Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?
The Netherlands has a system with both not-for-profit and for-profit insurers, that works reasonably well.
- Transparent, identical rules for minimum coverage and strict rules on minimum and maximum deductible for all insurers and insurees.
- Mandatory coverage for everyone (just like liability insurance is mandatory for cars in the US)
- Insurers do not have the right to refuse any applicants based on pre-existing conditions
- Insurers directly negotiate with hospitals on rates. Emergency care has to be covered regardless of whether hospitals are in network or not.
The Dutch model is a useful counterexample to the argument that you need a single-payer structure to contain costs. Netherlands uses regulated private insurers with community rating and risk equalization, yet achieves per-capita spending well below the US (roughly $7,200 vs. $14,570 in 2023 OECD data). The direct insurer-hospital negotiation you describe is also how Germany's sickness funds operate.
The US equivalent would be all-payer rate setting. Maryland has run a statewide all-payer hospital rate system since 1977 with documented cost containment. Issue #3 of this series focuses on a lighter-weight near-term version: capping commercial hospital payments at 200% of Medicare (already used by Montana Medicaid and thousands of self-insured employers). The Dutch model shows a stronger structural fix is feasible. The question is political path, not technical feasibility.
In my experience Kaiser / the Blues have their issues (mostly inefficiency), but not nearly as many directly anti-patient incentives as United Healthcare et al.
Generally speaking, you get decent outcomes with {not for profit} + {efficiency/outcome based KPI}, because the primary thing you're fighting is apathy (not for profit) instead of malicious profiteering (for profit).
And capitalism doesn't particular lend itself to running an insurance company. Fundamentally, there's not that much that should change year-to-year at insurers than {actuaries / pricing}.
Have pharmacy benefits or all the other kooky for-profit inventions really improved patient experience and outcomes?
