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One of the enduring conflicts in healthcare, really going back to the early 1970s when the first HMOs were formally recognized under the Health Maintenance Organization Act off 1973, has been the longstanding set of tensions between providers and private health insurers. Of course, there has been tension between providers and the Medicare and Medicaid programs as well, going back to their inception in 1965. Fundamentally, all along, hospitals and physicians have wanted to be paid the maximum amounts possible for what began as fee-for-service payment, and has gradually evolved through generations of discounted fee-for-service, and into value-based payment, and in some cases, capitated or full-risk reimbursement.
To some extent, those tensions will always exist in our endlessly complex healthcare system here in the U.S.—one that is so head-spinningly complex that it is virtually impossible to even explain to non-Americans (and sometimes even to some Americans). We have neither a purely capitalistic system, nor a fully government-run one that has eliminated all capitalistic incentives. Instead, we have a system so intricate and nuanced that making even the tiniest changes to incentives among the stakeholders of the system requires herculean efforts and the expending of massive amounts of political capital.