But Obama’s promise sent the reform effort off the rails. It meant that efforts to expand coverage marched ahead, but efforts to fundamentally reform the system got watered down.

Instead of true reform we got a series of bills that essentially cement the present system in place. The proposals do not fundamentally challenge the fee-for-service system. They don’t make Americans more accountable for their own health care spending. They don’t reduce costs. They just add more people into the mess we’ve got.

The president made this promise to ease passage. But it ended up hollowing out the substance of the reform. And the political benefits didn’t even materialize. Voters are still spooked by the costs, the centralization and the cuts they are sure will come.

If I had a magic hour with the president, I’d tell him this is his ninth-inning chance. He can stay on the current path. He might be able to pass some incremental bill that extends coverage. But he won’t have tackled the fundamental problems that first drove him to this issue. He won’t have cut health care inflation. He won’t have prevented a voracious system from bankrupting the nation, defunding the schools, pushing down wages and impoverishing the young.

On the other hand, he can shift back to the core issue: the perverse incentives that make this system such a mess. He can embrace proposalslike the Brookings proposals or, more comprehensively, the Wyden-Bennett bill  that address the structural problems instead of simply papering over them.

This remains a politically risky strategy. There are many industries that have an interest in making sure health care spending rises to 20 percent of G.D.P., and then 22 and then 24. But the president’s in political hot water already. He got there trying to dodge the hard issues. He might as well be there because he’s fighting for something real.

There are many people telling him to go incremental. They’re telling him to just enlarge the current system a bit and pay for it by pounding down a few Medicare fees. But did Barack Obama really get elected so he could pass the Status Quo Sanctification and Extension Act?

This is not the time to get incremental. It’s the time to get fundamental. Reform the incentives. Make consumers accountable for spending. Make price information transparent. Reward health care, not health services. Do what you set out to do. Bring change.