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Complaining about the service quality for public health insurance customers in Germany is pretty much the definition of "first world problem" though. FWIW I never switched over to private insurance even though my income would allow it, also once you get above a certain age you can't switch back and that's when the private insurers really start to rip you off ;)

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And despite that they are willing to pay, because if you are out of poverty your health is a high priority!

So yes, Americans love consuming healthcare. Is there any category they aren’t a high consumer of? You can’t measure efficiency only looking at the input side.

I think the main reason why high income Germans switch to private health insurance is less about service quality, but because they may actually pay less than public insurance (at least until they get near pension age). Can't talk for US citizens of course.

US health care is screwy, because one of the equitable things it tries to create is equal price regardless of age/sickness.

As a consequence, insurance companies generally try to sign up mixed-pool, younger, healthier (read: employee plans) over older, sicker, opt-in insurance (read: ACA).

There are ways they can and can't legally do that, but it's always the goal. In the same way that retail order flow is targeted by HFTs.

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