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The Republican vice-presidential nominee, Paul D. Ryan, has offered his latest ambitious plan for addressing the Medicare problem. But like Mr. Obama’s, it holds limited promise for containing the program’s escalating costs within sensible boundaries.

The Obama and Ryan plans are not without common ground; both propose an identical formula for capping the growth in Medicare spending per beneficiary. And both dip into the same toolbox (particularly lower payments to providers) to achieve a reduction of nearly $1 trillion in Medicare expenditures over the next decade from projected levels.

That’s where the agreement ends. Mr. Ryan believes that meeting the goal over the long term requires introducing more competition into Medicare through vouchers to purchase private insurance.

Under his revised plan, private insurers would be required to offer the same level of benefits as traditional Medicare, meaning that any savings would have to come from unidentified efficiencies (the ever-popular “waste, fraud and abuse”).

If the cap was breached — as it almost certainly would eventually be — Mr. Ryan blithely says, “Congress would be required to intervene.” Fat chance; Congress regularly does the opposite when it rolls back caps on payments to doctors and hospitals.

No one wants to lose an aging parent. And with price out of the equation, it’s natural for patients and their families to try every treatment, regardless of expense or efficacy. But that imposes an enormous societal cost that few other nations have been willing to bear. Many countries whose health care systems are regularly extolled — including Canada, Australia and New Zealand — have systems for rationing care.

Take Britain, which provides universal coverage with spending at proportionately almost half of American levels. Its National Institute for Health and Clinical Excellence uses a complex quality-adjusted life year system to put an explicit value (up to about $48,000 per year) on a treatment’s ability to extend life.

At the least, the Independent Payment Advisory Board should be allowed to offer changes in services and costs. We may shrink from such stomach-wrenching choices, but they are inescapable.

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