Leaving aside the insurance issue, why is the absolute price of American healthcare so high? The price of going to the doctor in the US, or buying drugs, can on occasion be 10 times what it is in Europe. It’s particularly surprising when in every other area – from clothing to electronic goods to gas –  American consumers are incredibly cost conscious and prices are almost invariably lower than elsewhere.

There are many reasons why US health spending is so high – and why we allow it to be high. One of the main lines of Paul Starr’s book The Social Transformation of American Medicine is that physicians have, over many decades, amassed considerable power over the policies that have been enacted, and they’ve shaped them to their benefit economically. So a lot of money flows to healthcare providers, physicians and hospitals, and also to suppliers of drugs and medical equipment. Those organisations are relatively powerful and they’ve been able to keep it going.

Also, Americans mostly don’t see the prices. Because of insurance, they don’t directly feel how expensive it is when they enter the system in any way – whether it’s a visit to a physician or a visit to a hospital. Worse than that, they mostly don’t even see the price of insurance directly. The vast majority of Americans have employer-based health insurance and much of the premium is paid by the employer. It doesn’t show up on their pay stub, and it doesn’t appear, to them, to come out of their own pocket – even though actually it does, through lower wages. When you think you’re getting something for free or pretty cheaply – whether it’s the insurance or the healthcare itself – you’re not that motivated to shake things up.

That’s for people who work. Then for retirees, almost all of them are on Medicare, so they’re getting considerable benefit through a public programme. They don’t see why that should change either. So things just keep marching along. We haven’t been able to put in place sustainable cost controls, either publicly or privately, largely because it’s politically difficult to do that.

You do see articles about spiralling insurance premiums and healthcare costs. Are attitudes changing, with people becoming more aware that this is unsustainable?

Healthcare is like every other issue in the American political discourse – it has its moments. It can rise to the surface if other things aren’t in the way. If the economy is bad, that’s always going to dominate what people are thinking about. Or other issues can dominate, depending on the news and where the crisis of the day is. But every once in a while, the spending on healthcare and the problems in healthcare markets do come up. They start to weigh heavily on people’s minds, and when that coincides with a political opportunity to do something then reform can happen.

That coincidence tends not to happen often. Maybe once every 15 to 20 years we get a genuine opportunity to do something substantial in health, and it doesn’t always succeed. That’s how Medicare happened in 1965. It had been considered, worked on and thought about for more than a decade in various forms. Other comprehensive health reforms have failed over the decades including, famously, the Clinton plan of the early 1990s. That was a time when there was a lot of attention paid to healthcare. People thought we should do something, and it seemed politically feasible. But it just wasn’t managed in a way that succeeded, because the politics are so hard. It’s like threading a needle. You have to do everything right to get something passed, even if it’s imperfect. Finally, in 2010, it was remarkable how well everything came together. It was very messy, but that’s the nature of it. It was the finest of margins, every vote in the Senate counted. They needed 60. They got 60.

I’ve seen charts showing that increased spending in the US doesn’t translate into higher life expectancy. Is that because the uninsured bring down the average lifespan?

There are studies out there showing that lack of insurance leads to higher mortality, but the estimates are not precise. It’s exceedingly hard to empirically relate insurance to mortality, because many health-related issues that lead to lower life expectancy take years to develop. In America, by the time you’re 65 you’re insured on Medicare. If you’ve reached that age, you’re likely to live quite a bit longer. What is the effect on mortality, after age 65, of being uninsured for some number of years when you’re younger? That’s very hard to tell.

Why we have lower life expectancy is a good question. Insurance does play a role, but it’s not the only thing that matters. What is true is that we spend dramatically more than any other country – twice as much as the next highest-spending country – and we have not just higher mortality but a whole range of quality measures that are worse than elsewhere. Sometimes much worse. So what one can confidently say is that we’re spending a lot but not showing a lot for it. That doesn’t mean that if we spend less, or just cut the budget, then we won’t lose something. It’s likely that we are getting something for all that spending – we’re just not getting it very efficiently.

One barrier to change is that rich and educated people, including members of Congress, believe that the US has the best doctors and hospitals in the world – and that if they move to more socialised medicine, as in Europe, then they will lose that.

It’s definitely a concern among the elite and health policy wonks. The way it plays out more broadly is that there’s immense status quo bias. That’s true everywhere. People tend to be comfortable with what they know. Everybody wants to believe that what they have and where they live is fantastic. People are very reluctant to give up the idea that the US is number one.

And you can receive the very best care in the world in this country. There is a reason why princes from Saudi Arabia fly into the US for treatment. But only a very tiny fraction of the population has access to the very best healthcare in the US. They don’t want to give it up, and I don’t want them to give it up either. But there are many people who don’t have access to the best care. In fact, there are many people who don’t even have access to basic healthcare. We’re not talking about state-of-the-art, triple-transplant surgery. We’re talking about routine preventative care, screenings, office visits and immunisations. The disparity is large between what the very best and the bottom quintile are able to obtain.

But is it true that the US is the best country in the world for top-end healthcare? Are there studies proving that if I’m treated for cancer at a top US cancer hospital, then my survival rate is higher than in other systems?

There are certain cancers we rate very highly on. Breast cancer is one of them – our survival rate for breast cancer is very good. But when you read anything claiming that the US has the best care in the world, they are cherry picking three or four specific diseases where we have very good survival rates. It could be because the care on those diseases is good. It could also just be that if you run enough statistics, then by random variation we’re going to be number one on a few things, even if we are middle of the pack or worse on 99 other things. It’s not a good way of judging the overall quality of healthcare.

Given the average age of members of Congress, they must have either been sick themselves or had a relative who has been, and so know what it’s like to deal with the healthcare system and insurance companies. Or do they have some sort of gold-plated insurance that means they’re shielded from the worst of it?

Actually, I am an employee of the US federal government so I have the same health benefits that congressmen do. It’s pretty much standard employee health benefits. For people who have decent jobs – as I do and as congressmen do – routine healthcare is not a big deal. But I’ve heard that it comes as a shock to people like us whenever they engage intensively with the healthcare system, for example if they or a family member becomes incredibly ill and is in hospital for a long time.

That’s when some of them finally say, “Boy, I was at a good hospital and still. Ugh. It was really unpleasant and I kept being asked the same questions. They didn’t seem to know that I’d already had that test. Thank God I had my wife with me during all this so she could made sure they didn’t amputate the wrong leg.” The stories are just shocking. There’s a story just recently that a large proportion of physicians don’t follow guidelines in washing their hands. It’s atrocious.