Barely drawing breath after his ground-breaking Cairo speech, Barack Obama is charging into what will be one of the biggest stoushes in American politics, his plan to reform the hopeless US health system.

Obama launched his campaign in a speech in Wisconsin, urging people who supported him to get behind the plan and lobby their Congress members, because “this may be our one chance to get health care reform through.”

It would be difficult to over-estimate the risks associated with trying to make even the most basic changes to US health-care. It was after all the failure of Hillary Clinton’s complex plan in 1993 that did more than anything to hole the Clinton Presidency below the waterline, at least as far as being a liberal regime went.

Clinton’s plan wasn’t even the dreaded “single-payer” system, the term the US Right uses as some sort of North-Korean image for what Australians would know of as Medicare — baseline state-run universal coverage supplemented by private options.

Instead it was an attempt to continue to run health insurance through private providers, while explicitly mandating how much they would charge, how much they would pay out, limiting their ability to exclude people with pre-existing conditions, and so on.

It was a scheme designed to please no-one — Big Health were always going to be against it, and the liberal-left wouldn’t get behind it because they were still holding out for a single-payer system, which would not — as would have the Clinton plan — flood rivers of gold into the insurance companies for stuff that could be done at knock-down prices by the state.

Since then, the organized left have been pretty much beaten down in Congress, and health care in the US has become much worse. This has given Obama a great political opportunity to get real reform through — but only at the price of proposing a scheme so unthreatening to Big Health, that it will see the wisdom of acquiescing to it.

Why did American health get so much worse than it was at the time of the Clinton plan, when it was already pretty dead? Deregulation between 2000-2006 was one factor — a release of the (fairly-worn) brakes that were on the insurers in terms of denying continuing care to the chronically ill, excluding pre-existing illnesses and aggressively using the bankruptcy laws to recover costs.

Another has been the open-ended nature of private medical care — as new techniques and tests are introduced year-on-year, open-ended health plans are faced with spiralling costs, created by the increasing demands of patients, and the desire of GPs to bill for endless additional (and often unnecessary) services.

With no qualitative and triage-based control of health-care spending, the more consumerist options will crowd out necessity. The ideal health insurance client is a member of the “worried well”, paying top-hole premiums for routine services, the lions’ share of the service fees going to the insurers. The worst client is the one for whom any rational health system should be designed — the chronically ill, the suddenly desperately ill, the seriously injured etc, and health insurers spend most of their energy throwing these people off their lists.

The coup de grace has been the sharp rise in unemployment in the US, which has deprived many people of their employer-based health insurance–– the auto manufacturers bail-out deal alone cuts by 50% the health care available to up to a million former car workers and their families, just as many of them are ageing.

The core of Obama’s plan is what’s known as a National Health Insurance Exchange, which is a sneaky way of offering public health insurance to the 45 million Americans who don’t have any insurance whatsoever (and aren’t eligible for the below-poverty-line Medicare scheme) — and simultaneously providing subsidised matching fixed-prices schemes offered by private providers, so that no-one can scream socialism.

Surrounding this are various measures such as $10 billion in grants to get nationwide electronic record-keeping up and running — US hospitals are the last places in the developed word where the faxes run hot day and night with paper records being transferred — and some real battles, such as prohibiting the exclusion of pre-existing conditions.

The advantages of the scheme are all political — people are so angry with health insurers (average premiums have doubled in the last six years), terrified of bankruptcy (half of the million bankruptcies a year in the US are due to medical costs), and worried for their children’s health, that Congress members who simply roll over for their Big Health campaign donors will find themselves the target of grassroots attack in upcoming party primaries for the 2010 elections.

The disadvantage is that it’s a monstrously expensive way to achieve what single-payer cover does for half the cost, and twice the result — provide universal optimum health. But if Obama can get this, and if the 2010 Senate vote gives an enhanced Democratic majority, then there is a bridgehead from which non-pauper public health cover can be expanded, thus denying the Right the chance to make a huge fight over it, and gradually converting the American people to the idea that public health provision is not socialism.

And also, if if if it succeeds, proving once again that the road of recent American political history is littered with the bones of those who underestimated Barack Hussein Obama.

If it fails? We may find out — health insurers here are starting to make noises about unaffordable Medicare and transitioning to a US health system. So remember to choose which leg you’d like to save if they both get infected, because your plan may not cover both.