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.