Tapu Misa: Reforms stymied by lack of imagination

For many of us watching on this side of the Pacific, President Obama's push to reform health care in the United States is a no-brainer. Why it's even debatable for the majority of Americans is a more interesting question.

Last week, in a speech to Congress, Obama tried to frame the reforms as "above all, a moral issue". At stake, he said, "are not just the details of policy, but fundamental principles of social justice and the character of our country".

That should have been an easy sell.

More than 46 million Americans - nearly a sixth of the population - don't have health insurance.

Even the insured have found themselves at the mercy of insurance companies, which brazenly deny coverage because of "pre-existing" conditions, cancel policies when policyholders become ill, or raise premiums to unaffordable levels. Tellingly, most bankruptcies in the US are the result of exorbitant medical bills.

But despite spending more per capita than any other nation on earth, Americans can only manage 37th for health outcomes, according to the World Health Organisation. The most expensive health system in the world is also the most wasteful. Fear of malpractice suits drives defensive spending by doctors. One-third of all medical care, the Institute of Medicine estimates, is waste: unnecessary x-rays and lab tests, and procedures to fix mistakes.

That so many Americans are denied health care is unconscionable. Almost everyone agrees that the growing cost of the American health system is unsustainable.

Yet, Obama's reform effort is in danger of foundering alongside other ill-fated attempts.

The challenge isn't just in loosening the vice-like grip of powerful vested interests: insurance companies, big pharmaceuticals, malpractice lawyers, and the medical profession, with their army of lobbyists and big cash contributions to key senators and members of Congress.

Obama's biggest obstacle may be the majority who have health insurance, are generally satisfied with their care, and aren't convinced that there's a problem.

As one commentator argued, "What is the crisis? When individuals can't get needed health care, it is certainly a crisis for them ...[But] the overwhelming majority of Americans do not face a health crisis."

The idea, promoted by T.R.Reid in his book The Healing of America, that "there's a basic conflict between the principle of health insurance and the pursuit of profit" is anathema to many Americans, who have an unholy fear of big government and "socialised medicine" - a term coined back in 1947 by a public relations firm working for the American Medical Association, to discredit President Truman's efforts to introduce universal health care for all Americans.

Despite Wall Street's meltdown, a Gallup poll in April found that 55 per cent of Americans think big government is the biggest threat to the economy, compared with just 32 per cent who voted for big business. It seems that Obama's $787 billion stimulus package and trillion-dollar bailouts have only made Americans more susceptible to Republican claims that health reforms constitute a government takeover of health care.

As Obama was at pains to point out last week, ensuring health care for all Americans isn't a matter of individual responsibility, and can't be left solely to big business - it requires government intervention.

"Our predecessors understood that government could not, and should not, solve every problem," he said. "But they also understood that the danger of too much government is matched by the perils of too little."

It seems to have escaped many Americans that they already have socialised medicine, in the form of Medicare, a government programme which provides care to the elderly, and Medicaid, a joint federal-state programme to cover the poor. Without such government programmes, as figures released last week by the US Census Bureau confirmed, the number of uninsured Americans would be much higher than the 2008 figure of 46.3 million.

As a New York Times editorial put it: "Critics of health care reform have done Americans two great disservices. They have obscured and denied the very real suffering of tens of millions of uninsured Americans and the very real danger that millions more could soon join them. And they have twisted and denied the goal of health care reform when they rail against a fictitious government takeover."

Which brings me to some of the reaction to last week's column on the social and economic cost of inequality in this country.

Some people seem to regard the possibility of a more equal society in the same way as many Americans regard universal health care: as a fantasy. Yet, there are successful models in other Western democracies. New Zealand had the fastest growth in inequality in the OECD in the 1980s and 90s because of government policies, not individual irresponsibility - and only government policies can help to reverse that.

It may be, as several readers suggested, that those with vested interests in the status quo will prove to be the biggest barrier to change. But public understanding and buy-in will be just as critical. As in the US, the biggest obstacle to a fairer society is more likely to be our own lack of imagination.