NO trees grow to the sky, and no sector of our budget can continue to grow at the rate of health care for the last 30 years. It is common knowledge that the United States spends more (in total dollars and per capita) on health care than any other country, and that it is growing at more than twice the rate of inflation. But we don't know what to do about it.Let me suggest four harsh realities that must be accepted if we are to thoughtfully contain health-care costs: * There is little correlation between how much a nation spends on health care and how healthy it keeps its people. We spend 12 cents out of every dollar on health care, but do not keep our people as healthy as people in Europe, Canada, or Japan. Health care and health are not Siamese twins - they are distant relatives. A nation's smoking and drinking habits, its diet, its public-health measures, whether or not it makes basic health care available to all of its people, and how it organizes its health care all are more important than a nation's spending level. America, in my opinion, already spends far too much on health care, and any reform should fund the inadequacies of our nation's health-care system by diverting money from its many excesses. * Every nation in the world rations medicine. Simply put, the miracles of medicine have outpaced the ability of even wealthy societies to pay for them. The US rations health care by price and by leaving 37 million people out of its basic coverage. England and a number of other nations ration health care by queuing. Some seek to set priorities in heath care, as the state of Oregon is now attempting. But no nation can afford to deliver all the health care that is arguably "beneficial" to all of its citizen s. Innovation grows faster than our ability to pay for it; we must have the maturity to admit that, as health-care economist Victor Fuchs says, "we can't give presidential health care to all Americans." * We must also recognize that every nation - even the most egalitarian and socialized - has more than one level of health care. If you have money in Sweden and need a procedure not covered by the government health-care program, you can go to England or the US. In Great Britain, Canada, and India, if a procedure is not covered by the basic health-care program, there are private doctors and hospitals that can meet your needs. In the US, we tolerate money being able to buy better food, better housing, better education, and never give it a thought. In our other publicly funded systems, we give people public housing, but don't buy them houses; we give them food stamps, but we do not allow them to charge in restaurants; we fund public education, but we do not send people to private schools. Searching for a one-level health-care delivery system is a chimera! It doesn't exist. The compassionate search should be to find the highest possible level of basic health care that can be delivered to all the people. Other nations may limit some high-cost procedures in their basic health package, but they argue that it is better to ration procedures than to ration people - as we do in the US. * Last, no other nation spends as much as the US on the beginning of life or the end of life. No other nation takes 90-year-olds with congestive heart failure out of nursing homes and puts them in intensive care units for their last few days of life. No other nation gives chemotherapy to 85-year-olds with hopeless metastatic cancer. No other nation spends as much money trying to save premature infants. In Sweden, they don't try to save any baby under 700 grams. They can prove to you that, in the world of limited resources, it is better to spend your money on prenatal care rather than postnatal salvage. They are aghast that we spend so much money on high-cost neo-natal care units, but don't give all of our women prenatal care. "By not asking how do you buy the most health for your society," they would argue, "you ignore the strategy that would actually save the most babies." Spending money on Smith for procedure A prevents us from helping Jones pay for procedure Z. We live in a new world of trade-offs - and the earlier we recognize this, the healthier we will be. The chief obstacle for health-care reform in the US is the unrealistic expectations of the American public. We continue to think that we can deliver all of the health care that is beneficial, even at the margin, to all of our citizens. Alas, we cannot. The good news is that we can give better health care for less money to more people if only we will confront some of these harsh realities - and make some hard choices.