The problem for every canine that ever chased a car was what to do when he caught it. That is the problem Americans have now in our chase for universal health insurance. We are going to be in big trouble when we catch it because it is going to cost so much by then we may not be able to afford it. Indeed, just when the consensus that all of us should have health insurance seems to be coming into the mainstream of American political and business thinking, our rapidly rising health care costs are driving the dream of universal health insurance further than ever from our grasp.

On a smaller scale, this scenario of rising costs undercutting efforts to expand insurance is playing out in many venues. Consider the following: Despite the fact that the federal State Children’s Health Insurance Program has provided millions of additional children with health insurance in recent years, the number of uninsured Americans has risen over the same period from about 45 million to about 47 million.

Many states are responding to budget woes by cutting their Medicaid insurance rolls after years of increasing Medicaid enrollments as a way to reduce the ranks of the uninsured at the low end of the income scale.

Further, rising health care costs and tight budgets threaten groundbreaking state government-sponsored efforts to reach universal insurance in Massachusetts and Maine, and just deep-sixed a proposed law to do the same in California. The likelihood that other states will now try innovative ways to achieve universal insurance is now smaller because while the political will may be there, the money is not.

The ranks of the underinsured are growing. These people have health insurance, but co-payments and deductibles are so large they effectively have little insurance except for catastrophic illness. Thus the number of Americans who are effectively insured is smaller than we think.

On a larger scale, rising health care costs are not simply undercutting efforts to expand health insurance, but also the entire American economy. Indeed, according to Peter Orszag, Ph.D, director of the Congressional Budget Office, in a recent commentary in the New England Journal of Medicine, “our country’s [future] financial health will be determined primarily by the growth rate of per-capita health care costs. Yet discussions of Medicare and Medicaid policy as well as broader health care reforms have not seriously addressed the issue of how to slow growth in spending.”

And there is really the point of all of this; we are talking a lot about universal insurance but not much about the fact it is becoming unaffordable. In fact, it is becoming pointless to talk about achieving universal health insurance if we are not going to do the ugly political work of reining in our costs. That is the lesson of Maine, Massachusetts, California and other struggling efforts across the country to reduce the ranks of the uninsured by increasing the ranks in Medicaid or other state-funded health insurance plans.

Despite growing evidence that rising costs are turning the dream of universal insurance into a nightmare, most of the current political debate is focusing on universal health insurance. If you ask Sens. Hillary Clinton, John McCain, Barak Obama, or any other politician these days about universal health insurance, you get a monologue about how to achieve it that comes gushing out like water from a high-pressure hose.

Ask them about how to control health care costs, on the other hand, and you get a few drips about electronic medical records, costly ER visits, stamping out Medicare fraud and getting everyone healthy. In these discussions, cost control seems politically victimless; whose ox could possibly be gored by reducing this waste except for those evil purveyors of wasted health care? And it seems easy; get health care computerized, get everyone a primary care physician so they stop going to those expensive ERs, prosecute some Medicare crooks and the job seems likely to be done. Right?

Wrong – those savings are just chump change. In fact, reducing health care waste to the extent really necessary means sharply reducing the number of tests and treatments of marginal value, and interfering with the ability of patients and physicians to make their own decisions about who gets what testing and treatment. Reducing that kind of discretion, either by market economics or other means, is how you get at unnecessary spending. It is how, for example, you correct the fact that the amount of money spent annually per capita on Medicare patients can range from about $5,000 in one area of the country to more than $13,000 in another with no difference in health status of the Medicare population served.

Given that controlling health care costs ultimately means controlling choices in health care by some mechanism or another, it is no wonder politicians trying to get elected to office would rather talk about universal insurance instead of reining in health care costs, and about waste in health care instead of the political dynamite of too much choice in health care. Sooner or later, however, they, and we, are either going to get real about controlling health care costs or have to give up the dream of universal health care insurance.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.