President Billary and the liberal dilemma: Bruce Anderson wonders if Bill Clinton can hold the middle ground

THE UNITED STATES spends 14 per cent of national income on health, a proportion that has doubled since 1970, largely due to increased government spending. Yet few Americans believe that the value of the care provided has doubled: 90 per cent are dissatisfied, the highest figure in the developed world. Now an influential group has produced proposals for change which favour a 'state-based, market-driven pluralistic approach'.

The Progressive Policy Institute, the Democratic think-tank which produced the report, is not trying to create a National Health Service but a system for national health care.

The PPI had a lot of influence on Mr Clinton during his campaign and the expectation is that his health proposals will draw heavily on its work. This illustrates a crucial difference between British and American politics. In the US, some, though by no means all, Republicans will condemn Mr Clinton's proposals as tantamount to socialism. In Britain, they would be regarded - correctly - as an important step in the direction of free market radicalism.

The present system of US health care is haphazard, expensive, inefficient and corrupt. This gives President Clinton a political opportunity, for reform would be timely and popular, leaving its opponents with no persuasive arguments.

In the Lyndon Johnson/Great Society era of the Sixties, such propoals would have been described as liberal before that word became tainted. It will be a long time before Mr Clinton feels it safe to use the L-word in public, but if his presidency evolves along such lines, he will draw on a powerful American political tradition which enabled the Democrats to dominate the presidency for almost 40 years.

Americans have a paradoxical attitude to government. They think it is too big and too expensive and they distrust politicians. But they still believe that government should try to solve problems, and they still expect their president to articulate an uplifting vision of America - and if he does so, he can develop a powerful cross-partisan appeal.

Whether Mr Clinton succeeds or fails in this regard will depend on what sort of liberal he turns out to be. If he declares his intention of reducing the size of government while enhancing its efficiency; increasing taxes to cut the deficit, but also curbing spending; eliminating waste in the defence budget, while maintaining America's superpower role; bringing help to the inner-city underclass, while insisting that they work to earn that help; introducing market-based health reforms, plus a drive for higher education standards - he could have a formidable platform.

All those objectives are vastly easier in rhetoric than in reality, but not all are unattainable. In four years' time, assuming an economic recovery, Mr Clinton could be hard to beat. Republicans believe that they and history have buried Great Society liberalism. They might be in for a shock.

There is an alternative scenario. Mr Clinton might prove to be a very different kind of liberal. The new Democratic liberalism of the Seventies and Eighties owed nothing to FDR, Truman or LBJ. It was a US equivalent of Bennery and proved as destructive to the Democratic Party as Mr Benn was to the Labour Party. These were liberals who hated America, loathed its world role, despised its history and reviled its culture. Most Americans, while believing in personal freedom, also accept the privacy of the Judaeo-Christian tradition, heterosexuality and family life, Western culture and the English language. The liberals sought to subvert all four. In place of the Great Society liberals' support for civil rights and opposition to racial discrimination, the new liberals tried to restore racial discrimination through job quotas while undermining the whole concept of civil society and civil rights in favour of a Balkanised America of competing minorities.

During his campaign, Mr Clinton kept such persons at a distance, but they still have one powerful friend in Washington: Mrs Clinton. In a symbolic gesture last week, the new First Lady changed her name. During the campaign, she was happy to be Hillary Clinton; now that her husband is safe in the White House she is insisting on Hillary Rodham Clinton.

As well as this declaration of independence, she is exercising considerable influence on mid-ranking government appointments. The friends she is introducing are precisely the type of Seventies and Eighties liberal who were kept in the closet during the presidential race. Admittedly, they are taking posts in more marginal areas of the Administration, but they could still have nuisance value and help to convince ordinary Americans that this is not a presidency for them.

The Republicans are already honing their phrases. We will hear a lot about President Billary. At the first opportunity, some Republican will say that such and such could not have happened if Bill Clinton had still been president.

Mr Clinton has the personality and background to appeal to the Reagan Democrats, the blue-collar workers who deserted Jimmy Carter. His wife has the personality and background to appeal to the Barbra Streisand Democrats, who flocked to Washington last week for the inauguration festivities. On that conflict hangs the fate of the Clinton presidency. If he wants to govern America successfully, Mr Clinton will have to ensure that he remains master in his own household.

The author is political columnist of the Sunday Express.