We will never reform or improve our system of paying for health care as long as policy wonks are in charge of the debate.

There is no shortage of talk about how to make improvements. Some of it — for example the approach advocated by former Gov. John Kitzhaber — makes a good deal of sense. But these ideas never seem to get anywhere. And now we have a clearer idea why.

A recent edition of Brainstorm magazine contains an essay by Mark Ganz, the head of the Regence Group health insurance group in Portland.

He argues that the only way to reform the system is to make a “significant shift in our health care culture.” The current culture, he maintains, spawns an “entitlement mentality among every stakeholder, which leads to an unsustainable level of resource consumption and spiraling costs that ultimately push people out of the system.”

Mr. Ganza is part of an effort to shift the debate. It’s called the Aspen Health Stewardship Project. Among the things he says the project team will do:

* “Identify specific areas in the health care system where the culture of control is highly pervasive and develop specific actions for countering that control model. We will also determine how broader cultural norms affect the strategic and cultural fit of any reform proposal.

* “Frame the health care reform debate on the right terms: Outline the fundamental areas any serious reform proposal must address to create a sustainable economic and care model that will best serve our country ... .”

Good luck. But don’t get your hopes up. Shifting the debate, or framing it, studying cultural models and trying to change — all that does not hold any promise for fixing the the problem in the lifetime of anybody now living.

The problem is simple: Medical attention costs too much. And because it costs too much, lots of people could not afford it without insurance. But with insurance, they don’t care what it costs because they don’t have to pay.

Why does it cost so much? Because we want the best.

Suppose a doctor thinks somebody might need a heart exam, the kind where they run a tube up a vein from your leg and into the heart. The patient has pretty good insurance, so nobody asks the price. Appointments are made, the exam is performed and the specialist at the Corvallis hospital says great, there’s not a problem. The patient doesn’t get the bill but sees the paperwork: Several thousand dollars. And that’s for somebody in good health.

Such procedures are performed as a precaution because it is possible to perform them. Skill and advances in technology have made many things possible in medicine, and they all cost a bundle. We all want everybody to be infinitely cautious. If they’re not, we sue.

That will never change, And so, no amount of policy wonking will reduce the cost of medicine.

When medicine was inexpensive, doctors listened to your heart, prescribed some pills and sent you home. And maybe three months later you were dead. And yet there was no talk of a health care crisis. Everybody realized that people lived only so long, that very often they got sick, and in the end everybody dies.

We’ve gotten away from that because of progress. We’re not willing to roll back progress, so now we have to pay the cost. (hh)