Improving the quality and coverage of health care is one of the greatest domestic challenges that the US federal government faces, yet this challenge is usually framed exclusively in fiscal terms. National health expenditure has risen dramatically over the last fifty years, from 6.9 per cent of GDP in 1970 to 18 per cent in 2020, prior to the public health emergency caused by the Covid-19 pandemic. However, despite the United States now spending more on health care than any other developed economy, the federal government is criticized routinely by health advocates – and periodically by the electorate – for failing to meet the basic health needs of US citizens.

Repeated attempts to refine the health care and welfare systems, starting during the Roosevelt administration in the 1930s, have met resistance in Congress for a combination of ideological and fiscal reasons. To care for all US citizens via a single-payer system, such as national health insurance in the UK, is thought not only to be too costly but also to strain against American values of freedom, market choice and low taxation. At best, US health care is a flexible structure that marries shared responsibility at federal, state and local levels with a decentralized mix of public and private provision. At worst, it is a patchwork of services that comprise what progressive reformer Edward Kennedy derided in 1972 as ‘a medical maze’ or what forty-five years later Elizabeth Rosenthal called a ‘system in disarray’.

While it is easy to overplay the failures of the US federal government to meet the health needs of an expanding and diversifying population (rising from just shy of 140 million in 1945 to over 330 million in 2020), the five authors of this section each consider the ways in which presidential and congressional politics have grappled with insistent calls to reform health care provision and entitlements. The five chapters are structured in chronological order, from the 1940s to the 2010s, with the first, second and fifth chapters forming a tight sequence in addressing the efforts at executive and legislative level to expand health insurance during the administrations of Harry Truman (1945–53), Lyndon Johnson (1963–69) and Barack Obama (2009–17).