we had some small discussion group about De Tocqueville, and someone (naturally) brought up France's high taxes and thick welfare state. "Well, the thing is," Emmanuelle said (quotes are inexact), "some of the things the French state provides are pretty good. For instance health care."

"Wait a minute wait a minute," one guy said. "If you were sick ? I mean, really sick ? where would you rather be? France or the U.S.?"

"Um, France," we both said.

Various sputtering ensued. What about the terrible waiting lists? (There really aren't any.) The shoddy quality? (It's actually quite good.) Finally, to deflect the conversation away, I said "Look, if we made twice as much money, we'd probably prefer American health care for a severe crisis. But we don't, so we don't."

Hell, I make more money than Matt and if I were really sick I'd rather be in France too. I've read quite a bit about France's healthcare system and it's effin great. To put it in a nutshell, you can pick any doctor you want, the quality of care is high, the doctors themselves seem pretty happy with the way it works, and the overall cost per person is half what the American system costs. Plus it covers everyone in the country, not just 70% of them.

But all you hear about in America is that you might have to wait six months for hip replacement surgery. And indeed you might. But that's because hip replacement surgery is usually pretty low priority stuff. On the other hand, if what you need is either routine medical care or else urgent treatment for something like a heart attack ? that is, the stuff that makes up 99% of actual real life medical care ? France is great.

I've long thought that the specter of "socialized medicine" is the greatest con ever perpetrated on the American public. Think about it. Suppose you were constructing a healthcare system from scratch. Choice #1 is national healthcare along the lines of France or Sweden. (Not Britain. Their system kind of sucks.)

Choice #2 is this: if you're employed, your employer might provide you with healthcare coverage of some kind. Anytime you change employers or your employer changes plans, your coverage and your doctor will change too. If you're unemployed, or you work for Wal-Mart, you get nothing ? though in a pinch you can always show up at an emergency room, which is perhaps the most expensive way of delivering healthcare known to man. If you're poor, there's a shabby government program that will sort of cover your kids, but probably not you. If you're over 65, another government program will cover some but not all of your medical expenses. And all of this will cost us about 14% of GDP, far more than any other industrialized country on the planet.

That's insane. No one would design a healthcare system like that. But that's what we have, thanks mostly to a weird set of coincidences and political compromises made around the time of World War II.

And who benefits from it? Citizens? Probably 95% of us would be better off with France's system than with ours. Businesses? Why should they be saddled with the cost and hassle of providing healthcare? Doctors? Maybe a bit, but an awful lot of them would probably be better off in France too. Insurance carriers and pharmaceutical companies? Bingo.

The whole thing is crazy. Over the years we've jury rigged a bizarre system that Rube Goldberg would be ashamed of, but somehow we're convinced that America has the best healthcare in the world. But the plain fact is that we don't. For a tiny percentage of us, medical care here is better than in France. For the vast, vast majority, France's system is superior to ours in practically every respect.

But ? quelle horror! ? that would be socialized medicine. And you might have to wait six months for hip replacement surgery. Probably best just to stick with what we have. After all, the insurance industry wouldn't lie to us, would they?

Interesting. We did have this exact conversation. It's hard to know what is real and what is not.

For example, not long ago in preparing for our upcoming trip to Provence I read Peter Mayle's "Toujours Provence" which, as you probably know and have read, is his wonderfully entertaining slice of life accounts of his experience there. One of the chapters talked about healthcare in Provence and pointed out that it was indeed very bureaucratic and perhaps hit and miss for what you may really have (in terms of diagnosis). Follow up and follow through seemed atrocious and direction from the doctor was fuzzy at best. He didn't directly slam it but his story didn't put it in a glowing light. Ah but that was Mayle's experience.

Mais peut-etre plus de la difference a Paris, n'est-ce pas? Dans la grande ville du pays? C'est meilleur, sans doute.

I live in a rural area around 8km from the nearest village, 12km from a big village and over 20km from the nearest town.

I was cycling home when a dog collided with my bike. The animal was unhurt but I fell off, but only seemed to be in some discomfort at that point. During the night, however, the pain became excruciating so in the morning I phoned my generaliste (GP) in the big village and fixed an appointment for that afternoon when my neighbour could drive me in.

I arrived 15 minutes early and was seen almost immediately. The GP telephoned the X-ray unit 3km away and explained the condition. I was told to come straightaway. I waited about 10 minutes to be x-rayed, then a further 15 minutes while the X-rays were being studied. The radiologist then explained that I had a fracture and a cracked rib. I was told to take the X-rays back to my GP immediately.

The GP studied the X-rays and decided that I should see an orthopaedic specialist. He telephoned the specialist (in the nearest big town) and I was given an appointment for the following morning. In the meantime I was prescribed painkillers, which came from the next-door pharmacy. I would at least sleep that night.

The following day I waited only a few minutes before being seen by the orthopaedic specialist, who decided that my current strapping was insufficient and my wrist and lower arm needed to be put in plaster, which he did. I should return in four weeks' time.

