> This argument doesn’t make sense to me. Insurance companies are structurally incentivized to minimize payouts across the board. They want hospital bills lower, physician compensation lower, and patient payouts as small as possible. If insurers had unilateral power, total medical spending would collapse, not explode.

They absolutely do not.

They have their profit levels capped at 15% by law and regulation. That means if the insurer wants more absolute dollars of profit, prices must go up.

It also means that if they push prices down they necessarily have less funding to administer those plans, even if the needs are the same (same number of belly buttons, same patient demographics and state of health).

As you note there's also other variables, but this claim: "Insurance companies are structurally incentivized to minimize payouts across the board" is absolutely and categorically not so.