Scott Gottlieb references work in this article that shows something surprising: it turns out that the US has the lowest out of pocket costs for medical care as a percentage of medical spending of all but four other developed countries. This may be part of the reason that our incentives to control costs are so out of wack. It is surprising given that you always think of the US as the raw capitalism model, but this is also in part driven by the fact that our overall expenses are so high. A higher absolute amount may be a smaller proportion. Our employer based insurance model plus medicare/caid (which has interestingly had declining co-pays over the last couple of decades) can give us the worst of both worlds it seems.