We are about to start the cycle again. By most accounts, President Bush plans to highlight health care in his forthcoming State of the Union address. His proposals may or may not have merit, but they surely won't fix the health system in any fundamental way. The reason is that most Americans don't want to fix the system in that sense. Most are satisfied with their care. Most don't see (or pay directly) most of their costs. Because politicians -- of both parties -- reflect public opinion, they won't do more than tinker.

Unfortunately, tinkering isn't enough. As everyone knows, health spending has risen steadily. In 2004, it totaled 16 percent of national income, up from 7.2 percent in 1970. As health insurance becomes more costly, the number of uninsured, now about 46 million, may grow. Worse, health costs may depress wage gains, raise taxes and squeeze other government programs.

Here's the paradox: A health-care system that satisfies most of us as individuals may hurt us as a society. Let me offer myself as an example. All my doctors are in small practices. I like it that way. It seems to make for closer personal connections. But I'm always stunned by how many people they employ for non-medical chores -- appointments, record-keeping, insurance collections. A bigger practice, though more impersonal, might be more efficient. Because insurance covers most of my medical bills, I don't have any stake in switching.

On a grander scale, that's our predicament. Americans generally want their health-care system to do three things: (1) provide needed care to all people, regardless of income; (2) maintain our freedom to pick doctors and their freedom to recommend the best care for us; and (3) control costs. The trouble is that these laudable goals aren't compatible. We can have any two of them, but not all three. Everyone can get care with complete choice -- but costs will explode, because patients and doctors have no reason to control them. We can control costs but only by denying care or limiting choices.

Disliking the inconsistencies, we hide them -- to individuals. We subsidize employer-paid health insurance by excluding it from income taxes (the 2006 cost to government: an estimated $126 billion). Most workers don't see the full costs of their health care. Nor do Medicare recipients, whose costs are paid mainly by other people's payroll taxes.

We're living in a fantasy world. Given our inconsistent expectations, no health-care system -- not one completely run by government or one following ``market'' principles -- can satisfy public opinion. Politicians and pundits can score cheap points by emphasizing one goal or another (insure the uninsured, cover drugs for Medicare recipients, expand ``choice'') without facing the harder job: finding a better balance among competing goals.

Every attempt to do so has failed. Consider the ``managed care'' experiment of the 1990s. The idea was simple: herd patients into health maintenance organizations or large physician networks; impose ``best practices'' on doctors and patients as a way to encourage preventive medicine and eliminate wasteful spending; and cut costs through administrative economies. But managed care upset doctors and patients. After a backlash, managed care relaxed cost controls.