> part of the success of medical tourism in India is the lack of stranglehold control over medical care by insurance companies. In India, I can: Get an estimate for service before it happens, and plan for it therefore, Pay for the service at the time of discharge with/without insurance

There are a lot of problems with the insurance industry in the US. The first two that you call out, though, are a bit more subtle, and have to do with the way medical billing has evolved in the US. (Medical billing is related to, but distinct from, insurance).

The reason that you can't get quotes beforehand is because the providers literally do not know what it will end up costing you. As I mentioned in another comment, Medicare effectively leans on private insurers (and uninsured patients[0]) to subsidize the costs of care delivery.

A simplified version: a certain lab test costs $100 from the manufacturers. Medicare decides to pay $80, and providers have no room to negotiate this. Let's say that, for a given hospital, Medicare patients comprise 50% of the patients (not unusual in certain areas). On average, the hospital has to make $120 on each of the other 50% of the patients just to cover the per-unit costs, before paying for the overhead of actually running and staffing a hospital.

So, they bill private insurers $400. They don't expect private insurers to pay $400/test, but they use this as a starting point. In the end, the private insurer (say, Aetna) will come back and say, "okay, we'll pay 200% of what Medicare reimburses, for all Aetna patients you administer this test to for the next year, if you stop sending us these bills"[1]. So, they strike a deal to pay $160/test[2]. That leaves $160-120 = $40 of revenue on 50% of the patients to pay for all the overhead, so hopefully the overhead can be limited to $20/unit, or the practice will go under[3].

Unfortunately, most hospitals can't present patients with different bills depending on their insurance status[4]. So, they present that bill for $400 to uninsured patients, not actually expecting that they'll pay the full amount. If you know this, you can tell them, "if you reduce the bill to $40, I'll pay in cash today." Unfortunately, most people don't know this.

So, the reason you can't get a quote in advance is that the doctor literally has no idea how much it will actually cost you. Because, even if they know your insurer, they don't know the details of your plan well enough to give you a precise quote. And the actual resulting price is only very indirectly related to how much it costs the provider.

[0] this second part - uninsured patients - is more an unintended consequence rather than the intended effect

[1] In reality, it's a bit more complicated, because it's not always set at the level of the insurer (ie, it's not always "all Aetna patients", but more likely "all ____ Aetna patients", which makes it more complicated.

[2] If you're really unlucky, the provider might even enter a capitated agreement with your insurer, in which case they receive a lump sum up-front without actually knowing how many tests they'll administer.

[3] Unsurprisingly, a lot of practices have gone under and been bought out by hospital networks in recent years (and hospitals have similarly gone under and been bought out by insurance companies).

[4] this is a combination of federal and state laws, as well as the infrastructure it would require