In Wales this fall, a woman had to wait 17 weeks for a cancer screening after finding a lump in her breast. The British press was outraged.

But the British routinely wait as long as nine months for non-emergency surgery. They accept waiting lines rather than pay higher taxes for their National Health Service.

Canadians can wait 11 months for cataract surgery or two years for a knee replacement. Yet they tell pollsters that they love their government-funded health-care system, partly because they never see a big bill.

Any mention of the need for reform in America's health-care financing runs smack into the issue of waiting lines. Americans will never put up with waiting for care, say those who like our mishmash of a health financing system. Nor will they accept rationing.

But an intelligent scheme to reform America's health-care system could provide coverage for everyone with rarely a waiting line and still save money. The French and Germans accomplish that today.

As for rationing? We already have it. In America, there is rarely a long wait for elective surgery - if you can afford it. But one out of six Americans lacks insurance. If you're one of them, you can limp around on your sore knee forever.

"We ration care today," notes Paul Ginsburg of the Center for Health System Change. "The uninsured get much less care than the insured and suffer worse health outcomes because of it."

Most Americans get their health coverage through their employers. That means that most people - those without substantial savings - are just a pink slip away from being uninsured.

Those with good insurance get better care than those with bad insurance. If an insurance company has denied you coverage for a medical procedure, then you have experienced rationing. If it has set a limit on your hospital stay, you know rationing.

And as medical insurance rates rise at double-digit rates, employers are busy restricting coverage. In other words, rationing is getting worse.

The latest trend is for companies to offer coverage with very high deductibles - $2,000 to $5,000 per family - coupled with the chance for a family to contribute to a tax-free medical savings account. For most middle-income families, who can't afford $5,000 in annual medical bills, such coverage is an invitation to ration their own care.

In essence, the difference between America and other advanced nations is HOW we ration, not whether we ration. Other nations are upfront about their rationing; we do it more subtly. They ration by government fiat. We let the insurance companies, employers and hospital admissions offices do the rationing.

The critical difference is that other wealthy nations give fairly good care to ALL their citizens, and we don't. They also provide it at a much lower price. And their systems produce health results generally equal to ours, and in some cases better.

How do they do it?

They use a variety of health coverage schemes. The Canadians and British use single-payer systems run by the government. The Germans use nonprofit private health insurers, called "sickness funds," closely regulated by the government. The Germans put the major cost on employers and workers through payroll fees. The Canadians use taxes.

But all use the clout of government or large buying groups to control cost. For instance, the Canadian and Japanese governments negotiate doctors' fees with large medical associations representing doctors. As the sole owner of the checkbook, the governments obviously have the upper hand.

The German sickness funds band together to negotiate prices with medical providers. For instance, the sickness funds will set an overall budget for all primary care doctors in a region. No matter how many services doctors perform, the amount in the budget stays the same, and fees are reduced to meet the budget.

Closely monitored cost controls tend to wring waste out of medicine. But if pushed too far, they can produce waiting lines. To wait or not depends on how much a nation chooses to spend on health care and how efficiently its system runs.

Britain, for instance, spends 41 percent of what America spends on each citizen's care - one of the lowest ratios among wealthy nations. Compared to America, the British perform one-sixth the number of heart bypasses per capita. CAT scans and other expensive procedures are much less common. And Britain has long waiting lines for elective surgery.

The French and Germans spend more than the British and have little waiting. The French spend slightly more than half what Americans do, and the Germans spend 57 percent.

But the fact that Europeans spend less doesn't necessarily mean that they deliver worse care, notes Richard Saltman, an Emory University professor who studies foreign health care systems. "The outcomes are just as good as they are in the United States."

Under Britain's universal health system, for instance, everyone has a primary care doctor. That lets the British provide preventive care and spot health problems earlier - before expensive treatments are necessary, he says.

Many look at these numbers and see the obvious: With an efficient medical finance system, America could cover everyone with no waiting lines and still lower the cost of health care.