Among the few self-evident truths about the U. S. medical malpractice system is that it desperately needs reforming. Medical and legal academic experts, stakeholders on every side, even President Bush and his predecessor Bill Clinton, all describe the present malpractice regime in terms like “broken.” No shortage exists of comprehensive proposals to overhaul malpractice; indeed, several are presented or evaluated in this book. But implementing any significant reform requires coordinated effort by a set of actors outside the health professions: politicians. Since malpractice first appeared on political agendas in the 1960s, Congress and successive administrations have been unable to decisively address the issue. Officials in some states have had more success, though typically short-lived: As of mid-2005, the American Medical Association (AMA) listed forty-three states as in or nearing a malpractice crisis. Without a workable political strategy for achieving reform, the much-deplored medical malpractice system will remain essentially unchanged. Malpractice's political aspects and prospects therefore demand attention alongside more commonly studied features.

Why have successive Congresses failed to enact any meaningful legislation addressing the malpractice system? Is that record likely to change in the near future? What explains national and state lawmakers' near-exclusive focus on “first-generation” reforms like caps on damage awards, rather than such “second-generation” proposals as alternative dispute resolution, no-fault insurance plans, and enterprise liability? Why have unlikely interest-group actors, like the National Association of Manufacturers, become exponentially more involved in malpractice in recent years?