If the engine of change in most democracies is a disgruntled middle class, then I am emboldened to make a prediction. The U.S. is headed toward a single-payer system of universal health care.

Everyone keeps his or her doctor and, more to the point, everyone will have one. The medical-delivery system — physicians, hospitals and pharmaceuticals — stays private, but the paperwork and bills are routed through and paid by the federal government.

Spare me the shibboleths and scare tactics — — Hillarycare, waiting lines for MRI's in Canada, the government picking your doctor, the Prussian and commie menace of socialized medicine. Disinformation and selective data from the usual think tanks has lost their sting.

Expect national health insurance to be demonized; it always has been. The fundamental change is that a broad swath of the public knows it is poorly served by an inefficient and bureaucratic system, and increasingly cannot afford what is available. Beyond the estimated 45 million Americans without health insurance, legions more have skimpy coverage, ever higher premiums, growing copayments and soaring deductibles.

People find out how little coverage they have as they parse the medical and insurance jargon of what is routine and required, and fumble for the right questions to ask.

Their kids are coming out of college into extended temp jobs that either offer no health benefits or provide better-than-nothing catastrophic coverage.

Sixty-five percent of Americans support the U.S. government guaranteeing health insurance for all citizens, even if it means raising taxes, according to a survey by the Pew Research Center for the People & the Press. The number stays strong across the ideological spectrum because poor access to health care affects red and blue states alike.

So how can I be so confident change is coming? Corporate America will embrace universal health care as a way to shift the cost of insurance expenses for workers and retirees to the federal government and the public.

Big business is already testing themes, hinting that burdensome insurance overhead makes them less competitive overseas. The expenses are real enough, but premiums growing by double digits could be replaced with a modest payroll tax and an income-tax bump for workers.

I am betting business would take a defined contribution to a health plan, federal or otherwise, to escape sole responsibility for a defined benefit. Think 401(k)s versus pensions.

Adios to negotiations with employees and insurance companies and the paperwork for both. No more premiums and no more copayments, and even the Wal-Marts of the world get tapped for a contribution for their workers.

For doctors, the direct savings are in administrative costs. Instead of hiring staff to file claims with any of 1,200 insurance companies, they deal with one plan administrator, one set of forms.

The one sweetener I would add is having the new health system pick up the costs of medical-malpractice insurance. Spread the cost and create more financial and political incentives for doctors to support the new plan.

Unions have fiercely opposed national health insurance all the way back to early in the last century. Their ability to bargain for medical coverage was a huge incentive for workers to organize, and unions did not want to forfeit their leverage. Even as union membership shrinks, there is resistance.

That is just nuts.

One indication of the fear factor in the insurance industry is the frantic, belated effort to help the uninsured with tax credits and grants — the same old nostrums within a health-care system that is falling apart.

Thoughtful alternatives exist, and leadership comes from within the medical profession. The Chicago-based Physicians for a National Health Program has 12,000 members and a template for a single-payer health plan.

The group's current president is a veteran of rural medicine, teaching, academia and health policy. Dr. John Geyman is professor emeritus of Family Medicine at the University of Washington, where he chaired the department from 1976 to 1990. He practiced medicine on San Juan Island the next seven years.

Geyman sees national change driven by runaway health-care prices, the failure of the marketplace to contain costs and the inability of people to afford medical care. He is not promoting the government-run health system of the loaded poll question — rather, full coverage at no more cost.

That will resonate with the middle class, and that will grab the attention of the political class.

Lance Dickie's column appears regularly on editorial pages of The Times. His e-mail address is ldickie@seattletimes.com