attempts to create some comprehensive health insurance in the United States: they spanned the Progressive campaign for compulsory insurance that originated before the First World War, to the failed Clinton reforms of the 1990s. All failed. The particulars of failure have been extensively trawled over in a rich series of policy histories(for an anthology of failure, Morone and Belkin, 1994; for the most recent comprehensive failure, of the Clinton reforms,Skocpol 1996) Not surprisingly, these individual policy histoeies all stress their own special contingencies. Behind all these contingencies lies broad structural features of the relations between the state and health care in the United States. The most important of these relate to the historical timing of the development of the system. The American federal state emerged late or at least emerged onto the health-care scene as a significant actor after the rise of other powerful interests in health-care policy. Of the latter, two were especially important. First, there were the interests embodied in the medical profession, who by the early twentieth century had organised into a powerful regulatory group, and a powerful, well organised national lobby in the form of the American Medical Association. The second was a nascent 'medical industrial complex': the creation of a high quality, well organised research based complex linked to important corporate interests, and united in the pursuit of advances in high technology medicine. The upshot was that, from the beginning the shape of health policy in the United States has been dominated by private corporate interests, and particularly by well organised suppliers of medical care (Wohl, 1984, on the origins of the 'complex'). This history also helps explain the second unique feature of the US system. The country almost unique in not offering some kind of comprehensive health coverage is also the country with by far the highest level of spending on health care. A word should be said about his correlation. Health spending has many of the characteristics of a 'luxury' good, not least that, across natians, spending rises with wealth. One of the best predictors perhaps the best