Patricia Hughes felt the pain in her chest while at work.

A nurse in West Ashley, Hughes drove to the emergency room at nearby Bon Secours St. Francis Hospital, where she underwent tests. Hours later, she was transferred by ambulance downtown to Roper Hospital, where doctors kept her overnight for observation.

Eventually, the chest pain was blamed on stress. Beside those tests, including electrocardiograms, she received little other treatment.

Her bill was $7,800.

Though their insurer paid much of it, Patricia's husband, Howard, still wonders why and how his wife's 27-hour trip through the health care system last year cost so much. Most of the time was spent simply resting with a monitor attached to detect any problems with her heart.

"I just don't understand why, year after year, hospital costs and health care costs far exceed the cost of living," the Mount Pleasant resident said.

For decades, the cost of health care has been rising much faster than inflation, except for a short break in the mid-1990s, during which managed care reigned.

By 2002, health care spending in America amounted to $1.6 trillion. That's nearly 15 percent of the gross domestic product, the measure used to indicate the size of the national economy.

The pain of these spiraling costs affects just about everybody: the Hugheses and millions of Americans like them; insurance companies; workers who have seen health costs rise four times faster than earnings and whose pay raises are easily swallowed by increases in premiums; andstate governments across the nation who are struggling to cope with Medicaid costs.

Last month, the Congressional Budget Office warned unless something is done soon, federal spending on Medicare and Medicaid could account for 11.5 percent of the economy by 2030 compared with 3.9 percent today.

Americans pay twice as much for health care per capita as do residents of other industrialized countries. Life expectancy rates, however, are no better.

How did it get to this? For doctors, patients and policy experts, the answers are numerous, complex and unending.

They point to administrative costs, a misplaced emphasis on treatment rather than prevention, the decline of managed care, competition and demands by Americans to the best and latest medical advances.

In other words, practically everyone contributes.

ADMINISTRATIVELY COMPLEX

For starters, health care has become a huge and expensive bureaucracy.

Consider that the Medical University of South Carolina has 58 billing workers for a hospital that charged patients and insurance companies $900 million last year (although it collected reimbursements that amounted to far less).

"I don't know of any industry where the billing cycle is so complex," said Lisa Montgomery, the hospital authority's chief financial officer.

Indeed, the health care system today is a maze of doctors' offices, clinics, hospitals, nursing homes, home care companies, drug companies, pharmacies, intermediaries and insurance companies, all wrapped together by massive amounts of red tape.

A study by researchers at Harvard University and the nonprofit group Public Citizen found the health care bureaucracy cost nearly $400 billion last year, representing at least 31 percent of the nation's health care spending.

Unlike most businesses, where a customer pays a business for a service either with cash or credit, most patients pay a fraction of their health care bill. Most of the expense is paid by an employer and an insurance company, or by Medicare or Medicaid. Each of these pays a different amount for the same procedure.

Sorting through all of that requires a lot of work.

Additionally, within a hospital, doctors and other specialists are often employed by different medical groups or practices, each with its own staff of billing clerks and, sometimes, different contracts with insurance companies.

Consider the Hughes' experience. Patricia's stay in the Roper St. Francis system resulted in seven different bills: one for St. Francis, two bills for the ER doctors, one for the ambulance that transported her from one facility to the other, another for the stay at Roper (although it's owned by the same hospital company), one from the doctor there, and a seventh from the pathology lab that interpreted a test.

"I think we pay an awful lot for health care in the United States because we've made it so administratively complex," said Lynn Bailey, a health care economist in Columbia. "You've got to wonder what they could do if they were doing something else besides chasing insurance companies."

PREVENTING PROBLEMS

You can't talk about the cost of health care in America without looking at Americans' health.

We're getting older. We're getting fatter. And many of us still smoke.

The aging of the population makes higher health care costs almost inevitable. By 2030, the Census Bureau estimates, one in five Americans will be over 65.

Average life expectancy is now 77 years. Our longer lifespan, the result of a century's worth of medical advancements, means the health care system is doing its job. Yet, the older we get, the more services we consume.

"We've been successful in prolonging life," said Dr. Jerry Reves, medical school dean at MUSC. "But as you prolong life, (people) develop more chronic illness and more age-related deteriorations."

These conditions are expensive to address.

Similarly, obesity is on the increase. In 1991, just 12 percent of adults were obese. By 2001, that figure grew to 21 percent.

The Centers for Disease Control and Prevention describes obesity as an "epidemic."

Weight problems are the cause of many health issues, including high blood pressure, heart disease, stroke, asthma, osteoarthritis, Type 2 diabetes, sleep apnea, muscle disorders, pregnancy complications and various types of cancer. All are potentially expensive to treat.

An obese person may generate 36 percent more in health care costs than does an average-weight adult, according to the U.S. Department of Health and Human Services.

Smoking, meanwhile, is the most preventable cause of death and disease, yet 46 million Americans still light up.

Tobacco use can cause chronic lung disease, heart disease, stroke and several forms of cancer, plus a variety of other problems. According to the government, about 14 percent of Medicaid expenses are related to smoking.

