It's hard to tell, because pricing is so opaque, but everywhere the incentives are misaligned.

Insurance companies are regulated on profit margins, which means it's actually in their interest for costs to rise, since their income is limited to a percentage of the costs. Administrative overhead at the insurance company is limited by percentage as well, but I don't think that includes the overhead at medical offices required to deal with insurance billing.

Users may be able to pick between different cost options, but at best they know the direct cost to them, not the overall cost. There's also a sense of wanting to get the most the insurance will cover, because that's why you paid for it.

Doctors' compensation is certain a factor, especially since there are effective rate limits on new doctors based on the number of slots for residencies, that aren't adjusted for population growth.

Employers (who are usually the ones selecting the insurance plans) may be cost aware, but might be selecting based on direct costs to the employer and not on total cost to the employer and employee combined.

Doctors?

Seems to be a huge reluctance for anyone in politics to place the blame on them. But I'm pretty sure they make far more in the US than anywhere else in the world.

And they pay huge amounts of their income to malpractice insurance.

Hmm. There's that word "insurance" again.

From what I've read, doctors are also substantial owners of the malpractice insurance companies. Also, their premiums are paid by their employers. In fact, salaries don't tell the entire story for doctors, since they are heavily invested in their own industry. For instance, at one point my health insurance provider advertised itself as being doctor-owned.

As mentioned above, a problem is that the system is so opaque, seemingly by design. A potential benefit of a government run system is that there could simply be fewer business entities. For instance, doctors could just work for the government, for a decent salary.

> But I'm pretty sure they make far more in the US than anywhere else in the world.

Yea, but the opportunity cost of getting there is huge. At graduation, most doctors are in the ballpark of $1MM behind where they'd be if they went straight into a professional career.

Also, doctor's salaries only account for 8% to 20% of total healthcare costs.

"At graduation, most doctors are in the ballpark of $1MM behind where they'd be if they went straight into a professional career."

So the two great failures of the American economic system, education and health care, reinforcing each other to make the situation even worse.

"Also, doctor's salaries only account for 8% to 20% of total healthcare costs."

Where does the rest go?

> Somebody's gouging us. Who?

Owners, executives and shareholders. Look at who owns the hospitals, practices, labs, insurers, suppliers and associated facilities.

that's not entirely true. There are nonprofit medical providers and they are equally expensive as for-profits; and there are also in the US a handful of "extreme for-profit" medical providers which are considerably cheaper (without sacrificing quality).

Non-profit doesn't mean "we don't pay our staff, partners and suppliers market rate". It's entirely possible that non-profits contribute towards rising medical costs through the same mechanisms that for-profit entities do.