There are a few principles that will dictate the future of the American healthcare system:
1. There will always be a two-tiered system. This will not be due to a flaw in system design or implementation, but is due to the unalterable dynamics of societies. there is not a country on earth that does not have multi-tiered healthcare. The United States will not have a single tiered system for the same reason that it does not have, in fact, a single tiered educational system, or a single tiered legal system, or a single tiered social welfare system. Economics, technology and data management will have a much greater influence on the shape of the American healthcare system than will politics. Politics however, will have a much greater influence on who becomes rich as a result.
2. Healthcare in general, and medical care in particular, can be divided up into three functional categories:
i. The technical or procedural aspect. This is the part of healthcare where someone takes out your appendix, adminsters chemotherapy, does endoscopy, or performs a CT scan;
ii. The cognitive aspect. This is where someone interprets data and makes decisions about interventions, and
iii. The clerical aspect. This is where data is collected, collated,and and packaged.
These three aspects will become more distinct and regardless of what type of healthcare reform or payment system is implemented, will dictate the future of healthcare.
The procedural aspect will be taken over by technicians. this trend has been underway for a couple of decades and has resulted in niche practices by "proceduralists.: It is also apparent in the now common practice of attending physicians or primary care providers referring patients to specialists who perform procedures on request, with no other role in diagnosing or managing a patient;s condition. In the future, these people will be less educated in broad aspects of medicine and will be hyper-specialized technicians. Since these procedures will be will established and understood, the practitioners performing them will be more like tradesmen than professional decison makers. They will have less education and more procedural training, and consequently will be expected to do less and will be paid less.
The cognitive aspect will largely be displaced by massive data management systems. This will commonly be referred to as AI, but will involve computer algorithms classifying each patient and processing huge amounts of epidemiologic, genetic, and clinical data to arrive at diagnostic and treatment plans for individual patients. These systems will become more reliable as experience is gained and they will drive down the costs associated with routine care. One offshoot of this will be a new medical specialty: the "outlierist" or the "anomalist" who will be looked to for the artisanal elements of medicine when the data driven computer algorithms are unsuccessful.
The clerical aspect is taking up a larger portion of providers time right now. They spend significant time gathering and entering data that eventually will form the databases on which the artificial neural networks, inference engines, Bayesian belief networks, and other computer modeling systems will operate. Provider systems and payers will soon realize that these tasks can be both largely automated and performed by medium skilled workers without medical degrees.