Following the demise of comprehensive health care reform in 1994, some reformers are seekingcomfort in the successful “incremental” strategy for enacting Medicare that emerged out of President Harry Truman’s failed campaign for national health insurance in 1948–50. But despite similarities between the Truman and Clinton health security efforts, overall contexts of government and politics are much less hospitable to governmentally funded reformstoday than they were after Truman’s defeat. Back then, market transformations and political dynamics were both pushing toward expanded access to health services and insurance coverage. Today, by contrast, both push in the opposite direction. The private insurance market is fragmenting, federal budgetary constraints stymie new programs, and the deficit dominates debate over existing programs. Equally important, a stable proreform coalition like that of Truman’s day has yet to emerge, while a new and fiercely conservative corps of Republicans is championingcoherent programmatic alternatives based on antigovernment premises. Although passage of the Kassebaum-Kennedy health insurance reform bill in 1996 unleashed a wave of enthusiasm about incremental health care reform, formidable political, fiscal, and technical obstacles continue to standin the way of even relatively modest incremental solutions.

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