Budget politics has always been an obstacle to adopting national health insurance. The questions of budget politics—the risk or size of deficits and the size of government—have a conservative effect. In any country, very few people would endorse deficits for their own sake. In America, support for larger government on principle, displacing the market, has rarely had close to majority support and has surely been diminishing. Defining social policy expansion as a budget issue is a standard tactic for persons opposed to the policy.

The events of the 1980s have in many ways made budget politics more of an obstacle to sensible health care reform—which I define as reform that insures all Americans, yet keeps this country from opening an even wider lead on the international field in the race to spend on health care.

During the 1960s a portion of elites such as economists, the press, and politicians would at least defend deficits in principle under some circumstances. Misinterpretation of the events of the 1970s, exaggerated arguments by economists who think that hyperbole is required in the political arena, the possibility that the 1980s deficits favored Republican constituencies, the fact that a Republican president was in office for those deficits, and the unprecedented scale of the deficit in full-employment terms during peacetime, combined in the 1980s to commit Democratic politicians, economists, and opinion leaders to at least the rhetoric of deficit-reduction. President Clinton has continued the process.