1992. As the new administration took office, health care reform was a prominent initiative. Failure to reach consensus on national health care legislation in 1993–1994 indicates the level of conflict between stakeholders over needs, resources, and values. Conflicts were most striking with regard to balancing responsibility between federal and state levels of government. Federal legislators placed a higher value on the states' rights to determine health care policy for their populations than on having a uniform national health care policy. Conflicts also arose in balancing the needs of the uninsured and other vulnerable populations (served by programs such as Medicaid and Medicare) and the political goal of a balanced budget.

A third factor has been the pervasive and growing anxiety of individuals and families about health care coverage. Because health insurance in the United States is most often provided through employer-based programs, this concern reflects, in part, a growing sense of insecurity about employment. It also reflects an ambiguity about where the responsibility for health care insurance lies. Although considered an entitlement by some, there is a growing sense that responsibility for health care is being placed on the individual. After much negotiation and compromise, federal legislators have found common ground on certain aspects of this issue. Two years after the demise of comprehensive health care reform legislation, a bipartisan bill—the Health Insurance Portability and Accountability Act of 1996—addressing the portability of employment-based health insurance and prohibiting the denial of coverage for preexisting conditions was signed into law.

Conflicts at the national level over issues of accessibility, quality, and affordability of health care reflect the vastly different needs, resources, and values of stakeholders in the health system. Within communities, especially in a pluralistic society such as the United States, there also is considerable diversity among stakeholders in their perspectives, interests, needs, resources, values, influence, and access to power. For example, the public values health care that is affordable, places no limits on choice, provides comprehensive benefits, limits the financial risk to consumers, and offers open access. Group purchasers and payers attempt to balance the needs of their covered populations against the need for predictable and minimal financial liability, protection against legal and ethical dilemmas, and administrative simplicity. Health care providers want to optimize patient interests while maximizing revenues and minimizing intrusion from third parties. Policymakers serve to protect the perceived interests of the com-

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