I used to think the gold standard for American health care reform would be a “universal” or “single payer” system similar to Canada’s, where everyone is covered, there are no bills to consumers, and government directs spending to providers.

Canada’s system is called Medicare. It started when our Medicare did, in 1965, and become nationwide by the early 1990s.

For the U.S., this would involve getting private Advantage plans out of Medicare and having the government offer similar plans directly, which — despite industry nonsense — it could easily do. There’s nothing magical about private insurance.

It would also require a much tighter rein on the joint federal-state Medicaid programs, which Republican governors have outrageously abused to deny fully funded care to an expanded group of poor people while imposing onerous work requirements.

That would still leave some Americans uninsured. Filling the gap might require more generous subsidies, and a return of the penalty for not buying insurance that a Republican Congress zeroed out in a vain attempt to persuade the Supreme Court to strike down the Affordable Care Act (ACA).

But it could be done. Massachusetts has achieved virtually universal coverage through a more robust version of the Dirigo Health program enacted under Maine Gov. John Baldacci and repealed by his successor. The nation could too.

Yet I’ve begun to wonder whether even this would be enough to solve the problem of sky-high costs.

After all, other countries, including Germany and Switzerland, have private insurance — though much more tightly regulated — and manage universal coverage with reasonable costs.

What makes the U.S. truly unique is its remarkably low proportion of public hospitals. Hospitals are the gatekeepers for health care spending, driving insurance rates and even drug prices, the more familiar villains, based on enormous market power — and their ability to bill states and the federal government.

We often think the big distinction is between for-profit and non-profit hospitals, and for-profits do try to shed unprofitable patients and avoid unprofitable procedures.

Yet non-profits are hardly blameless. Following the ACA debate, one remarkable investigative report identified a non-profit hospital in West Texas as collecting the highest Medicare reimbursements of any hospital in the country.

There was seemingly nothing unusual about the hospital, and, confronted with the facts, the administrator at first denied it could be, then finally admitted the reporter was correct.

Another report’s depressing conclusion was that the reason our health care costs are so high is they’re already high and keep going up every year.

That’s because our programs, with few exceptions, bill solely for medical procedures, and not for keeping Americans well — what one might naively presume to be the goal of having a health care system.

Maine, for instance, is still mostly nonprofit. Yet don’t imagine these are still the “charitable” community organization their property tax breaks are based on.

Just ask nurses at Maine Med in Portland, who succeeded in forming a union only on the third try, over two generations, with hospital management using anti-union techniques even Starbucks CEO Howard Schultz might admire.

In Farmington, Franklin Memorial Hospital tried a different approach. Starting in the 1980s, it offered wellness programs and revised its mission so thoroughly that, within a decade, there were measurable increases in community health.

Small rural hospitals were once championed in Congress by the likes of Maine Sen. Olympia Snowe, but support has ebbed and Franklin, like most small hospitals, was eventually faced with the business imperative that market share is everything.

In 2014, it sold out to Maine Health, Maine Med’s parent. Slowly but surely, and without more than token news attention, almost all the once-independent community hospitals in Maine have been acquired by Maine Health or Northern Light (previously Eastern Maine.)

Central Maine Med in Lewiston made a disastrous attempt to compete and nearly foundered after unwisely acquiring Parkview in Brunswick. Then Mid Coast — a merger of Brunswick and Bath — picked up Parkview and choked, then sold to — you guessed it — Maine Health.

The only successful community merger came in Augusta and Waterville, where MaineGeneral built Maine’s only new hospital in decades on a North Augusta campus.

We’ve ended up with only two large hospital chains; Maine Health is dominant. Its board meetings are private, and the state requires only minimal disclosure.

There’s one truly public hospital in Maine — city-owned Cary Medical Center in Caribou. Worth a news story, don’t you think?

In the end, we must finish the project begun by the ACA to achieve universal coverage.

Yet we’ll never reduce costs satisfactorily until we start applying scrutiny — a lot of scrutiny — to the way hospitals operate.

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