The central cause of runaway health spending is clear. Hospitals and doctors are paid mostly on a fee-for-service basis and reimbursed by insurance, either private or governmental. The open-ended payment system encourages doctors and hospitals to provide more services — and patients to expect them. It also favors new medical technologies, which are made profitable by heavy use. Unfortunately, what pleases providers and patients individually hurts the nation as a whole.

What’s needed is a fundamental remaking of the health-care sector — a sweeping “restructuring” — that would overhaul fee-for-service payment and reduce the fragmentation of care.

The place to start would be costly Medicare, the nation’s largest insurance program serving 45 million elderly and disabled. Of course, this would be unpopular, because it would disrupt delivery patterns and reimbursement practices. It’s easier to pretend to be curbing health spending while expanding coverage and spending. Presidents have done that for decades, and it’s why most health industries see “reform” as a good deal.