Page last updated at 18:31 GMT, Friday, 24 July 2009 19:31 UK

America's great healthcare debate

By Kevin Connolly
BBC News, Chicago

Hospital room (file pic)
A hospital visit can be costly for uninsured Americans

When a political topic is hot in America it dominates the cable chatter on 24-hour TV channels.

When it's REALLY hot, it dominates the advert breaks too - and no topic is hotter than health care.

Rival lobbying organisations are spending millions of dollars on airtime - offering startlingly different diagnoses of what is wrong with the American healthcare system, and different prescriptions for treating it.

Some call straightforwardly for the government to expand its own role as a provider of health coverage, as it currently provides only for the old and the poor.

Others warn of the dangers of "socialised medicine" - the most riveting of them carry warnings from Britain and Canada about the dire consequences which will follow if the United States copies their government-funded systems.

You would almost get the impression that the streets of those countries are piled high with the unburied dead - but behind the oversimplifications, it is clear that America is engaged in a debate about how big a role government should play in rationing healthcare.

No insurance

To get a sense of what that debate means in the daily lives of what journalists tend - rather irritatingly - to call "real people", I travelled to Illinois, Barack Obama's home base, where he engaged with this issue: first as a community organiser, then as a young state senator.

On one side of the debate in the town of Aurora, I found Kathy Hunter, a mother of two children who used to have health insurance through her husband's policy and who lost it when they were divorced.

So Kathy is now one of the 47 million or so Americans who have no health insurance - a statistic bandied about so often that it is easy to forget the lives which lie behind it.

If they have in Washington, or in state government, this wonderful care - why don't I? Why am I not entitled to that as a human being?
Kathy Hunter

We sat together at Kathy's kitchen table and sorted through the bills which arrived after a brief trip to the emergency room after she suffered an anxiety attack a few months back.

There was - happily - nothing wrong, but the total cost of a few tests and a few reassuring words from a doctor totted up to around $4,000 (£2,437). The government-funded medical welfare system Medicaid might agree to pick up the tab, but it might not and if it does not Kathy has no idea how she will pay the bill.

From her point of view, the problem is huge, but it is also simple.

"I sit here at night and I wonder: "What am I going to do, where am I going to come up with this money?'" she tells me.

"If they have in Washington, or in state government, this wonderful care - why don't I? Why am I not entitled to that as a human being? And that's what I don't understand, why can't we figure out a way for everyone that everyone can be covered - at least for the basic care."

From the vantage point of Kathy's kitchen table, it is hard to disagree with the notion that something must be done - but politics of course is the business of settling exactly what.

And healthcare makes for particularly difficult politics because it throws up questions about where American society is heading.

'My choice'

We know now, in broad outline at least, what Barack Obama thinks should be done. He wants a government insurance scheme to run in parallel with and in competition with private insurance providers.

But there are problems with that plan.

America already spends more than any other developed country on healthcare (around 16% of GDP where 10 or 11 is the norm). And it is not noticeably a healthier society as a result.

In the short term, providing a government scheme would be costly. And in the long term, if it was both good and affordable, it might put private insurers out of business - and that would mean that by default America would start moving towards a state-provided system.

46 million uninsured, 25 million under-insured
Healthcare costs represent 16% of GDP, almost twice OECD average
Reform plans would require all Americans to get insurance
Some propose public insurance option to compete with private insurers

Which brings me to Sandy Westlund-Deenihan and the other side of the argument.

Sandy runs a light engineering company on the outskirts of Chicago. Like her father and grandfather before her, she takes pride in providing healthcare for her workers.

She pays 65% of the costs of insuring her employees (they make up the rest) and even though it is a significant cost for a small business, Sandy would not have it any other way.

"I am in favour of insuring the people who don't have any insurance, but don't handcuff me because I'm doing the right thing," she told me.

"I really want to have a choice, and I really don't want the government interfering. If I want to take that out of the profits, and give it to my employees, that's my choice."

It is only fair to point out that Sandy is not opposed to healthcare reform - she would like to see something done to help people like Kathy for example - but she shares the instinctive horror that many Americans feel for the idea of the government running the healthcare system.

Politically vulnerable

Democrats often argue that the barrier to healthcare reform is an efficient and well-funded lobbying system run by the insurance and drug companies that make money from the current system. But things are never quite that simple.

US President Barack Obama at a town hall meeting on healthcare reform (23 July 2009)
Mr Obama has been trying to explain his policy to the US public

To many people here - certainly to many conservatives - the idea of government healthcare conjures an impression of a federal bureaucrat deciding what tests and treatments you may or may not have.

From that point of view, an expanded role for government is the problem, not the solution.

This is the political minefield that Barack Obama is currently negotiating - is there a way through it that will protect Kathy without alienating Sandy?

At the heart of this, of course, is a battle between two competing visions of America's future.

Does it want to become more European or will it stick to the view which has allowed it to prosper - that the free market is the most creative and efficient way to allocate resources, even when those resources are hospital beds to treat the badly injured or the terminally-ill.

It is a problem that former presidents Roosevelt, Kennedy, Truman and Clinton all grappled with in the course of their presidencies with varying degrees of success, but Mr Obama has been relying on his undeniable mandate for change and his extraordinary powers of persuasion to ensure that things turn out differently this time around.

He wanted it sorted out before the summer recess on Capitol Hill but has been forced to accept now that it will not be.

And there are big politics at play in all this too - Republicans sense that Mr Obama is vulnerable on this issue and they are pushing back hard against his plans.

If they can stop him on this, they reason, they can rob his presidency of much of its momentum.

The summer months are normally fairly quiet in Washington, but with the White House keen to see all this go to a vote in September there is every chance that the summer of 2009 will see a real battle raging in America's capital.

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