The greatest lesson of the failure of comprehensive health reform in the early 1990s is that politics comes first. Even the best-laid policy plans are worthless if they lack the political support to pass. Putting politics first means avoiding the overarching mistake of the Clinton reformers: envisioning a grand policy compromise rather than hammering out a real political compromise. It also means addressing the inevitable fears of those who believe that they are well protected by our eroding employment-based system. And it means formulating political strategies that are premised on the contemporary realities of the hyperpolarized U.S. political environment, rather than wistfully recalled images of the bipartisan politics of old.