WASHINGTON DC (By James Carney, Time) November 23, 2008 ― The last time a democratic president tried to fulfill a campaign promise to overhaul the nation's health-care system, he stumbled into a buzz saw of opposition so brutally effective that it didn't just kill the effort, it rendered the issue politically toxic for 15 years.

Now it's Barack Obama's turn. With the economy staggering, the Federal Government spending billions to help prop it up and the nation still engaged in two costly overseas wars, the timing for health-care reform seems dreadful. And yet it could still happen. Obama ranks health-care reform third on his list of top priorities — behind addressing the financial crisis and passing an energy bill. Despite suffering from a malignant brain tumor, Senator Ted Kennedy has returned to Capitol Hill principally, he says, because he wants to orchestrate the passage of health-care legislation. "There's real momentum behind getting something big done," says one adviser to the President-elect. "This could be the best chance we've ever had."

Three key developments over the past 15 years have made this moment possible. First, the number of uninsured Americans now tops 45 million. Meanwhile, all the proposals under serious consideration — starting with Obama's — would allow Americans to keep their current insurance coverage if they're happy with it. The specter of the feds ordering everyone into a mandatory government-managed plan is fading away. Most important, the cost of health insurance to both the employers who provide it and the employees who pay premiums has continued to soar. Because of that, companies of all sizes — from corporate behemoths to corner stores — have switched sides on the issue of comprehensive reform. Having fought to defeat Clinton's plan in 1993, they are now some of reform's loudest advocates. "This is the No. 1 priority for small businesses," says Todd Stottlemyer, president of the National Federation of Independent Business. "We see it as a matter of national economic security."

Even the weak economy may be an impetus to reform. An expected spike in unemployment will increase the rolls of the uninsured, driving more of them into emergency rooms and boosting premiums on the insured. Struggling companies may be forced to cut or kill their employee coverage just to survive. And while the cost of Obama's reform is high — an estimated $75 billion a year — a big price tag hasn't kept Congress from raiding the Treasury to fix the economy's many other ills.

One other advantage: Obama's plan is not as sweeping as Clinton's was. It does not mandate universal coverage except for children. It subsidizes low-income Americans who want to buy insurance and creates an exchange to give people access to health care at affordable prices — all reasonable and pragmatic steps. Still, a fight is inevitable. Health care represents 16% of the nation's economy, with vast and competing interests as stakeholders. Which is why the obstacles to systemic reform remain enormous. Says the adviser: "We know how hard this will be."