In September 1993, President Bill Clinton stood before a joint session of Congress, presenting to the assembled representatives and the nation what is now remembered as the most ill-fated proposal of his presidency. Clinton's bold plan for “Health Security” was a sweeping legislative attempt to provide affordable health insurance to all Americans and, in doing so, to complete the long-unfinished business of the Social Security Act of 1935. Within a year of his dramatic speech, however, the president's plan lay in tatters, his presidency in disrepute, and his congressional majority in shambles. Although Clinton would recover from these blows (only to be mired in scandal during his second term), the cause of universal health insurance had encountered another seemingly decisive political defeat – the fifth of the twentieth century. For the foreseeable future, American medical financing would continue along the peculiar path taken in the years after the New Deal, with an incomplete patchwork of private health insurance providing the core of health protection for American workers and their families.

The demise of the Clinton plan offered up a political murder mystery with a virtually inexhaustible supply of suspects and clues. In the years since, no shortage of culprits have been accused. A few appear unquestionably guilty: Clinton had a tenuous electoral mandate, a delicate congressional standing, and a flawed proposal and political strategy. But the most compelling explanation for the messy failure of the Health Security plan – the one overshadowing and underlying all others – is also the one most likely to be taken for granted.