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 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.

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 some of Dominica's leaders were as committed to achieving their goals as Obama is.

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 claims. Not a single Republican voted for the measure in the House. Passed by the Senate, the Bill will eventually extend coverage to 32 million uninsured Americans and ban such insurance company practices as denying coverage to people with pre-existing medical problems.

Most Americans will, for the first time, be required to carry health insurance — through an employer, a government programme or by buying it for themselves. Those who refuse will face penalties from the Internal Revenue Service. Tax credits to help pay for premiums also will start flowing to middle-class working families with incomes up to $88,000 a year, and Medicaid will be expanded to cover more low-income people.

We say all this to illustrate the fact that the Dominica Labour Party Government of Roosevelt Skerrit, like Obama, promised, in their 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, after ten years in office, because Dominicans are now no closer to attaining national health insurance. Mr. Skerrit's party apparently believes that that goal is unattainable and, unlike President Obama's US, we seem to be a nation that scales back its aspirations or takes the easy way out. We have also noted that Mr Skerrit has given up completely because there was absolutely no mention of universal health insurance in the DLP 2009 manifesto and significantly, no one is talking about that anymore. In fact, the Dominica Public Service Union recently received some concessions from Government, during the salary increase negotiations, for its own health scheme.

Nevertheless, the rising cost of health-care, the increasing prevalence of non-communicable diseases such as diabetes and hypertension, and changes in the structure of the population will undoubtedly force government to consider alternative and sustainable ways of funding health care. We have been warned. An International Monetary Fund (IMF) working paper titled "Universal Health Care 101: Lessons for the Eastern Caribbean and Beyond" suggests that " health care plans should be part of the government's medium and long- term strategy and health plan's cost should be incorporated into the medium-term expenditure framework, so as to ensure the current and future financial viability". The IMF paper 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.

What about increasing taxes? Which callous government will risk the rage of the public by imposing new taxes on an already severely over taxed population? 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 of an ageing population.

It seems obvious, therefore, that small, resource-poor countries like Dominica, operating individually, will find it difficult to offer comprehensive universal health care to its people or to implement a system similar to the one that the United States has just begun. Hence, it is reasonable to suggest that these islands must pool their resources to create an OECS health insurance scheme. Some analysts have added that the proposed scheme would be more viable if it incorporated the more developed islands of the Caribbean, such as Trinidad and Tobago and Jamaica.

"I wonder if," wrote Caribbean journalist Ricky Singh in the Nation Newspaper, "with humility, Caribbean Community leaders could summon some of that "Obama-like spirit" in the interest of advancing the major goals of CARICOM". We share Singh's sentiments and hope that our leaders would, like Obama, refuse to scale back their aspirations on universal health insurance, or succumb to the intimidation of the private sector on that matter.