TORONTO _ For Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving to Toronto about four years ago was almost a no-brainer.
He's part of a small cohort of American doctors who, for personal or professional reasons, have moved north to practice in Canada's single-payer health care system. Now when he sees patients, he doesn't worry about whether they can afford treatment. He knows "everyone gets a basic level of care," so he focuses less on their finances and more on medical needs.
As a U.S.-trained physician and a health system researcher, he is studying what he says is still a little-understood question: How do the United States and Canada _ neighbors with vastly different health systems _ compare in terms of actual results? Does one do a better job of keeping people healthy?
For all of the political talk, in many ways it is still an open question.
"The Canadian system is not perfect. Neither is the United States'," Cram said. "Anyone who gives you a sound bite and says this system should be adopted by this country ... I think they're being almost disingenuous."
Still, American support for government-run, single-payer health care is picking up.
Sen. Bernie Sanders, I-Vt., who emphasized single-payer health care in his 2016 presidential candidacy, helped move Canada into the U.S. spotlight.
Lawmakers in California and New York have taken steps toward such programs on a statewide level, and the concept is a hot topic in campaigns for governor in Illinois and Maryland.
In addition, polling finds doctors and patients increasingly supportive, though the percentages in favor typically drop when questions are focused on the costs of such a system.
In Canada, medical insurance comes through a publicly funded plan. And, while covering everyone, Canada still spends far less on health care than the United States does: just over 10 percent of its gross domestic product, compared with 16 percent in the US.
To many American advocates, Canada's health system sounds like the answer to challenges in the US.
But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree?
"The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others," said Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.
It's an obvious disconnect, said Emily Queenan, a family doctor now practicing in rural Ontario. Queenan grew up in the United States and did her residency in Rochester, N.Y. By 2014, after about five years of frustrating battles with insurance companies over her patients' coverage, she had enough. She found herself asking: Why not Canada?
She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don't worry about affording treatment.
"We have here a shared value that we all deserve access to health care," said Queenan. "That's something I never saw in the States."
Sanders has pushed the discussion, with a "Medicare-for-All" bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture in which everyone gets top-notch care, with no worries about its cost to them.
"They have managed to provide health care to every man, woman and child without any out-of-pocket cost," Sanders said at Toronto General Hospital. "People come to a facility like this, which is one of the outstanding hospitals in Canada. They undergo a complicated heart surgery, and they leave without paying a nickel."
It sounds idyllic. But the reality is more complicated.
While progressives say the Canadian system provides universal health care efficiently, the Commonwealth Fund, a nonprofit research group, puts it just two spots above the United States _ which ranks last _ in its health system assessment. It suggests that in timeliness, health outcomes and equitable access to care, Canada still has much to improve.
"If you deny there are trade-offs, I think you're living in wonderland," Cram said.
Under Canada's system, provinces use federal guidelines to decide what's covered, and there's no cost-sharing with patients.
"Come to our waiting room," said Tara Kiran, a family doctor at St. Michael's Hospital in Toronto. "You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don't."
But that insurance _ which accounts for 70 percent of health spending in Canada _ applies only to hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren't covered. Most Canadians get private insurance to cover those.
In countries such as Britain or Germany people can opt out of government health insurance to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift.
In the US, the debate focuses more on bringing down health spending _ a concern in the United States, too, but one often overtaken by politics.
Canadian provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada's single-payer system is supported by a combination of federal and provincial money, raised mostly from personal and corporate income taxes. (A few provinces charge premiums, which are income-based and collected with taxes.)
Taxes in Canada are generally higher than in the United States. Canada, for example, collects a levy on goods and services and taxes wealthier citizens at a higher rate.
But many in Canada here call that a concession worth making.
