Even people in the US don't understand why those $200K hospital bills aren't real.

Insurance providers (including government programs) have a fixed limit for what they pay for procedures. They pay min(billed_amount, allowed_amount) so providers don't want to risk leaving money on the table by having billed_amount < allowed_amount. To ensure this doesn't happen, they bill an arbitrarily high number with the expectation that insurance will lower it down to some much smaller number.

So every time you see posts on the internet where people talk about their "$200K hospital bill" they're always talking about that arbitrarily high value. If you have to pay cash for some reason, they will reduce the value to the cash pay amount which is in line with the insurance paid numbers.

Nobody ever pays those high hospital bill amounts.