Disagreements over the expansion of health care subsidies were 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 rising health care costs.
Trump has consistently promised to cut costs and this week was expected to announce details of a new plan regarding the possible expansion of subsidies from the Affordable Care Act, often known as Obamacare.
However, the announcement was postponed due to uncertainty over what he was planning. Trump said on November 25, “Someone said I want to extend them (subsidies) for two years.” “I wouldn’t want to extend them for two years. I wouldn’t want to extend them at all.”
The ongoing debate has once again drawn attention to the US health care system, generally considered the most expensive in the world.
Is the US system the most expensive?
According to the OECD report titled Health at a Glance 2025Released in November 2025, the US spends the most on health care in the world by distance per capita. The gap between US per capita spending and second-ranked Switzerland is greater than the gap between Switzerland and 23rd-ranked Italy.
John McDonough, professor of public health practice at Harvard TH 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: It’s the frog in slowly warming water, where the temperature keeps rising and people just say, ‘Oh my God, it’s getting hotter in here,'” he told DW. “This has been going on for almost half a century.”
Experts say that on one level, American health care is extremely expensive because it provides world-class services and a high level of innovation, which is influential around the world.
However, McDonough says its costs are high, including “huge disparities in outcomes and quality for low-income people versus African-Americans and Latinos.”
He added, “So, yes, there are a lot of good things. There are a lot of good innovations. There’s a lot of excellent care provided. And there are big, big flaws and shortcomings in this system.”
John Silas of the European Observatory on Health Systems and Policies in Brussels, Belgium, says a major reason for high costs in the US is high prices for insurance and other services, due to a lack of transparency and control over how prices are set.
“I don’t think there’s a clear answer to why prices are so high, other than the fact that this is a market that will bear it,” he told DW. “There is a lack of price transparency. It’s very difficult. You can’t really buy into the system.”
According to Klaus Hurelmann, senior professor of public health and education at the Hertie School of Berlin, the issue of high prices is rooted in the highly commercialized market ethos that underpins the American system of health care.
Speaking to DW, he said that in the US “the market mechanism dominates” and individuals are primarily responsible for “securing their own life chances.” It includes health care as a “market good with selective state intervention”.
McDonough strongly agrees, saying that Americans have allowed health care to be “too dominated by business and corporate ethics,” including too much “financialization and commercialization” that has infected the system.
“The system, in many ways, is 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 a wide variety of health care provisions and insurance available.
The Medicare program covers people age 65 and older, 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 Native Americans. There is also the option of purchasing individual insurance from private insurers.
However, according to recent estimates from the US Census Bureau and CDC’s National Health Interview SurveyAt least 8% of the population – more than 25 million people – has no health insurance coverage.
The Commonwealth Fund, a private US foundation that regularly measures US health care performance Compared to other wealthy countries, the US health care system is routinely found to be the worst performing among 10 high-income countries.
Other countries that have this profile are Australia, Canada, France, Germany, Netherlands, New Zealand, Sweden, Switzerland and the United Kingdom.
looking towards europe
Health policy analysts often speculate about the possibility that the United States will learn lessons from some of the countries that perform better than it in these surveys, especially when it comes to 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 copy.”
Germany’s complex system includes mandatory health insurance schemes and widespread access to services, which, according to Hurelmann, offers “important lessons, particularly the commitment to universal access and solidarity-based financing”.
“But this is not a plug-and-play model,” he stressed. “It works because it fits into a specific welfare-state philosophy and political culture that is quite different from that in many other parts of the world.”
Hurelman also points to affordability issues amid rising insurance costs, including so-called out-of-pocket out-of-pocket payments for patients.
When John McDonough was asked whether he would like America to have a German or Swiss model of health care, he didn’t mince words. He said, “I’ll take almost any other country’s system. It’s just that they’re all better than what we do.”
He believes the key to the success of those systems is the ethos of the nonprofit and the fact that they have to operate within consistent rules.
“Right now in the United States, we have massive for-profit institutions that are consolidating and growing and dominating the system in particularly harsh and harmful ways, creating a lot of chaos,” McDonough said.
For Hurelman there is a deep philosophical difference between how most European governments view health care and how the US government views it.
He argued, “In Europe, health is widely seen as a social right. In the US, it is often seen as a private responsibility. This deeply influences system design, financing, and public expectations.”
Edited by: Uwe Hessler
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