Health care reform is back on the national agenda, but there is a good chance the results will be different this time around. Nationwide initiatives for universal health insurance began in earnest with Harry Truman’s 1945 effort (proposed to be financed through Social Security taxes) and have resurfaced periodically ever since. While each attempt has its own history, echoes of “socialized medicine” helped sink them all. Today, however, less ambitious, less threatening and more bipartisan models for reform are emerging from several states. The passage of a plan in Massachusetts signed by Republican Governor (and presidential aspirant) Mitt Romney on April 12, 2006, all but ensures that the issue will be on the front burner in the 2008 presidential election. Potential Republican candidates such as Senate Majority Leader Bill Frist and Newt Gingrich, as well as other prominent Republicans like Florida Governor Jeb Bush, have also helped focus attention on health care reform. Because conservatives as well as liberals are now talking about health care reform, the odds that something will happen are higher than ever.

Pressure building from within American society raises those odds even higher. An NBC/Wall Street Journal poll conducted April 21–24, 2006, asked subjects to prioritize a list of items for Federal government action. Health care ranked third, just behind gas prices and the war in Iraq. But what, exactly, will happen once the American political system engages on this issue? Between growing attention from Republicans and more concern bubbling up from below, are we finally on the threshold of serious national health care reform? Or are the politics once again going to be just “too hard?”

The answer is unknown, but some important lessons for the future can be gleaned from earlier attempts at reform. A major health coverage expansion came in 1997 with the State Children’s Health Insurance Program (SCHIP). SCHIP gave new Federal dollars to the states in the form of block grants or lump-sum payments to cover low-income children. It won passage because it was explicitly not an open-ended entitlement program, and because its essential features had been both foreshadowed and trial-tested by activities in the states. By 1997 eight states already had coverage for children’s programs. Because of the new Federal money and flexibility, states rushed to take advantage of this program. SCHIP was and still is strongly supported by both Democrats and Republicans. Senators Orin Hatch (R-UT) and Edward Kennedy (D-MA) helped pass this legislation by securing an increase in the tobacco tax. During the SCHIP debate, Kennedy pointedly asked colleagues from the Senate floor whether they stood “with children or with Joe Camel and the Marlboro Man.” Pieces of legislation that enable politicians to say things like that...