The principal challenge to scientific medicine is no longer discovering new cures but affording new discoveries. Modern medicine represents an awesome, ever-expanding repertoire of life-saving and life-enhancing diagnostic, surgical, and pharmacological inventions. American medicine is quite literally the envy of the world. In the 20th century, it has contributed to a doubling of life expectancy and vast improvement in the quality of our lives.

Each step in the march of medical progress is heralded in the news. A vast research infrastructure–federal institutes and grants, academic medical centers, corporate research and development, and biotech venture capita –propel this progress. But so too does a largely unheralded evolution in public expectations–about what medical care we’re entitled to, and who should pay for it.

The boundaries of “normal” are shrinking: Marital discord is now an ailment.

Modern medicine encourages us to define more and more human conditions by their clinical diagnoses. The boundaries of “normal” are shrinking: Marital discord, social anxiety, clinical shyness, over-active kids–these and many more emotional states have recently entered the official diagnostic code. How many terminal patients endure heroic medical interventions inflicted at great pain and expense, rather than die a traditional death at home? (As we slide down this slippery slope, we sense the danger. Some have begun to voice concern about the medically prescribed drugging of our children. And, in reaction to the “medicalization” of death, dying Americans have started to seek refuge in a hospice, a medically sanctioned halfway house between hospital and home.)

Medical diagnosis of the human condition also triggers demand for its treatment. Consider, for example, the typical middle-aged jogger who sees a physician for knee pain, gets an MRI and perhaps surgery rather than moderate the daily pounding of her limbs. Marital discord–once the province of priests, lawyers, and family members–is now an ailment, for which insurors in Massachusetts are required to cover 24 therapy visits per year.

At the same time, health insurance has become an instrument for financing large, predictable expenditures, similar to home mortgages, college loans, and retirement savings–except that with health insurance someone else (employer or government) generally pays. Beyond protection against unforeseen catastrophe, health insurance now subsidizes a growing array of routine medical services. As coverage lowers the effective price of any particular service to patients (often to zero), it stimulates demand. The decision as to which services get covered and at what rate of payment then becomes a critical factor in the business success of any medical service provider–hence, the public debate and intense lobbying over Medicare drug coverage and payment rates for hospitals, nursing homes, home health care, and HMOs.

It is the interaction of science, societal expectations, and insurance subsidies that fuels medical progress. In childbirth, for example, all three forces propelled us well beyond bed rest and a few low-tech interventions (forceps, epidural, C-section). Until recent decades, pregnancy was routinely excluded from conventional insurance as a reasonably predictable and affordable event, costing less than $1,000. Then along came HMOs, which covered delivery and months of routine prenatal care. Later, HMOs added coverage of birth control devices and systematic efforts to identify high-risk pregnancies and avoid premature delivery of low-birth-weight babies.

Now obstetrics encompasses laboratory conception involving an expanding set of miraculous techniques. In vitro fertilization typically costs $5,000-$10,000 per cycle; most couples try at least three cycles before succeeding or giving up, though some couples will go through 10 to 20 cycles. When successful, about 10 percent of such pregnancies produce multiple (three or more) premature infants, on whom we spend another $100,000-plus for neonatal intensive care. Because Massachusetts mandates insurance coverage of fertility treatment, the enormous cost of this extraordinary, but discretionary, technology is spread across premium payers. As a result, the procedure is far more frequently used here–4.5 times the national average rate, according to the federal Centers for Disease Control and Prevention. (Taxpayers may be relieved to learn that Medicare and Medicaid are excluded from the Massachusetts mandate, so there is an age-limit of sorts–65–and low-income women are generally denied this entitlement.)

Has medical care improved? Definitely. Are we deploying medicine’s precious resources wisely or fairly? Not when children are routinely put on Ritalin for “acting out,” but clinical resources to treat suicidal and homicidal youngsters are woefully inadequate. Not when we mandate coverage for marital counseling, but we discharge paranoid schizophrenics to the street. Not when in vitro fertilization is a mandated benefit for those under 65, but uninsured teenagers cannot afford birth control and fail to get the prenatal care they and their babies truly need.

