For over a year, a ghost has hovered over the White House. It was the threat that the failure of health reform might mean for Barack Obama to follow the same ominous path of Bill Clinton, who in 1994, after losing the battle for the reform, suffered a crushing defeat in the midterm elections in November, so remaining hostage to the new Republican majority in both Houses of Congress. The passage of the reform has exorcised the ghost, and contradicted the prediction of a Republican senator who, during the harsher phase of the battle, said: "The health reform will be the Waterloo of Obama."

With the reform, within the next ten years, 32 million American citizens, compared with 47 million who now are uninsured, will get health insurance. And insurance companies will not be allowed any more to deny the insurance on the pretext of past illness or terminate the insurance in the occurrence of new severe or chronic diseases. Half of the new insured whose income is less than about 30,000 dollars will come into Medicaid, the public insurance provided for the poor. Sixteen million people, with incomes up to 88 thousand dollars, but without insurance by an employer, will get a public subsidy, decreasing in relation to family income, to buy insurance from private companies. When the reform is fully implemented between 2014 and 2019, the insurance will be mandatory and 95 percent of the US population will have health insurance.

The battle for reform was no holds barred by the Conservatives, but there has been a surprising event. The medical-industrial complex, in contrast to what has always happened over last decades, has supported the reform in its final version. The insurance companies have imposed the mandatory insurance that allows them to expand the insurance market to about twenty million new policyholders, largely young adults with lower health risks. Hospitals will, in turn, increase the "customers" by providing assistance to new tens of millions of patients.

The powerful pharmaceutical industry, on own side, assertively supported the reform, having obtained to retain complete freedom in pricing, even with respect to the public health plans (Medicaid and Medicare), which include one hundred million costumers, plus a knot of other measures ensuring its dominance in the domestic market for drugs. And its support has been displayed by spending 100 million dollars of television ads in favor of reform.

To understand this reversal of health-industrial complex we must return to the beginning of the debate on health reform. The crisis in American health care system has been discussed in recent decades in the form we might call a triangle in which each of the three sides manifests an aspect of the crisis. The most apparent side was that of tens of millions of Americans uninsured, a unique phenomenon in developed countries. Another side of the triangle was the enormity of healthcare overall cost, totaling the astronomic figure of two and a half trillion dollars, something like 17 percent of U.S. gross domestic product. In other words, twice the average expenditure in the European Union where by and large, unlike the U.S., healthcare has a universal character. The third side of the triangle often left in the shadows but hardly less important, is the inequality of protection for insured: in other words, the phenomenon of under-insurance that affects tens of millions of Americans, insofar as their insurance is not adequate to address the risk of a serious illness.

The reform addresses the first side of the triangle of the crisis, insofar as the number of uninsured will be drastically reduced within ten years, nevertheless without achieving a universal protection. According to the estimates of the CBO, Congress ….in fact, when in 2019 the reform will be fully implemented, 23 million people - one third of whom illegal immigrants - will still be uninsured. However, the problem that the reform is not able to solve is the inequality of citizens - even when properly insured - face the risk of the disease.

The insurance world is in US a puzzle, a source of insecurity and anxiety for millions of families. An insurance policy for a family amounts to average $ 13,500, but the average is misleading. Some examples can illustrate this aspect.  An individual 50 years old must pay an average fee three times as a young man. A woman thirty years old is charged more then a male of the same age because motherhood is considered a risk from which the insurance company wants to be shielded.  A large company, where unions have a strong bargaining power, might provide a high level of insurance that can amount to the double of the average. In other cases, the policy includes provisions for reduction of coverage, such as deductibles or co-pays, leading to bankruptcy families who experience severe or chronic medical conditions. The New York Times wrote in an editorial: “The U.S. is the worst place to be suffering from a serious illness”. And, of course, not referring to the privileged people who can afford high priced insurance with standard levels of service among the highest in the world.

