In an address to a joint session of Congress on Sept. 23, 1993, Clinton pledged to deliver universal health insurance to the country. Under Clinton’s proposal, everyone in the United States would carry a card signifying federal government assurance of continuous health insurance coverage.

Conservatives attacked the plan. Americans, we were told by “Harry and Louise,” didn’t want Big Government, more taxes or to sacrifice any flexibility in insurance choices.

So the Health Security Act died without even being voted on by Congress. In November 1994, California voters rejected Proposition 186, a “health security” initiative that would have established a “single-payer,” government-administered universal health insurance plan.

The Clinton plan and Proposition 186 joined a long list of failed universal health insurance proposals, dating from as far back as 1912. These rejected plans, snared on the thorns of American politics, haunt current efforts at health care reform.

Today, 41 million Americans are uninsured. States, reeling from the economic downturn, are cutting back on Medicaid.

Dozens of private HMOs have pulled out of Medicare, abandoning millions of seniors.

Working Americans face escalating out-of-pocket payments as employers shift a greater share of health care expenses to employees, and national health care costs are increasing feverishly.

As a result of the crisis, health care reform is back on the political agenda, and new universal coverage bills have been introduced in Congress. and California.

Rep. John Conyers (D-Mich.) is sponsoring HR676, the United States National Health Insurance Act, to create a tax-financed single-payer system by covering all Americans under Medicare. And in California, legislation is pending to establish a state-based single-payer program.

A recent report by the Century Fund called for federalizing financing of Medicaid and allowing families with higher incomes to be eligible for Medicaid. A Commonwealth Fund report suggested more than a dozen “small but significant steps to help the uninsured,” such as extending COBRA benefits when people lose their jobs

However, as the Commonwealth Fund acknowledges, “Even if all (small steps) were enacted, they would neither significantly reduce the number of uninsured nor substitute for comprehensive reform.”

Will the health care reform debate of 2003 have a different outcome from that of 1993, or for that matter, from 1970 (the year of the dueling Nixon and Kennedy plans) or 1950 (when a national health insurance bill backed by President Truman also failed to be enacted)?

Most experts concede that the simplest way to guarantee coverage for all Americans is to make every resident automatically eligible for coverage under a single public plan, avoiding the chaos of eligibility linked to specific employers or degrading and cumbersome “means testing” of family income.

Single-payer systems also have appealing economic virtues, operating with far lower administrative overhead costs than private insurance and exercising greater care to rein in health care inflation.

California recently contracted with the Lewin Group, a private independent consulting firm, to analyze 10 alternative proposals to increase coverage.

The firm concluded that pay-or-play models, which require employers to finance coverage, would increase state health care costs by $2 billion, while a single-payer plan could reduce overall costs by $7 billion and provide comprehensive coverage to all Californians.

The single-payer plan would also trim $18 billion in unnecessary administrative costs and excessive prices for prescription drugs and medical supplies – more than enough to afford universal coverage.

The HMO industry is now dominated by for-profit insurance plans intent on delivering high returns to investors. Large for-profit chains have bought up nonprofit community hospitals, removing health care decisions from communities to distant corporate headquarters.

The pharmaceutical industry remains the nation’s most profitable industry, with net profits after taxes of 19 percent of revenues, compared with 5 percent for all Fortune 500 firms.

A recent issue of the American Journal of Public Health proposed several benchmarks for judging reform proposals: universal and equitable coverage, comprehensive benefits and quality health care, affordable and equitable financing, simplified administration and sensibly organized work, accountability and a strong public health system.

The work ahead is to create the political change that can implement a universal health care plan that would achieve these goals.

This is condensed from a recent article by Dr. Kevin Grumbach, who is a professor of family and community medicine at University of California – SF and a founding member of the California Physicians Alliance and Dr. Philip R. Lee, who served as assistant secretary of health in the Johnson and Clinton administrations, is the former chancellor of UCSF.