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 histories 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 State. 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.