 But the reform does not deal with these aspects of deep structural inequality. It also leaves unresolved the problem of the cost of health care. Its growth has been unstoppable during the last twenty years. In the early Nineties was around 12 per cent of GDP, in 2009 had exceeded 16 percent. According to the estimates of CBO, in absence of radical changes, it will reach twenty percent of GDP by 2020. A hyperbolic cost, amounting to one fifth of national income. The reform will bring about no additional cost to the federal budget (rather a surplus is expected), but is unable to contain the overall costs (insurance, pharmaceutical and hospital), growing at a rate of inflation above the average, hitting the earnings of people who are not institutionally poor but live in the limbo of precarious jobs with lower incomes. There are a hundred million Americans - Barack Obama affirmed in a speech in support of the reform - which over the last two years has been kept for a more or less long period without healthcare insurance.

Were different solutions possible? One proposal deeply debated within the Democratic Party echoed the European and Canadian models of universal health care considered as a citizen’s right. Translated in US terms, the proposal was designed to extend to all citizens the successful model of Medicare - the public system financed by contributions from employers and employees, now limited to the elderly. In simplified terms: "Medicare for all".

But Barack Obama considered too radical this scheme, since it implied the eradication of private insurance companies which draw their profits from a market of about 150 million policyholders. So Obama embraced, as the cornerstone of reform, a much more moderate solution: namely the "Public option". That is the establishment of a public insurance company operating alongside private ones as a component of a wider and competitive insurance market. The "public option", albeit was a less radical and comprehensive overhaul then "Medicare for all", yet was a forthright element of innovation, pointing to a system with cheaper and more egalitarian standard protections. During the summer the three involved competent House Committees adopted, albeit with many limitations, a scheme of reform assuming the principle of "public option". But, once in the Senate, the reform was blocked and the “public option” wiped out.

In effect, the lobbies had unleashed their firepower against any notion of "public option", setting in motion the great machine of ideological distortion. Obama was accused nationalizing health care and being a “socialist”. Nevertheless the lobbies and the big conservative press, led by Fox, would not have prevailed without playing the division among Democrats who had a vast majority in both Houses of Congress. On the other hand, Republicans were not interested in any compromise, since their exclusive purpose was the White House defeat. Obama had in vain looked for a bipartisan solution. In effect, the actual bipartisanship in Washington being that of the lobbyists who provide funds to designed congressmen without distinction of party. Democratic Senator Max Baucus, chairman of the so-called “Gang of six”, a mixed group intended to find a bipartisan solution, was the fourth in the list of senators who received more funding for election campaigns throughout his senatorial career.

 Placed in this frame of a year of fierce political battle, the approved reform can be regarded as a significant political success for Obama. Yet, hardly, might it be defined a “historic” reform, comparable to the great social reforms that have marked the American society in the course of the XX century. To the American social definitely belongs the Social Security, promoted by Franklin Roosevelt in 1935, when the public pension system was established. As well as the health reform in 1965, when Lyndon Johnson established Medicare and Medicaid, the two public insurance schemes now covering about one hundred million Americans.

the reform of 2010 widens the grid of Medicaid, the system originally dedicated to the poor, so bringing in sixteen million American citizens, while providing a subsidy to another sixteen million to purchase a private insurance policy. It certainly is an important step forward. But it is a matter of fact that the American health care model remains the most expensive and the most unequal among developed countries.  The reform is the result of a fierce battle that dominated the first year of Osama’s presidency. But it is also the symbol of a conception that in US dominates the conservative political culture. When you want to assail or disqualify a model of social policy, it is enough to say that it echoes the "European social model".  Yet, a model that, in the case of health, albeit all the differences between one country and another, ensures an egalitarian system with costs ranging between half and two thirds of US per capita expenditure. European systems that, starting with the French one, were placed at the top of world rankings compiled by the OECD.

The paradox is that the Conservatives in the European political debate, along with many so-called “reformists" admit that the American social model is socially unequal but, at the same time, regard it as economically more efficient.  Indeed, a pure ideological prejudice, given that American health system is a patent example of social inequality mixed with economic inefficiency.

In his speech on health care before a rare joint session of Congress, on September 9, 2009, president Obama remembered that the issue of health care dragged in America for a century, starting with the first attempts of Theodore Roosevelt. And, proudly, added: “I am not the first President to take up this cause, but I am determined to be the last”. Ambitious proposal from which the reform of this spring, unfortunately, remains still far away.

Related Paper: "Obama nel labirinto della riforma sanitaria - Una metafora del capitalismo americano" http://www.insightweb.it/web/node/148