WHILE AMERICANS pay a great deal more for their health care than the people of the other rich countries, they are no healthier. They are on average less healthy than the people of many countries that spend not nearly as much. Americans have known for many years that the system here works badly, and things aren't getting any better.

More than 30 million people have no health insurance, and a much large number have insurance that -- whether they know it or not -- is inadequate. Big city hospitals are suffering serious financial losses in the struggle to care for them -- and that struggle is affecting the quality of care for those who can pay. Morale among physicians is deteriorating. Businesses groan at the speed with which health insurance premiums keep rising. There are uncountable studies, proposals and plans to reform the system. But its sheer complexity, and the enormous amounts of money involved in every aspect of it, seem to defeat every hope of fundamental improvement.

What's needed is a big table at which everyone takes a seat -- not only doctors and hospitals but taxpayers and patients -- and all the players together make the necessary concessions to get what they want and need. It's possible to sketch out the deal that can be struck.

Patients need, above all, universal health insurance that covers fully adequate basic care -- an assurance that they will have care when they need it, whether they are employed or laid off, whether they work for big corporations or for themselves. The other side of the bargain? A recognition that universal insurance has to have limits. It can't cover everything that anybody or his doctor might think of. If you want more than basic care, you are going to have to pay for it yourself.

Doctors, for their part, are going to have to accept fee limits that bring costs under better control. What they need out of the deal is, first of all, some degree of protection from malpractice litigation, narrowing the grounds to real negligence and holding awards to real losses. Another idea, slightly more radical, might also be on the table: public funding for all medical education. If doctors were not loaded with huge debts as young students, perhaps they would be less preoccupied with income as middle-aged practitioners.

The hospitals' part of the bargain is already familiar to them. They would be expected to keep holding down costs and holding emergency room doors open. With universal insurance, they could afford it.

As for taxpayers, they have been saying warily that they won't support universal health insurance until they see more effective cost controls. But that has it backward. There won't be good control of costs until there's universal insurance.

It ought not be necessary to wait for a deeper crisis of care before beginning to work out this kind of a deal around the table. The present state of the American health care system is a reproach not only to the country's conscience but to the kind of energy and imagination that it has so far brought to this fundamental public responsibility.