Some years ago a cartoonist depicted a great American political leader, unnamed, whose body was above the clouds, except for the Texas-style boots on his feet. Below was a group of people asking the great leader what he saw in the heavens above the clouds. In reply, the great leader said that he saw a world of plenty. And what else, he was asked. In a reader-imagined Texas dialect he responded that he saw great things-brotherhood among people of all nations and races, peace, and all of the other ideal things we all wish for. And how, asked the people, are we to get these wonderful things? Down came the words: we shall wheel and deal! That describes health policy formulation in the United States! We are a wheeling and dealing society because we are a diverse nation with conflicting desires and interests which are the result of our historical development, differing cultures and regional life styles, regional economic imperatives, religious and social persuasions, and even the sometime inexplicable behavior of politicians. As a consequence there are frequently strong disagreements over perceived needs and priorities. We are rarely able to attain a national consensus on health policy issues. To the extent that we have a national health policy, it is, in the words of Emily Friedman, 'forged by social tensions'. Writing recently in Hospitals , she said: 'Many years ago, Mohandas K. Ghandi, when asked what he thought of western civilization, replied, "I think it would be a very good idea". One is tempted to say the same of U.S. health policy: we don't have one. Rather, the structure and financing of American health care is determined by tensions within and among a series of opposing forces that alternate in dominance at any given time.'