One of the casualties of Hillary Clinton's sniper fire fib and the refusal of Barack Obama's former pastor to shut up has been a serious presidential-level debate about health-care reform. Of course, that assumes a serious debate is possible.

Take your pick -- Clinton, Obama or Republican nominee-to-be John McCain. None is really discussing the health-care reform we need. They're talking only about health insurance and who pays for it. Even if our next president implements a plan that gets everyone covered, it's doubtful our healthcare woes will be solved.

Just look at Massachusetts.

In 2006, the Bay State passed a law requiring each citizen to carry health insurance, much like North Carolinians are required to have auto insurance. For those who could not afford traditional plans, the state set up a taxpayer-subsidized option. It's been in place for nearly a year. The good news is that about half of the uninsured have signed up. The bad news: Wait times to see a doctor have exploded. And so have costs.

It seems Massachusetts, a small state with four world-class medical schools, doesn't have enough general practice physicians to fill the needs of approximately 350,000 new patients. It also doesn't have the money. Funding for the second year of the government-subsidized insurance plan is about $100 million short, a deficit lawmakers are thinking of covering with higher tobacco taxes.

If Massachusetts can't make this model work, it's not likely a national-scale program will do much better. Medicare, the American model closest to universal health coverage, is generally loved by its beneficiaries, but the program has one major problem: It threatens to bankrupt the country, even more so than Social Security.

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ONE OF MEDICARE'S DIRTY LITTLE SECRETS is that, increasingly, it pays the bills for rich seniors who could pay for their own health care. These days, Medicare rarely makes health care available to an aging population that never had it. Typically, it just assumes health-care costs that previously were handled in the private sector.

Clearly, insurance coverage is not the most critical health-care problem we face. It's the unrestrained costs. What's sorely missing in the discussion by the presidential candidates is the role of the most effective cost control in both the private and publicly funded health-care arenas: us, the consumers. Today, cost is rarely, if ever, a factor considered by patients. But it should be, even in the most critical cases.

The American Society of Clinical Oncology has undertaken a groundbreaking initiative to develop guidelines for its members to use in discussing the cost of treatment with patients. This is of particular concern to oncologists because cancer treatment costs are rising approximately 15 percent per year.

Leonard Saltz of the Memorial Sloan-Kettering Cancer Center explained to the Associated Press that some patient choices will be gut-wrenching. For example, the drug Tarceva, used to fight pancreatic cancer, costs approximately $4,000 a month. Although the drug has remarkable success stories, on average it offers patients only a few more weeks of survival. Is the money worth a few extra weeks? That's a judgment only a patient can make, but the price of the treatment is rarely a factor a patient is encouraged to consider.

Informed patient choice is also critical in combating higher costs for prescription drugs. Pharmaceutical companies deserve praise for the lives saved by their products and research. They also deserve scorn for exaggerating ailments to push their own prescription drugs.

Shannon Brownlee, an author and senior fellow at the New America Foundation, cites Glaxo's Zantac as the pioneer of "condition-branded" marketing in which a minor ailment is positioned as a precursor to a more worrisome condition.

In Zantac's case, the problem is heartburn. Glaxo (now GlaxoSmith Kline) warns that heartburn could be a sign of acid reflux. True. But Brownlee counters that most cases go away without treatment. And good old Alka-Seltzer still licks heartburn without a costly doctor visit or prescription.

Health care is a complicated issue that won't be cured by a single presidential diagnosis. My support will go to the candidate who sees the informed patient as an integral part of the cure, instead of a symptom to be treated.