Thus modern medicine, however miraculous, can still be both excessive and deficient at the same time. This pattern of care and payment for care is unfair and also unwise. It represents a casual, almost haphazard, deployment of medical services where we need a thoughtful stewardship of precious resources.

Managed care is one step toward stewardship of the precious resources of modern medicine. One goal of good managed care is to monitor the notoriously uneven practice of medicine and to promote effective prevention and cure. Better care is often less costly care.

HMOs pioneered coverage for routine mammograms, PAP smears, and other cancer screening; Medicare HMOs have achieved a record of earlier diagnosis than fee-for-service Medicare for such cancers. HMOs not only pay for annual eye exams and glucose strips, to manage diabetes, but actively encourage diabetics to use these benefits. HMOs teach asthmatics to monitor their airflow and self-medicate at the first sign of an attack. HMOs try to avoid wasting resources and hurting patients by the inappropriate removal of a child’s tonsils, a woman’s uterus, or a breast cancer victim’s bone marrow (recently proven ineffective, years after Massachusetts and other states mandated insurance coverage for it.)

Is there more that managed care can do in this sweet spot, where better care costs less? Yes, by deploying costly drugs wisely, by systematically preventing medical errors, and by reducing the administrative costs imposed by health plans themselves.

Are there dangers here as well? Yes. Even nonprofit HMOs must guard against sacrificing the real needs of individual patients to financial constraints, to bureaucratic inertia, and to market pressures. Health plans in Massachusetts have voluntarily initiated various patient protections and the state recently enacted others.

As a society we must confront the limits of our resources.

But the next step is something HMOs cannot do on their own. As a society, we must confront the limits of our resources. Unless we are prepared to sacrifice public education, efficient transportation, public health and safety, basic housing, and social insurance to the mushrooming growth of Medicare and Medicaid, we must acknowledge limits to the medical care we can afford. Unless we are willing to sacrifice wage increases and economic growth to escalating health insurance premiums, we must confront the reality that the medical buck stops somewhere.

Nobody wants to admit it, let alone deal with it. Not the legislators who mandate coverage for marginal benefits; not the physicians who urge heroic measures for dying patients; not the 70,000 signatories to a Massachusetts ballot initiative demanding universal coverage, with unrestricted access and quality, at no additional cost; and not the movie-makers, journalists, and cartoonists who routinely equate an HMO’s concern for cost with greed for profits.

From their own selfish standpoint, health plans love rising premiums. HMOs would rather compete on quality, access, and service — that is, on motherhood and apple pie. Life is easier when insurance executives can simply turn to their customers for more money. Indeed, HMOs are doing so in 2000, with 10 to 15 percent premium increases, to the extreme discomfort of their clients.

But what happens after those premium increases? Fewer employers offer insurance and fewer employees accept the offer. Between 1979 and 1995, premiums rose far faster than wages. As a result the percentage of uninsured workers across the US also rose, from 15.1 percent to 23.3 percent. Simply raising premiums to pay for more and more care creates its own, very serious problems of decreasing affordability and enrollment.

Paradoxically, even as medicine progresses, so does our discontent. To reverse this, insurers must find credible ways to address the cost of care and the cost of coverage in a way that makes good, effective health care affordable for everyone. Likewise, if physicians want to deploy modern medicine wisely and fairly, they should add to their traditional role as advocate for individual patients a new imperative to steward precious medical resources for the good of all patients. Politicians must recognize the consequences of mandating new medical benefits, in terms of affordability and access to insurance.

Finally, if Americans want a fairer, more caring health care system, then we should open our pockets to pay for a basic package of effective prevention, diagnosis, and treatment for everyone.

Jon Kingsdale is senior vice president, planning and development, for Tufts Health Plan.