One presumes that if there was broad and deep dissatisfaction with this style of healthcare then some party or politician would have capitalized and zoomed into power and dismantled it. This has not happened. Can you make sense of this conundrum for me?

Sincerely,

Bernie

Hello again and thank you for all of the letters you sent in response to last week's column. This week Bernie wants me to explain a conundrum involving socialized healthcare in democratic countries.

I have to admit that I wrestled with this for some time. Is Bernie asking me to explain a philosophical position or a political one? His question, as I read it, could be taken either way.

One thing I do know is that the failure of a political party to make the dismantling of the national healthcare system the central plank in its platform should not be seen as a tacit endorsement of the system by a country's electorate.

As a matter of politics it can take years -- even decades -- for a government-run system to deteriorate to the point where the costs outweigh the benefits to such a degree that the voters demand sudden and radical change. There was, after all, a gap of several decades between the moment California Gov. Ronald Reagan first proposed significant reform in the nation's welfare system and 1996, when Congress passed and President Bill Clinton finally signed the landmark (and, as it turned out, stunningly successful) welfare reform law.

Change on this level is often difficult to achieve and may only come about in extraordinary circumstances, like Great Britain in the late 1970s when things got so bad the voters were willing to embrace Mrs. Thatcher's radical program to bring free-market reforms to the British economy.

There are any numbers of reasons for the time lag, not the least of which is government being nowhere near as efficient in weeding out failures as market-based system have to be in order to survive.

At the same time, the politicians and most major political parties in Europe and in Canada have found ways to make the nationalized healthcare system work for them. Helping a constituent to receive services they need through the application of political pressure, rather than as a result of urgent medical need, can make a hero out of any ordinary member of Parliament. From their perspective, what's not to love about a system like that?

It is also true that most of the people who utilize the national healthcare systems -- to get stitches, to have broken bones set, to get regular checkups -- do not require innovative or life-saving techniques and so are probably perfectly happy with the inexpensive care the government can provide, pretty much without issue.

But, as one think tank director here in the United States told me, only a small percentage of Canadians have to deal, on a yearly basis, with the really bad outcomes, like a death caused by or contributed to by long waiting lines for diagnoses or procedures.

"If you have lost a family member because of the waiting lines, you are hopping mad and probably ripe for reform," the director told me. "For the vast majority of Canadians, though, the system has been fine. Until the day it isn't, that is."

The director of a free-market think tank in Europe told me pretty much the same thing. "What is playing out is Frederic Bastiat's difference between the seen and the unseen. Votes in the European Union (and American tourists) see cheaper healthcare prices. They do not see the longer waiting times to new treatments. And people with extreme acute pathologies -- ones that could benefit from having those new treatments jump over the Atlantic faster -- do not organize politically to make this happen because they prize keeping healthcare costs down far above the perceived benefits of innovation."

"It's a bit perverse," the American think tank director added, "but if the system treated everyone worse but didn't kill anyone, there would be a lot more pressure from voters seeking reform."

"The fact is that the system kills quite a lot of people -- but that's still only a tiny percentage of the overall population -- so it reduces the pool of people who are dissatisfied," she said.

Another point worth considering is the impact of United States healthcare system on the world's, in effect allowing populations underserved by non-innovative, ration-rich nationalized systems to act as free riders on the American plan.

As long as the United States exists as a safety value for those in need of urgent, critical or innovative care and therapies, the pressure that could be applied on politicians to reform their non-market based, government controlled systems will never materialize. Critics would say denationalization of the healthcare system amounts to taking away from the voters a free entitlement, something that is there's by right. And that's the winning argument as long as those whom the national healthcare system can't or won't help have someplace else to go when they need to, e.g., the United States.

There are also those Canadians who have been critical of the public system sending expectant mothers into the United States to get their babies delivered. But that's not because their babies are more likely to die because the U.S. has higher infant mortality rates (which is a subject for another column); it's because it makes it harder for family members to get to the hospital to visit. People may mind, they may be inconvenienced, but not to the degree that they want to invest time and treasure in changing the system.

It's fair to say that the demands for changes in the nationalized healthcare systems are ratcheting up in places like Canada and Great Britain, albeit incrementally. If the United States moves to a system more like Canada's or Europe's, expect the demand for change to come even faster.

