Insurers have brought down costs compared to what it would be like otherwise in a volume based medical world.

Also federal law dictates how much of every premium dollar has to be spent to pay for care. Also the amount of reserves that have to be maintained is considerable.

I have worked on both the provider and payer side and have always been astounded that payers get the bulk majority of the blame for the costs. If cost controls, utilization management, and abuse prevention mechanisms etc developed by payers did not exist, care would be far more expensive and completely based on paying for each service with few controls