If President Obama is re-elected next year – always a big if for presidents – he’ll have a vital decision to make about his health care legislation, the major achievement of his first term.

The major provisions of the Affordable Care Act take effect in 2014, and the country won’t be able to afford them. This isn’t because of Republican claims that the Obama plan represents “big government,” but rather the reverse. Obama chose to accept the existing system, dominated by for-profit insurers, drug companies and hospitals.

The cold, hard fact is that our health care system is bankrupting the country. It’s been many years since an ordinary American could pay annual health care bills without assistance from the government or an employer.

American health care used to be just a bit more expensive. Now it’s nearly twice as expensive as our economic competitors, and getting steadily worse. Because it now represents 16 percent of the economy – double its proportion in 1970 – it’s distorting the budgets of every business and every level of government.

You’d think, amid the worst economy in decades, that health insurers would be show restraint, but you would be wrong. Premiums went up 9 percent in 2011. Think about that figure. It’s three times the current inflation rate; business as usual.

The health inflation juggernaut rolls on, impervious to all attempts to control it. Americans look for villains in these situations, and there are a few.

My favorite is Anthem, the mega-insurer that cleverly took over nonprofit Blue Cross plans in a host of states, including Maine and New Hampshire. The “Blues” as we once called them, struggled to contain rate increases while maintaining adequate reserves.

Anthem showed them what they were doing wrong. Impose huge annual increases, make lots of money, and stop worrying about whether people can afford it. Since taking over Maine Blue Cross in 1999, Anthem has raised regulated rates on individual policies every year, usually requesting increases of 10-15 percent

Unfortunately, this isn’t just about Anthem and other highly profitable insurers. Take away their profits and we’d still have incredibly expensive health care.

A study was commissioned by Vermont to prepare the launch of its single-payer health plan, replacing the for-profit insurance model that’s so ruinously expensive. Dr. William C. Hsiao, the author, finds that much of our extra costs come from a profusion of unnecessary steps – drug benefit companies, insurance brokers, underwriters, pharmaceutical advertising and promotion -- you name it -- each taking a cut. Add our incoherent system for paying providers, which rewards those who perform expensive procedures, rather than keeping us healthy – and you have the financial disaster we’d rather not talk about.

We must, though. And Obama will have to lead. There are promising payment reforms in the ACA, and new guideline for Medicare and Medicaid. Some experts believe rapid adoption of physician-owned practices such as the Mayo Clinic, Lahey Clinic and, in New England, Harvard Vanguard -- which provide better care at lower costs -- could help. But expecting these steps to bring health cost escalation even close to “normal” inflation before the patient expires is probably dreaming.

The best study I’ve seen on health care costs concludes that our costs are high simply because they are high. We’ve been conditioned to expect health care will cost far more every year, and so we hardly notice a 9 percent increase amid terrible financial conditions.

Here’s what Obama will have to do, if he remains president: Impose price controls on health care. This hasn’t been done since Richard Nixon was president, and before that, during World War II.

Nixon’s primary motivation seemed to be winning re-election. But Obama faces an unmistakable crisis and will have just run his last campaign. A major sector of the economy has essentially lost control of pricing. No reforms, and there have been many, have turned the tide.

Price controls would prompt fevered blasts from the industry, and the political opposition. But the president can do this on his own, and it could ultimately save the system.

We’ve been told for years that we can’t afford Medicare and, particularly, Medicaid. This isn’t wrong, but it’s completely misleading. We can’t afford health care, period.

Shifting completely to private insurers, as Republicans want, will make things much worse. Ultimately, we will need a national health care system worthy of the name. But first, we have to stop the bleeding.

Price controls can give breathing room to have a rational discussion of how we can do what every other major democracy has done – provide health care without bankrupting ourselves. Nothing else has worked.