Health reform is again on the national agenda. Serious debate about how mental health might fit into national health policy has not occurred since 1993. The focus of the Clinton reformers was on benefits, integration with the general health system, and a new role for the public sector. A number of issues remain relevant today, such as uncoordinated public and private services, cost-shifting, and poor quality care for people with serious mental illness. This column considers the barriers to full inclusion of mental health in health care reform and proposed solutions that were identified in 1993 and describes how they can inform policy decisions in 2009.