In any country other than the United States, it’s hard to feel the intensity of the national dispute over healthcare. It’s consuming Barack Obama’s presidency, and so it should. He’s right to have told Americans that they can’t afford their medical system (that is genteel understatement) and that it’s going to bankrupt their Government soon.

But he’s wrong in the way he’s trying to solve it — including his curious detachment from the details of the plan that will make or break his presidency. Why has his grand notion gone so badly adrift?

At last, yesterday afternoon, Obama was plunging into the high-profile advocacy that he has avoided for months, fielding questions from pensioners’ groups. He wants to salvage some kind, any kind, of legislation. The best guess at this point is that he will indeed get something from Congress by the end of the year. But as the efforts in both Houses stand, they address Obama’s demand for cover for the 47 million Americans without insurance — yet do nothing to say how the US will pay for this.

Obama’s bald statement that the Bills in the House of Representatives and Senate are, or will be, “revenue-neutral” is simply untrue. Voters are not fools, hence his plunging poll ratings — and hence the chance that Congress will throw the Bills right back at him.

My colleague Anatole Kaletsky, in a superbly blunt article on June 18, pointed out that “healthcare, not bailouts, could break America”. Premiums have risen by 58 per cent since 2000, although average wages have edged up only by 3 per cent. The result is an erosion of living standards. “America’s ‘excessive’ consumption, widely seen as the most fundamental cause of world economic instability, has been due entirely to health spending.”

The White House has made this case well enough to jolt the Democrat-controlled Congress into an attempt at reform. But here, Obama made his first mistake. His team clearly was thinking (and his Secretary of State could remind him) of the debacle of Hillary Clinton’s efforts to redraw US healthcare. She and President Clinton drew up the plans, in hundreds of pages, and dropped them on an unprepared Congress, as if they were playing at think-tanks, not politics. It failed, and Clinton got his punishment in the midterm elections, when Congress turned Republican.

Obama has gone too far the other way. He has declined to draw up a detailed plan himself, but lobbed a few general principles in the direction of Capitol Hill, and left it to his former Senate colleagues.

The New York Times yesterday carried a hagiographic sketch of Senator Max Baucus, of Montana, together with two Democrats and three Republicans, working for hours a day to devise a compromise. That’s justified only in that the most likely version to emerge from any door of Capitol Hill is the Baucus one. But that doesn’t make it a good one. It answers Obama’s desire for more coverage for poorer people. It doesn’t cut the cost or choices of existing healthcare — too painful. Obama doesn’t say in credible detail how the $1 trillion over ten years should be funded.

Americans have evidence in front of them of how the postwar healthcare systems of Medicare and Medicaid ballooned beyond original estimates of costs. Massachusetts, which extended its coverage and is now faced with costs it cannot meet, is another case.

Congress looks as if it will either pass something so expensive as to be unworkable — or throw it back at the White House. Either way, without a radical change in the script, the most important and expensive policy of Obama’s presidency is heading in a direction that he won’t want.

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