The problems with obesity and smoking highlight an issue related to problems in today's health care system. Many of the diseases and conditions that contribute to much of the nation's health care bill are preventable.

Studies have consistently found 20 percent of the people -- smokers, the overweight and others who do little to watch their health -- generate 80 percent of the nation's health care bill.

Similarly, high blood pressure, or hypertension, can be easily controlled with routine drugs that help prevent heart attacks or stroke. Yet, less than a third of South Carolinians with high blood pressure have it under control. Most continue with the condition because of inattention to their health.

The biggest problem, according to experts, is that the health care system is designed to treat a problem only after it arises. Too little money is spent on prevention, they say.

THE UNINSURED

Health care costs also are rising because of the rising number of uninsured Americans.

In South Carolina, the uninsured represent about 12.6 percent of the state's population, or 500,000 people. Nationwide, about 43.6 million people don't have coverage.

Many are young people of varying incomes who feel they have no need for coverage because they are relatively free of health problems.

Others want it but can't get it because their employer doesn't offer insurance, or because they're unemployed, or they can't afford the premiums.

The uninsured avoid seeing doctors before their conditions worsen and seek treatment only when their health becomes seriously eroded.

Many of these patients' bills go unpaid, and thus the cost is spread to those with health insurance. According to the Institute of Medicine, the uninsured cost the nation as much as $130 billion a year.

"We're paying that (much more) because hospitals and physicians have to charge more to make up for the non-pays," said Viki Fox, who is heading a study of the uninsured for the state Department of Insurance.

Many experts say one of the best ways to control health care costs is to cover the uninsured. Others disagree.

Sam Baker, associate professor of health services policy and management at the University of South Carolina's School of Public Health, said doing so may be good public policy, but covering this population would still lead to higher costs overall.

"I think neglect is probably cheaper overall," he said. "It's true that these people get care in very costly settings when they get it, but what they don't get is probably more (costly) than what they did get."

TOO MUCH HEALTH CARE

That notion exposes the flip side of the question. Do Americans expect and receive too much medical attention, and how much is necessary?

To some, especially insurers, the nation is confronted by the health care cost crisis because it rejected managed care.

Managed care sought to reduce unnecessary expenses by setting up filters -- some view them as roadblocks -- designed to make sure people didn't get unnecessary procedures.

That approach worked, though people deplored managed care's "gatekeepers," and companies abandoned HMOs.

Meanwhile, Ed Sellers, chief executive at BlueCross BlueShield of South Carolina, has often pointed the finger at the massive amount of construction that goes on in health care.

Sellers uses an analogy to make his point. If a city is flooded by too many car dealerships, eventually there will be more cars for sale than people willing to buy them. But the health care system works differently. Hospitals, Sellers says, know if they build a new facility, they won't have trouble finding patients to fill it.

That's because doctors and hospitals are the ones ordering tests and procedures, Sellers says, and patients often simply do what they're told. So while reimbursements to providers may not have gone up in recent years, health care costs have climbed because doctors are ordering more tests, he says

Hospitals dismiss this notion. They say it's a flawed line of reasoning conjured up by insurers. They also point out that South Carolina regulators won't let them build new facilities unless they can prove expansion is needed.

Still, there is evidence backing the insurers' contention. A 2000 study by the Health Research and Educational Trust found people who live in areas with more hospital capacity are more likely to use the hospital, even after the study factored out socioeconomic differences and illnesses.

The study also discovered additional hospital stays did not lead to better health.

RISING OVERHEAD

Health care providers say another factor contributing to rising costs is their own rising expense for items that include salaries and premiums for malpractice insurance.

Staffing shortages have hammered health care in recent years. Demand is high for anesthesiologists, radiologists, pharmacists, X-ray technicians and, most notably, nurses.

Increased competition for these workers has driven up salaries, which make up the bulk of a hospital's costs.

"The competition drives those costs up," said Reves, the MUSC dean. Those costs get passed on to patients and insurers.

The same holds true with premiums for malpractice insurance, which have been rising rapidly around the country. In South Carolina, they rose an average of 24.1 percent this year, although, some note, they remain low compared with neighboring states.

Nevertheless, higher premiums lead to higher costs. Doctors take on more patients to meet their overhead costs. Some say they also end up practicing defensive medicine, ordering unnecessary procedures and tests, out of fear they may be sued.

NEW TECHNOLOGY

Among these reasons, possibly the biggest factor is the vast amounts of new technology, treatments and prescription drugs on the market.

In other industries, new technology generally reduces costs by improving productivity, but advances in health care technology lead to increases because consumers end up paying the cost of research that goes into developing the drug or making the machine.

Many critics complain some of this technology leads to overuse. There also is criticism aimed at drug makers who try to squeeze out makers of cheaper generic medications.

Others point out that new technology has prolonged lives and made available advances unheard of not long ago. Doctors can now treat low-birth-weight babies who might not have survived only a few years ago. Surgeons can transplant organs or give a person a new hip and have them on their feet in a few days.

All of that, of course, costs more money than ever.

Jonathan Maze covers health care and nonprofits. Contact him at jmaze@postandcourier.com or 937-5719.