The health-care debate: How do you like "socialized" firefighting?

Here's a paradox.

Health care reform may be defeated this year in part because so many Americans believe the government can't do anything right and fear that a doctor will come to resemble an IRS agent with a scalpel. Yet the part of America's health-care system that consumers like best is the government-run part.

Fifty-six to 60 percent of people in government-run Medicare rate it a 9 or 10 on a 10-point scale. In contrast, only 40 percent of those enrolled in private insurance rank their plans that high.

Multiple surveys back that up. For example, 68 percent of those in Medicare feel that their own interests are the priority, compared with only 48 percent of those enrolled in private insurance.

In truth, despite the deeply ingrained American conviction that government is bumbling when it is not evil, government intervention has been a step up in some areas from the private sector.

Until the mid-19th century, firefighting was left mostly to a mishmash of volunteer crews and private fire-insurance companies. In New York City, according to accounts in The New York Times in the 1850s and 1860s, firefighting often descended into chaos, with drunkenness and looting.

So almost every country moved to what today's health-insurance lobbyists might label "socialized firefighting." In effect, we have a single-payer system of public fire departments.

We have the same for policing. If the security-guard business were as powerful as the health-insurance industry, then it would be denouncing "government takeovers" and "socialized police work."

Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care.

The truth is that government, for all its flaws, manages to do some things right, so that today few people doubt the wisdom of public police or firefighters. And the government has a particularly good record in medical care.

Take the hospital system run by the Department of Veterans Affairs, the largest integrated health system in the United States. It is fully government run, much more "socialized medicine" than is Canadian health care with its private doctors and hospitals. And the system for veterans is by all accounts one of the best-performing and most cost-effective elements in the American medical establishment.

A study by the Rand Corp. concluded that compared with a national sample, Americans treated in veterans hospitals "received consistently better care across the board, including screening, diagnosis, treatment and follow-up." The difference was particularly large in preventive medicine: Veterans were nearly 50 percent more likely to receive recommended care than Americans as a whole.

"If other health-care providers followed the V.A.'s lead, it would be a major step toward improving the quality of care across the U.S. health care system," Rand reported.

As for the other big government-run health care system in the United States, Medicare spends perhaps one-sixth as much on administration as private health insurers, although the comparison is imperfect and controversial.

But the biggest weakness of private industry is not inefficiency but unfairness. The business model of private insurance has become, in part, to collect premiums from healthy people and reject those likely to get sick — or, if they start out healthy and then get sick, to find a way to cancel their coverage.

On my blog, foreigners regularly express bewilderment that America may reject reform and stick with a system that drives families into bankruptcy when they get sick. That's what they expect from the Central African Republic, not the United States.

Let's hope we won't miss this chance. A public role in health care shouldn't be any scarier or more repugnant than a public fire department.

Nicholas D. Kristof is a regular columnist for The New York Times.