Declaring the U.S. health system the "envy of the world," as President George W. Bush did during his 2004 reelection campaign, was once an easy applause line for politicians.
But this year, two leading presidential contenders, Republican Donald Trump and Democratic hopeful Sen. Bernie Sanders, have invoked America's foreign competitors when discussing their healthcare plans.
There is a lot abroad that might interest Americans.
Canada, Britain, France and other developed countries not only spend substantially less on healthcare, but their citizens also often report better access to medical care and far fewer financial worries.
They also enjoy better health. Although Americans three decades ago lived as long as Britons and longer than Germans, the Irish or the Portuguese, they now live on average two years less than residents of these countries.
"The United States is a real outlier," said Francesca Colombo, head of the Paris-based Organization for Economic Cooperation and Development's health division, which tracks health system performance around the world. "All countries have challenges with their healthcare systems, but the U.S. is widely seen as having many more."
The presidential campaign has thrust a renewed spotlight on the U.S. healthcare system, with Republicans, including Trump, promising to repeal the Affordable Care Act and Sanders pledging to replace it with a government-funded system that would provide "Medicare for all." Former Secretary of State Hillary Clinton, the Democratic front-runner, is the only candidate who said she would build on that law, commonly called Obamacare.
The act, which President Obama signed in 2010, is closing some gaps between the U.S. and its global counterparts, in part by guaranteeing Americans coverage for the first time.
The law has also helped about 20 million people get coverage, according to government data. And although healthcare costs are still rising, the increases have been slower than they were before the law was enacted.
But resistance to the law has blocked millions of poor Americans from getting health insurance in states that have chosen not to expand their Medicaid safety nets through the law.
And though the law imposes many new protections — including banning insurers from denying coverage to sick people — it largely preserves America's complex and expensive system with its multiple forms of insurance and largely unregulated prices.
"The particular way we have chosen to do this has left us with a whole range of ills … including a system that is much, much more expensive," said Dr. Donald Berwick, a former Harvard University physician and longtime patient safety advocate who ran the Medicare and Medicaid programs in Obama's first term. "We are literally laughed at by other countries."
The average price of the cancer drug Gleevec, for example, was $6,214 in the U.S. in 2013, according to a survey by the International Federation of Health Plans. That was nearly double the price in Switzerland and more than six times the price in New Zealand.
Similarly, heart bypass surgery cost nearly five times as much in the U.S. as in the Netherlands. A hip replacement was more than double in the U.S.
Berwick, who has worked extensively with international healthcare systems, ran unsuccessfully for governor of Massachusetts on a platform advocating a single government-funded health plan as the best way to control costs. Sanders is now doing the same, invoking similar systems internationally.
Trump, though he has disavowed such a "single-payer" plan for the U.S., noted that such a system "works in Canada" and "works incredibly well in Scotland."
Those comparisons have drawn fire from many conservatives, who argue the American system still outperforms its competitors.
"Single-payer would ruin America's healthcare system, deliver subpar car for patients, kill jobs and bankrupt the country," Pacific Research Institute President Sally C. Pipes warned in a recent Forbes column.
For some medical conditions — such as breast cancer and heart failure — U.S. patients do have better survival rates than patients in other industrialized countries, according to data from the Organization for Economic Cooperation and Development.
And Americans generally wait less to see a medical specialist, though they have more difficulty seeing a primary care physician when they are sick.
More broadly, Americans die more frequently from illnesses that can be averted or controlled with timely medical care, including childhood measles, diabetes and colon cancer, research suggests.
And in nearly all industrialized countries — whether the government directly provides insurance as is done in Britain or heavily regulates private insurers as in the Netherlands — patients enjoy more financial protections.
Canadian and British patients, for example, usually aren't charged co-payments when they go to the doctor or even when they are hospitalized.
In Sweden, patients' annual out-of-pocket costs were capped at about $168 for medical services, according to a 2013 report by the Commonwealth Fund, a New York foundation that studies health systems domestically and around the world.
And in Germany, caps protect patients from having to pay more than 2% of their income for medical care; the cap is 1% if patients are low-income or have a chronic illness.
The added protections mean lower bills.
Just 1% of British patients said they had serious problems paying medical bills, the Commonwealth Fund report found.
In the U.S., by contrast, 23% of patients reported similar financial hardship.
"In other countries, there is much more of a feeling that coverage is reliable, that it is constant," said Robin Osborn, who directs the fund's international health policy program. "There isn't the sense of vulnerability that we see so much in this country."