RX FOR US HEALTH-CARE SYSTEM

The economic spasms of the health-care system now come with increasing frequency - such as:

* Over 5,000 low-income patients recently dropped from a Pittsburgh health maintenance organization that says it can't exist on Medicaid's rate scale.* A grief-filled Virginia couple publicly appealing for $200,000 for a liver transplant for their uninsured dying child.

* A life-threatening curtailment of financially hard-pressed emergency services in Florida's Dade County.

Is under-finance really the cause of these and endless similar episodes throughout the health-care system? Superficially, it appears to be. But what's noteworthy about the economics of health care is that these crises are occurring while the United States is setting world records for medical expenditures, in total spending, costs per capita, and percentage of gross national product.

These figures have all gone up, despite six years of harsh medical-finance policies of the Reagan administration. Even with inflation squeezed down to record lows, medical spending keeps growing at a robust pace - three to four times the rate of other costs last year.

There's also been growth in another statistical measure - people who don't have money or insurance for purchasing the wonders of U.S. medicine. They're now thought to number over 35 million, the highest since health insurance became a standard benefit of employment in the post-war years.

How did we attain this monumental achievement of spending more and getting less? The answer is that it happened easily within the peculiarly U.S. patchwork of health care - the only one in the industrialized world that isn't underpinned by national financing and guaranteed access to a reasonably high level of basic care.

The fundamental failing of the U.S. system is that its resources are tuned to money rather than to medical need. Where the two match up, as is generally the case for the stably employed whose jobs come with health insurance, doctors and hospitals are poised to do their best - and perhaps even do too much, according to some critics. But that's not the case with the millions who are outside a medically gerrymandered system that encompasses private insurance for the employed, a federal reimbursement system exclusively for Social Security retirees, a federal-state system for the very poor, plus a national hospital network for veterans.

Many of the irrationalities encouraged by this system are depressingly cataloged in an exceptionally perceptive, as well as hopeful, new book, ''America's Health in the Balance:Choice or Chance" (Harper & Row), by Dr. Howard H. Hiatt, former dean of the Harvard School of Public Health.

Dr. Hiatt notes that our vast medical expenditures, unaccompanied by any priorities for the well-being of the U.S. people, lead to such bizarre outcomes as state appropriations for heart transplants, at $150,000 each, while "thousands of preschoolers are not immunized against common childhood disease." Heroic surgical treatments are commonplace in insured sectors of health care, along with life-support systems that prolong death, rather than extend life. But at the same time, Dr. Hiatt notes, preventive measures and health education for the general population remain neglected, though both are highly effective and relatively inexpensive means of improving health.

Canada, he observes, has developed a system of health care that combines national financing with administration at the provincial level. In harmony with many U.S. health specialists who find much to admire in the Canadian system, Dr. Hiatt urges attention to its workings. But a U.S. solution, he cautions, will have to be matched to the U.S. context of major regional variations and traditions.

Where do we start? Dr. Hiatt and other critics of the U.S. health-care system vary widely in their diagnoses and prescriptions. But there's one point on which they all agree: the present system is unacceptable and is rapidly on the way to becoming intolerable.

Copyright 1987, Daniel S. Greenberg

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