[twoodfin]

Why's it have to come out as profits? Couldn't they just be a big lumbering bureaucracy that never gets cut because they never have pricing pressure?

Sure, but that would show up in the CMS numbers, and it doesn't.

Insurers are absolutely price-conscious, both of what they pay for and what they charge. It's not as if businesses will accept year after year double digit increases without shopping around. If there were big money to be made undercutting existing insurers, someone would go after that market, but there isn't: Health insurance profit margins are low single digits at best.