Despite recent setbacks, Barack Obama still holds out audacious hope for US healthcare. But as opposition continues to undermine his position, the president has a monumental battle on his hands to get meaningful reform, says Douglas Noble

In the past six months, the debate over US healthcare has covered considerable ground, with all the controversy aroused by 1948 Britain and the infamous 90 per cent vote against the NHS by the British Medical Association. Yet the mood was upbeat before Christmas; Democrat Tom Harkin summed up the festive spirit: “We’ll get this passed before Christmas and it will be one of the best Christmas presents this Congress has ever given the American people.”

We are going to have a complete government takeover of our healthcare system faster than you can say, ‘this is making me sick’

The House of Representatives passed the Affordable Health Care for America Act and the Senate later passed the Patient Protection and Affordable Care Act; 50 million uninsured headed out to buy extra trimmings for the festive bird.

The Senate bill differed in several places from the House bill: it costs $200m less, insurers $5m more and, critically, does not contain a government run insurance plan. Compromise was on the cards. Snowbound at their desks in Washington DC, the Republican delayers lay defeated.

The basic statistics told several stories. First, the House was harder to sway - 50.6 per cent in favour of the bill versus 60.6 per cent in the Senate. Republicans were furious with the first vote, despite a notable concession to cease publicly funded abortion services. One Republican congresswoman from Michigan, Candice Miller, summed up the mood: ‘We are going to have a complete government takeover of our healthcare system faster than you can say, ‘this is making me sick’.” A somewhat insensitive metaphor for the 50 million dispossessed.

Internationally, the two successes left the world feeling that US Congress was finally going to tackle the woeful underprovision of care. But despite the 60-39 positive vote in the Senate, 39 “blue dog” conservative Democrats in the House had joined their republican counterparts voting against the bill - the strength of feeling against Barack Obama’s plans in the ranks has been an ongoing noose around his neck.

Then the death of Senator Ted Kennedy triggered a by-election in Massachusetts. The seat was won by Republican Scott Brown, largely due to dissatisfaction with the Obama health bill - almost 40 per cent of Massachusetts voters listed healthcare as their main concern. Kennedy had held the seat since before Lyndon Johnson first embarked upon health reform with the creation of Medicare and Medicaid in 1965. There have been few hardier democratic strongholds. The full significance is that the balance has now tipped in the Senate - 59 Democrats, 41 Republicans. Democrats can now only be sure of pushing through a vote with Republican defectors - a so-called super-majority of 60 is needed in the Senate to prevent a filibuster.

The next step is for a revised and combined bill to return to the Senate. The views of the newly elected Brown are clear: “Massachusetts wants real reform and not this trillion-dollar Obama healthcare that is being forced on the American people.” Filibuster does not begin to describe Brown’s intentions - his most recent suggestion being that the current bills are torn up and plans for healthcare reform started from scratch.

What he and his party do want is at best unclear - apart from more of the status quo, and platitudinous “smaller steps” such as reducing costs paid out from malpractice claims.

Compromise has been the name of the game following both votes. The centralised government run insurance plan seems unlikely - thought to be Obama’s best chance of hauling back power from the fat cat private sector. Suddenly, the bill looks significantly watered down. Yet, the central tenets of the current proposals still hold much hope: tackling ruthless insurance companies that refuse to provide coverage for previous medical problems; the insurance exchange in a modified form; an expanded programme for the poorest; and saving $1 trillion from preventive medicine and scaling back current government schemes. Although unclear at this stage, hopefully employers will take more responsibility for providing insurance with access to the incentivised exchange. Unscrupulous employers could face heavy fines.

The watered down version of the bills is speculated to offer 30 million (60 per cent) of the uninsured vastly better access to healthcare.

In the midst of wrangling over bills and costs, quality metrics and the finer points of social care plans have taken a back seat. One agenda that has managed to stay in the forefront of American minds is the case for preventive medicine - attributed for many of the projected cost savings. With the release of the Conservative green paper on health (focusing mainly on public health and the new Department of Public Health) there is much for UK managers and policy makers to watch in the US debate.

Larry King’s comments sum up the public health mood: “When we look at these statistics, we’re spending billions of dollars on preventable diseases, and new healthcare legislation could go a long way to improving prevention, first and foremost.”

Michelle Obama has been in the media frequently and is supporting preventive medicine endeavours, recently saying that work on public health initiatives “is to me one of the true keys of changing the health paradigm in this country”. In the State of the Union Address, President Obama tackled the issue of one in 10 Americans being out of work, clearly underlining the concomitant health risks of the situation.

In the UK, the renewed spotlight on public health offers much hope for improved quality of life, and cost savings - clearly seen by Andrew Lansley, Sir Michael Marmot et al. Chief medical officer Sir Liam Donaldson recently suggested that reducing consumption of cheap alcohol could save almost 100,000 hospital admissions per year. Given that one in four people will be over 65 by 2025, with a corresponding increase in medical intervention, reducing unnecessary costs is essential.

The Tory paper on public health certainly steers us out of the deep waters of solely fixing the next acute preventable disease at increasing expense, into the relatively shallower waters of public health.

Ringfencing public health budgets, giving local primary care trusts and local authorities joint power over such budgets, and getting all healthcare workers such as pharmacists involved in provision of care are all central features. The new Department of Public Health aims to be firmly rooted in the measurably proven preventive arts. Watching the evolution of a similar debate in the US may provide many opportunities for learning and cross-working.

Despite continual denial, spending cuts in health seem inevitable. One minister recently addressed a group of public health professionals indicating that spending would increase by 11 per cent until April 2011, after that we would be locked in to realise the opportunity of that investment until 2016. Finding money saved from public health interventions is increasingly attractive.

Obama still holds out hope, audaciously, for the future of US healthcare as the two bills are bought together for a final vote later this year. Senator Brown and others will do all in their power to impede them. Progress on public health may be the key to delivering reform.