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This essay serves as the foreword to Implementing U.S. Health Care Reform, a symposium held in 1993.

The exact specifications of the new health care system depend on the package that President Clinton will send to Capitol Hill and the changes that Congress will make in the reform package. Some of the basic structures and organizing principles of the new system that are being considered by the President are already the subject of intense public scrutiny.

The design being considered would involve new relations between the federal government and the states, between the public and private sectors, and between health care financing and delivery. The federal government would establish the parameters of the new system through national legislation, regulation, and guidelines, with implementation occurring principally at the state level. State flexibility would become a hallmark of the new system, with states having considerable leeway in implementation. Provided that states follow national parameters, they probably could establish very different kinds of health care systems, ranging from a single payer to managed competition within a budget. Given the strong preference among many health policy experts for a single-payer system, it is extremely important to emphasize the states' authority to implement such a system. A large state, for example, might consider establishing a system of managed competition in urban areas, and a single-payer system in rural areas where effective competition is constrained by the small number of consumers and providers.

The new system will provide the right to health care to all citizens and lawful residents of the United States, all of whom will receive health security cards, transferable to any area of the country. The card would also guarantee access to health care independent of employment or other eligibility criteria. Therefore, the new system will address the American public's concern for long-term security in health care--coverage would be portable and move with the individual if he or she changed jobs or lived in another part of the country.

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19 Am. J.L. & Med. 1-20 (1993)