Western health care is stuck in the sickbay Never in human history has the general health of most ordinary people been better than it is now. But paradoxically, there can scarcely ever have been a time when health care has been a more difficult political problem for the governments of advanced countries than it is now. These two apparently contradictory facts are not unconnected. It is precisely because of the stupendous advances in the treatment of disease that the role of government has become so contentious. With the scope for life-prolonging medical intervention now virtually limitless - and thus spending on it being potentially limitless as well - there are moral and practical questions about its availability and distribution which every democratic society has to address. So this is where we find ourselves. In Britain, we have a government in deep trouble because it cannot find a way to relinquish an old model of health care, however anachronistic and unsatisfactory that system is shown to be. And on the other side of the Atlantic, there is a government embroiled in what may be a fatally damaging attempt to introduce an unpopular new model. Here, the limitations and drawbacks of a state-owned-and-run monopoly of medical provision have been known and (at least privately) admitted by every party in government over the past generation. But so great is the mythological terror evoked by the word "private" in conjunction with "health" among politicians that any attempt to break that monopoly and bring health care out of the wartime era of command economy rationing must be denied and abandoned before it is even properly explained. This cowardice on the part of the entire governing class is largely generated by the extraordinarily effective propaganda of vested interests such as the health service unions (including the shamelessly self-serving BMA). So ubiquitous and tireless is the noisy activism of these lobbies that the views of all those ordinary people who are open to persuasion about the reform of public services never get a look-in. Note to politicians: there is a new generation of adults out there who buy their holidays and their electronic equipment on the internet, who purchase their insurance on price-comparison websites - and who do not like being told when it comes to matters of life and death that they cannot go to the hospital, or have the treatment, or see the doctor of their choice. A Left-wing newspaper last week referred piously to "night porters and nurses motivated by the ideal of a service untainted by profit." Seriously? How many real people would feel the treatment they gave or received was "tainted" because it involved profit if it also delivered genuine accountability to patients? This question of patient-power under a state-run monopoly has been around for a long time. But there are newer problems for the NHS, such as the failure to charge foreign visitors or recent immigrants who use its services that also stem from the principle on which it was founded a political and social eternity ago. A system that is absolutely, unconditionally free at the point of use with no questions asked and no exceptions made (which, in fact, prohibits users from topping up their free provision with private funds) cannot easily provide a mechanism for charging foreign visitors. The reason that most European countries have so little difficulty getting foreigners (or their governments) to pay for treatment is because they have social insurance-based health care that involves money changing hands. So foreign patients being charged, or payment being reclaimed from other European states, is a normal part of its business. Our NHS is uniquely cash-less. What would a GP's receptionist do with a credit card if it was handed over? What would a hospital do with an offer of personal payment by a visitor? Oddly, though, dentists and opticians who offer NHS treatment have no such difficulty: a point that the BMA failed to mention when it went into instant opposition to the Government's idea of charging foreigners, as if the taking of money by GPs would be somehow inhuman or sordid. In effect, our primary health care and hospital system seems so determined to eliminate any reference to the need for payment that it pretends that money does not exist - which must certainly contribute to the abuse (or over-use) of the system about which so many GPs complain, even as their union perversely opposes any form of charge on foreign visitors. Can Simon Stevens, who has just been appointed head of the NHS in England, make any difference to all this? At least he has experience of life in a place that has precisely the opposite phobia from ours: in the United States, where Mr Stevens worked for a private health company for 10 years, it is the idea of state-run health provision that provokes nightmares. So profound is the American fear of government power that Barack Obama has created a strange mongrel system in which private insurance companies offer health coverage - which individual citizens are required by federal law to purchase. It is almost unheard of in a free society to force every living individual to buy a product they may not want, under threat of a legal penalty. And a great many Americans do not want health insurance: either because they are young and healthy enough to believe they don't need it, or because they cannot afford the premiums even though they are not poor enough to qualify for government subsidy, or simply because they would rather pay-as-you-go when illness strikes. The consequence is that this looks, to many American eyes, like the loss of a basic freedom to live your own life and take responsibility for yourself. And then all the fears of inept government-run programmes were rather splendidly confirmed when the roll-out of the Obamacare website - which was supposed to allow everybody to buy health insurance as easily as they bought a book from Amazon - turned into a fiasco of comic dimensions. Even the liberal media and Left-wing comedians whose loyalty to the Obama administration is normally of North Korean proportions, went to town over the website that was blithely devouring applicants" data - if it allowed them any access at all. If lots of young, healthy people - whose participation is essential to balance the cost of the older, unhealthy ones - give up at this point and refuse to enrol, even under the threat of a fine, then Obamacare will collapse. Along with the political credibility of the administration's flagship policy will go the hapless idea of creating a health care system that combines private provision with public coercion. Over here, we wait to see whether the Coalition Government, which seems reluctant to take any more risks, has the political nerve to produce a formula for health care that meets the expectations of a 21st-century electorate.