>One of the big issues with the US system is that the patient is put right in the middle of the decisions so sees all the rejections, has to deal with all the paperwork, and pays the price when things go wrong.

This is the admittedly huge emotional problem, but distinct from cost problem. Hospitals and insurance billing systems can be as dysfunctional as they want because all of the financial liability is outsourced to the patient.

If this outsourcing were not possible, insurance and hospitals would have worked the issue out long ago. I expect all treatment would be pre-approved by default, and hospitals would carry the cost of misbilling (like how a retail store eats a fee for credit card purchases)

After going through 8 specialists, I ended up learning a bunch myself, and paying out of pocket for the last one.

Patients need to be more involved.

Singapore is an interesting example of that.

There is universal healthcare through compulsory national health insurance (premiums subsidized if needed).

However, the insurance only covers a portion. About 10-20% will come from a forced medical savings account.

Then there is the cash part of the cost.

The government has designed the entire system to make sure no patients pay $0 of their own money. Even indignant patients will work with a social worker to figure out what they can pay. If it's only $2, then they are billed $2.

It's a pretty good system in terms of keeping costs down, keeping patients involved in the cost of their care, yet ensuring nobody goes without critical healthcare.

The issue with the US is that it's kinda set up for patients to be at the center, but misses critical components (like price transparency) to the point that even though patients are required to manage their own healthcare financiing, they aren't actually given the tools to do it efficiently.

It would be more culturally fitting if the tools simply weren't offered - they're actively hidden!