Rupert Cornwell: Healthcare clash exposes sickness in the US system

Out of America: Climactic battle in Washington this Christmas could decide the fate of Obama's presidency

Christmas week is normally when American politicians, like the rest of us, head for home and hearth. Not, however, this year in Washington for the 100 members of what is laughingly referred to as "the greatest deliberative body on earth", the United States Senate.

The backdrop will be idyllic – if forecasters are right, a foot of snow on the ground to set off the seasonal decorations in one of the most handsome cities on earth. But our heroes will have little time to enjoy it. They will be fighting the climactic battle of this latest attempt by an American president to right an ancient wrong: the failure of the richest country earth to provide healthcare coverage for all its citizens.

The struggle dates back almost a century. Back in 1912, Teddy Roosevelt promised health insurance for all, but lost the election. In the late 1940s, Harry Truman tried, only to have his efforts denounced as a Communist plot. Failure, Truman later wrote, was the biggest regret of his presidency. Kennedy tried and failed, and so did Richard Nixon and Bill Clinton. Only LBJ achieved a measure of success, with the passage of Medicare and Medicaid, government-run schemes for the old, the poor and the disabled. Now the make-or-break moment has arrived for Barack Obama, and the stakes could not be higher.

Everyone agrees something has to be done. Left untouched, healthcare will soon be consuming 25 per cent of the US economy. But Obama's approval ratings have fallen to below 50 per cent – the worst of any president in modern history approaching the end of his first year in office. So much for the dreams that accompanied his election victory barely 13 months ago. Thirteen months? It feels like 13 years.

In part, the President's fall from grace reflects the healthcare tangle. Insofar as they understand the hideously complicated legislation, running to some 2,200 pages, a majority of Americans are now opposed to the current version of reform. Not only are Senate Republicans unanimously against, arguing essentially that "Obamacare" is socialism in thin disguise. For opposite reasons, a growing number of liberal Democrats are turning away from it on the grounds that it doesn't go far enough. If the bill does go down in flames, the blow will be massive – not only to Obama, who has staked so much on its passage, but also to any chance of serious healthcare reform in the foreseeable future. The residue of bitterness may poison American politics for years – that is, of course, if it could be poisoned any more.

The healthcare debate, especially the Senate part of it, has exposed the disagreeable realities of the American political system. The first is that the system is hopelessly dysfunctional. While the House of Representatives – whose procedural rules are more akin to those of our own House of Commons – passed its version of the bill weeks ago, the Senate has been proceeding at its customary snail's pace. One culprit is the endless opportunity for obstruction afforded by the tradition that a super-majority of 60 is required to cut off debate. This time Republicans are pushing the rules to the limit, but let no one doubt the Democrats would do exactly the same if roles were reversed.

As it is, Democrats and their independent allies number exactly 60. But keeping that group together is a process likened to "herding cats". One senator can hold his entire party to ransom, and several have done so. Joe Lieberman of Connecticut has successfully insisted that any version of a public insurance scheme, which might have competed with the private companies, be dropped. Ben Nelson of Nebraska, meanwhile, is demanding a blanket ban on abortion funding, enraging pro-choice Democrats. But he, too, was placated yesterday.

The second reality is the omnipotence of special interests in the American political process, in the case of healthcare the drug and insurance companies. The whole point of this bill is to get spiralling costs under control – yet the Senate threw out an amendment that would have permitted the import of cheaper prescription drugs from abroad. Any connection with campaign contributions from the drug companies is, it goes without saying, purely coincidental. As, of course, is that fact that Lieberman has received almost $500,000 from the insurance companies, many of them headquartered in Connecticut.

So it looks as if Harry Reid, the Senate majority leader, will herd his 60 cats. If he can keep to his timetable and close off debate, the crucial vote will come on Christmas Eve. But few would bet against Republicans coming up with a new wheeze to string out proceedings, into the early New Year and perhaps beyond. And even if Reid prevails now, further problems loom.

The bolder bill passed by the more liberal House, which does contain a public option, will have to be reconciled with the Senate one before the measure is put to a final vote and sent to Obama for his signature. Many House Democrats insist the public option must be reinstated. As for Howard Dean, the former Democratic presidential candidate (who is also a doctor), he says the best thing would be to scrap the present version, which is a sell-out to the insurance companies, and start again from scratch. To which one might reply, dream on.

The standard wisdom until recently was that something was bound to be passed. Now only one thing is sure – that, like it or not, the only version of healthcare reform with a hope of making it to the statute book is the watered-down Senate product. And the measure does extremely worthwhile things, extending coverage to 30m of the 45m Americans currently without, barring the insurance companies from denying coverage to people with pre-existing conditions, and making it easier for individuals to purchase insurance. Liberals must now choose. Is half a loaf better than none at all? This snowy Christmas, the fate of a presidency may hang on their decision.