Nice deconstruction of the current operating models around the world. In addition to your point about no checks & balances on providers (which leads to issues with transparency and inability to comparison “shop”), we cannot underestimate the optimization practices of health insurers since they are for profit. Insurance (in general, not just healthcare) used to be about risk distribution. Insurers worked hard to have distributed pools and expected to pay claims. The drive to maximize profits has led to not distributing risk but concentrating it. So we want people who are sicker to pay higher premiums (as if being sick would never impact your ability to keep your job) and every car accident or speeding ticket leads to a surcharge. Any one who actually USES insurance for its purpose is penalized.