One of the most fascinating books I have ever read in health economics is The Painful Prescription, an analysis of rationing in the British National Health Service (NHS) by Henry Aaron and Bill Schwartz. The Brookings Institution has now published an update, Can We Say No?, and it's every bit as rewarding as the original.

Britain spends less than half of what the U.S. spends on health care on a per capita basis. (The British also get less.) For more than a half century, the NHS has promised health care free of charge to all its citizens. Yet upward of a million people are on waiting lists for care. Unable to get what they need from the public system, many pay out of pocket in the private sector, which provides one out of every five surgeries and almost one-third of all hip operations. Although equality of access to care has always been an overriding goal, gaps in mortality rates among British social classes have been widening over the past three decades.

Although British politicians for years described the NHS as "the envy of the world," Aaron, Schwartz and coauthor Melissa Cox show that the British are routinely denied services Americans take for granted. For example:

• Bone marrow transplants per capita are one-third more frequent in the US than in the UK.
  
  
• The rate at which the British provide coronary bypass surgery or angioplasty to heart patients is only one-fourth of the US rate.
  
  
• Britain has only one-fourth as many CT scanners as the US and one-third as many MRI scanners.
  
  
• The NHS hip replacement rate is only two-thirds of the US rate.
  
  
• To provide the level of intensive care unit (ICU) services that US hospitals have, British hospitals would have to increase their spending by five fold.
  
  
• The population-adjusted treatment rate for kidney failure (dialysis or transplant) is five times higher in the US for patients age 45 to 84 and nine times higher for patients 85 years of age or older.

Overall, to achieve a level of care comparable to US standards, Britain would have to increase its level of spending by one-third, according to the authors.

The one thing missing from the book was also missing in the original - a "public choice" explanation of how rationing choices in Britain flow logically from the politics of medicine. I tried to fill that gap in a book I wrote almost 30 years ago. For the most recent version, see Lives at Risk, the book I wrote with Gerry Musgrave and Devon Herrick.

John C. Goodman is president of the National Center for Policy Analysis. His e-mail is john.goodman@ncpa.org.