US presidential candidate Barack Obama was not even born when national health insurance was first proposed under the Truman presidency in the 1940s. Twenty years later, Congress voted in Medicare, a publicly funded, national insurance programme for everyone over 65. At the time, Medicare seemed to be the first step towards universal coverage. But further steps were never taken. Failed health reforms in the 1970s and 1990s have left the United States as the only developed country not to provide all its citizens with access to health care.

America’s inability to fix something that all other developed nations take for granted may seem baffling. But two facts begin to explain the puzzle: 94% of Americans who vote have health insurance,1 and nearly three quarters of people who have insurance think that what they have is either good or excellent.2 While most voters agree that everyone has a right to high quality, affordable health care, no one wants to give up too much of what they already have to fix the problem. Mindful of this, proposals by Mr Obama and presidential rival, John McCain, steer clear of grand reform. The question is whether either candidate’s proposals will be enough to make a real difference to health care but not too much to put off voters.