The health care system is heading for collapse; that seems pretty clear. When I'm feeling optimistic, I think that the crash might happen soon enough and decisively enough to push us into building something better. When I'm feeling pessimistic, I expect the present sickness of the system to linger endlessly, worsening so gradually that we won't be sure when the thing is dead.

Currently, I'm feeling pessimistic, my feeling influenced most immediately by the initial failure of Congress even to patch the Medicare payment system. Even now, when it seems that you'll be able to revel in the benefits of a princely 1 percent increase, my pessimism continues to hang on. It will probably not pass quickly, either.

I'll feel better when Congress doesn't just patch the Medicare payment system but replaces it with one that works for the country and for physicians. For that matter, I'll feel better when presidential candidates start talking about primary care as an important part of the solution to our problems. I'll feel better when the government, insurers and the American “health care consumer” appreciate the value of primary care. I'll feel better when the system is based on primary care rather than stacked against it.

For now, however, I think we have the health care system we deserve, just as we have the government and the economy we deserve. Our government is paralyzed by our polarization and our intolerance of complexity, nuance and uncertainty. Our economy is being undermined by our belief that we can own what we can't afford. Our health care system is crumbling under our abdication of responsibility for our own health in favor of a simpleminded reliance on expensive drugs and more expensive technology.

I'm sorry to speak depressing words in a depressing time, especially since things aren't all bad. Take what you do, for instance. In practicing family medicine, you're fighting the good fight, working at the point where life, health care and common sense all meet. You can feel good about that, whatever else the system hands you. I know I do.