Although pronouncements of the ¿health care crisis¿ have been made for thirty years, in many ways the fundamental underpinnings of the U.S. health care system have changed very little. However, calls for health care reform have progressed through four distinct phases. From before the 1965 passage of the Medicare and Medicaid programs until about 1972, the primary issue was expanding access to care. From 1972 through 1976, health care reform proposals experienced a transition period. From 1976 until about 1992, cost containment became the dominant theme. Since 1992 there has been a renewed emphasis on improving access to care. But Americans have mixed feelings about health care reform. On the one hand, Americans want improved access to care, increased efficiency, and high quality care. On the other hand, Americans are leery of higher taxes and expanding the government's role in health care decision-making. In the final analysis, it is ultimately politics which governs the form of health care reform by effecting compromises between what is ideologically desirable and what is economically plausible.