The brouhaha in the US about healthcare has generated in Britain bemusement and irritation. The British are not shy of complaining about the National Health Service. But to swap free-at-the-point-of-delivery healthcare for the US private insurance system would beggar belief. As David Cameron’s Conservatives know to their cost, to hint at privatisation is to invite political immolation.

Beneath the transatlantic waves lies an awkward truth; one that politicians of all shapes and sizes – conservative and progressive, European and American – would prefer not to discuss. Healthcare is rationed everywhere.

Some countries, of course, choose to spend more on health than others, just as they set different priorities for education or defence. Some prefer direct state provision, others more plural arrangements – compare France’s devolved not-for-profit insurance with Britain’s monolithic NHS. But all the models, the American included, share one characteristic. They ration access, while pretending otherwise. In Britain, the state imposes the limits; in the US the market does much the same job. What separates them are questions of efficiency and equity.

The NHS stands condemned by US President Barack Obama’s opponents as an instrument of state-sponsored euthanasia. Its socialised medicine, Americans are asked to believe, would have deprived, on grounds of age, Senator Edward Kennedy of treatment for a brain tumour.

Such charges are palpable nonsense, serving only to unite British politicians in defence of the distinctly imperfect NHS. The Tories have been put on the defensive. Mr Cameron has spent years insisting his party cherishes the NHS. Now one or two discordant Tory voices are heard cheering on Republican attacks on Mr Obama’s proposals.

Mr Cameron’s discomfort will not deter Republicans. As my colleague Edward Luce has written in these pages, US conservatives sense a chance to re-ignite America’s culture wars. Defeating health reform might derail the Obama presidency. Facts cannot be allowed to get in the way of such political calculation.

European criticism of the US model tends to focus on its inequities – the 40m-plus uninsured Americans denied access to anything but emergency care. The more startling fact is the truly enormous cost.

I say “US model”; in reality, there are two. How many of Mr Obama’s critics, I wonder, realise that the 8 per cent of national income US taxpayers stump up for Medicare and Medicaid is only a fraction less than the proportion of its income that Britain spends on the entire NHS? By this measure, US healthcare is as “socialised” as any in Europe.

Overall, the 16 per cent of national income the US pours into health is nearly twice the 8.9 per cent average of members of the Organisation for Economic Co-operation and Development. In per capita terms, as the OECD’s excellent Health Data 2009 shows, the gulf is wider. US spending was nearly $7,300 per head in 2007, against the OECD’s rich country average of just under $3,000.

What those Americans lucky enough to have top-flight private insurance get for this is care unmatched in terms of technological capabilities and expertise. The US leads the way in medical and pharmaceutical research. Facilities are modern, treatment is prompt.

The rationing is applied by the exclusions imposed by employers and insurance companies on all but the most expensive policies and, most obviously, by the fact that many working Americans simply cannot afford any insurance. To say everyone can get emergency care is little comfort to the diabetic or cancer sufferers denied ongoing care.

Yet all this money has failed to improve overall health outcomes. Life expectancy for Americans is a year below the rich country average of 79, while infant mortality is well above the average. Britain just beats the average on both scores.

True, there are other social and cultural factors to be taken into account. But that the world’s richest country can spend so much and still lag so far behind the best is an extraordinary indictment. On present trends, this hopelessly inefficient system will soon consume 20 per cent of national income, making it as unaffordable as it is inequitable. The challenge for all US politicians is surely to devise a system that spends less more efficiently and fairly.

Britain has a different problem. It needs to spend more. A sharp increase in NHS resources in recent years has eased the queues. But care is still restricted by waiting times or limited availability of some treatments. Given its demographics, Britain will need to devote a rising share of its income to health – at a time when a burgeoning government deficit requires public spending restraint. One way or another, patients are going to be asked to contribute directly to their care.

At least, though, the NHS is relatively efficient. Britain gets a lot more bang for its buck than the US. Rationing will always be unavoidable – on both sides of the Atlantic. And it is foolish to argue that state-run systems are always the most effective. But Mr Obama’s critics are throwing stones from a glass house in which the panes are already broken.

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