Everyone talks about the health insurance crisis in America, but rarely do we talk about the other crisis: people with decent insurance coverage who simply cannot access healthcare. There’s more to this than single payer versus private coverage. Health insurance is meaningless if patients cannot actually obtain timely medical care.

This week I helped a friend access healthcare in America. She has health insurance from a national provider. She is a recent legal immigrant (from a place with good national health care) but had little idea how getting a doctor here actually works. She had come down with a terrible case of shingles, which had spread across her face and back and was moving toward her eye. But she had no primary care physician. After three ER visits she still had no referral. The emergency room dispensed only minimal pain medication and told her to find a primary care physician on her own. None she called would accept new patients before a six-week wait. We finally, using a combination of sweet talk and some advanced begging, found a rare doctor willing to put the patient ahead of the paperwork. She recovered.

For many Americans, the challenge is no longer only paying for health care but finding a clinician who is available to provide it in a timely manner. According to the Centers for Disease Control, 10.6 percent of insured U.S. adults could not obtain an appointment when they needed medical care in the previous year, unrelated to cost or insurance. Some 4.6 percent could not reach providers during open hours because of work or caregiving. About 4.4 percent could not easily find a physician compatible with their insurance, while 2.4 percent said providers were too far away. The latter is a critical issue in rural America and across the bulk of America that has little to no public transportation. All those figures above exclude people who never seek care because they cannot afford the deductible their insurance requires.

Maybe it is time to move to Canada. Two acquaintances just immigrated there after a multi-year screening process that included producing original college and high school transcripts, taking a health exam, taking a French language test, interviews, and forms, lots of forms. They needed to hire lawyers to get them over a few humps, but ultimately made it. Their motivation resonates strongly: They want decent health care.

I don’t want to break bad news to the newly-minted Canadians, though they have probably already found out for themselves the problems of accessing healthcare in their new home. Canada’s largely taxpayer-funded system provides universal coverage for medically necessary physician and hospital services, but coverage does not necessarily translate into access. Seventeen percent percent of Canadian adults do not have a regular family doctor, more than in America. Some 77 percent say it is not easy to obtain care on evenings, weekends, or holidays. Emergency rooms are overcrowded as a result, in part because 15 percent of ER visits could have been treated in primary care if it were available (a problem America shares because the homeless and others uninsured use the ER as their only doctor). The more specialized the health need, the longer the wait. Some 36 percent waited three months or longer for an initial specialist consultation. The median wait from a primary care physician referral to treatment is around 30 weeks. But at least they do not face the risk of bankruptcy from a medical emergency.

What is a Canadian, already paying for health insurance via taxes, to do? There is no one good answer. Some relief is found among the approximately two-thirds of Canadians who pay for private health insurance on top of the mandatory national kind. That private insurance, except in Quebec, primarily covers only services outside the universal provincial health plans, such as prescriptions, dental and vision care, and other supplemental benefits. It generally does not purchase faster access to medically necessary physician or hospital services covered by the public system. Other sick people resort to private clinics and pay in cash. A lucky few use employer-paid executive health programs. A few even resort to travel to the United States and pay cash directly for specialist care to avoid potentially dangerous waits. These workarounds reflect a fundamental reality of Canada’s health care system: The principal barrier is usually access, not insurance coverage, as in the United States.

Many of the reasons for these access problems are similar in the U.S. and Canada. They include population growth outpacing growth in primary care providers, retirements among the baby boomer docs, and increased demand from an aging population. Doctors in America face the additional administrative burdens of insurance prior authorizations and processing claims through the specific system each insurance company requires. There is also a problem training more doctors in the U.S. to meet demand. Medical education slots face limits because the federal Balanced Budget Act of 1997 capped Medicare funding for residency positions, which hospitals rely on heavily to pay for that training. Congress froze the number of funded residency slots (at a cost of some $21 billion) based on 1996 levels. The number of new slots trails the rising need for doctors. American doctors also face a substantially greater risk of malpractice lawsuits than in Canada. In addition to paying out for expensive malpractice insurance, American doctors must also practice defensive medicine, care and tests ordered primarily to minimize the chance of getting sued. This reduces physician capacity.

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If you’re looking for solutions (or planning on emigrating somewhere), the place to look might be Denmark. Denmark has a tax-funded, universal health care system in which nearly all medically necessary physician and hospital services are provided without charge. Funding comes mainly from national taxes. Most Danes do not receive their primary health insurance through an employer, and unlike patients in Germany or the Netherlands, they do not generally pay mandatory health insurance premiums to a sickness fund or private insurer. To work around the access problem, about one-half of Danes have voluntary private health insurance. Unlike in Canada, this coverage is allowed to provide fast access to private hospitals and specialist consultations without some of the delays of the public system. It supplements rather than replaces the public system as it grows. Denmark also helps ameliorate the access problem by assigning almost every person in the country (over 99 percent) a primary care physician. There are still problems with a lack of doctors, especially since Denmark made the decision to greatly open its borders to large numbers of immigrants, and it can be hard to switch doctors from the one you are assigned to use. Denmark solves the access problem not by abandoning universal care but by allowing supplemental private care. Denmark demonstrates that universal coverage and private alternatives need not be mutually exclusive.

This is where someone asks how much it all costs. It is a complex question, given the cost of the variety of health insurance plans with their varying deductions and provided services in America, plus a very messy tax code that almost ensures no two Americans pay the same amount of tax. With the danger of oversimplifying things, but to try and bring some clarity to all this, OECD calculations set the average tax wedge Americans and Canadians pay at about 30 percent. For Denmark, the same OECD study shows a single worker earning an average wage faces a tax wedge of 36 percent. But in return Danes get free universal health care, free public schools and universities, pensions, generous unemployment insurance, child care and family benefits, and elder care. Americans and some Canadians pay for all of those things in addition to taxes.

We have spent decades in the U.S. arguing over how to pay for healthcare. Increasingly, the question is instead whether anyone can actually access it. America, alongside Canada, supposedly has some of the most advanced healthcare available in the world; too many people just can’t use it. Coverage under any system is not the same as access.