Why U.S. health care reform is so difficult.

ealth care reform now heads the U.S. domestic agenda, but this generation of policymakers may be less successful than its predecessors in effecting major changes. The president wants universal coverage and a wider array of services. Key members of both parties, such as Senators Dole and Moynihan, resist anything so grandiose. “Yes, there are problems,” declared the Republican congressional leadership. “But there’s not an emergency that requires a complete overhaul of the medical system.”’ The current debate pits visions of justice and fairness against fears that reforms may prove more costly and cumbersome than maintaining the status quo. Promoting “the general welfare” is tough in a country where progress is measured incrementally. Advances occur in fits and turns, “watersheds” alternate with retrenchments. “The two parties which divide the state, the party of Conservatism and that of Innovation are very old. . . . Reform is affirmative, conservatism negative,” Ralph Waldo Emerson observed in 1841. “The Conservative assumes sickness as a necessity, and his social frame is a hospital. . . . Reform converses with possibilities, perchance with impossibilities.” In this dialectic, “Innovation is the salient energy; Conservatism the pause on the last movement”*