So pick up your pencils and check the response that best describes what he did. Danny Williams

1. made a smart medical choice by carefully weighing his options and having his surgery in the place where he would have the best chance of a good outcome and fast recovery;
2. made a smart geographical choice by having his surgery in Florida in the middle of winter, near his condo where he could convalesce;
3. made a Newfoundland-first political gesture by saying, if it isn't offered in St. John's, I'll not make us look bad by goin' down the road to Toronto;
4. didn't know and didn't care about either the availability or quality of minimally invasive mitral valve surgery in Canada; or
5. followed the thousands of other Canadians who, over the years, driven by anxiety and relying on reputation, have checked into the Mayo or Cleveland Clinic to nail down a diagnosis, get a second opinion or secure the highest-quality repair work.

I'm thinking d, e and c, in that order. It is consistent with the Williams persona: supremely confident in his own decision-making, quick and decisive position taking, and money enough to get what he wants, when he wants, where he wants. Whatever else he is as a politician, he is no garden-variety obfuscator with his finger perpetually in the wind. It never occurred to him that by virtue of being premier, he needed to consider the broader implications of his decision. It's my money and it's my heart, and I have an absolute right to go where I want for care - a right I did not cede when I consented to govern.

No one would care a whit about what Danny Williams did if he weren't premier. But he is, and, like it or not, his flight is freighted with potential political significance. Medicare is the single most important program any provincial government delivers. If a premier's actions betray a legitimate lack of confidence in what medicare can deliver both at home and elsewhere in Canada, it shakes the system to its foundation. The single-payer, tax-financed system stands revealed as a watered-down mediocrity, unreliable when the stakes are high. It confirms that two-tier is essential because a single tier can't deliver the goods.

On medical grounds, what Williams did was neither necessary nor prudent. This wasn't an evidence-based decision founded on sound knowledge of the availability of services and health outcomes in both countries. It was a guy worth several hundred million dollars doing what guys worth several hundred million dollars often do. If I thought for a moment that he based his decision on sound evidence and a thorough review of all of his options, his choice would give me pause. But it is clear that he did no such thing. He called a pal, took his suggestion and took off. The rich are very different from you and me. They get to spend a lot for a little.

As for any political consequences, he may be correct in assuming that NLers are no more inclined to toss out his government than Albertans are inclined to turf theirs. Since his approval ratings routinely trounce those of his counterparts across the country, who's to doubt his instincts? Maybe his constituents love him not in spite of but because of how he behaves. He brings a swagger and confidence to his province and relishes in a good skirmish. And I suspect he's also banking on the public giving him a thumbs-up for giving the figurative finger to Central Canada: by god, if Danny has to leave the rock, good on him for flying right by those arrogant University Avenue bastards.

It's more interesting to imagine what is not, in fact, true - that Canadian medicare couldn't deliver the valve job and the Williams choice was the right one on all grounds. Would that cut the legs out from under the single-tier medicare system and prove that it's just not good enough anymore? Does any shortcoming undermine the whole enterprise?

The answer is a resounding no. Medicare is a public service. If public, tax-financed programs are expected to deliver the highest conceivable standard of service to the entire population with finite resources, no public service will pass muster. It is impossible for every public high school to provide the same quality education you can get in private schools where tuition is $30,000 a year. The litmus test for a public service is whether it is good enough to satisfy the middle class whose taxes support it and who are more or less obligated to use it. That some rich people opt out of public education proves nothing about the adequacy of public education, just as the lack of capacity to perform certain unusual procedures is no proof of the failure of medicare. The main intent of medicare is redistributive - the healthy and wealthy subsidize the care of the sick and the poor. But the care also has to be good, and throwing all citizens into the same boat creates a community of interest in quality. The collective judgment of the middle class ultimately decides whether the system is adequate. That judgment should be based on both personal experience and systematic evidence. No system will achieve a perfect score on all dimensions; it is the overall performance, and the perception of that performance, that tells the tale. And, of course, it should improve all the time.

The Williams story is interesting not because of its implications for medicare but for its irony. As the facts of this case and a good deal of other research have shown, Canadian medicare is actually very good when life is on the line and organs need a tune-up. We have no shortage of world-class institutions and programs at the glamour end of medicine. If you're really sick in Canada, or if you have a rare and interesting affliction, chances are the system will fawn on you. Who's ahead of the pack in the search for a cure for diabetes? The creators of the Edmonton Protocol. Who identifies the genes responsible for debilitating children's conditions? Take a bow, scientists of SickKids. Who's pioneering robotic surgery? The University of Calgary. Canadian high-end medicine is in the premier league, even if it isn't in the premier's league.

So Danny Williams needn't have gone south for his valve repair - he would have been in excellent hands in Canada. Where he and the rest of us should be concerned is in the more pedestrian precincts of the system: primary healthcare, chronic disease management, the day-to-day care whose quality can make such a difference to so many lives. He decided to forego the system where it actually performs, and puts himself in its hands where it is far more likely to fall short. He's got lots of company there - opinions about healthcare quality tend to be forged in a data-free environment. We need more politicians willing to stir the pot. I'd have cheered if he had gone south in a snit because he couldn't get team-based, evidence-informed, same-day, patient-centred primary healthcare supported by first-class information technology. That's the symbolic stick in the eye that medicare deserves, and the real Achilles heel of the system.