the issue would be alive in this campaign even if the situation hadn't deteriorated. But it has. Forty-seven million Americans are now estimated to be without health insurance.

Those old TV ads, funded by health-industry lobbyists and featuring the fictitious Harry and Louise fretting over government bureaucracy, helped doom Hillary Clinton's health-care plan. Ironically, bureaucracy came with a vengeance anyway -- only it was private insurers who did the job, with their infernal HMOs and second-guessing of doctors. All the while, health-care costs rose exponentially, putting a huge burden on businesses big and small and swelling the ranks of the uninsured.

This set of facts, which makes the United States a shameful anomaly among industrialized nations, poses a problem for the Republican candidates, although not one they recognize. On ideological grounds they are still driven to insist that health care is primarily a personal responsibility, not a government one.

• John McCain of Arizona is fairly representative of the thinking on the right. In a Washington Post summary of issues, he said, "The road to reform does not lead through Washington and a hugely expensive, bureaucratic, government-controlled system."

The senator thinks the best way to expand access to health care and control costs is to harness competition to offer more affordable insurance options. He is in favor of low-cost health clinics in retail stores and calls for more emphasis on preventative care. He supports tax-exempt health savings accounts and tax credits to help people pay for insurance.

• Mitt Romney, when governor of Massachusetts, helped put in place a ground-breaking health-care plan that mandated coverage but utilized private insurers (with subsidies for the needy). But now styling himself as a true conservative, he does not promote his state's plan as a model; he just wants to give states incentives to deregulate and reform their health insurance industry so that market forces can work.

He also favors improving health savings accounts and making qualified medical expenses fully deductible. More controversially, he would stop the "free riders" in emergency rooms -- that is, he would use some of the money currently spent on providing expensive care for the uninsured to help the needy to buy private insurance.

• Mike Huckabee, the former governor of Arkansas, was once obese and now is saved -- and so it is no surprise that he puts great emphasis on personal responsibility for health, calling on Americans to quit smoking, lose weight and exercise. He believes people who live healthy lives should be rewarded in their health insurance costs. That's a good idea, but beyond this he can only offer conservative nostrums that would be a Band-Aid on the chronic national problem.

To paraphrase Sen. McCain, what we have is a hugely expensive, bureaucratic, privately controlled system that is not going to get seriously better without the attention of candidates who take it seriously -- and the Democrats do.

• Hillary Clinton has learned something from her earlier health-care reform defeat. In her plan to bring health insurance to all Americans, people could keep their own plans if they like. Those who want to change plans or who are not covered could choose from the same plan available to members of Congress -- a nice populist touch -- or opt into a public plan like Medicare.

Sen. Clinton would create a level playing field of insurance rules across states and markets to ensure that no American is denied coverage, refused renewal or forced to pay excessive premiums. The senator from New York would provide working families with a refundable tax credit. Although her plan foresees cost savings in stressing prevention, modernization and efficiency, her own cost estimate is at least $110 billion.

• Barack Obama has a price tag on his plan of $50 billion to $65 billion, but it has been criticized because it does not mandate coverage for everyone as Mrs. Clinton's does. The senator from Illinois would create a National Health Insurance Exchange to help Americans who wish to purchase a private insurance plan. The exchange would act as a watchdog and help reform the private insurance market by creating rules and standards to make coverage more affordable and accessible.

As with the Clinton plan, no American would be turned away because of a pre-existing condition. Mr. Obama also wants a benefits package like the federal plan that covers Congress.

The two terms of George W. Bush have increased, rather than diminished, the number of Americans without coverage. Now even business wants a solution because companies that cover their own employees are saddled with ever-rising insurance costs, yet they know how vital such coverage is to their loyal employees.

The next president of the United States must work with Congress to deliver a plan that tames the costs, delivers the care and extends peace of mind to every American, regardless of income.