There is a lot of skimming at multiple levels. Far too many middle layers and gatekeepers, constantly haggling and looking for more ways to profit. Continuous market consolidation to fewer players looking to exploit economies of scale over decades. Perverse incentives everywhere.

There are still people trying to behave ethically within this framework, but it's hard when the framework itself is so corrupted by profit motives which should never have been there in the first place. Direct providers should be running the show, not financiers. They need to be aware of how to balance the books within reason and be paid properly, but beyond that it should be much more patient focused. We definitely don't need so many profit-taking leeches in all the places we have them now.