Jeremy Laurance: A health debate outsiders find hard to understand

Americans' affection for their deeply flawed health service – with the highest costs and poorest coverage (50 million uninsured) in the industrialised world – can be hard for outsiders to comprehend. How could any civilised country, let alone the planet's richest, defend such a state of affairs?

In truth, many Americans have long supported reform in principle. Polls have shown a majority back extending insurance cover. But when they are presented with the bill for doing so – increased taxes, curbs on benefits – attitudes harden.

It was fears about erosion of healthcare benefits that led voters in Massachusetts, one of the few US states with near universal coverage, to reject the Democratic candidate and elect Republican senator Scott Brown, causing a political earthquake. The loss of the state wiped out the Democrat's wafer-thin majority in the Senate, ultimately forcing last night's vote in the House of Representatives.

Like citizens everywhere, Americans want to do right by their neighbours, but only if it does not require personal sacrifice. Those who can access it have become accustomed to their no-expense-spared health service; they are not prepared to compromise on access or quality. They don't want to pay more and settle for less.

But like all industrialised nations with ageing populations, that is what they face. Medical costs are rising around the world but in the unfettered market in the US they are spiralling out of control. The California insurer Anthem Blue Cross announced a 39 per cent hike in premiums last month. Nationally, US health spending grew at its fastest rate for 50 years in 2009, to $2.5 trillion (£1.7trillion). It is projected almost to double by 2019. The entrepreneurial nature of the system is what makes it attractive to those Americans with generous insurance coverage. They want care when they need it and they want freedom and autonomy; they don't see the inefficiencies.

Socialist-style health systems such as the NHS are dismissed, especially by Republicans. Where did David Beckham go to have his recently ruptured Achilles tendon fixed? A private clinic in Finland, not the NHS in the UK.

Curbing usage is one challenge. But experts say the bigger problem facing the US is curbing the prices charged by doctors and hospitals. America has the most vibrant health market in the world. What it lacks is a health system.