Americans face two pressing problems with their health insurance: first, finding a health insurance policy they can afford and, second, making sure their coverage will be there when they need it. Sadly, today, too many people find that health insurance is either unaffordable or unaccountable.

Recently the congressional debate over managed care reform has joined these two issues, using one to undermine the other. Critics of managed care reform argue that it will exacerbate the affordability problem, leaving more Americans uninsured. But affordability without accountability is no solution.

Congress is debating managed care reform because Americans who have health insurance no longer trust that it will deliver the care it promises. Health insurance is supposed to protect you when you get sick. But too many consumers are worried their health plans won't be there for them when they need them most: They won't be able to get care from a qualified specialist; they'll have no recourse if coverage for a needed treatment is denied; and their plan will face no consequences if they're harmed as a result.

The pending legislation responds to these worries by requiring health plans to abide by new rules and by giving patients new rights. The rules set boundaries on how plans can manage care. The rights allow patients to appeal some health plan denials to outside experts and to go to court when the rules are broken. In other words, if a plan refuses to play by the rules and a patient is hurt, the plan will have to pay the consequences.

What does this have to do with the uninsured? The link is whether and how much these reforms will raise the price of insurance. The Congressional Budget Office has estimated that a patient bill of rights--including health plan liability--could increase premiums by 4.8 percent. Critics of managed care reforms argue that premium increases will cause even more Americans to be uninsured. Their response is to water down or eliminate key elements of reforms.

Weak (or no) reforms might avoid the cost problem. But the strategy rests on a peculiar logic. To paraphrase one state regulator: "It's like making cereal cheaper by selling empty boxes." Keeping health insurance affordable by allowing plans to vitiate the promise of coverage renders health insurance meaningless. Worse, it leaves people who paid for health insurance effectively uninsured when they get sick.

It's true that the cost of insurance is the primary reason that 44 million Americans lack coverage. But 60 percent of the uninsured are poor or near poor--with incomes less than $26,000 for a family of three or $32,000 for a family of four. By contrast, the cost of a typical family policy can be $5,000 to $6,000.

Most of the uninsured work but are not offered health benefits by their employers, even in a booming economy. Without the employer's support, these people lack the resources to buy insurance, with or without reforms.

The way to make insurance affordable for everyone is to ensure them adequate resources to buy meaningful coverage. Experience tells us that will require subsidies approximating the full cost of insurance. Offering a low-income family a discount through the tax system simply won't do the trick.

The issues of affordability and accountability should be joined, but not to use one against the other. It won't help the uninsured to sell everybody "empty boxes." Nor will it help to offer tax policies that are empty promises. We need reforms to keep health insurance accountable. We need other measures to make insurance affordable. The challenge is to achieve both. Both have to be real.

Judith Feder is dean of Georgetown University's Public Policy Institute. Karen Pollitz is an adjunct faculty member there.