There is an MLR (Medical Loss Ratio) rule; essentially, an insurer can keep 20% of premiums they collect. So in order to increase profits, they have to inflate premiums; in the end, 20% of $1,000 is much better than 20% of $100. And that's the reason hospitals charge $50 for an ibuprofen pill. There are other tricks like vertical integration (an insurance company owns a medical provider), quality improvements, etc... But in the end, it's an optimization game — max(users * premium_cost) — and that's why for-profit medicine/insurance sucks. (Now, spend 1% of all collected premiums for lobbing, to make sure the system keeps working lol).