If Americans are serious about curbing medical costs, they'll have to face up to a much tougher issue than merely cutting waste, says Brookings Institution economist Henry J. Aaron.

They'll have to do what the British have done: ration some types of costly medical care -- which means turning away patients from proven treatments.

Cutting billions worth of "pure waste" -- in needless hospitalization, surplus beds, Cadillac-model machinery and superfluous tests -- would only temporarily slow the growth in health spending, which now tops 10 percent a year, Aaron told a symposium sponsored by the American Academy of Physician Assistants last week in Reston.

Eventually the "cornucopia of technology" and America's aging population will combine to drive up health costs by 6 or 7 percent a year anyway unless something else is done, he said.

That "something else" is what Aaron calls the "second stage" of cost control. It's a much more complex step, requiring choices that no one -- doctor, patient or politician -- likes to make.

Aaron and Dr. William B. Schwartz, professor of medicine at Tufts University School of Medicine, recently completed a study of how these choices are made in Britain, a country which spends half as much per person as the United States on health care.

Some medical services widely available in the United States are strictly rationed in Britain, Aaron and Schwartz report in their book, "The Painful Prescription." For example, British doctors order half as many X-rays per capita as their American counterparts, and use half as much film per X-ray. They do one-tenth as much coronary artery bypass surgery. British hospitals have one-sixth as many CAT scanners and less than one-fifth as many intensive care unit (ICU) beds.

*Half the patients with chronic kidney failure in Britain are left untreated -- and die as a result.

Their most remarkable finding was not that trans-Atlantic differences exist in the practice of medicine, but that medical rationing is so readily accepted in Britain. No angry queues form outside the dialysis center, no great uproar occurs in a system that routinely denies people care.

The key to the British system, they contend, lies not in regulation but in a different attitude toward medicine, mortality and the scarcity of resources.

Unlike their American counterparts, who tend to believe in saving lives at all cost, British doctors define "what is best" in terms of "what is available," Aaron said.

As the director of a tiny 10-bed ICU in an 800-bed London hospital put it: "Yes, this would be too small in America. But if you took this unit and set it down in Sri Lanka or India, it would stick out like a sore thumb. It would be an obscene waste of money."

The burden of enforcing medical rationing in Britain falls mainly on doctors, who act as "gatekeepers" in the system. They know funds for kidney dialysis are limited, so they simply don't refer older patients for the life-saving treatment.

Asked how he could turn away over-55 kidney patients from life-saving dialysis, one doctor told Aaron and Schwartz: "What you don't seem to understand is that everybody over the age of 55 is a bit crumbly."

"As alien as that sounds to us," Schwartz said at a recent National Institute of Medicine symposium, "it may in the future not be so alien if we really mean business about cost-cutting."

Other factors help make medical rationing politically feasible in Britain. Most doctors, as salaried employes of the National Health Service, don't suffer financially from cutbacks in care. Malpractice suits are discouraged. And British patients are more accepting of a doctor's authority.

"Next to the Queen," Schwartz said, "the National Health Service is the most popular institution in Britain."

It will be "a lot harder to move into this second stage of rationing in the U.S.," Aaron warned. "The American public has not yet begun to understand what is being asked of it when it comes to limiting the growth in hospital spending." has not yet begun to understand what is being asked of it when it comes to limiting the growth in hospital spending."