I work for a non-health insurance company. I believe that removing insurance companies from the equation would definitely make things more efficient - at the very least my company doesn't have the motivation to really cut down on expenses, most managers are more worried about internal power struggles, I've seen so much waste I'd start my own company in a heartbeat if only it wasn't so capital-intensive to start, and a papework and political minefield (which of course lets the old boys get by with a lot of leeway in terms of actual efficiency improvements).