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Given the choice, which health-care regime would you pick: the free-market U.S. system with its swift but costly - and sometimes out-of-reach - state-of-the-art treatment? Or, the state-controlled Canadian system with "free" care, equitable access and rationing that creates waits?

That question has been debated innumerable times in all manner of forums, including talk radio, medical conventions, election campaigns, academic treatises and, of course, films such as Michael Moore's Sicko.

It is hard to draw a firm conclusion from most of these discussions and diatribes because they are fraught with underlying biases - economic, political and cultural.

There is also no objective, dispassionate manner of determining which system is actually best.

In 2000, the World Health Organization rated the performance of health-care systems in 191 countries: Canada ranked 30th and the United States 37th. But you can take issue with their measurement tools.

The WHO also ranked the overall health of citizens: Canadians ranked 35th and Americans 72nd. But, again, is all (or any) of that difference due to respective health systems?

Money is an oft-used measuring stick. In 2004, U.S. per capita health spending was $6,096 (U.S.) compared with $3,038 (U.S.) in Canada, meaning that, if nothing else, Canada delivers health care a lot more cost-effectively.

Despite all the attention paid to the Canada-U.S. comparison, we rarely, if ever, hear from consumers/patients at the coal face.

That void has been filled by a fascinating paper published recently in Open Medicine by Saskatoon-based health consultant Steven Lewis and colleagues at the University of Calgary and the University of Toronto.

The assumption is that given a choice - and the financial means - patients would invariably choose the U.S. system.

But the research, which involved 310 Americans living in Canada (all for less than five years), offered a much more nuanced view.

The survey found most of the expatriates preferred the American system for emergency, specialist, hospital and diagnostic services.

However, the Canadian system was favoured over its American counterpart when it came to access to drug therapy, out-of-pocket costs and cost relative to care.

Among respondents, the U.S. system was lauded for the timeliness, availability and quality of care.

The Canadian system, for its part, was criticized for its wait times and personnel shortages, but praised for its universality of coverage and equity.

After the numbers were crunched, 74 per cent rated the U.S. system as good or excellent, compared with 50 per cent who said the Canadian system was good or excellent.

But, interestingly, the bottom line was a little different: 45 per cent of Americans in Canada said they preferred the U.S. system, while 40 per cent chose the Canadian system - a virtual tie.

Now there's a caution here: The respondents live principally in big cities such as Vancouver, Calgary and Toronto, and they are almost all highly educated, high income earners.

That means that they all had health insurance when they were living in the United States, and have supplemental private insurance in Canada.

The views of respondents might also be skewed because they are relatively young and healthy, and they have not had a lot of interaction with the health system.

About one in four has spent time in hospital or had surgery, and one in five has a family member with a chronic illness.

While this is a prosperous group, it is telling that 24 per cent said that health costs in the United States caused them financial hardship; only 5 per cent had that problem in Canada.

One-third of respondents said that, in the United States, the provision of health insurance was an important factor in their choice of job.

When considering a move to Canada, 95 per cent of respondents said that knowing there was a universal health system in Canada was a positive motivator.

At the same time, those surveyed said they had preconceived notions about the Canadian health system: 35 per cent figured it would be worse, 29 per cent expected better, and 37 per cent thought it would be about the same as the U.S. system.

In other words, those surveyed had and have reservations about both systems. While they are Americans living in Canada, their views of the health-care system are almost identical to those of Canadians.

Most intriguing of all, though, Mr. Lewis said, is that the study tells us that "people's views of the overall quality of a health-care system are not purely a function of their own experience."

Speed and quality of treatment are important, but so are universality, equity and cost-effectiveness.

In other words, people take into account more than their own experiences and needs; their questions and concerns, in Canada as in the United States, range well beyond: "What have you done for me lately?"