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I did a ton of looking into this over the years. That everything is a little bit at fault, is why if you exhaustively eliminate (say) insurance overhead, it leaves a weird amount of the elevated costs intact.

Thinking you’ve found the one main reason makes it easy for opponents of reform to dismiss your solution, because you haven’t found it, because there’s not a main reason. It also means “cut private insurance out of the process” doesn’t fix it

Consider: public insurance schemes in the US spend far more for some given amount of care than peer states do, even as provides complain these programs don’t pay enough—that latter part is because all their vendors, suppliers, and personnel demand more money than their counterparts in the rest of the OECD states. Every single part of the system costs too much.

Switzerland pays more than us for doctors, barely, but also has unusually high healthcare costs for Europe (though not as bad as ours) and is richer than the US. Luxembourg is close but is an outlier for basically everything, they crush us in median income and such as well. Bermuda, a little lower, but it’s an island nation (everything’s more expensive) and, like Lux, richer than the US, another outlier. Nearest comparable looks like Australia, paying doctors an average (this avoids missing the effects of crazy-expensive top-end specialists, as a median might) about 76% what we do. The rest of the OECD’s lower than that.

You want one thing that is contributing, but such a trivial amount that it’s hardly worth addressing until everything else is fixed: it’s doctors’ liability insurance. They really want to reduce that cost, for obvious reasons, and Republicans want to fix it because… they hate poor people who’ve been harmed being compensated “too much” I guess… and it does contribute to higher costs, but very little compared to practically everything else. That one gets way more attention than it merits.

The unifying factor of other countries’ healthcare schemes that keeps them cheaper than the US doesn’t seem to be that they’ve minimized the role of private insurance (some haven’t!) but that they have explicit (like government-set price lists) or or implicit (via e.g. monopsony) price controls. It seems like you can use any of several approaches, some of which keep private health insurance in a prominent role (Switzerland! Though they at least have the good sense to force them to be nonprofits, IIRC) so long as you have, one way or another, price controls.

The only near-exception to this I’m aware of is Singapore, but… it’s Singapore. Plus they do have some explicit price controls, and I think it’s fair to say healthcare providers there might consider there to be a persistent, credible implied threat of more price controls or even harsher measures from the government, should prices rise too much, because… it’s Singapore.

[edit] FWIW I do think fixing the insurance situation is an excellent place to start, even the best starting point, and that the insurers in the US are probably beyond salvaging through integrating them into a better system, and should just be eliminated or their role drastically reduced; I think this would make less progress toward fixing prices than some suppose it would, though would still do a lot for that, but it’d, crucially, fix most of the hidden costs of our system, like patient-hours lost to waiting on hold to try to get insurance to pay what they’re supposed to, HR folks messing with insurance-related issues, et c, which are huge and don’t make it into straight cost comparisons with other countries because those aren’t “healthcare costs” (putting a dollar value on that would make us look even worse than we already do)