At the end of 1999, the U.S. economy was the envy of the world. The Dow Jones was over 11,000 (now 9,600) and the NASDAQ was over 4,000 (now 1,970). Equally impressive was our federal government's financial condition: For the first time since 1969, the federal government reported a budget surplus in 1998 and 1999. Even during those "good times," however, our country failed to provide universal health-care coverage for all citizens: Approximately 44 million people were uninsured, and millions were underinsured. The time seemed right for our political leaders to guarantee basic health care for all citizens.

From my vantage point as an emergency physician in 1999, our country needed to reassess its priorities. The emergency department served as the only safety net available 24 hours, seven days a week because of federal legislation guaranteeing all emergency department patients access to medical evaluation regardless of their ability to pay.  It was, however, "limited" access: There was no assurance that you would be able to find follow-up medical care without some financial guarantee.

The Institute of Medicine estimates that approximately 20,000 patients die each year because of lack of health insurance. Here is one of many examples. In December 1999 I cared for a 52-year-old man who developed chest discomfort while working. He had just started a job that week. According to a fellow worker, the man stated that he didn't feel well and then collapsed. Paramedics responded and determined that he had suffered a cardiac arrest; they attempted to resuscitate him and transported him to a hospital where I was the emergency physician on duty. Despite our best efforts, we were unable to save his life.

Delayed seeking care
His wife arrived 30 minutes later, confirming that he had started a new job that week. He had complained of some discomfort intermittently over the past 10 days but delayed seeking care because he had no health insurance before that week. He made an appointment to see a physician as soon as he started the job, but, unfortunately, his appointment was not until the following week.

With the 2000 presidential election less than one year away and a rosy economic scenario, the timing seemed right to focus the public's attention on the inequities of our health-care system. A group of emergency physicians, including the editors for three leading emergency medicine journals, agreed to publicize the inequities of our health-care system, emphasizing the very limited nature of the safety net. We wrote an editorial that was published in all three journals early in 2000 highlighting our concerns regarding the inequities of our system and the need for change: "Our society's failure to provide universal access to essential health care violates the ethical principle of distributive justice. This principle requires a fair allocation of health care resources among members of society."

Neither party provided leadership
In that editorial we urged the presidential nominees, George Bush and Al Gore, to present their plans concerning the uninsured problem and offered to publish their proposals. Sadly, neither candidate nor their representatives indicated interest in presenting their views. Despite a budget surplus and a healthy economy, neither political party provided leadership necessary for health-care reform.

Politicians often allude to the "wisdom of the American people." Some of us questioned what happened to that "wisdom," as well as the wisdom of our political leaders in 2000.

Fast forward to 2009. Our economy is struggling to recover from the worst recession since the Great Depression. There are now more than 45 million uninsured and another 25 million underinsured. Health-care costs continue to escalate, as does the federal deficit and debt. The special interests have again attempted to derail reform with both old and new scare tactics: the usual catchphrases — "socialized medicine" and "bureaucrats making decisions instead of physicians and patients" — as well as some new scare tactics: "death panels" and "euthanasia." Ironically, we hear little about "justice" or "fairness" — core values of our society.

In 2000 we had an opportunity, but failed to act. Will we repeat that error in 2009? What happened to the "wisdom of the American people" and many of its political leaders?

Robert Knopp, a physician and medical educator, lives in St. Paul.