This chapter examines the development of modern presidential policymaking to better appreciate both the changing resources of the institution and the increasing expectations for policy leadership. It traces the president&s;s role in the policymaking process. The chapter analyses what scholars know about how presidents attempt to realize their domestic policy agenda amid a constrained political environment. It introduces an alternative approach to studying the relationship between presidents and domestic policy that calls attention to the varying contextual factors that shape policymaking opportunities and constraints over time. The chapter presents a brief review of presidential efforts to reform health care. The president&s;s role in domestic policymaking has been anything but static through the course of American history, with the institution becoming increasingly involved in public policy over time. A more significant change for presidential-congressional relations is found in the practice of proposing a legislative policy agenda.