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It only took a disparaging tweet from U.S. President Donald Trump for Britons to unite behind the universal health-care system that they have spent recent months, well, disparaging. While almost everyone agrees the National Health Service is in crisis, even its critics still call it the best system in the world.

For all its budget cuts, extenuated nurses, rising wait times and "black alerts" – capacity-strained hospitals warning patients to go elsewhere – the NHS consistently outperforms other developed-country health-care systems in international rankings. The U.S.-based Commonwealth Fund's benchmark survey of doctors, patients and the overall public in 11 rich countries ranks the NHS at the top of the pack. The U.S. system comes in last. Canada is No. 9.

And yet, the NHS is struggling. Thousands marched in London on the weekend to call for more government funding for a public health-care system that has been reeling from years of cuts imposed by austerity-inclined politicians. While the NHS might win praise for its accessibility and quality of care, it has confronted the same problems of sustainability as other Western health-care systems as it faces the demands of an aging population and the wrath of tapped-out taxpayers.

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The U.S. President, responding to calls from Vermont Senator Bernie Sanders and others for the creation of an NHS-like system in his country, could not resist the bait. "The Democrats are pushing for Universal Health Care while thousands are marching in the U.K. because their U system is going broke and not working. Dems want to greatly raise taxes for really bad and non-personal medical care. No thanks!" Mr. Trump tweeted earlier this week.

The take-away here for Canadians is that our own "semi-universal" health-care system is so fraught with problems that progressive Americans no longer see it as a reference – the NHS is their model. Yet the NHS's difficulties show that even the very best publicly funded health-care systems are not immune from disease. Born in the postwar era of abundance, they have not aged well. Many have become too frail to cope with an onslaught of rickety baby boomers.

While Canada's No. 9 ranking on the 2017 Commonwealth Fund survey was better than our 10th-place showing in 2014, this "improvement" was relative. France's mixed public-private system, it turns out, has declined even faster than our own mixed system, in which Canadians rely on private insurance for dental and drug coverage that the public system doesn't provide.

What's more, such national rankings obscure the increasingly gaping disparities in the accessibility, quality and efficiency of care across the country as wealthier provinces such as Alberta, British Columbia and Ontario pull ahead of Quebec and Atlantic Canada.

This is the portrait that emerges from a new C.D. Howe Institute study that draws on provincial data that was aggregated by the Commonwealth Fund to arrive at an overall ranking for Canada. While no provincial health-care system attains NHS-level scores, some do a better job than others. Quebec's saving grace is its public drug-insurance program. Otherwise, it appears to be up against the same odds as Atlantic Canada as its population ages faster than its economy grows. Quebec also gets flagged for especially poor co-ordination between specialists and primary-care doctors.

The C.D. Howe study concludes that even if "all provinces were to achieve the top level on wait times, in addition to improving drug and dental access, that would propel only B.C. and Alberta into the middle tier of [international] performers. The same gains would move Ontario, Quebec and Saskatchewan to the international average, but still leave [other provinces] far behind."

The think tank argues that Ottawa should pay the Commonwealth Fund to conduct more interprovincial analysis on its behalf, suggesting that "cross-province results could further enable best-practice identification." But there is only so much provinces can learn from one another. Canada's provincial health-care systems operate in such dramatically different political, economic, demographic and social environments that imitation is rarely possible.

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Universal health-care or not, Canada appears destined to follow the U.S. trajectory where the accessibility, quality and timeliness of the care you receive depends not just on your income, but where you live as wealthier states and provinces provide more comprehensive care.

Growing gaps in drug and dental coverage, especially for working-class Canadians with no or inadequate employer benefits, means more lower-income Canadians will skip trips to the dentist or won't fill prescriptions. Wealth gaps among the provinces means Canadians in some regions will have access to better and more timely care than those in other parts of the country.

We can only wish we had the NHS's problems.

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