One of the major successes of United States President Barack Obama's first term was the implementation of the historic $938 billion health care overhaul that guaranteed health coverage for 32 million uninsured Americans. The programme was expected to touch the lives of nearly every American citizen. Because of his persistence and obstinacy, Obama presided over the biggest shift in U.S. domestic policy since the 1960s. This was a huge success although there were major difficulties with the operation of the programme.

Boasting about his achievement Obama said: "We are not a nation that scales back its aspirations. We are not a nation that falls prey to doubt or mistrust. We don't fall prey to fear. We are not a nation that does what's easy. That's not who we are. That's not how we got here."

We sometimes wish Dominica's leaders were as committed to achieving their goals, especially a health insurance scheme that works effectively.

But back in Washington, Republicans remain firm in their opposition to this giant remake of the US's health system, declaring it much too costly and unlikely to produce the results that Obama claimed. Not a single Republican voted for the measure in the House. Passed by the Senate, the Bill eventually extended coverage to 32 million uninsured Americans and banned such insurance company practices as denying coverage to people with pre-existing medical problems.

Most Americans, for the first time, are required to carry health insurance — through an employer, a government programme or by buying it for themselves. Those who refuse face penalties from the Internal Revenue Service.

We say all this above to illustrate the fact that the Dominica Labour Party Government of Prime Minister Roosevelt Skerrit promised, in its 2005 Manifesto (at page 24), "to establish a National Health Insurance System to provide health insurance and coverage to the public."

Obviously, the government failed to satisfy that promise because Dominicans in 2015 are no closer to attaining comprehensive national health insurance than they were in 2005.

The Government apparently believed then that that goal of a national health insurance scheme was attainable but unlike President Obama's United States of America, we are a nation that, unfortunately, scales back its aspirations and takes the easy way out.

We have also noted that the DLP has not given up the idea of establishing a national health insurance system although that promise was not included in the DLP 2009 manifesto. However, it reappeared in 2014 where the party promised to "design and introduce a form of National Health Insurance in collaboration with PAHO."

In July 2014 with a PAHO-supported national consultation on universal health coverage, Government took a step closer towards the establishment of the Insurance Scheme. And Health Minister Dr. Kenneth Darroux has stated that the proposal is on his "to do" list.

We are of the view that the establishment of "a form" (to borrow the DLP's words) of national health insurance is absolutely vital and extremely urgent. We urge Government to avoid the temptation of using the proposed health insurance scheme as a vote-catching tool and thus implement the system a few months before the next general election in 2020. That would be devastating to the very poor because these people are dying in increasingly large numbers because basic health care services is too expensive.

Other factors such as the increasing prevalence of non-communicable diseases and changes in the structure of the population must force government to consider alternative and sustainable ways of funding health care.

An International Monetary Fund (IMF) working paper titled "Universal Health Care 101: Lessons for the Eastern Caribbean and Beyond" recommends two ways of financing universal health care. The first is general taxation and the second is mandatory payroll/social security contributions. Reliance on external funding is definitely not an option, the paper argues, because that level of funding has disappeared and the sustainability of any health system cannot be based on the generosity of donors. In other words, Dominicans should not expect either Venezuela or China or Morocco to fund our universal health care system. We have to it all on our own.

Using social security contributions is a more palatable option but officials of the Dominica Social Security will probably argue that since almost forty percent of the population is unemployed, the additional burden of health care should not be placed on the shoulders of the few persons who pay social security contributions. In any case, the DSS is currently struggling to remain viable in the face of mass migration of the productive labour force and the draining impact on DSS resources by an ageing population.

It seems obvious, therefore, that small, resource-poor countries like Dominica, operating individually, will find it difficult to sustain any comprehensive universal health care programme or implement a system similar to the one that the United States begun under Obama.

Hence, we suggest that these islands must pool their resources to create an OECS health insurance scheme. Some analysts have suggested that any sustainable scheme must incorporated the more populous islands of the Caribbean including Trinidad and Tobago, Jamaica and Guyana. Can CARICOM achieve this?

"I wonder if," wrote Caribbean journalist Ricky Singh in the Nation Newspaper some time ago, "with humility, Caribbean Community leaders could summon some of that "Obama-like spirit" in the interest of advancing the major goals of the people of the region. Like Obama, on the issue of national and regional health insurance we must refuse to scale back, fall prey to fear and procrastination because, to quote the DLP manifesto, "the health of the nation is the wealth of the nation".