Healthcare reform reaches US Senate

Concessions secure 60th vote but scheme is shadow of what was promised

In the early hours of this morning, the US Senate is scheduled to start voting on a sweeping reform of the nation's healthcare system, bringing coverage within reach of 30 million Americans who have no medical insurance and achieving something that has eluded US presidents for more than a generation.

And yet what Barack Obama might have imagined would be a moment of jubilation for his own party, still smarting from the collapse of their last major effort under Bill and Hillary Clinton 15 years ago, comes with the acrid taste of compromise and backstairs deal-making, and the lingering sense that the White House failed to hold out for more radical measures that the president promised during his soaring election campaign last year.

In healthcare, as on plans to tackle global warming, the popular movement for change that President Obama hoped could sweep away the roadblocks of Washington politics has instead been halted and dissipated.

Howard Dean, the former chairman of the Democratic National Committee, has suggested the whole bill should be ripped up and started over, and reiterated his criticisms on the Sunday talk shows. It contains "major loopholes" meaning healthcare will still be too costly for consumers, he told NBC's Meet The Press. "The insurance lobby actually wrote a good piece of this bill. We don't think there's been much of a fight by the White House."

After months of haggling, and facing blanket opposition from the Republicans, Democrat leaders first threw out the White House's planned "public option", which would create a government-run insurance scheme to compete against the private sector, and then also quashed the idea of expanding the federal Medicare scheme. The fall-back position, of a private sector solution that creates national "insurance exchanges" where the uninsured can buy subsidised health plans, comes with a string of restrictions on insurers, including a promise that they cannot refuse to cover the chronically ill. But there are worries that the changes will fall short of the goal of cheap, universal coverage.

The 60th Senate vote required to secure passage came on Saturday from a Nebraska Senator who, in exchange for his support, was offered federal subsidies for his state and wording that excluded abortion from the new national insurance scheme. And the final shape of reform will not be known for several weeks, because the Senate bill must be married with a House bill that still includes a public option.

The "time-honoured rules" of Congress have been frustrating, David Axelrod, the White House chief strategist, said yesterday, but insisted that the bill amounted to real reform. "There is no major piece of legislation passed in this country that doesn't include compromise - that's the legislative process," he argued.

Vicki Kennedy, widow of the late Senator Ted Kennedy, threw the weight of her political dynasty behind the compromise. In an article in the Washington Post she said her husband argued that half a loaf was better than no bread. "Ted knew that accomplishing reform would be difficult. If it were easy, he told me, it would have been done a long time ago."