To understand why significant healthcare reform is unlikely to happen, it might help to consider the following hypothetical:

You have recently abandoned your long-term care career to become principal at a financially strapped high school. Much to your surprise, the school board has decided that the best way to restore fiscal growth is to completely revamp its grading system. The usual “A” through “F” letter grades will be replaced by an as-yet-to-be-determined alternate.

Here's Question No. 1: Where is opposition and support for this shift going to come from?

You can bet support won't derive from the “A” students. Why would they want to mess with the status quo? It has served them quite well, thank you very much.

And so it is with the provider community. Despite a general dissatisfaction with Medicare and Medicaid rates, providers have mostly benefited from the way things are, at least as far as payments are concerned. Yes, Medicaid rates are far from adequate. But at least they are guaranteed. Not surprisingly, provider-related organizations have been less likely to back a fundamental change that might significantly alter reimbursement methods. Why would they?

The so-called “F” students (the 45 million or so people who are currently without  healthcare insurance coverage) are more than willing to see change.

In fact, they are demanding it.

Which brings us to Question No. 2: How is the fight likely to play out?

The short answer here is that one side–the “F” student coalition–has already begun playing its hand. It did this last November when it helped elect a president and Congress that promised to fundamentally change healthcare in America. This group is counting on a Democratic-controlled Congress and White House to essentially revamp the grading system.

Not surprisingly, the “A” students feel differently. Many are calling proposed changes unfair.

Of course, we have more than a hypothetical situation on our hands here. The U.S. healthcare system currently accounts for 16% of the country's gross domestic product and is projected to consume a quarter of total GDP within the next 10 years.

To say the least, the stakes are high. So who's going to win? I think it's too soon to tell.

But if I had to place a bet, I'd go with the “A” students. They almost always do better when it comes to multiple choice exams.