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Gary Younge
Obama is losing the health debate – but he can still mobilise and win

A 1,000 demonstrators gathered at North Carolina's capitol on Saturday to support Barack Obama's proposals for universal healthcare. In one of four rallies across the state, some carried placards stating: "If it's broke, fix it", and "Insurance profits bad for my health", while ironic "Billionaires against healthcare" strode the grounds in top hats, carrying fat cigars and glasses of champagne as they mocked their enemy. Across the street stood 50 counter-protesters with signs saying "Socialism is an Obamanation", and "Revolution is brewing: 2010", and "Not ready for Obama's communist America".

In between stood a statue of Confederate general Zebulon B Vance with the inscription: "If there be a people on Earth given to sober second thought [and] amenable to reason … it is the people of North Carolina." Given the fistfight that broke out at a local town hall meeting on healthcare recently that is, at best, debatable.

With Congress about to return to work, the struggle for healthcare reform reaching its most crucial and intense phase. Opportunities for a Democratic president to overhaul the system while his party has commanding controls both houses of Congress come around once in a generation – if that. Yet over the last few months the momentum has been slipping away. According to an ABC/Washington Post poll shortly before summer 53% of Americans approved of how Barack Obama was handling healthcare reform, against 39% who did not. Today 50% disapprove and only 46% back him. To get through Congress any bill will inevitably contain compromises. The issue is who will need to be placated and what will have to be surrendered.

Faulkner Fox, an organiser for Durham4Obama, knew there would be times like this. From the moment she started campaigning for Obama during the primaries she has provided unstinting but never uncritical support. After Obama took North Carolina by a hair's breadth in November – the first Democrat to do so since Jimmy Carter – she demanded that the campaign leave its data so the local group could continue organising.

In January, before the inauguration, she called a meeting to talk about what they should do next. She expected around 40; more than three times that number showed up. "We had brought together this very diverse brilliant group of people and it was clear to me that this should not stop on 4 November. We could not let those people go back into the woodwork. We had to keep going. We never thought Obama would do all the things we wanted to do and we always knew that we would have to pressure him to get some things done. That's how politics works."

When trade unionist and civil rights leader A Philip Randolph demanded that Franklin Roosevelt integrate the military, Roosevelt responded: "I agree with you. I want to do it. Now make me do it." Here they are, making him do it.

They formed working groups and started organising. Michael Pearlmutter, who co-chairs the healthcare committee, provides a daily digest of the day's healthcare stories. One of their principal targets is their senator, Kay Hagan, who swept in on Obama's coat-tails but has since dragged her feet on all the major votes. A moderate Democrat in a conservative state, she is anxious to find ways to cover her right flank. Ask the pro-healthcare demonstrators at the capitol how they think she will vote and they shrug. But Faulkner, Pearlmutter and their fellow activists have given her little wriggle room.

"We flood her voicemail," says Fox "We visit her, email and get people to write her letters. She always knows we're here. She does the right thing in the end. But we have to make her." Currently in the middle of a 30 events in 30 days spurt of activity, last week 75 people showed up to learn about campaigning, including how to peacefully deal with rightwing hecklers.

That is no minor feat. Central to derailing Obama's reforms has been the high-profile disruption of town hall meetings by conservatives alleging, among other things, that universal healthcare would create death panels that could kill your grandmother. Small in number but well organised, they captured the attention of the media. It is the silly season, and a lot of these people are quite silly. Like the "birthers", who insist that Obama was not born in America, most of their claims are not only demonstrably false but downright daft. They have argued that if Steven Hawking were British he would be dead, even though Hawking is British and alive. They insist that under the NHS the state decides whether to "pull the plug on grandma".

But life expectancy in the UK is higher than the US, meaning that even with our supposed state-sponsored euthanasia our grannies still live longer than theirs. In a blend of the comic and the tragic one protester, who was hospitalised after he got into a fight at a town hall meeting in St Louis, had to have a whip-round to pay for his medical bill – it turns out he had no health insurance.

There are legitimate arguments, both philosophical and economic, against the proposed reforms. Antipathy towards government runs deep here, and the national debt was last week forecast to reach $9tn. But that would be a case for different kinds of overhaul – not none.

Sooner or later something will have to be done about American healthcare. As a percentage of GDP the US spends twice as much on it as the UK, and yet one in six aren't even covered. According to government figures, life expectancy for women is lower than in Albania and infant mortality is higher than Cuba. This national disgrace conceals a regional outrage. Black infant mortality in Louisiana is on a par with Sri Lanka; in the very city where the reforms will be decided, Washington DC, life expectancy is lower than the Gaza Strip.

The rightwing protesters are ridiculous, but that does not prevent them from being effective. "It's much easier to turn up at a meeting and yell," says Pearlmutter, "than to propose something that works. Healthcare is complicated. Even within our own working group there are many different positions."

The fact that the right has diminished Obama's chances does not mean they have boosted their own. An NBC poll shows that while only 41% support Obama's proposals, 62% disapprove of the way the Republicans are handling it.

But those who complain that the right's intervention has been the work of co-ordinated activists rather than spontaneous individuals miss the point. The problem is not that the right were organised but that – with a few exceptions like Durham – the left has not been. At the very moment when he needed the "movement" that got him elected most, it appears to have largely stopped moving.

The bad news is there are all too few places like Durham. The good news is there is still time. A significant part of the country is desperate to be convinced and the battle for public opinion – which will ultimately determine how wavering congressmen vote – is finely balanced. "We're not going to out-yell them," says Fox. "So we have to out-organise them."

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