Presidential campaigns are often as notable for the issues not debated as for the issues that receive the most media and candidate attention. As one looks over the political landscape today, it seems hard to believe that just four years ago there was an overwhelming consensus that the United States stood on the brink of major and long overdue health care reform that would make health insurance universal and slow the escalation in health care costs.

Fast forward just four years, and with little more than the tiniest policy changes in place, we’re still unlikely to hear much noise about health care. How we arrived in this strange predicament and what lessons we can draw from it are the subject of Harvard sociologist and Mount Desert Island summer resident Theda Skocpol’s provocative new book, “Boomerang: Clinton’s Health Security Effort and the Turn Against Government in U.S. Politics” (W.W. Norton, 230 pages, $27.50).

Skocpol points out that most of the social indicators that suggested a health care crisis in 1992 remain at least as serious today. The number of uninsured Americans is at 41 million, an increase of 2 million to 3 million since the Clinton debates on reforms. Just as basically, some plans to “save” Medicare would entail major changes in the health delivery options for many older Americans. The specter of corporate downsizing leaves many other Americans as concerned about the loss of health care as about declines in income. Private insurance premiums continue their relentless rise.

Skocpol’s work shows, however, that adequate health care reform isn’t possible without a willingness to challenge the common wisdom of the political pundits: citizens won’t accept taxes and distrust all government intervention in markets. These postulates of the punditocracy governed Clinton’s health initiatives.

In order to avoid discussion of taxes, Clinton promised to finance health care simply by requiring business to pay for it through a mandate. In order to keep costs down, the administration crafted a complicated scheme of premium caps and health care alliances that would serve as a purchasing agent for most small and medium size businesses. Republican criticisms of these notions were right on two scores: mandates are a form of taxation and the alliances and caps were a form of market intervention.

Skocpol argues, correctly I believe, that the Clinton program would have had a better chance if he had sweetened the mandates with promises of tax-supported subsidies for small businesses. In addition, the intricate health purchasing cooperatives might have been proposed initially as voluntary associations through which businesses could have cooperated to control costs. But even this approach, Skocpol correctly points out, would have faced the considerable pressure of the deficit hawks determined to reduce federal spending.

Skocpol suggests that had Clinton endorsed the far simpler Canadian-style initiatives, he probably would never have received the nomination of his party as a “New Democrat.” And as one who promised to put America back to work, he would have had to offer credible job creation programs to counter the loss of insurance company jobs.

In the current climate of antipathy to government, there was perhaps nothing he could have done. Unfortunately, the elaborate Clinton proposals on health alliances, especially given the president’s unwillingness to explain these forthrightly, opened the administration up to fierce caricature. These caricatures only fueled the anti-government momentum in our politics.

Where do we go from here? Although the failure of Clinton’s centrist initiative may lead some to abandon the fight for health reform, I believe that continuing deterioration of the system may open the door for further reexamination of the antigovernment thrust in our politics. The health care crisis now goes far beyond the reductions in coverage. The vaunted private market, which is supposed to guarantee choice for all, is pushing more of us every day into managed care systems in which both patients and medical professionals are losing their options.

I believe health care reform would have an easier time if it started with three simple premises: 1) a genuinely universal system ought to be financed through federal taxation; 2) cost containment in the area of health care cannot be delivered simply by markets; 3) and adequate and efficient health delivery requires giving the health consumer more voice in the system.

Tying health care to a job creates needless complications, insecurities, and inequities regarding one of the most basic rights of civilized life, the right to health care. In any case, as Skocpol indicates, polls show that many Americans aren’t as unsophisticated about taxes as pundits imagine. Insured Americans pay for their insurance though premiums or lower wages and often subsidize the uninsured. They would be willing to pay a tax for guaranteed health care.

But if the government pays all health providers, won’t it manage the system? Skocpol’s argument clearly suggests that honesty is needed here as well. If government pays the bills, it must put some limits on compensation. Without limits, physician and hospital driven initiatives — not necessarily even in the patient’s interest — will relentlessly drive inflation. But there is regulation and regulation. Government can mandate HMO-style care and then let everyone choose their own HMOs.

But such a course is not appropriate everywhere and not really necessary, even if we want to alter the way health care is delivered. Government could set global budgets for both hospitals and physicians — negotiated with all major players — and then let these manage not only day to day health care but also expansion of the system.

Ideally it could do this through grants to states, which would then be free to experiment with a range of physician and patient-run HMO-style alternatives to traditional fee for service practice. Such state and consumer-controlled modes of regulation also offer opportunities for flexibility, choice, and sensible forms of competition.

Skocpol’s work implies that in the long run adequate health care will only emerge from an honest debate that moves beyond the stale markets vs. government rhetoric of our current politics. The real question today is how to combine the flexibility of markets and consumer choice with forms of government initiative that keep markets genuinely open and provide basic equity.

Unfortunately, any call for some of these health care reforms today will be translated by powerful insurance and media concerns into “socialized medicine.” One of the great strengths of Skocpol’s book is her clear elaboration of the role that both the insurance lobby and conservative social movements played in distorting Clinton’s message.

Getting across a more subtle message about the ways government and markets can support each other will require a rebirth of those unions and progressive grass-roots movements that have driven the best moments in our politics.

Skocpol recognizes the magnitude of this task. Nonetheless, she also knows that the deteriorating quality of health care amidst continuing celebration of the market create an opening around which progressive movements could organize.

John Buell is a political economist who lives in Southwest Harbor.