I hope that helps.

Hi, Cary,

I'm a 50-something male, the father of two mostly grown girls. I'm happy to say that both my parents are still kicking. I'm on good terms with my brothers and sisters most of the time. Am blessed with good friends and other relations, and tend to get on well with my co-workers. I am fortunate in so many ways, but feel like I consistently disappoint everyone I know. Here's why:

I cannot, for the life of me, give a genuine compliment. It simply doesn't come naturally. When I try, and I do, in order to maintain all the aforementioned relationships, it feels forced, more a matter of obligation than a gift that might put wind in the sails of someone I truly care for. I feel strongly that giving should spring from joy, or at least from a heartfelt desire to see the recipient enlivened by it. When I have nothing to offer in response to a job well done, or I can't cite the intrinsic value of those I love, everyone loses. I feel like I've warped the emotional and social development of my children, alienated any number of perfectly wonderful lovers, and generally kept the world at arm's length.

I can recall certain compliments given to me through the years. Some of them made all the difference, whether in attaining some goal or simply affording me an elevated sense of self and my rightful place in the world. The value of timely acknowledgment is obvious.

After years of psychotherapy and the obsessive self-examination endemic to my generation, I believe I know where this stinginess of spirit comes from. I am the eldest of six. At a very tender age, there were five younger, cuter kids standing between me and the object of our affection. Mama was driven to distraction, to put it mildly, by the demands placed on her, but it was the 1950s and she set a selfless and stoic example. I had complete sympathy for her plight, even at the time. The fact remains, however, that, as a young child, I needed more than I got. I craved my mother's attention. I needed to know that she valued me as more than her helper, her strong little man. I clearly recall, at the ripe old age of 7, coming to the conclusion that I would never get it. "That's OK," I reckoned, "I can get by without it" -- "it" being her love.

You can imagine the sibling rivalry in all its permutations. Eventually I took refuge in the written word -- books were my escape. But even before I learned to read, I had realized that giving any sign of approval or encouragement to my brothers and sisters could only serve to increase the gulf between me and my mom. Does that make sense? I can rationalize otherwise, of course, and now we're all "one big happy family," but the damage is done. I want to be gracious and giving. When I even think to reach into that purse, however, it's pretty much empty.

Do you have any thoughts on this? Would appreciate whatever you can offer.

Can't Give a Compliment to Save My Life

Dear Compliment Impaired,

Sure, I can see how the family dynamic you describe could still be affecting your relations with others. But since you have done the hard work of finding this out for yourself, I think you are ready to change. It's time to put some new behaviors into action.

The therapist I'm working with now makes it really simple: Once you can see which behaviors are serving you and which ones are holding you back, you can begin shedding the ones you don't need. Just like that. She uses a very gentle metaphor, like leaves falling in autumn. You just let some things go. You don't need them. You bid goodbye. Like when the leaves fall, it allows for new growth.

Now, that may sound a little New Age, but, hey. What's wrong with a little gentleness? We sometimes feel that we have to stamp out or grind out or burn away these old behaviors, or punish ourselves every time we engage in them. But behavioral change doesn't have to be so grueling a process, nor do we have to be extremely programmatic or explicit about what exactly we are no longer doing. We can just start letting things go and replacing them with new behaviors.

But, aha! When you start letting a certain behavior go, what happens? Suddenly you are fearful! Because at the time, that refusal to give away any compliments or admit that anyone could do anything well or deserved any praise was protecting your position in the family, protecting your access to your mother's love! So you may feel fear when you begin to let these old behaviors drop away. You need to reassure yourself.

In connection with that, this business of the purse is interesting. You say when you want to give a compliment, you reach in and the purse is empty. While "purse" can refer to a gender-neutral container for money, as in the "congressional purse strings," or in fairy tales where merchants have purses, in my childhood only Mummy had a purse. Daddy had a wallet. There was money from Mummy and money from Daddy, but they were different kinds of money. I guess a contemporary scholar might say that money was gendered. In fact, wow, right now I am remembering the powerful emotions of fear and excitement and guilt when my mother would open the purse and dispense money. Wow. It was a charged moment. And, as I consider it, I see that the money that came from my father had a different feel, a different set of assumptions about it. (Sorry, I will take that up with myself later! We're on your dime now!)

