As someone who has worked to assist older adults and people with disabilities get health care for the last 20 years and experienced through countless clients the benefits of a public insurance system (Medicare) that pools risk across millions of people, bargains for reasonable provider rates, as well as guarantees people automatic and affordable coverage, choice of doctors and providers and protection from financial risk, I want to revisit Jon’s critical point in Sick, that all but the most wealthy of us who do not yet qualify for Medicare are vulnerable to needing costly care and not being able to pay for it. On that point, I think we all agree.

What’s fascinating and where further discussion is necessary is the reason we are virtually all at risk, even if we have private insurance. Having watched the private health insurers gain a foothold in Medicare through their offering of private Medicare plans, I’m convinced the chief reason is the private insurers. Highly regulated and with subsidies or not, they will never be able to offer Americans health security. And there’s one very basic reason why.

Private health insurers will always be in the business of avoiding risk since their ultimate goal will always be to turn a profit; and, the easiest way for them to make money is to steer clear of providing coverage to people who are sick and need costly services. It’s for this reason alone, that a bunch of well-intentioned citizens could not establish the best health insurance company in the country—one that promoted their quality care for people with cancer, heart disease and diabetes, AIDS and MS: They would be out of business before they opened their doors. But, as a result, we have a private insurance industry that not only does not promote the quality care it covers (when it does) but actually claims that its treatment protocols are proprietary information, business trade secrets that it will not disclose.

So—to take issue with Matthew—there really is a world of difference between a public insurance system that relies on private insurers to deliver the coverage--like the ones emerging in Massachusetts and California--and a public insurance system that cuts out the private insurer middleman, as does traditional Medicare. In Massachusetts, we have already seen that costs are double what people originally anticipated and we are likely going to see them rise far higher as well as see cuts in benefits as the “solution” to reining in the higher prices.

What a true public insurance system offers is something that you cannot expect from private insurers: 1) automatic coverage so no one falls through the cracks; 2) low administrative costs (you cut out the marketing and profits and save a bundle); 3) negotiated and lower prices; 4) a public accountability as to what is covered; 5) the ability to set protocols based on best practices, reduce misuse and overuse of services and promote quality care; 6) a lifetime guarantee for people in this country that they will get the care they need if and when they need it. I would love someone to prove me wrong about this.

The question then becomes: How do you get from here to there? And the solution is not “hybrid” in the sense that Jon and others talk about it. It’s not building on our highly fragmented system. But, it’s not eradicating the private health insurance system that is serving millions of Americans right now either. It’s an American solution, a version of which Senator Edwards is promoting, and which Jacob Hacker lays out in his Health Care for America plan—a solution that gives people the choice to keep the private insurance they have if they like it but gives them a public insurance option as well if they do not have insurance or they would prefer it.

The advantage of this model is that it offers the United States the opportunity to provide its citizenry with lifetime health security if they want it. If it works better than private insurance (and it should if it works like Medicare) and costs less (and it should if it works like Medicare), over time, many people will choose it. Of course, the Medicare model can and should be improved on, but more on that later….