(Spoiler alert: Wizard of Oz metaphor continues below.)

Truman Medical Centers, a health system (what we used to call "group of hospitals") in Kansas City, is about to start charging uninsured patients who live in KC and Jackson County upfront for non-emergency services. Well, it's about time, isn't it?

Every other enterprise in the U.S. has figured out that banks, not butchers or bakers or candlestick makers, have a comparative advantage in managing individuals' credit risks. So, they accept credit cards. Why are hospitals just now figuring this out?

Well, Truman Medical Centers didn't used to have to worry about it: Missouri Medicaid subsidized uninsured treatment. When that funding shrank, in 2005, Truman started to demand payment from uninsured patients who lived outside KC and Jackson County, which continued to give Truman $36 million a year to cover uninsured patients.

But that's no longer enough: Truman claims uncompensated care now runs to $79 million a year. Now, I don't know anything about Truman Medical Centers other than what I read today, but I do know that hospitals creatively account for uncompenated care, by using list prices instead of actual transaction prices to add it up. But they also labor under crazy government (Medicare & Medicaid) pricing that make it difficult to do otherwise, (a challenge that some states have tried to address legislatively).

But why were taxpayers subsidizing the hospitals for non-emergency care until now? EMTALA (Emergency Medical Treatment & Active Labor Act) only requires stabilization in emergencies. This development indicates that subsidies were too great and might be coming back under control.

And what will the political repercussions be, when uninsured patients have to pay upfront? Missouri ranks 32nd in the U.S. Index of Health Ownership, and 24th in the "provider burden of regulation" category. Maybe Truman will do what hospitals often do: lobby for more handouts and protection (described in wonderfully appalling detail in Prof. Regina Herzlinger's recently published Who Killed Health Care?).

Or maybe Truman will embrace the change, welcome cash-paying patients, and actually seek to compete for them. Let's hope so: U.S. hospitals are very powerful politically, and the Yellow Brick Road to consumer-driven health care will be a lot easier for us to follow if they take the lead.