Yeah MLRs removed an incentive for payers to fight long run rate increases as long as they can model the risk effectively and pass on the cost to members via premiums, but they still tend to fight rapid increases because they break their models and retroactively misprice existing plans. Otherwise we wouldn't see contentious contracted rate negotiations between commercial insurers and providers, but we do.

Absolutely not here to praise US health insurance companies, but they're not the ones using regional leverage to negotiate higher rates - that's the providers.