What are the chances of any significant health care legislation making it through Congress and becoming law with President Bush's signature?

Both parties have promised voters in the past two elections (or more) that they will provide a prescription drug benefit for senior citizens, reduce the number of people without health insurance and find a way to address the costs of long-term care that force so many families almost literally to bankrupt themselves.

But the struggle to reach agreement on how to arrange and how to finance these programs so far has yielded more frustration than results.

On a single day last week, I saw evidence that alternately offered caution and hope.

The hearing on Medicaid in the House Energy and Commerce health subcommittee showed just how fierce the partisan forces are that beset any effort to change the way the government tackles medical issues. Medicaid is the 37-year-old federal-state partnership that pays doctor and hospital bills for welfare recipients and pays for nursing home care for millions of the chronically ill.

Medicaid costs have been running out of control, draining the Treasury and causing even more havoc in state budgets. The Bush administration outlined an approach last month that would give states more flexibility to manage the program and additional money in the short term to help them through the recession, but it would require a payback in future years and limit federal financing for the long term.

At the hearing, Republican legislators praised the plan, while Democrats condemned it. Veteran Democratic Rep. John Dingell of Michigan called it "a legislative bait-and-switch scam." The governors who testified were equally divided, with Republicans Jeb Bush of Florida and John Rowland of Connecticut urging approval and Democrat Bill Richardson of New Mexico criticizing its central features.

But if the politicians appear to be as gridlocked as ever, outside their offices you can see hopeful signs of a gathering consensus. One was the public relations campaign that last week brought together more than 100 organizations to sponsor town meetings and discussions on expanding access to health insurance. "Cover the Uninsured Week" united such familiar antagonists as the U.S. Chamber of Commerce, the AFL-CIO, the American Medical Association, the Health Insurance Association of America and Families USA (a consumer group). They and scores of others joined the Robert Wood Johnson Foundation in the effort.

Utilizing census-based figures showing that more than three out of 10 Americans under age 65 were uninsured during part or all of 2001 -- almost 75 million people -- the organizations tried to dramatize a crisis with profound social, economic and health effects. They did not try to define a solution; but their message was that this is a problem that cannot be ignored.

A more substantive approach to finding agreement has been taking place in recent years under the auspices of the Health Sector Assembly, which has enlisted 60 major players -- representing a wide range of providers, employers, employees and consumers -- in annual seminars on health care issues. Organized by Roy Pfautch, a veteran of the American Medical Association, and largely financed by pharmaceutical firms, it has developed not specific legislation but sets of detailed principles for reducing the ranks of the uninsured, handling the health care needs of the elderly and financing long-term care.

On the same morning as the quarrelsome Medicaid meeting, I met with six of the Health Sector Assembly's active leaders, who wanted to share their belief that serious dialogue among people of widely different backgrounds and interests could "bring together people who are usually on opposite sides," as Ron Pollack of Families USA put it.

Two forces have brought them closer together, they said: Honest discussions aimed at finding solutions that might command majority support and the growing signs that the present health care system is headed for collapse. "In the past," Pollack said, as other heads nodded in agreement, "everyone had something in the current system that it was their top priority to protect. Now everybody agrees that the status quo is not even a good second choice."

When that realization spreads to the politicians, action may be possible.