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The president's in the House of Representatives is understandable. It suggests the endgame is on.

But it is not going to become law as it stands. It doesn't stand a prayer of passing in the Senate. Joe Lieberman, who is an independent with a habit of flirting with both parties, to prevent anything with a public option getting through.

To British eyes, this focus on the public option seems a little odd. It would just mean one government-run - but not government-funded - insurance scheme among many others. Some Republicans fear it is the thin end of the wedge and would lead, horror of horrors, to something like our National Health Service.

Of course to many of us Brits, the cry "keep government out of health care" just sounds a little kooky, on a par with "keep government out of defending the nation" or "keep government out of building roads". In Britain one of the main things the government does, one of the main reason people pay taxes, is for health care, so naturally the revulsion at it in the States seems a little strange.

In the USA, people fear this would lead to rationing of health care, which is how came about over the summer. Someone who wrote in to my last post on healthcare pointed that taxpayer-funded healthcare gives governments the excuse they wanted to pontificate about smoking or drinking. This is true, although government here does pretty well on the pontification and restriction front without what is called "socialised medicine".

But I think in the debate between all the different systems of health care one vital point is missed. Whether they are left, right or centre, they are becoming unsustainably expensive. It is after all the cost of the American system that leads many to conclude it needs radical overhaul.

At the debate's heart are two points. The number of people who don't have insurance, because they can't or don't want afford it. And the industry's reluctance to pay out for those with serious conditions. Private or public, it is a scarce resource, and that is what leads to rationing.

Some years ago, a UK government-sponsored report into the NHS said that it was a potential 'black hole" for spending. This is the depressing truth, born of amazing advances in medicine. People in the West live to have very expensive treatment for cancer and heart disease because they no longer routinely die of measles or TB. The longer we live, the more we need to spend on medical treatment. I don't see how any commercial or political fix can deal with this hard fact.

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