The dirty truth about American health care is that it costs more not because insurers are so powerful, but because they’re so weak.

There are few truly single-payer systems in the developed world. Canada has one, as does Taiwan. Most countries rely on many, many insurers. Germany, for instance, has more than 150 “sickness funds.” The Swiss and Dutch health systems look a lot like Obamacare’s health-insurance exchanges. In France, about 90 percent of citizens have supplementary health insurance. Sweden has moved from a single-payer system to one with private insurers. Yet all these countries pay vastly less for drugs, surgeries or doctor visits than Americans do.

Why? Because in every case the government sets prices for health-care services and products. Insurers in Switzerland don’t negotiate drug prizes with Pfizer. The Swiss government simply sets its drug prices and lets Pfizer decide whether to sell in Switzerland — or not.

“The problem is that in the U.S. payers are fragmented while in other countries they are unified even if there are many insurers,” said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University.