Not long ago, national health insurance was a dream whose reality was fast approaching. Today it is an idea whose time has passed. The goal of universal health care coverage had to be scrapped for the realization that the nation simply could not foot the bill if full coverage were to be extended to all. Putting on the economic brakes is the task at hand.

One approach, that of the health maintenance organization, offers a full-care package for a set annual fee. Another, more recent alternative-- what Stanford's Alain Enthoven calls the "consumer choice" concept-- would unleash conventional market forces to temper costs through competition among providers of care. Whatever merit these plans may have, the fundamental question remains: even with HMOs and consumer choice, can we afford universal entitlement to the ever expanding capabilities of modern medicine? Health care costs are rising in HMOs as elsewhere, and the consumer- choice approach, if it were politically acceptable, might well be transient at best in its impact. Regardless of how any payment scheme might slow the escalation, health care for everyone-- of the quality we can provide, for all of today's illness--is too costly. The extravagance of our present health care system will ultimately override the impact of any payment arrangement. Economic reform, while necessary, must be secondary to the reform of health care itself.

As a nation we look at health care primarily as treatment of disease. We view cost as payment for sickness, and point toward more-sickness-better- treated per unit of resource. Under such a scheme, the cost crisis can never be solved. Even if the surgeon could speed up performance of, say, a gastrectomy, more gastrectomies would always cost more money. But if that surgeon were able to prevent some patients' ulcers from developing in the first place, what then of productivity? Changing our approach from sickness-treated per unit of resource to health-engendered per unit of resource could lead to a major reduction in the overall cost of the system.

The prepaid group arrangement made its impact through a sharp decrease in days of hospitalization per patient. Now, beyond whittling away at unnecessary hospital days and operations and laboratory tests, we must reduce illness itself and engender health. Consumer choice and similar programs also reorder economic incentives but still focus upon purchase of treatment instead of the greater economy of maintaining health. Our prime economic imperative must be to invest in health rather than in sickness.

Our investment must be threefold: prevention of illness through life style changes, prevention of illness through basic biomedical research, and rational restraint in the application of therapeutic measures.

To take the last issue first--I do not suggest denying care to the patient who can be salvaged, or even reasonably maintained, but simply emphasize that preserving what once was a person but is now lost, not only denies humaneness of care and dignity to the dying but consumes resources for ends that benefit neither the patient nor society.

Prevention of illness through life style changes may be even more difficult than reasonable care of the dying --witness our sorry record in discouraging smoking, obesity or alcohol consumption. And once we learn how to encourage healthier life styles, we will have to confront their economic consequences, since our unhealthy life styles fuel major portions of our economy.

Finally, consider the importance of research. Given our nation's wealth, we spend relatively little on basic biomedical research. Yet the achievements of such research have been spectacular, not only gains in knowledge, but in solid economic returns as well, such as in the development of vaccines against polio and measles. The answers to such scourges as cancer and heart disease, which can shorten our lives, or Alzheimer's disease, which can enfeeble our last decades, will come ultimately from basic biomedical research. To sacrifice such effort is false economy.

In the months ahead, debate will intensify on the costs of health care, with competition, market forces and the consumer choice approach among the possible answers. Medicare and Medicaid reimbursement will tighten further, even though such restrictions tend to shift costs from government to the private sector more than limit expenditures for care.

Attention today to controlling reimbursement and to reordering economic incentives, however, must not be allowed to push aside the more basic national need: reordering the nature and extent of illness itself. To shepherd our resources we must move beyond paying for sickness to preventing it, beyond restoring good health to engendering it. Otherwise we shall never be able to care properly for all who do become ill. We must move beyond the short-term gains to be gleaned merely by rearranging the economic incentives. We must enlarge our vision and look beyond today's economics to tomorrow's health, where the real savings are to be found.