> So they're now using a mixed strategy of both out-sourcing and in-sourcing medical training to address high costs.

Not as much as they could though - there are still federal caps on the number of fellowship seats available as well as pretty strong restrictions for physicians coming from overseas (although if I recall correctly, California has less stringent restrictions than most)

We discuss insurance as a big part of the cost problem, but regulatory capture on the supply end is another huge (and unnecessary) factor.