Health care, like many other arenas of social policy, offers plentiful evidence both to those who picture the policy process as highly dynamic and innovative and to those who prefer to portray it as beset by deadlock and stalemate. Over the last two decades federal policymakers have invented an array of programs designed to make the system more efficient—health maintenance organizations, peer review organizations, health systems agencies, certificate-of-need, a prospective payment system, resource-based relative-value-scale fee schedules, to name the most prominent—but they have been unwilling to extend health coverage to the 17% or so of the nonaged population that lacks it or to change the nation's mixed public-private health insurance system in basic ways.

This pattern is less paradoxical than it may seem at first glance. A diffuse concern about the rising costs of care could well support a string of (largely ineffective) programs that apply gentle brakes without disturbing the system deeply, but benefit-expanding measures and still more federally sponsored programs to achieve a better balance between benefits and costs have met solid political obstacles. The public, fairly content with the system but poorly informed about its workings, wants immediate access to good care at “affordable” rates and rarely cares to hear about tradeoffs among these goals.