But I would like to ask: Whose purse are you reaching into? Are you reaching into your mother's purse? Or your own purse? Is it always empty? If it is your mother's purse, perhaps it will always be empty. That is, some things are in the past and cannot be changed. But if it is your purse, you can then fill it. That's where the reassuring-yourself thing comes in: You need to fill that purse. You need to load it up with compliments so you can give some of them away. You may start by giving yourself some really good compliments. Find some opportunities during the day to give yourself a compliment or two. How does it feel? It feels pretty good, doesn't it? Hey, give yourself a pat on the back. You deserve it.

Then start giving compliments to others. Of course it's not going to feel natural at first. It's like flipping pancakes with your left hand. But do it anyway. You'll get used to it.

There are lots of ways to start. You don't have to be incredibly timely. You could just think back to the last thing one of your daughters did that you were grateful for. What was it? It doesn't have to be profound. Giving a compliment doesn't have to be praise, which implies relative judgment and thus the possibility of future failure; it can just be gratitude. You can just say, "You know, a couple of weeks ago when we had all those things to do to get out of the house on time, and I was afraid maybe we'd be late? I was very impressed with how you got everything done on time and we got out the door. It might sound like a small thing to you, but I appreciated it, and wanted to tell you."

In learning to give compliments, you're giving up an old orientation to the world, in which giving a compliment threatened your position. You were competing with siblings for your mother's love. You're not doing that today.

Today, you can afford to give your daughters every blessed little ounce of appreciation and admiration and love and encouragement that you have. Nobody's going to step in and usurp your role. Today, you don't weaken yourself by giving a compliment. In fact, you strengthen your position with them in that way. You strengthen the bond.

Now, it does take some courage to start doing this. They may not react the way you hope they will. If they are not used to getting compliments, they may think it's weird at first. But give it time. Stick with it. I think you'll be pleased with the results.

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To put numbers on it: As of 2004, U.S. citizens were carrying, on average, 14 percent more debt than income; as of last month, the U.S. government owed China something on the order of $1.3 trillion; as of, well, now, the total amount of our national debt is more than $10 trillion. So maybe the time has come, as Atwood suggests, to examine "debt as a human construct ... that peculiar nexus where money, narrative or story, and religious belief intersect, often with explosive force."

In other words, if you're expecting tips from Suze Orman, kindly head for another shelf. "Payback" is a hop-and-skip journey through Atwood's teeming brain, and anyone familiar with the Canadian writer knows this is a lively place to be. Over the course of a couple hundred pages, we jostle against sin eaters and the Code of Hammurabi and Genghis Khan and goddesses of justice and the Antinomian heresy and the spiritual twinship of debtors and lenders.

We also learn quite a lot about the devil, who has been among mankind's busiest creditors, and we get a healthy sampling of Atwood's straight talk express: "Among the first things that people were able to pawn were other people ... Hell is like an infernal maxed-out credit card that multiplies the charges endlessly ... There are two kinds of taxation systems: ones that are resented, and ones that are really resented ... Taxes are like zebra mussels: once they've been introduced, they're very hard to get rid of."

Oh, sure, anyone can come up with a good aphorism or two, but I can't think of anyone who has explained the subprime mortgage crisis quite as cogently as Atwood: "Some large financial institutions peddled mortgages to people who could not possibly make the monthly rates and then put this snake-oil debt into cardboard boxes with impressive labels on them and sold them to institutions and hedge funds that thought they were worth something."

Where Atwood particularly excels (not surprisingly) is in showing how strongly debt figures in some of our most beloved Western fiction. "When I was young and simple," she writes, "I thought the nineteenth-century novel was driven by love; but now, in my more complicated years, I see that it's also driven by money, which indeed holds a more central place in it than love does, no matter how much the virtues of love may be waved idealistically aloft."

"Vanity Fair," seen in this light, becomes a case study in debtor's refuge. "The Mill on the Floss" is a parable of "the trickle-down theory of revenge." That fiery gypsy Heathcliff may have loved and lost Cathy, but he paid her back by snatching up her encumbered estate. (As Atwood drolly notes, "The best nineteenth-century revenge is not seeing your enemy's red blood all over the floor but seeing the red ink all over his balance sheet.") As for that philandering Madame Bovary, Atwood writes, "Emma isn't really punished for sex but for shopaholicism. Had she but learned double-entry bookkeeping and drawn up a budget, she could easily have gone on with her hobby of adultery forever -- or at least until she got saggy -- though she'd have done it in a more frugal manner."

