Can this marriage be saved? The couple argued incessantly about everything prior to their wedding: the color of the dishes, whether to have children, who would manage the money and clean the toilet. When words failed, they shouted and threw things at each other. The bride’s family refused to attend the wedding. Even the groom’s family, their ladies dressed in blue, squabbled with each other about the wisdom of the marriage.

The marital vows were full of ambiguities and many prenuptial agreements were put off into the future, subject to more research and professional counseling. When the couple emerged from the church they were greeted not with rice but with foul smelling offal thrown at them by the bride’s family, accompanied by shouted promises to do everything possible to destroy the marriage. Even so, the couple held hands, looked lovingly in each other’s eyes – and only once or twice unobtrusively kicked each other.

Well, that’s one story, the one that focuses not on the Obama triumph that the reform bill represented but on the many problems and acrimony that the actual legislation left in its wake. The other story is that it was a historically important piece of legislation, that it will not be easy to dislodge, and that if history is any guide the public will eventually come to like it, as happened with Social Security in 1936 and Medicare in 1965. Its strongest asset is that it extends insurance coverage to an estimated 33 million people, mandates preventive care under Medicare, does much to close the doughnut gap in that program’s pharmaceutical coverage, puts a comparative effectiveness program in place, and strengthens primary care.

Its weakness lies in its cost control provisions, hardly any of which are immediate and direct and most of which are long-term and indirect. During its earliest phases, moreover, many of its cost – increasing provisions will be put in place. For the next few years, then, the usual costs – that is, most of them – will continue to rise at the current 6% to 7% a year, and the economic baseline of costs will be considerably higher by the time the potential savings begin to kick in.

It was long ago agreed that the most touted cost saving measures early on – prevention, information technology, and comparative effectiveness research – hold much less promise than initially believed. As for the long-term provisions, the most promising is that of the 2015 establishment of an independent Medicare Advisory Board. It will be charged, among other things, with the tasks of monitoring and controlling Medicare costs. Its most important feature is one designed to cope with the deeply embedded resistance of Congress to setting spending limits, requiring an up or down vote on its proposals. Precisely because of its potency it will almost certainly be a target for elimination or dilution. A newly proposed Senate bill to control insurer premium increases could be helpful as well.

Many others judge it as a strong measure, but I have little confidence in the 2014 establishment of state health insurance exchanges, designed to allow individuals and small businesses to comparison shop among insurers for standardized health packages. While it is hard to say many good things about the health insurance industry, I have come to believe their claim that the background costs of the present health care system allow little room for any dramatic drop in premium prices. At best the differences among policies with comparable benefits will be marginal. Similar policies will have similar costs for insurers: company A is hardly likely to offer the same benefits as company B at 25% lower costs, any more than cars or cell phones have sharply different prices for identical features.

Often used as a model for the exchange plan is the Federal Employees Benefit Program, available to all federal employees and allowing them a wide variety of shopping possibilities. It is a bad model. Its annual cost increases have, if anything, been higher than general health care cost increases, in the 8%-a-year range. Because of the background costs in the health care system, I never believed a public option plan would have been much more successful either and would in any case have covered no more than an estimated 3% of the population.

In between my best and worst choices are some that are promising, aiming to deal with those background costs. They include efforts to embody “bundling” strategies in the Medicare program, the establishment of the Patient-Centered Outcomes Research Institute to oversee comparative effectiveness research, lowering Medicare Advantage subsidies, and reforming health insurance regulation. I shudder, however, at a provision to encourage government investment in new therapies. The private sector already has much money to do that, and the historical record shows that new therapies are much more likely to increases costs than decrease them.

Many of the more moderate opponents of the final reform bill argued for an incremental strategy, one step at a time. With the cost control features of the bill much less well formed and many constructed as works in progress they still have a chance to make a difference. Not only must the strong provisions be protected from political attacks, the weak ones need to be refined and strengthened. Cost control must be managed in a coherent and unified way, moving beyond a collection of independent policies, a mark of the reform legislation. Jonathan Oberlander and Joseph White proposed one important policy aim, that of a “mechanism with the potential for system-wide control of medical spending,” to be achieved in part by “all-payer regulation.” By the latter they mean “common payment rules for medical care” and a “standard fee schedule for doctors and hospitals.”

In line with that recommendation I would add the importance of uniform cost cutting. Patients, physicians, hospitals, drug and device manufacturers, and insurers should all take simultaneously the strong hits that serious cost control will eventually require. Everyone for too long has been asking for too much of everything, from more expensive technological innovation to ever better health no matter how healthy we are, and to too much profit all around for the providers and purveyors of medical goods.

We need, in effect, a greening of medicine and health care. Just as the environment can not stand unimpeded economic growth as the ideal, neither can medicine stand the escalation of costs that comes from unimpeded medical progress and trench warfare against death. We are winning some of the biological battles, but we have come to the end of cheap victories in that warfare. We are up against the same tension that marks environmentalism; between a belief in better management and technology as the answer, and a belief that nothing less than a change in the way we live our lives, in sickness and health, will be adequate. I am on the latter side in both cases.

Daniel Callahan is the editor of the Health Care Cost Monitor. His most recent book is Taming the Beloved Beast: How Medical Technology is Destroying Our Health Care System.