There is a remarkable consensus that American medical care—particularly its financing and insurance coverage—needs a major overhaul. The critical unanimity on this point—what Paul Starr has rightly termed a “negative consensus”—bridges almost all the usual cleavages in American politics—between old and young, Democrats and Republicans, management and labor, the well paid and the low paid. We spend more on and feel worse about medical care than our economic competitors, with nine out of ten Americans (including Fortune 500 executives) telling pollsters that our health system requires substantial change. That is the good news for medical reformers in the Clinton administration, the Congress, and the polity at large.

The bad news for these reformers is that, for a variety of ideological and institutional reasons, American politics makes it very difficult to coalesce around a solution that reasonably satisfies the requirements for a stable and workable system of financing and delivering modern medical care. We have no assurance that the rare agreement on the seriousness of the nation's medical ills will generate the legislative support required for a substantively adequate and administratively workable program of reform.