Background Cost containment is a major policy challenge and one of the key drivers of health care reform. In this article, we focus on the role cost control has played as a reform driver in the Norwegian hospital sector between 1980 and 2014. Methods We use data on aggregate expenditure as well as on activity changes from year to year. We also use qualitative data for illustrative purposes. Results We identify 4 phases in the period 1980 to 2014: two where activity increases have dominated the agenda and 2 where cost control has been emphasized. The desire to either increase activity or improve cost control has been important reform drivers. Conclusion Cost control has been a major reform motivator in the period, and some of the policies aimed towards achieving cost control have been successful. But as cost control is achieved, waiting lists and popular dissatisfaction increase and new policies are implemented to increase activity.