PERSPECTIVE ON HEALTH CARE : Smarter Spending Means Saying <i> No</i> : People are dying for want of the basics, while others get state-of-the-art medicine that won’t alter their prognosis.

In the ward of a large county hospital there is an 87-year-old woman waiting for a $1,500 MRI scan of her head. She has had seizures all her life, but the doctors now want to see if they can find out what’s causing them. “It won’t change what we do,” says one of her doctors, “but it would be interesting to know.”

Another woman waits in the emergency room with her abuela (grandmother). The hospital is full--no beds anywhere. So the doctors see the patients in the emergency room and try to start treatment while they wait for beds. The granddaughter is tired. She worked 12 hours today and came home to find her grandmother coughing and feverish. They have been waiting eight hours and haven’t seen a doctor yet.

Upstairs, a 24-year-old man is dying of AIDS. He also has something terribly wrong with his blood--it won’t clot anymore. He bleeds from his IV site, his feet are bruised just from standing up. I told him that he will die soon. Someone suggests a bone marrow biopsy, which might tell us if leukemia is causing his problem. We couldn’t treat it anyway.

Downstairs, the woman takes her abuela home. She has to go back to work in four hours. She decides to come back after work. Too bad, because her grandmother will be dead by then. Pneumococcal pneumonia costs very little to treat, but you need to be in the hospital to get IV antibiotics.

It takes only a few months of working in the county system to see that people die waiting for simple treatments while beds are filled with patients getting state-of-the-art studies that will not change the course of their diseases.

Everyone agrees that health care costs too much and cares for too few. There is less agreement about why. One simple answer is that doctors charge too much and drugs are too expensive. This answer ignores the single largest element of the rise in medical costs over the past decade: hospital costs. And costs rise because we have filled our hospital beds with people getting expensive, often unproved treatments, so we don’t have money to provide simple, life-saving treatments.

This means that someone with terminal cancer can get thousands of dollars worth of experimental chemotherapy, with no chance for a cure, while someone else has a stroke from untreated hypertension for want of a simple office visit and some pills. The system is overflowing with people getting things that probably won’t alter the course of their diseases, while others, equally needy, do without even the basics.

Under the current system, neither the care-givers nor the patients have any incentive to control costs, nor is there any reason not to try unproved and expensive treatments.

We as a society are willing to spend only a certain amount of money on health care for the uninsured. This makes sense, because without some limit, health care could consume half of our GNP. It follows that since there are fewer beds than patients, and less money than things to spend it on, we must decide how to spend our health-care dollars. The only alternative to making these decisions is unlimited spending.

Once we have said no to unlimited spending, health-care spending becomes a zero-sum game. One dollar spent on someone is a dollar not spent on someone else. In practical terms, this means that every organ transplant means thousands of dollars less for vaccinating children. This means that our decision-making process can no longer only look at what is best for the individual patient, but it must also look at what each decision will mean for society. In other words, can we afford an organ transplant if it means 10 more measles deaths in the next five years?

If private insurance companies want to pay for heart/lung transplants or for expensive procedures that are likely to be useless, I suppose that’s a business decision. But if we as a society want to care for those who can’t buy their own insurance, and we have a limited supply of money, then we don’t have the luxury of bad decisions like this.

We can afford to give health care to everyone without insurance without spending a nickel more than we do now--but not the kind of health care we’re giving now. More health care is not a matter of spending more, it’s a matter of spending smarter. It means saying no to many things: no cancer treatments to terminal patients, no respirators for 24-week-old fetuses that have little chance of surviving, no experimental, one-in-a-million treatments. But it means saying yes to many more: vaccinations for all children, prenatal care for all expectant mothers, treatments that are proved, effective and relatively cheap. This will require hard choices, but it will not cost money.

You cannot watch someone die of a preventable cause in one room while money is being wasted in the room next door without wondering when the system will change. Maybe the current experiment in Oregon will show us how much can be done by reordering priorities and making difficult decisions. Even if this experiment fails, we as a country cannot pour our money down the drain simply because we are afraid to state clearly our priorities and to act on them.