Following the demise of comprehensive health care reform in 1994, some
reformers are seeking comfort in the successful ''incremental'' strat
egy for enacting Medicare that emerged out of President Harry 'Truman'
s failed campaign for national health insurance in 1948-50. But despit
e similarities between the Truman and Clinton health security efforts,
overall contexts of government and politics are much less hospitable
to governmentally funded reforms today han they were after Truman's de
feat. Back then, market transformations and political dynamics were bo
th pushing toward expanded access to health services and insurance cov
erage. Today, by contrast, both push in the opposite direction. The pr
ivate insurance market is fragmenting, federal budgetary constraints s
tymie new programs, and the deficit dominates debate over existing pro
grams. Equally important, a stable pro-reform coalition like that of T
ruman's day has yet to emerge, while a new and fiercely conservative c
orps of Republicans is championing coherent programmatic alternatives
based on antigovernment premises. Although passage of the Kassebaum-Ke
nnedy health insurance reform bill in 1996 unleashed a wave of enthusi
asm about incremental health care reform, formidable political, fiscal
, and technical obstacles continue to stand in the way of even relativ
ely modest incremental solutions.