'While I think it's a cruddy Bill, at least it is a start'

It may be a "cruddy" bill, but it's better than nothing. That was the view from the trenches of America's health service yesterday, as doctors and patients tried to size up the potential impact of the landmark vote on their troubled industry.

At St Joseph's Hospital in Burbank, California, 2,500 miles away from the political showdown on Capitol Hill, Dr Pamela Biren was coming off a 10-hour night shift in the emergency room. She was "hopeful but not exactly confident" that Barack Obama's Bill would revitalise the lot of patients.

"I'm a liberal, and there's no question that I'm totally for reform," she said. "People need to have insurance, and they need to be taken care of. I saw about 20 patients last night, with anything from heart attacks, to a man who had a gunshot wound in his leg. Half had no insurance, and I worry for what will happen to them down the line."

California is no stranger to the problems of America's current system. In August last year, the LA Forum indoor arena hosted free medical and dental checkups that drew overnight queues and about 10,000 patients. But Dr Biren is not convinced this Bill will help. "It has been so compromised by the insurance companies, who have spent millions on lobbyists to protect their interests, I fear it might make things worse for some people," she says. Other medics are concerned that the Bill will do nothing to address the biggest problem facing American healthcare: the rising overall cost of treatment, which means the medical industry now eats up a sixth of the nation's economy.

"There is no way to pay for better treatment without major changes to the pharmaceutical industry," said Dr Jeremy Kaslow, who runs a private Integrated Medicine practice in prosperous Orange County, Los Angeles.

"Almost all the rising costs I see are due to the huge prices of medicines, which just keep on rising. This Bill will add an awful lot of money to the burden facing taxpayers, but do nothing to address that problem."

For campaigners who've fought to address the fact that the world's wealthiest nation is unable to provide decent medical care to tens of millions of citizens, yesterday's vote was, however, being billed as a small step on a long journey towards reform.

"Fifty years ago, the first civil rights Bill didn't even extend the right to vote to black Americans," said Jerry Caldwell, a Democratic activist who has organised pro-reform demonstrations in Los Angeles. "So however much we dislike this legislation... it will be improved upon in coming years."

Another cautiously optimistic campaigner was Donna Malamud, whose 80-year-old mother, Shirley, suffered a stroke in January and has since been shunted between hospitals in San Diego as insurers bicker over care costs.

"We have insurance, yet my past three months have still been a nightmare," she said. "So it sickens me to think of what happens to people who don't have insurance. And it sickens me to think that the World Health Organisation ranks US healthcare 37th in the world. While it's a cruddy Bill, at least it's a start."