‘The unfinished business is done’

A toast was raised to the NHS in last year's December issue of Clinical Medicine to salute a service where everyone, regardless of income, can obtain medical care free at the point of delivery – a remarkable achievement for any healthcare system.

This festive celebration was prompted by the efforts of the President of the United States of America, Barack Obama, and the Democratic party who, at that time, were battling to obtain approval in the Senate and House of Representatives for their Health Care Reform Bill which would provide health insurance for the first time for some 47 million Americans.

Of the 100 seats in the Senate, the Democrats had just enough (60) to muster the required two-third's majority to pass the bill. That was until the death of Edward ‘Ted’ Kennedy, on 25 August 2009, who had served in the Senate as the representative for Massachusetts for 47 years and who had been a staunch and longstanding campaigner for universal healthcare.

Many Americans were unhappy about the proposed changes since, of those who vote, 94% have private health insurance and of these 75% thought their medical insurance either good or excellent. While supporting the concept of affordable healthcare for all no one was keen to relinquish what they already had to solve the problem and the costs were perceived as a burden too far in an economic recession.

These strongly held views influenced the outcome of the election for Kennedy's successor which was won not by the Democrats but by Scott Brown, a Republican. As a result of this unexpected outcome, the Democrats ‘supermajority’ was lost.

The chances of passing the Health Care Reform Bill thus seemed remote and the spectre of previous unsuccessful attempts loomed large. In the face of such determined opposition, most would have given up the unequal struggle and turned their attention to other issues but not Barack Obama.

Some clues to his extraordinary persistence and tenacity can be found in his autobiography published in 1995 when he was only 34 years of age.¹ After graduating in political science in 1983 from Columbia University, he sought work by writing to every recognised US civil rights organisation but without success. He eventually took a post as a research assistant to consultants working for a multinational corporation in New York principally to repay his student debts. His colleagues smiled indulgently when he discussed his future intentions of working to mobilise the poor to enable them to contribute positively in their own deprived communities.

After two years he relinquished this safe job and moved to Chicago as a trainee in a group organising urban blacks and suburban whites to work together around a plan to save manufacturing jobs in metropolitan Chicago using local churches as an effective institutional base. His extraordinary persistence and determination to overcome all the challenges and difficulties in achieving his goals in an area of extreme poverty, unemployment and hopelessness demonstrated that here was someone different who was not to be easily deterred.

This character building experience stood him in good stead. Despite all the odds stacked against him, and against determined opposition, the Health Care Reform Bill was eventually passed by the Senate on Christmas Eve 2009 and by the House of Representatives on 21 March 2010. The bill was signed into law in the presence of Ted Kennedy's widow, Victoria Kennedy. After the ceremony her son, Patrick, made his way to Arlington Cemetery where he laid a note on his father's grave: ‘Dad, the unfinished business is done’. This year we can but toast the triumph of improved access to healthcare at the point of delivery for all those previously excluded.