We spend more than $2 trillion on medical care, but 45 million Americans lack health insurance. And most Americans with health insurance still worry about whether it will continue if they or their relatives become seriously ill.

Something needs to be done, as both presidential candidates acknowledge. So what reforms do they propose, and how do they match up against the problems cited?

Insurance coverage and the cost of care are the leading problems. The candidates' approaches to each reveal fundamental differences on how to expand insurance, and superficial similarities on how to control costs.

John McCain's approach to expanding insurance relies on tax credits, substituting $5,000 a family for the tax deductions that currently underwrite employment-based health insurance. The image is that of individual consumers shopping around for coverage by insurance firms relieved of burdensome state regulations. The method is orthodox Republicanism, using direct cash payments to make the market for health insurance work better.

However, there is no evidence whatsoever that consumers shopping around for insurance will countervail the inflationary forces in medical care. Nor is there any basis for believing that the initial subsidies will buy decent coverage; families today pay an average of $12,000 a year for health coverage.

By contrast, Barack Obama's plan relies on employment-based coverage and the regulatory constraints McCain would scrap. Obama would also require firms either to provide health insurance or pay a percentage of their payrolls to support another option for those not insured at work.

This is the familiar "pay or play" option of the last Democratic health-care reform attempt in 1993-94. And, in another expected appeal to Democratic orthodoxy, Obama would pay for increased subsidies with tax increases on the wealthiest Americans.

Both options for expanding coverage, then, are familiar, but Obama's approach would more reliably accomplish that purpose.

The most striking gaps between problems and plausible remedies arise in how both candidates approach the cost issue. Both suggest that more prevention or "wellness" programs will work as anti-inflationary devices. Beyond that, there are repeated appeals to the substantial cost savings that better information technology can bring. If we just had better clinical research and electronic medical records, the theory goes, we could save billions by paying only for what works, helping doctors learn what that is, and avoiding mistakes.

All of these ideas have merit. But as answers to the persistent inflation in medical prices, private-insurance premiums, and government health expenditures, they reflect wishful thinking. They rest on aspiration, not established cost-control practice.

When the campaigns claim that countries such as Canada have shown these savings are attainable, citizens should be warned. No industrial democracy has controlled the costs of universal coverage by these means. And, to the extent information technology and paying for performance are employed today to improve care, they are as likely to increase costs as they are to decrease them.

Really controlling costs requires restraining salaries in the health-care industry. It's a controversial task, not a fashionable platitude.

The candidates' common appeals to prevention, wellness, improved protocols, and more accurate information are worthy but largely irrelevant to cost control. Indeed, it is hard to come up with innovative, effective mechanisms of reining in costs, even after a hundred years of reform talk and practical experience here and abroad.

After decades of attention to American medical care's woes, we now have a debate largely of the deaf. Claims are made without anything remotely like adequate documentation. Aspirations are lauded for their appeal to the party faithful, while serious suffering takes place in the fraying parts of the American nonsystem for financing medical care.

One views this exchange of familiar hopes, rather than solid reform plans, with sadness.

Sad as it is, however, it's no accident. American health policy debates have for some time been dominated by technical fixes, faddish nostrums and gimmicks. The news cycle of commentary about reform ideas is both brief and superficial. The journalistic norm of balance means sensible and non-sensible ideas are given equal time.

No wonder, then, that the campaigns appeal to the ideological fundamentals of their party faithful. And no wonder, either, that we learn so little from one period of reform debate to another.