RALEIGH - Many relatively healthy people who have insurance coverage through their work see the debate over health-care reform in rather abstract terms. Sure, they realize the security that would come from a guaranteed choice of affordable health plans regardless of their job status, but how will health reform -- as proposed by the presidential candidates -- really affect them?

The general feeling seems to be that we should have a health reform debate, given the deteriorating state of the current system, but whether it is desirable or even politically possible to accomplish major change is in question.

Even doctors, health policy experts and health-care advocates like me often fall into this trap of debating the structure and political possibilities of reform. On some level, I suppose this is necessary. After all, we've got to have a road map of where to go even after we finally get the political courage to press the accelerator.

There's one big problem with this discussion though. Major health-care reform is already happening.

Slowly, stealthily, almost without notice, enormous changes are going on in our system more radical than any realistic proposed reform plan to rein in costs and expand access.

One of the biggest is the exploding growth in the for-profit consumer loan industry, coupled with the rise of high deductible/high coinsurance health plans.

These so-called "consumer-directed" health plans are seductive. Pushed hard by insurance companies -- N.C. Blue Cross and Blue Shield CEO Bob Greczyn is a major advocate -- such plans lower monthly premiums by drastically increasing overall deductibles into the thousands of dollars, instituting sizeable co-pays for prescription drugs and demanding big payments for events such as hospital admission.

Employers are attracted to the plans because they can continue to offer health coverage at a less than astronomical premium. Employees are less enthusiastic -- most people are pretty smart about spotting lousy health coverage -- but often have little choice but to accept the change from comprehensive insurance.

This puts many workers in a terrible position. Everything's fine if they stay more or less healthy, but one broken bone, one bout with a serious illness, and suddenly they face thousands of dollars owed to hospitals and doctors. This debt isn't discretionary, like deciding to borrow money for a car purchase or home addition; when someone needs major medical care at the hospital he usually isn't in a position to walk off the lot as if he were buying a used car.

Enter your friendly consumer loan industry. Sensing a business opportunity, financial companies such as Chase, Citibank and GE are rushing to tap into this newly created debt market. They offer credit cards through doctors' offices, finance lines that health providers can market directly to potential patients, and even co-branded credit cards with large hospitals.

Consumer Reports magazine did a great job this month assembling the pitches and problems with making money off of the ill and desperate. Interest rates of 25 percent to 27.99 percent. Giving financial incentives -- for example, being paid in full up front -- to doctors and hospitals who then steer patients into high-cost loans. Start with zero percent interest "teaser" rates that skyrocket after a few months if the bill hasn't been paid.

Even hospitals are starting to get into the act. One troubling trend, typified by a small North Carolina financial service company, is for hospitals to do a complex credit score on everyone who walks in the door. The boast is that such scoring can estimate just how much a patient can be expected to cough up when the bill arrives.

Of course, this doesn't take into account if the patient needs to send kids to college, or save for retirement, or get a new roof -- but, hey, that's just business. If you want to buy something, you ought to pay for it.

That last sentence exposes the essential moral flaw at this latest rush to health-care market nirvana. Most people who are in a hospital would vastly prefer to be somewhere else. Most people don't plan to be bankrupted by high health costs, and they buy the best insurance plan they can afford. All this is little comfort, however, as these latest major changes ripple through our health system. Many people now will be locked into years of paying down debt incurred because of illness or accident that could happen to anyone.

Being without insurance at all is a terrible thing. But that isn't the case for most of us. For those of us affected by these changes in coverage, the deprivations will be less severe, but no less gradual and insidious. Dreams of college deferred for our children. An impossibility or long delay of homeownership, a retirement defined by work and an occasional vacation delayed or never truly taken.

This doesn't have to be our future. But changing the course of the industry-driven health reform happening right now means a realization that the health-care debate is already well under way. And, most importantly, that we all -- from the poorest uninsured person to the most comfortable middle-class worker -- have a huge stake in the outcome.

(Adam Searing is project director of the N.C. Justice Center's Health Access Coalition.)

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