As promised during his campaign, and under pressure from many quarters, President-elect Barack Obama may seek badly needed changes in the way the United States finances and delivers health care. Responding to public interest and perceived need, several previous presidents have attempted to enact some kind of national health insurance: Harry Truman in the 1940s, Richard Nixon in the 1970s, and most recently Bill Clinton in the 1990s. These attempts went nowhere. In pursuing comprehensive health care reform, President-elect Obama should be aware of four major reasons why, in the past, we heard so much talk and saw so little action.