Abstract

What are the prospects for meaningful reform of U.S. health care? To answer this question requires understanding why previous reform efforts failed—the combination of deep structural biases against large-scale public provision and the inherited constraints posed by the rise of employment-based insurance. Generally, the context is more favorable today than it was fifteen years ago. But the prospects for change hinge on learning the right lesson of history: Politics comes first. Putting politics first means avoiding the overarching mistake of the Clinton reformers: envisioning a grand policy compromise rather than hammering out a real political compromise. It also means addressing the inevitable fears of those who believe they are well protected by our eroding employment-based framework. And it means premising political strategies on the contemporary realities of hyperpolarized politics, rather than wistfully recalled images of the bipartisan politics of old.