There is enough of this witty and discursive analysis to make you genuinely curious about where Atwood is heading -- and to make you wish, finally, she hadn't headed anywhere. For in the final pages of "Payback," the mystery of debt is quite summarily solved, and the solution is far less interesting than the problem.

"All wealth," declares Margaret Atwood, "comes from Nature." If that capital N hasn't already tipped you off, we have arrived, gears screeching, in the meadowlands of the Canadian Green Party, where money is an illusion and the only debts we truly owe are to Mother Earth. In service of this theory, Atwood has cobbled together an embarrassingly inane revamping of Dickens' "Christmas Carol," in which "Scrooge Nouveau" is visited by three "spirits of Earth Day." (I wish I were kidding.) The scenario climaxes in a utopian vision of quite startling banality: "All religious leaders have realized that their mandate includes helping to preserve the Almighty's gift of the Earth and have condoned birth control; there are no more noisy, polluting gas-powered leaf blowers or lawn mowers; and global warming has been dealt with at a summit during which world leaders gave up paranoia, envy, rivalry, power-hunger, greed, and the debate over who should start cutting down the carbon footprint first, and rolled up their sleeves and got on with it."

No monocropping, no overfishing. No tall buildings to get in the way of migrating birds. If kiddie troubadour Raffi could imagine the future, this is what it would look like. Many of us, of course, share Atwood's hopes for an environmentally sustainable society; what we are less likely to share is her Luddite aversion to modernity. "Mankind made a Faustian bargain," she intones, "as soon as he invented his first technologies, including the bow and arrow." She approvingly notes the example of "earlier peoples" who "felt they had to pay back what they'd received. This is where the idea of sacrifice came from: human sacrifice, in certain South American tribal cultures, is still referred to as 'feeding the earth.'"

Which humans would Atwood like to feed to the earth? My guess is those tweedy, pencil-necked economists who tell us that "borrowing is actually laudable because it turns the wheels of 'the system,' and that spending lots of consumer money keeps some large, abstract, blimpish thing called 'the economy' afloat." Well, yes, it does. That's part of the problem. Atwood never really distinguishes between "bad debt" (credit cards) and "good debt" (college loans, mortgages). The niceties of Keynesian economics, of microfinancing ventures, of the ways in which financial entities act as both borrowers and lenders ... these are either beneath or beyond her.

What's left, in the end, is a vague spiritual itch. If, as Atwood believes, creditors are every bit as morally compromised as debtors, then the only way to restore the world's balance is to forgive whatever is owed us -- to wipe every slate clean. She has in mind the Old Testament concept of Jubilee, which called on Hebrews to cancel all debts every 50 years, but for some reason, she never mentions the international Jubilee campaign, a liberal coalition dedicated to erasing all developing-world debt. Nor does she mention debt-for-nature swaps, which have channeled millions of dollars of canceled debt into conservation projects.

No, Atwood has her eyes on a bigger prize. She wants to balance the books for all moral debts. In her book's looniest moment, she imagines a revisionist history of 9/11 in which America forbears to avenge itself against al-Qaida. "We realize that acts of vengeance recoil upon the heads of the inventors," says Atwood's imaginary president, "and we do not wish to perpetuate a chain reaction of revenge. Therefore we will forgive."

Atwood at least understands how unrealistic this scenario is. What she doesn't understand is that forgiveness, in order to be meaningful, requires a party willing to be forgiven -- and conscious, moreover, of needing forgiveness. To put it mildly, al-Qaida meets neither of those criteria. Does Atwood really imagine that America's refusal to retaliate would have swayed Osama bin Laden from his course? Dropped him to his knees in a paroxysm of self-reproach? Eliminated any future terrorist threat to U.S. citizens?

If so, she is guilty of both intellectual and imaginative failure. There is no reason why a novelist of her gifts can't give us new perspectives on micro- and macroeconomics. But, at crucial moments, Atwood forsakes artistic engagement for ideological reflex, and she ends up pretty much where she began, more certain in her certainties. If poets really are the unacknowledged legislators of the world, the time may have come for a recall vote.