For sophisticated Americans who have good insurance and good income, the quality of healthcare in the United States is unsurpassed, says Prof William Lassey. "For the higher income groups, life expectancy is comparable with most of Europe. Those of us who have adequate resources for complete medical insurance can get the very best medical care in the world, a lot more of it than we need. We overuse it because it is available and because it does not cost us all that much.
"But there are actually relatively few people at the very top who have that sort of complete access to such resources. The United States has anything but the best life expectancy among modern nations of the world. It is lower than in all European countries."
This is true particularly of the Hispanic, African-American and Native American sections of the population. Among Native Americans, life expectancy is something in the order of 50 years, compared with an average for the United States of 73 years.
"There are a number of reasons. One is the high rate of poverty. People don't eat well or they don't exercise. How Americans regard their healthcare system therefore depends on who they are. But in general, the surveys indicate a high level of dissatisfaction, because our expectations are so high. The reality is not up to expectations."
Medicare, which covers older and some disabled citizens, is inadequate, he says, as every Medicare patient has to spend huge amounts on prescription drugs and other treatments that are not fully covered. "Out-of-pocket costs are unreasonably high, partly because of the cost of the drugs in the United States, which is much higher than in Canada or Mexico or most countries of Europe," says Lassey, who is an emeritus professor of health policy and administration at Washington State University and a co-author of Health Care Systems Around The World, a 1996 book.
"The drug companies are free to do as they please, and they are the most profitable business enterprises in the United States and, probably, in the world. Americans are angry at the idea that drug companies can make so much money and yet they have to suffer and feel deprived because of high costs. It is fair to say that almost everybody is dissatisfied to some degree.
"For example, my wife and I each have a sister, both divorced, and basically they are on the edge of poverty because of medical costs. They spend hours trying to figure out how to get medication. They were housewives and don't have social security or other retirement income. We are angry, because there is this personal realisation of failure; they have to have such a struggle.
"If there is one single thing that the American population thinks needs to be done, it is to provide insurance through Medicare for prescription drugs."
A retired couple with health problems might have to spend $300 a month on supplementary insurance, as Medicare does not cover a lot of things. In addition, they might have to make part payments for medication, if insurance will pay only part of the cost.
Medicaid is a programme that covers selected lower-income groups, such as single mothers and impoverished old people, but it is also often inadequate.
"There are a great many physicians who won't accept Medicaid patients, especially better-qualified physicians. The rates of payment for physicians are very low, and the schedule of compensation depends somewhat on the community. They are significantly lower than the physician will get from a private patient or from Medicare. Physicians who agree to accept Medicaid patients are very often less qualified and not able to secure a list of patients of Medicare or private patients" - although there are exceptions.
"For those who have insurance, access to American hospitals is quite easy, depending on where you are located and what particular specialisation you need to have treatment for. For example, if you want treatment from an ophthalmologist, you might have to wait for two or three months for an appointment in some locations. Physicians who have the best reputation have long waiting lists."
Specialists in the US health service are paid well, earning from $200,000 to $1 million a year, says Lassey. Family practitioners and paediatricians are much less well paid, earning between $75,000 and $100,000. "The most modern hospitals, where surgeons have the best reputation, tend to have waiting lists. In many smaller communities, where there isn't a lot of pressure, you can get in quite readily. But ordinarily, for something like a bypass operation, you might wait for two weeks to a month. The first thing you are asked in an unsubtle way is: 'What is your insurance?'
"If you don't have insurance, very often they will tell you they have a full schedule and will try to get you go someplace else. It is somewhat illegal, but it happens all the time.
"Few US physicians are willing to do expensive surgery without the patient being insured, because they might not get paid. There are emergency rooms that will accept people, but the conditions are very difficult. More and more hospitals are restricting their emergency rooms, and even closing them, because they get too many patients who can't afford to pay."
There is also an urban-rural divide. "Statistics clearly indicate that the rural population receives much less adequate healthcare than the urban population. The population has lower income on average, and the consequence is that it is difficult for physicians who train in modern medicine to practise comprehensively.
"I know of dozens of physicians who would go to rural area to serve the population, but after a few years they get very frustrated. So they move to a larger community with a higher insured population. For example, my father has resources to pay for medical care but has to travel 200 or 300 miles to get certain things done.
"Hospitals in rural areas are struggling to survive, because there is a relatively low patient load for the region they serve. They also have trouble employing nurses. The lowest-income population are most dependent on the smallest hospitals, so the quality and the general availability of services are almost universally limited in rural areas."
Some hospitals are run by local governments; others are private non-profit and a few are private for-profit. Despite federal subsidies, "hospitals disappear from a lot of remote rural areas, because they don't have enough business."
Lassey says the ambulance service in urban areas is excellent, often privately run and paid for through Medicare. In rural communities, the ambulance service is usually a public enterprise run by volunteers.
"Unfortunately, the number of people willing to do this has fallen off, so a lot of small communities have to call for an ambulance from a larger town nearby, and it often comes late. My mother died because of the slowness of the ambulance service. She had a stroke. If she had been taken care of quickly, she would have probably been fine. It was three hours or four hours before she got to the hospital, in North Dakota. You don't hear a lot of it reported in the press, but it is a daily occurrence, especially in smaller communities, where the population is paying the price for professional ambulance services."
Another big problem is a shortage of nurses. "Nurses have been leaving the profession in droves. They don't think the pay is adequate, though among other professions which are primarily female, it is relatively well paid. Working conditions are not viewed very positively; hospitals, nursing homes and home healthcare bring a lot of stress; and women have other alternatives now. Nursing schools are having a terrible time."
The greatest challenge is to get enough nurses to serve the ageing population and the population in general - a view that the Republic will ignore at great cost.