Or, it’s the voters.
Even without the argument that ultimately voters are responsible for the government they get in a country with free and fair elections like the U.S., health insurance is a very direct example of voters explicitly opting for a worse option.
The ACA was being written in 2009 and 2010 and the argument was whether it constrained the insurance industry too much or not enough. The very specific policy proposal on the table was the public option which would have allowed the govt to offer an insurance policy that would have effectively set a floor to the quality of policies the healthcare industry could offer and a ceiling on the cost.
And the 2010 election fell right in the middle of the debate and American voters overwhelmingly chose the politicians arguing against the public option and for fewer restraints on the insurance industry.
Beyond that you can just look at every other developed country in the world, and all of them have better healthcare because their voters constantly vote for politicians who offer better healthcare policy, as opposed to the U.S. where voters choose the opposite.