POLICY: Toto, we're back in Kansas and it's 1991 again.

Back in 1991 in a very, very brief moment of (reflected) non-stardom, which I rediscovered on an old photocopy when I was unpacking some boxes during my recent move, my name (and those of my co-authors on a piece about Japanese health care) was in an article about other countries health care systems on the front of The New York Times. At that time the health care debate was about to warm up, and the NYT was trying to educate the public--or at least the small fraction of it that reads or cares about the "paper of record"--about a few basic facts.

Those included the fact that the amount spent on healthcare as a share of GDP vastly exceeded that of other industrialized countries, that American outcomes in terms of infant mortality rates and life expectancy were only in the middle of the pack, and that some 14% of the population had no health insurance--a situation unique to the US. A series of articles about other health care systems (Canada, Germany and Japan's among them) hinted at the fact that there may be alternative models that we possibly should just consider here. And additionally another article showed that you could, if you wanted to, cover all Americans without spending more on health care--(another article in which I glommed onto the much superior intellects of Evans, Barer and Morrison).

Well, surprise, surprise, 13 years later all those facts are still true. We have made some progress in improving overall health, we are spending a boat load more money (roughly double in nominal dollar terms, from about $800bn to $1.6 trillion), and there has been a little more research suggesting that in some specific health areas we are in fact doing a little better. But overall, despite a bunch of industry propaganda, we're spending a lot more on what can be claimed is more or less a luxury good, and we're still doing that equally inefficiently as we were 15 years ago.

And as in 1991, the New York Times has published an article explaining that all those problems are still here. We have made some improvements in some areas, the Commonwealth Fund and Harris have discovered that there are some areas where the US does alot better than other countries (and worse in some other areas), and we are of course spending more while covering a lower percentage of its population with insurance. The reason that we spend more is mostly because of higher unit prices, rather than more services. While this may be news to NY Times readers, it's not to either Health Affairs readers who know about the "It's the Prices" article from Anderson, Rheinhardt et al, or to Americans who understand that drug prices are a whole lot higher here than elsewhere. It's also true that prices in hospital and physician services are higher here. For example when I was researching the comparison between Stanford and Tokyo hospitals back in 1990-1, it was apparent that after everything worked out, prices were about double here. In another example I had an office visit and a blood test in new Zealand in early 1993 and exactly the same visit and blood test here 7 months later. The total in New Zealand was about $65 US. In San Francisco, even with the PPO discount, the total was over $200. Funnily enough real incomes of physicians in New Zealand have gone down by about 20% over the last 20 years. Here their experience has been the opposite.

But so what? We've known about these disparities for at least 15 years. We've known about the problems of uninsurance in the US for over 90. The reasons that the system hasn't changed are wrapped up in American domestic politics, and will stay wrapped up in American domestic politics. Those politics may change over the next few years--and I think they will change and that universal health security will be a bigger issue in 4-8 years--but no one will care about these international comparisons when that time comes around.