As many political humorists remind us regularly, politics “inside the Beltway” is not always of interest or relevance to the rest of the world. Yet for political scientists interested in the ongoing evolution of America's health care system, what goes on inside the Beltway has great import. For any proposed reform, there are three basic steps: getting the issue on the political agenda, securing passage of pertinent legislation, and implementation (although we intend to narrow our discussion to the first two).

A common criticism of academic political science is the disparity between the textbook portrayal of policymaking and the reality of what happens in Washington. In this article, we use abbreviated case studies to inject a dose of “inside the Beltway” reality into the images of policymaking. Included in our discussion is an account of how one issue—catastrophic health insurance—reached the political agenda and then more general comments on how health legislation has been considered and passed in recent years, with particular emphasis on the use of the budget reconciliation process. While cursory, we think these reflections provide a thumbnail sketch of how Washington is attending to important issues of health policy.