I saw a cutter in my office. She was about 15 and had the telltale linear tracks on her forearm. She had been treated successfully for depression in the past but had been off her medicine for more than a year. She said that she had been cutting during that time, but her mother had just noticed the upswing in self-destruction. In spite of this relapse, I have great hopes for her full recovery.

I would like to have the same feeling of hope for the ongoing self-destruction of American health care. It is scary, the similarities between my sad young patient and the U.S. health-care system. Both the person and the system can and are labeled sick and crazy. The two are self-destructive, neither seem able to stop themselves; but optimistically there are some paths for cure.

The sick-and-crazy label seems fairly self-evident. The system of health care has to be pretty wacko to think it can survive while it is sucking the financial life out of Americans without giving health in return. Our clinic is a small business; we hire employees; we give them a wage for services rendered; we pay taxes. We subsidize their health insurance premium. We are expecting a raise in our insurance costs to the tune of 18 percent.

As physicians, we are not increasing our fees by 18 percent. Instead we will have to offer less take-home to our staff. So it is with every employer in America with health-insurance premium increases. The cuts to employees are getting deeper and deeper. Their real earnings drop as the costs of benefits go up and the services go down. The cutting starts with the reduction in salary and the increase in everything else made and sold in America that has health insurance linked to it. Buy a car made in Detroit, pay for the health insurance of the autoworker in Detroit. Nowadays health insurance costs more than the metal of a vehicle.

We think we are all driving around the streets in expensive steel cars; we're not. We are cruising State in light-blue half-exposed hospital gowns.

My patient just seems to have this urge to inflict pain. I had a painful experience of my own talking to some executives trying to propose a way to reduce costs of the administration of health insurance. It very rapidly deteriorated into a debate over whose money it was, instead of a conversation about how to make the system better. It was a Three Stooges film fest. As a passionate physician I probably was the wrong carrier of the message; after I spoke I felt a poke, which prompted a jab, which triggered a bonk, which provoked a stab. It was like we couldn't stop the impulse to injure each other. After the confrontation I felt more cut than my patient. It was crazy and painful and has left a few scars.