IN HIS ELECTION campaign, President Bush didn't put forward a health care plan so much as a handful of ideas about health care, none of which will extend coverage to all Americans and few of which are likely to cut skyrocketing costs. Although some of his suggestions, such as private health savings accounts and limits on malpractice damage awards, might help drive the cost of health care downward over time, none seem likely to do so in a significant way. That means that controls on health care costs over the next four years are going to have to come from somewhere else: Insurance companies, pharmaceutical benefit managers and others who play big roles in the health care system may find it necessary to get involved.

In recent weeks, the officials who run Medicare and Medicaid have also made it clear that they intend to start thinking harder about which procedures they will pay for and to force medical companies to do the same. In several prominent cases involving cancer, Alzheimer's disease and heart disease treatments, and possibly weight-loss surgery, administrators have approved the use of expensive new drugs and procedures, but only on the condition that patients who use them agree to participate in studies of effectiveness. Medicare argues that it should administer the studies but medical companies should pay for them. This could bring about an important set of changes, particularly if the practice of studying outcomes is more widely adopted by other big insurers. Over time, such studies could begin to force American medical practice to become more evidence-based and less subject to the expensive whims of fashion. If pricey new procedures don't show greater success than older, less costly ones, Medicare should refuse to pay for them.

The question, of course, is whether Medicare officials will be able to fend off the lobbyists for the drug and medical companies that make the newer but not necessarily more effective cures and to tell patients that they can't get them if they aren't worth the money. To do so will require a degree of political will that ultimately must come from the White House itself. The administration may not be willing to play an active role in cutting costs, but we hope a new Cabinet team will clearly support the Medicare officials who want to try.