Barack Obama's presidency will not stand or fall by the fate of his proposed reform of the US health system. Nor is the Senate's postponement of any vote until after the summer recess fatal. The delay is, however, indicative of the almighty battle of wills the President faces, with the US Congress, with his own Democratic Party, and with the massed ranks of special interests ranged around the behemoth that is the healthcare establishment in the United States – the insurance companies, the drug firms, their lawyers and lobbyists.
Together, this makes for a huge, wealthy and powerful coalition. When it also incorporates the majority of Americans who say they are content with their present health provision, there can be no mistaking the magnitude of Mr Obama's task. But, as he said in his latest foray to win over the sceptics, "this debate is not about me – I have great health insurance and so does every member of Congress". It is about the 47 million people who at any one time have no private health insurance, about the 25 million who discover their cover is inadequate, and about the toll this takes on the country as a whole.
Americans can hardly say they had no warning. Mr Obama was voted in on pledges that included tougher regulation of the financial sector, diplomatic re-engagement with the world, withdrawal from Iraq and – right up there with those priorities – reform of the health system to make insurance accessible to all. Nor can the uninsured complain about the quality of his advocacy. Mr Obama has been as categorical and consistent as any scandalised European in his condemnation of the inequalities the US health system exacerbates. Figures for infant mortality and life expectancy lag behind those in much of Europe, while more personal bankruptcies are caused by health costs than any failed business or financial scam.
Yet the longer the debate goes on, the more it seems to resemble the last blighted effort at health reform, the scheme scornfully written into history as Hillary-care. Opponents of reform seem suddenly to be on the front foot again, playing the politics of fear. They are citing waiting lists, gate-keepers and the supposed scourge of "socialised medicine", just as they did 15 years ago. Universal health insurance, they insist, will be bought at the expense of those who now enjoy some of the most comprehensive and advanced treatment in the world.
There are many reasons, however, why Mr Obama can, indeed must, succeed. He can succeed because he has clearly studied and learnt from the mistakes made by Mrs Clinton. Rather than circumvent the insurance companies, he wants to co-opt them. And he has laid out the principles of reform, while leaving the practicalities to Congress. This has created a confusion of plans and contributed to the delays, but it has left Mr Obama free to campaign from the high ground. It has also removed the personalisation that proved so lethal to the Clinton scheme; this time blame for failure will be shared.
And Mr Obama must succeed because, although the present system serves many well, it also leaves too many people out, while devouring an ever-increasing proportion of GDP. With most people insured through their workplace, unemployment rising, and the budget deficit yawning wider, all the assumptions on which the US healthcare edifice rests are looking shaky. With energy, commitment, and even the country's parlous economic figures on his side, the President has every reason to stay in the fight.Reuse content