Total out of pocket cost in this case, which was higher than normal because this guy has an expensive GP, was about a hundred bucks.

That socialized medicine stuff is hell, isn't it?

To me, though, the priceless fact of UK healthcare is this: I pay for it when I can pay, and I get it when I need it. What that means is that, yes, when I'm getting a paycheck, money comes out whether I'm sick or not, but when I'm ill, I get healthcare whether I have money to fork-over or not. I don't feel that money coming out of my paycheck, but believe me, as someone who grew up in the US, I am acutely aware of the fact that when I'm thinking about seeking medical care or advice, I know with a certainty that the price is not an issue.

When I was getting ready for my eye surgery, I didn't forget that even some people I know who have health insurance in the US would have had to write-off their eye if they'd been in my situation because the cost of surgery, two nights in the hospital, and after-care might not all be covered and what they still would have had to produce out-of-pocket would have broken them. Someone with no insurance wouldn't even have been able to consider it. (And that's leaving aside the four weeks I spent house-bound while I kept my head in the necessary position to make sure the procedure works. Would your employer give that to you?)

I get the care I need when I need it, and so far it's been good care. I never have to think about whether I can afford it. Like I say, priceless.

And keep in mind that this is Britain, which is generally thought to have one of the worst national healthcare systems in Europe.

It's funny, isn't it? Conservatives keep telling us how bad healthcare is in the socialist hells of Europe and Canada, and yet the people who actually live in Europe and Canada mostly like their healthcare just fine. In fact, they like it better than most Americans like American healthcare (see Exhibit 1 in this report). They pay less for it than we do, too (see Figure 1 in this report).

Marc Danziger may think that "If I had a chronic or serious disease, and insurance, I'd rather be here," but I can't figure out why. After all, Europeans seem to get pretty good treatment for chronic and serious diseases, even compared to well insured Americans. I'm afraid the alleged advantages of America's healthcare system continue to evade me.

? let me deal with the usual problem one encounters when trying to draw lessons from foreign experience: somebody is sure to bring up the supposed horrors of Britain's government-run system, which historically had long waiting lists for elective surgery.

In fact, Britain's system isn't as bad as its reputation - especially for lower-paid workers, whose counterparts in the United States often have no health insurance at all. And the waiting lists have gotten shorter.

But in any case, Britain isn't the country we want to look at, because its health care system is run on the cheap, with total spending per person only 40 percent as high as ours.

The countries that have something to teach us are the nations that don't pinch pennies to the same extent - like France, Germany or Canada - but still spend far less than we do. (Yes, Canada also has waiting lists, but they're much shorter than Britain's - and Canadians overwhelmingly prefer their system to ours. France and Germany don't have a waiting list problem.)

In 2002, the latest year for which comparable data are available, the United States spent $5,267 on health care for each man, woman and child in the population. Of this, $2,364, or 45 percent, was government spending, mainly on Medicare and Medicaid. Canada spent $2,931 per person, of which $2,048 came from the government. France spent $2,736 per person, of which $2,080 was government spending.

Amazing, isn't it? U.S. health care is so expensive that our government spends more on health care than the governments of other advanced countries, even though the private sector pays a far higher share of the bills than anywhere else.

Most Americans probably don't know that we have substantially lower life-expectancy and higher infant-mortality figures than other advanced countries. It would be wrong to jump to the conclusion that this poor performance is entirely the result of a defective health care system; social factors, notably America's high poverty rate, surely play a role. Still, it seems puzzling that we spend so much, with so little return.

? the United States scores high on high-tech services - we have lots of M.R.I.'s - but on more prosaic measures, like the number of doctors' visits and number of days spent in hospitals, America is only average, or even below average. There's also direct evidence that identical procedures cost far more in the U.S. than in other advanced countries.

? Americans spend far more on health care than their counterparts abroad - but they don't actually receive more care.

1. Reporters just don't know all that much. Let's face it, covering health care issues is awfully hard?it's a complex topic!?and not many reporters do it well, even when they're writing about issues here in the United States. You pretty much have to devote yourself full-time to the subject, as, say, Robert Pear of the New York Times has. And that's just to learn the U.S. system... Not surprisingly, reporters have an especially shallow grasp of health care programs in other countries, so the coverage tends to degenerate, more than usual, into "he said, she said" affairs. In fact, I'd have to do a Nexis search, but I'd wager that it's usually not a paper's resident health expert doing stories on single-payer in, say, France or Canada. It's probably an international reporter who has a million other beats and no time to learn all the gritty details of this or that system.

2. Anecdotes count for more than statistics. This is something of an off-spurt of #1, but also a problem with the media in general, and it's especially detrimental to health care coverage. Reporters lo-o-o-ove covering the poor grandma who waits months for a hip replacement?it's a human interest story! Or those long lines for surgery. Yeesh! But here's the thing: These stories say nothing at all about health care. Everyone has a story: For every grandma waiting for a hip replacement in France, there's an uninsured American who has to pay $95 for a doctor visit to make sure she doesn't have strep throat. Cold, hard, bloodless statistics are all that really matter here, but news coverage of health care in other countries tends either to skimp on statistics or bury them in favor of the attention-grabbing anecdote.

