SPECIAL COMMUNICATION 10 Years Beyond the Health Security Act Failure Subsequent Developments and Persistent Problems

months later, the initiative was dead, having failed to pass either house of Congress. Comprising 1368 pages, the HSA would have established near-universal coverage, restructured the marketplace for health insurance, and also affected many other aspects of health services. The HSA’s framework is used herein to analyze the current health care situation in theUnited States because the HSA represents the last se-rious effort to craft a comprehensive ap-proach to reforming our complexhealth care delivery system, and its content and its failure are still relevant. Health reform for the 21st centurydid not occur during the 20th century,2 and Congress has not since considered sys-tem-wide reforms. A decade of incre-mental change has left theUnited States with large numbers of uninsured, in-creasing costs, questions about quality, and dissatisfaction with managed care. Many have focused on purported rea-sons why the HSA failed, but that is not the purpose of this article. Rather, this analysis uses the framework of theHSA and subsequent developments in health services financing and delivery to seek insight into thepersistent problemswith the US system. It asks how health care issueswere perceived a decade ago, out-lines the HSA approach to addressing them, traces what happened during the intervening period, and draws implica-tions to inform policy going forward