Dr. John Lumpkin, health care director of the Robert Wood Johnson Foundation, believes the problem with the U.S. health care system was outlined by cyberpunk novelist William Gibson in the early 1990s: the future's already here, it's just not evenly distributed.

In a keynote talk at the Institute for Health Technology Transformation conference in New York City last week, Lumpkin said that while the U.S. has the best medical science in the world -- cutting-edge imaging systems, near-miraculous surgeries and body-part replacements -- its health care system is plagued by waste and disparities of access.

That's why, while some are worried about the fate of the Affordable Care Act because of the coming U.S. presidential elections, Lumpkin said that pressures on the system mean change has to come no matter what.

"Regardless of what happens in 48 days in the election, the future of the Affordable Care Act and health reform...isn't going to sink," he said.

Pressures

For one, the ranks of the uninsured keep growing, rising from 43 million in 2007 to 48 million in 2011, Lumpkin said.

Plus, the U.S. health system gets little bang for its buck, spending a big chunk of its GDP on health despite achieving a middling rank on global health indices. And Lumpkin said U.S. failures here can't all be blamed on differences in lifestyle or diet. An August Health Affairs article, cited by Lumpkin, for instance, found America fell below the UK, Germany and France for mortality rates for conditions "amenable to health care interventions."

U.S. health care often offers spottier service as well. Lumpkin said in a poll of American adults, 23 percent said test results or records weren't available at the time of appointment, twice as high as in Germany and two and a half times higher than in the Netherlands.

Reform

As for the fate of the ACA itself, Lumpkin outlined four scenarios, depending on what goes down in the ballot box on Nov. 6:

One, Obama gets re-elected and the Democrats retain control of the Senate -- this is business as usual.

Two, Romney's elected but the GOP doesn't make headway in the upper chambers. "There will be budget manipulation but the bulk (of the ACC) will go through," he said.

Three, Romney takes the crown and the Republicans win a majority in the Senate, but fail to pull the 60 seats needed so they can vote cloture on bills and get legislation through. Still, through simple-majority budget votes they could possibly "defund major portions" of the ACA, Lumpkin said.

Four, Romney's elected, the GOP sweeps up 60 Senate seats and the ACA is repealed.

"If you believe that (is going to happen), I've got a bridge that goes over to Brooklyn that you can have for a really low price," Lumpkin said.

Lumpkin also believes that some of the Republican governors who say they will not participate in the expansion of Medicaid are going to be singing a different tune pretty soon. Hospitals eating expenses for patients without health insurance, knowing that there's "free money for uncovered patients," will lobby their state governments to relent, he predicts.

"After the election, reality is going to sink in," he said.

Big data

Legislation isn't he only route to change, of course. Computer models founded on "big data" could better enable doctors to model disease processes and identify hotspots where cheaper, earlier interventions could save money in the long run.

For instance, in Camden, N.J., health analysts found that just two buildings in the city were responsible for nearly $27 million in health care costs. The researchers sent nurse-practitioners to interview patients in the building, and found many ultimately costly problems were easily fixed. One man, who frequently showed up in the ER in a diabetic coma, for example, simply didn't know how to draw insulin properly into his syringe.

"One intervention helped save money," Lumpkin said.