3. Health care professionals in single-payer systems have reasons for drumming up "crisis" rhetoric. This is something that doesn't get noticed very often. For instance, in a national health care system like Canada's, every year the government has to set a budget for hospitals, limit how much doctors can charge, etc. It's a big debate, and to gain leverage, doctors of course love to talk about how there are shortages and people can't get necessary treatments and so on and so forth. Naturally, their complaints get picked up by the Canadian media and trickle on into American papers. But no one stops to think that these health care professionals are all self-interested actors who have their own reasons for playing up the system's faults.

The England Problem. For linguistic and other reasons, the European country Americans are most cognizant of is the United Kingdom which happens to have a health care system (the NHS) which goes very far in the opposite direction from the U.S. system in terms of command-and-control health care and which, consequently, offers a very exaggerated version of the downsides of government-run health care.

The France Problem. While the NHS model actually has a certain appeal to me (leave that for another day), it's something that utterly lacks political appeal in the USA and isn't a realistic model for any American reforms. The most likely candidate for something we would want to imitate is France. Unfortunately for the cause of American health care reform, France and the United States have a long-term history of cultural antagonism that makes "we should do it more like they do in France" a public policy kiss of death. Worse, most people are aware that the French economy does not perform in a manner many Americans would want to imitate. People tend not to peer too closely at what it is about the French model that leads to those results, and instead the whole thing gets tarred as bad. But nothing about adopting a French-style health care system would require us to adopt French-style labor rules, French-style housing projects, French-style approaches to cultural diversity, French-style dirigisme, etc., etc., etc. Perhaps most crucially, it wouldn't force us to adopt French-style tax rates.

The Canada Problem. The US-Canada health care dynamic is asymmetrical, because wealthy Canadians can travel to the United States to take advantage of the aspects of our system that work better (for relatively prosperous people) than does their system, while working- and middle-class Americans can't go to Canada to take advantage of the aspects of their system that work better than ours. The result is that you have lots of anecdotal evidence of people fleeing Canadian waiting lists to get their hips fixed in the USA, but no anecdotal evidence of people taking their kids to Canada to get affordable, high-quality preventative care for their kids. In the limited domain of pharmaceuticals, this has changed and Americans now can (and do) go to Canada to get cheap drugs. Not coincidentally, I think, this is the area in which you have the most public support for left-wing solutions.

Cost Underestimation. Apropos of the French-style taxes, it seems natural to assume that governments which provide health care for all their citizens are spending more than are government which provide health care to only some citizens. It's natural to assume, but it isn't true. Reporting on the actual composition of federal spending is always dismal, which leads people to grossly underestimate the extent to which your tax dollars are already going to pay for health care, since Medicare is a universal coverage program for the segment of the population that is by far the most expensive to treat.

Hidden Costs. On the private-sector end, few people understand exactly how much is being spent on health care. This is because the employer side of insurance premiums is hidden from the view of all but payroll people and policy wonks. Additionally, the scale of tax subsidies provided to the health care industry is basically unknown to all beyond the elite.

Bipartisanship as Fairness. Perhaps the biggest problem is simply that since single-payer isn't the official view of the Democratic Party. One problem with "he said, she said" writing is that if he is lying, he gets to get away with it. Perhaps a bigger problem is that if he and she agree that we shouldn't do X, it winds up going without saying that X is, in fact, a terrible idea. If a major political official started insisting that France had a great health care system, you might be able to browbeat the press into acknowledging that he was right. But until someone does it, it will simply continue to be taken for granted that it must not be.

Rich Journalists. Last but by no means least, one must point out the obvious. If you're well-off and seriously ill, the American system probably is the best in the world. Even if you are wealthy, you might never have gotten so seriously ill if you'd been living in a country with proper health care, but once you are seriously ill, the USA is the place to be. Journalism is dominated by relatively prosperous people, and perceptions of the health care system are dominated by people who have a great deal of experience with it, which is to say people who have been seriously ill who who've had close family members fall seriously ill. The things the American system is really, really bad at tend to be hidden from view.

Rotting teeth are a consistent motif among their interviewees, and with a poignancy not often found in policy books, the authors peg tooth decay as a reliable barometer of one's employability and caste status. As one uninsured woman who works part-time in a call center (and therefore out of public view), tells them: "I've gotten toothaches so bad, so that I just literally pull my own teeth. They'll break off after a while, and then you just grab ahold of them, and they work their way out ... The hole closes itself up anyway." As the insured reader guiltily and involuntarily runs his tongue over his teeth upon reading these lines, the authors' caste argument essentially proves itself.

And there's plenty more where that came from, as the authors present through their subjects a laundry list of ominous examples of untreated suffering, ranging from gallbladder disease to diabetes to asthma, addressed alternately by hopeful neglect and homemade cocktails of alcohol and over-the-counter pain medication ? or in the harrowing case of an Idaho man with recurring bone spurs in his feet, a power sander.