WHATEVER ITS reasons, the DMA cannot deny the tremendous pressure it’s under to hold down ever-escalating expenses, including prescription-drug costs. In recent years, spending for the MassHealth program has spiraled out of control. Last year, for example, the DMA budget hovered around $4.3 billion — almost 20 percent of the state’s entire $21.3 billion budget. Yet the agency ended the fiscal year $188 million short, and DMA officials had to ask the legislature for a supplemental appropriation to cover the deficit last June. This number represented the largest MassHealth shortfall in a decade — until today. This year, the DMA has filed for a $258 million supplement that will bring its total budget up to $4.8 billion.

The DMA’s exploding budget seems to have prompted dramatic action. Consider the agency’s prior-authorization policy, which specifies that certain drugs must receive approval from the DMA before it agrees to pay for them. Most insurance companies, both public and private, use this technique to make sure prescribed medication is the most suitable, least expensive form available. Last year — just months before reporting its multi-million-dollar shortfall — the DMA took the unusual step of adding to its prior-authorization list as many as 66 brand-name medications that had been routinely covered for years, including Motrin, Tylenol with codeine, and Demerol. In a March 2000 bulletin to MassHealth pharmacists, Mark Reynolds, then the acting DMA commissioner, alluded to soaring drug expenses by describing the new policy as essential for ensuring “the most appropriate, efficacious, and cost-effective medications.” Yet the move left scores of MassHealth recipients statewide without routine coverage for standard muscle relaxants and nasal decongestants. As a result, Elizabeth Silver of Springfield-based Western Massachusetts Legal Services sued the DMA on behalf of two MassHealth members. The problem, she explains, was not that the agency added the drugs to its list. It was that patients who followed the agency’s rules for prior approval — by having their doctors provide letters explaining why the patients need the drugs — still were denied coverage. The lawsuit, filed on May 31, 2000, prompted the agency to drop its newfound practice last fall. Silver suspects that the policy had amounted to one thing all along: “It appears these were cost-cutting measures. It appears [officials] were using this procedure to ration health care and health-care dollars.”

That wouldn’t surprise many health-care experts. According to Arthur Caplan, who directs the Center for Bioethics at the University of Pennsylvania, when any insurance company denies coverage — especially for non-experimental, proven treatment — the issue “almost always has something to do with money.” He adds: “No matter what, cost is a concern.”

Insurers, after all, cannot afford to pay for every treatment or medication that every recipient might request. And so they often limit coverage — and thus costs — by relying on what BU’s Mariner calls “the old language” of “medical necessity.” The term, she says, can have several meanings. Typically, it refers to the idea that treatment for a significant medical condition should be limited to measures that will benefit the patient, but offer only a basic level of care. For instance, it may be medically necessary for someone with a broken leg to have a cast and crutches, but not a wheelchair. It may be medically necessary for a person who suffers pain to have prescription drugs, but not costly brand names.

“The notion of medical necessity is really a spectrum,” Mariner says. Because technological advances in medicine have broadened what may constitute a medical necessity, she notes, “obviously, there’s a lot of room for judgment” among insurers.

And experts say that judgment, particularly for public insurers, can be driven by considerations beyond immediate patient needs. Mariner notes that, unlike private companies, the MassHealth system “has two competing obligations,” because the DMA must offer adequate health care to hundreds of thousands of MassHealth recipients using limited public funds. On the one hand, it has a duty to give an individual member the best possible treatment. On the other hand, it must consider how each decision about one member affects the entire membership. MassHealth, explains Mariner, “is always walking on a tightrope,” balancing one member’s needs against those of others. Officials must ask, “Do we approve payment for a very expensive medication for one person? Or do we pay for drugs for 100 people instead?” “This is a real dilemma,” Mariner says. “These are equally justifiable goals.”

Moreover, the system faces special political constraints. Currently, according to Caplan, Medicaid has become the “most explosive area of cost growth” for states across the country — so much so that “lawmakers view the program as a major drain on other state programs.” The public, meanwhile, has never responded well to the idea of tax increases — especially to pay for services for the poor. So officials are, as he puts it, “desperate to find ways to decrease that expenditure.”

MILLIONS OF people, of course, have found themselves, like Leto, caught in the whirl of today’s spiraling health-care economy. Alan Sager, a health-services professor at BU’s School of Public Health, estimates that well over 70 million Americans are forced to pay thousands of dollars out of pocket for medications because they lack adequate prescription-drug coverage. “This is a tragedy,” Sager says. “Crazy prices lead to horrible dilemmas for people. It’s suffering versus dollars.”

Sager says cases like Leto’s show how the federal government has failed to “protect us from the outrageous drug companies.” He argues the US could, indeed, find a way to finance skyrocketing medication costs — for example, by eliminating the administrative waste that stems from a fragmented system. Consider that US health-care spending will amount to about $1.4 trillion this year. Of that figure, Sager reasons, 20 to 30 percent goes toward administrative costs, but he believes that only 15 percent of the total bill would be adequate to cover administrative expenses. Administrative savings, he believes, could yield anywhere from $70 billion to $280 billion — more than enough to insure those lacking prescription-drug coverage.

“This is a human-made tragedy,” he says, “and it’s completely avoidable. The dollars are there.”

The politicians appear to be there, too: rising drug costs were a dominant theme of the 2000 presidential campaign. So far, most suggested solutions amount to some variation on price regulation. Government assistance for senior citizens who are enrolled in the federal Medicare program has also been advocated.

But Leto’s predicament shows that politicians have a long way to go before they can end the raging cost-versus-care debate. If we cannot solve this question when it comes to medicine’s most extreme cases — chronically ill patients with life-threatening diseases — how can we fix the health-care system for the rest of us?

For Leto and her family, the answer seems grim. “This system,” Jefferson says, “is nothing but a slow death sentence for people like Cynthia.”

Kristen Lombardi can be reached at klombardi[a]phx.com.