It's the same thing, when it comes to the problem I'm pointing out, no matter how we describe it - medical providers charge different rates for the same products to different insurers, and insurers pay different rates for the same products to different providers. And the range of variation is not actually large, but we introduce tremendous complexity to the system in order to achieve it. It's not "competition" in the classical sense, and doesn't provide the benefits of competition to consumers, providers, or insurers.