To understand fully the persistent failure of the United States to enact national health insurance requires an appreciation not only of the role of government and the dynamics of politics but of underlying social realities. One consideration, which dates back to the Great Depression, is the absence of the middle class from a coalition in favor of such a policy. This absence reflects both the constricted vision of the middle class and the spirited campaigns of groups like Blue Cross to make certain that middle-class needs were met in order to reduce pressure for government intervention. Another critical social feature is the special entrepreneurial character of the American medical profession. Physicians saw themselves as small businessmen and, as such, shared and promoted a suspicion of governmental intervention. All the while, Americans justified the absence of a national program in terms of the ethos of voluntarism, which had a sufficient base in reality for the posture to be maintained without great embarrassment. In fact, the rhetoric that surrounded the enactment of Medicare reinforced these views, making it appear that, the elderly aside, all was well with the provision of medical services in the country. Even as national health insurance assumes a new prominence on the political agenda, it remains unclear whether these several considerations will allow for the enactment of sweeping changes.