Ten years after the failure of President Clinton’s Health Security
Act (HSA), the United States continues to face multiple stresses in health
care, including large numbers of uninsured individuals, increasing costs,
questions about quality, and dissatisfaction with managed care. Using the
framework of the HSA—particularly universal coverage, spending and managed
competition, insurance for low-income persons, and patients’ rights—the
post-HSA evolution and current status of the US health care system is traced
and lessons to guide future actions are outlined. Neither incremental legislation
nor private sector changes in health care organization and financing during
the past decade have ameliorated the problems addressed by the HSA, and new
troubles have emerged. These problems affect every group in the country and
continue to deteriorate health care, yet there has been no political support
for large-scale reform. The core components of a vision for future action—universal
coverage, quality improvement, cost containment, and subsidies for the economically
vulnerable—are essential. There is a pressing need to construct a clear
vision that would tie together incremental steps into a rational approach
to comprehensive reform and to actually move toward the realization of that
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