With 71-year-old Arizona Senator John McCain and former Massachusetts Governor Mitt Romney locked in a battle for the soul of the Republican party and little more than a hair’s breadth between the Democratic party’s front runners, all eyes are now on ‘Tsunami Tuesday’, when upwards of twenty states hold their primaries.

The four leading candidates are promising a head-on assault on one of the most serious and intractable political problems facing the US: the soaring number of people who now can’t afford health insurance. This is without doubt one of the ugliest scars on the face of the world’s richest nation: a country that spends 16 per cent of its wealth on health – more than any other developed state – but which has failed to address the plight of those citizens, now 16 per cent of its total population, who have no insurance.

Over 80 per cent of uninsured people come from working families. In 2005, over 27 million workers had no health insurance, in most cases because they just couldn’t afford it. The typical cost of health insurance for a family of four in the United States would be of the order of $11,500 (€8,000); the same family in Ireland would certainly pay less than €2,000 a year.

Millions of these voters have been caught in the sub-prime lending trap and are taking the full force of the global financial gale which, for most people here, has been little more than a gentle summer breeze. And they’re looking for a saviour who will at least try to put the wind at their backs.

The American healthcare system is driven by health insurance. Although most people are still lucky enough to get it as a perk of the job, concern is rising that the decline in the manufacturing base and the transition to part-time and contract work are undermining the traditional access route. In less than two decades, the percentage of people with employment-related health insurance has plunged from 70 to 60 per cent. There are now 47 million Americans, including nine million children, without cover.

All four front-runners in this presidential election appear to be promising a pain-free, easy-pay way out of the problem of escalating healthcare and insurance costs. With the former now rising at twice the rate of inflation and the current $2 trillion budget expected to double in the next decade (driven in part by the falling numbers of insured people), there is agreement that costs need to be reined and insurance coverage increased.

Interventionist

The Democrats are typically more interventionist. Hillary Clinton is promising the utopia of an affordable, accessible universal health-insurance scheme and the nirvana of a low-tax economy. Citizens will have access to the same level of benefits as their representatives in Congress or, if they prefer, the choice of a public plan similar to Medicare. There are to be new nationwide legal safeguards against exorbitant prices and unfair discrimination.

Obama goes further by promising direct subsidies for the poorest people availing of a public plan. He also emphasises the idea of portability, meaning people wouldn’t lose their insurance when changing jobs. Like Clinton, he has an almost blind faith in government’s ability to reduce costs through modernising systems, though neither has any time for the market approach to reducing inequality and improving quality.

The Republicans are content to let the market reign supreme. McCain wants to put families “in charge of their own healthcare dollars” in a competitive market, which drives down costs and drives up quality. Patients would be at the centre of care, involved more in decisions about treatment and prevention, informed by a new transparency on medical outcomes, quality of care, costs and prices, and empowered by national standards.

Romney could be forgiven for thinking that the Democrats are guilty of handling stolen goods, given that he was the first US governor to introduce a law guaranteeing health coverage for everyone in his state. This was achieved through retaining public healthcare money, which the federal government wanted to cut, while requiring the “eminently insurable” to take out health cover.

In Massachusetts, these people were not single stay-at-home mothers, as many had thought, but young unmarried men who could afford insurance but didn’t bother with it. Romney’s problem now is that he doesn’t appear ‘sound’ to other Republicans if he advocates this nationally.

By Christmas, we will know if the US is leaning towards a new healthcare settlement. That the ‘land of the free’ is entertaining notions of compulsion in order to improve accessibility and contain costs shows just how debilitating and destabilising the healthcare issue has become.

The Boston/Berlin argument, which some commentators here say encapsulates our choice of trajectory for the future, can thus be seen for what it is: a simplistic, reductionist sound bite which ignores the potential of solutions that others have tried and which we would be wise to consider.