10 years beyond the Health Security Act failure: subsequent developments and persistent problems

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 vision.