The steep cost of health care remains a thorny political issue in the United States.
Disagreement over the extension of health care subsidies was at the center of the recent 43-day government shutdown, while President Donald Trump’s approval ratings have been severely hit by cost of living concerns, including on the soaring cost of health care.
Trump has consistently promised to cut costs and this week was expected to announce details of a new plan regarding the possible extension of subsidies from the Affordable Care Act, often referred to as Obamacare.
However, the announcement was postponed amid uncertainty over precisely what he is planning. “Somebody said I want to extend them (subsidies) for two years,” Trump said on November 25. “I don’t want to extend them for two years. I’d rather not extend them at all.”
The ongoing debate has once again drawn attention to the US health care system, commonly regarded as the most expensive in the world.
Is the US system the most expensive?
According to an OECD report entitled Health at a Glance 2025, released in November 2025, the US spends the most on health care in the world by a distance, per capita. The gap between the US per-capita spending and second-placed Switzerland is greater than the gap between Switzerland and Italy in 23rd place.
John McDonough, professor of public health practice at the Harvard T.H. Chan School of Public Health in Boston, USA, says the rising cost of health care in the US has been a serious issue for decades.
“If you’ve heard the overused metaphor in the United States: this is the frog in the slowly heating water, where the temperature keeps growing and people just say, ‘my, it’s getting hot in here'” he told DW. “This has been going on for almost half a century now.”
Experts say that on one level, US health care is extremely expensive because it provides world-class services and high levels of innovation, influential the world over.
However, this comes at such a high cost, says McDonough, including “vast disparities in outcomes and quality for people who are lower income, for African-Americans and Latinos.”
“So, yeah, there’s a lot of good stuff. There’s a lot of good innovation. There’s a lot of excellent care that is provided. And there are major, major flaws and shortcomings in this system,” he added.
Jon Cylus from the European Observatory on Health Systems and Policies in Brussels, Belgium, says a major driver of high costs in the US is high prices for insurance and other services, with a lack of transparency and controls on how prices are set.
“I don’t think there’s a clear answer to why prices are so high, aside from the fact that it’s a market that will bear it,” he told DW. “There’s a lack of price transparency. It’s very difficult. You can’t really shop around in the system.”
According to Klaus Hurrelmann, senior professor of public health and education at the Hertie School in Berlin, the issue of high prices is rooted in a highly commercialized market ethos that underpins the US system of healthcare.
Speaking with DW, he noted that in the US “market mechanisms dominate” and individuals are primarily responsible for “securing their life opportunities.” This includes health care as a “market good with selective state intervention.”
McDonough strongly agrees, saying that Americans had allowed health care to be “too dominated by business and corporate ethics,” including too much “financialization and commercialization” infecting the system.
“The system, in many ways, it’s no longer about the patient. It’s about maximizing shareholder value for the people who are the owners.”
Too many systems and not enough coverage
The US system is not centralized, with multiple forms of health care provision and insurance available.
The Medicare program covers people aged 65 and over, while Medicaid aims to help low-income families. There is also employer-provided health insurance called Employer Sponsored Insurance (ESI) and separate programs for military veterans and for Native Americans. There is also the option of buying individual insurance from private insurers.
However, according to recent estimates from the US Census Bureau and the CDC’s National Health Interview Survey, at least 8% of the population — more than 25 million people — have no health insurance coverage.
The Commonwealth Fund, a private American foundation which regularly measures US health care performance against that of other wealthy countries, routinely finds that the US has the worst-performing health care system overall among 10 high-income countries it profiles.
The other countries it profiles are Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland and the United Kingdom.
Looking to Europe
Health policy analysts often speculate about the possibility of the US taking lessons from some of the countries that outperform it in these survey, particularly when it comes to the issues of affordability and coverage.
Klaus Hurrelmann says that while the German system has qualities that make it a global reference point, “it is not a simple blueprint to be copied.”
Germany’s complex system involves compulsory health insurance schemes and widespread access to services, which, according to Hurrelmann, offers “important lessons, especially the commitment to universal access and solidarity-based financing.”
“But it is not a plug-and-play model,” he stressed. “It works because it fits a specific welfare-state philosophy and political culture that differ significantly from many other parts of the world.”
Hurrelmann also points to affordability issues amid rising insurance costs which include so-called out-of-pocket extra payments for patients.
John McDonough does not mince his words when asked if he would like the US to have a German or Swiss model of health care. “I would take almost any other nation’s system. It’s just that they’re all better than what we do,” he said.
He believes the key to those systems’ success is an ethos of nonprofit and the fact that they have to operate under consistent rules.
“In the United States right now, we have massive for-profit entities that have been consolidating and growing and dominating the system in particularly harsh and harmful ways that is creating a lot of the chaos that we see,” said McDonough.
For Hurrelmann there is a profound philosophical difference between how most European governments see health care and how the US government sees it.
“In Europe, health is widely seen as a social right. In the US, it is much more often seen as a private responsibility. This deeply influences system design, financing, and public expectations,” he argued.
Edited by: Uwe Hessler
