Especially in election years, it is worth stating the obvious: reforming health insurance arrangements in the United States will not be easy. This truth is sometimes lost in the heat of a spirited political campaign, and indeed, the two remaining contenders for the Democratic Party's presidential nomination as of this writing, Senators Barack Obama of Illinois and Hillary Clinton of New York, have each raised expectations among voters that they will deliver a sweeping health care overhaul soon after taking office in January 2009.

It is of course conceivable that their promises could come true; it might turn out that Congress could pass a major health-care reform package in 2009 or 2010. But there are important reasons why such plans have not been enacted to date, and these include not solely the interference of so-called "special interests" in politics, as Senators Obama and Clinton have suggested. Rearranging health insurance to cover all, or even some, of the uninsured is a tremendously complex undertaking, both politically and programmatically. That’s true of reforms aimed at expanding government involvement in health care as well as those intended to encourage more intensive price competition and consumer choice.

This is not to suggest there is no constituency for reform. There clearly is, and it has been growing in recent years. Existing insurance arrangements have become more unstable, leading more and more Americans to ponder whether there might be a better way. And surely there is a better way to organize the provision of health insurance. But formulating and legislating a new approach will require a clear understanding of the forces destabilizing today’s arrangements, as well as the reasons past reform efforts have failed to secure broad political support.

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