The fall elections could create a new climate for benefits brokers and health insurance company executives as well as for other participants in the U.S. health care system.

The recent passage of a bipartisan health reform package in Massachusetts shows that change is in the air.

In my opinion, proposals for creating a national universal single-payer health care system are gaining momentum.

What will you do if the single-payer movement becomes an unstoppable express? Cry about the upheaval, or climb aboard and find new ways to do well by doing good?

I’m a physician, and I helped set up and run a health maintenance organization. Of course, I wanted that HMO to do well. We tried as hard as anyone else to use our democratic rights to influence legislation to favor our products. That’s the American way.

But results from every national poll, including those sponsored by health insurance trade groups, show that the cost of health care is one of likely voters’ top concerns. In most cases, worries about health care costs rank second only to concerns about the fighting in Iraq.

In the health insurance industry, we are getting too comfortable with stories about huge annual coverage cost increases.

An insurance agent recently told a school superintendent I know to expect another “usual” 21% increase in health insurance rates for the coming year. Some employers, especially those trying to maintain solid benefits packages, are facing even steeper increases for the fourth or fifth or sixth year in a row.

Experiencing increases of that kind is not a “usual and customary” event in the minds of the customers paying for the health insurance.

If we start to think that five straight years of double-digit increases is normal, we’re in trouble.

No one knows for sure what will happen in November, but there’s a strong possibility Democrats could take control of the U.S. House. There’s even a possibility they could take control of the Senate.

If the Democrats get more clout in Washington, some almost certainly will introduce a high-profile, single-payer universal health plan.

My prediction is that Democrats will attract the most attention with proposals that get away from the kind of cautious tweaking of the current system seen in the Republican-driven Medicare Part D prescription drug plan and the Democratic House Caucus platform.

Voters have had it with piecemeal tinkering and are pushing for real change.

Here are what the universal, single-payer proposals might look like:

1. Medicare Inc.

One type of single-payer plan might call for the federal government to add an income tax of about 7% to pay for what would amount to an expansion of the current Medicare program.

The strength of this proposal is that we all know what Medicare looks like.

The weakness is, of course, that we all know what Medicare looks like.

Simply expanding Medicare could lead to national bankruptcy, by replicating the many problems in the current Medicare system, such as lack of efforts to use market forces to hold down the cost of prescription drugs.

Doctors will howl for higher fees for their services, and hospitals will demand higher rates for their services.

We already spend about 15% of the U.S. gross domestic product on health care, and ‘Medicare: The Single-Payer Version’ probably would increase the cut going to health care without doing anything to improve dismal U.S. life expectancy statistics.

2. A Fresh Start

Another kind of single-payer, universal health plan could rely on the federal government to start the program, set eligibility rules and pay premiums for the indigent. These rules will be simple such as offering coverage to all 295 million Americans but requiring no premiums for children under 19 years. A new nonprofit insurance company, which might be called Health Security America Inc., would provide basic health coverage for all.

The nonprofit company might be run by elected citizens that would use open hearings to design plans and set premiums.

One important safeguard against fiscal irresponsibility would be to prohibit the nonprofit company from issuing long-term debt.

Under the first scenario, private insurance companies might assume the kind of “administrative services plus” role that they assume in the current Medicare managed care and prescription drug plan systems.

Under the second scenario, the new nonprofit company would take over the actuarial risk in providing basic health benefits, but private insurance companies could participate by packaging the basic, universal coverage with extras, such as coverage that would help pay for access to private hospital rooms, international coverage, cosmetic surgery or other similar coverage not deemed part of a basic plan by citizens.

With the burden of skyrocketing basic health insurance costs lifted, health insurers and other insurers could increase sales of disability insurance, rich long term care insurance policies and retirement savings products that could help consumers meet their needs for financial security. At a minimum, health insurance problems would no longer dominate the agenda of monthly board meetings of private insurers.