In devil-take-the-hindmost fashion, the problem of restraining national medical spending is being partially met -- through the deterioration and collapse of health services for millions of the nation's inner-city poor.

The process amounts to a gory scandal, largely obscured by the political inarticulateness of the victims and by the correct, but limited, perception that American medicine suffers from too much doctoring at too high prices. What's left out of that picture is that, for perhaps as many as 20 million people, the nearby city or county hospital not only is a hospital; it's also "the doctor," since private practitioners generally have a strong aversion to setting up shop in nasty neighborhoods.

Now, as a result of acute inflation in all things medical, plus anti-tax politics and spotty coverage provided by the supposedly safety-net Medicaid system, many of these hospitals are financially foundering. Their difficulties are regularly compounded by medicine's unspoken class system, which routes insured patients to less desperate institutions; at the same time, the big inner-city public hospitals serve as the dropping-off place for patients who have no way to pay their bills.

"Dumping," as it's known, sends about 2,000 patients each month to the Los Angeles County Hospital. The inevitable response to deficits is a reduction in services, and, in several recent instances, hospitals have been shut -- regardless of the population dependent on their care. How many hospitals are skidding toward the brink? No one knows for certain, but the figure is generally thought to be at least 200, though the economy of medicine for the poor is probably far worse than it looks.

In a recent talk to the American Hospital Association, Nathan J. Stark, undersecretary of health, education and welfare, pointed out that over 40 million Americans are either uninsured for medical care or have extremely limited insurance. He also noted that the poor, for lack of accessible alternatives, have forced the emergency rooms of inner-city hospitals to function as general practitioners' offices -- at "staggering" costs, given the expense of equipping and staffing a modern emergency facility.

And then, summing up these and other inadequacies of inner-city health care, Stark observed, "These are serious problems which have so far defied solution." What he didn't address himself to is why.

The answer, of course, is that regardless of what the critics have to say about the health value of health care, Americans want it -- nearby, in plentiful supply and waiting to serve them. And those who know how to use the political system -- prominent among them being organized labor, government employees and professionals -- are more concerned with availability than cost. Very few complaints about the cost of medical care actually emanate from the heavily insured segments of the population. That may be changing as health-insurance premiums run wild. But for its beneficiaries, the system has been satisfactory. And they've responded with political support, if only of a tacit nature, for letting the health-care industry make its own economic rules.

Indifference to cost containment doesn't mean, however, that ever-upward is to be the story of money and medicine. Something has to give. And what's becoming plain is that it's not to be the gold-plated segment of the system that beckons foreign royalty for what's touted as the best medical care in the world -- also available to you and me, if our health insurance is paid up.

The issue was never whether we're to have cost containment. Rather, it's always been just whose costs are to be contained. And the answer that's being imposed on the inner cities is that the savings will be exacted from their already inadequate system of health care.