Healthcare in the United States is a commodity rather than a social service. It is up to individuals to ensure they receive healthcare, in an environment in which social solidarity plays second fiddle to economic forces. One in five Americans are underinsured or have no health insurance. Without it, access to healthcare is severely curtailed. Yet with healthcare spending of $4,356 per person in 1999 - a massive 13 per cent of GDP - some citizens must be benefiting.
The US system is probably the world's most multitiered, according to Dr Kevin Gorey of the University of Windsor, in Canada. There are at least 10 levels of care available, depending on age, income and the level of insurance an individual can afford or his employer will provide. There are regional differences that further complicate the delivery of care. Areas with public and teaching hospitals can better serve the poor than districts that are less well resourced. Yet this patchwork of healthcare programmes serves millions of Americans well. What does it do best?
The excellence of US emergency-room medicine is not just a figment of an ER scriptwriter's imagination. There is probably no better place to suffer major trauma - whether in the form of a road traffic accident or gunshot wounds - in terms of the likelihood of surviving.
For those with adequate insurance, well-developed preventive medicine is also a feature of the US system. Mammography is encouraged and breast-screening programmes are well developed. This is reflected in cancer-survival rates, which are two to 10 times greater for those who are well insured.
It is interesting to compare outcomes in the US with those in Canada. In one study, residents of relatively poor neighbourhoods in Toronto survived breast and other cancers for longer periods than people of similar economic status in Detroit. This is a strong indication that the more egalitarian Canadian system produces better outcomes.
But for those who can afford it, there is ample evidence that cancer care in the US is the best in the world. One of the main reasons for this is the amount of money that the federal government pours into cancer research.
According to Dr Jeffrey Abrams of the National Cancer Institute, cancer research is now part of everyday clinical practice. The institute has set up a national forum to identify new research opportunities as gaps emerge in existing research. These are then fast-tracked, so the delay in moving from concept to practice has been significantly reduced.
Ultimately, the new system makes more treatments available more quickly, as well as broadening the number of citizens with access to the latest developments in cancer care. Already, patients can get more detailed information on cancer trials and a list of physicians registered for each clinical trial. The aim is to make it easier for patients to choose the latest treatment options and to avail of experimental drug regimes.
It is a new dimension in accessibility for patients. You can ring or e-mail a specialist team, for example, tell them you have just been diagnosed with prostate cancer and ask to be part of their research and treatment programme.
The US is second to none when it comes to the treatment of life-threatening conditions such as heart disease, cancer and major trauma. Its primary-care system is not as good as that available in other Western countries. From a patient's perspective, the system is fragmented, unfriendly and unstable.
But it is true to the American dream: those who wish to work hard and earn a good living will be able to afford the best healthcare. If you are unconcerned by fairness, and life has been good to you, then the US has probably the best health system in the world.