A true not-for profit insurance company that is trying to take the high road in our dysfunctionally financed and delivered health care system will be like a guppy in shark infested waters. Similarly, one would think our not-for-profit hospitals would look like the good guys. Sadly, in order to stay in the black, they have to respond to the perverse incentives just like the for-profits. They invest in high tech equipment and seduce the super specialists in order to do the cost shifting that is necessary to offer high quality primary care, which in some instances is a loss leader.

The public plan option, which is a publicly owned alternative to private insurance companies, in theory would be the not-for-profit to which you allude, nationally. In theory, on an even playing field, it would drive down the price of insurance. Unless we are REALLY careful, the insurance companies will game the system so that the sickest, most expensive patients will gravitate to the public plan. If that happens, it will fail because of adverse selection. Then, those who are profiting from the current system will say that its failure is proof that the government can’t be trusted to do health care. A poorly designed public option is a trap.

The ultimate “public plan” is a single risk pool, publicly financed, privately delivered care, every one in, nobody out, improved Medicare for All. No guppies. No sharks. Just a bunch of trout. Then we can have a system and, as a community, do what we can to redress the perverse incentives.