The American Health Care Paradox: Why Spending More is Getting Us Less

Inadequate attention to and investment in services that address the broader determinants of health is the unnamed culprit behind why the United States spends so much on health care but continues to lag behind in health outcomes.

DECISIONS ABOUT HOW TO DELIVER social and health services in Scandinavia are governed largely by the concept of local accountability. The strength of local government is apparent in comparative data from Scandinavia, France, Italy, and Great Britain, which show local government budgets accounting for larger percentages of total government spending

Ironically, Truman’s well-intended initiative to increase access to health care ultimately served to escalate costs by making hospitals the centerpiece of the health care landscape.

Atul Gawande, an American surgeon and journalist, offers a metaphor for the shortfalls of such piecemeal approaches to change, “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence.”

Nixon. In the course of their growth, managed care organizations have become focused on reducing health service use (and attendant costs) rather than on managing health,

Our system has not got a place for [people living on the streets without steady housing] to go. These are people who get really sick, get really complicated, and we spent a lot of money on their [open heart surgery], but no money on their recovery . . . And ninety percent of them have an active substance abuse issue. When we tried to do substance a

The idea is that housing is necessary for any larger health outcomes or behavioral changes, such as less substance abuse and violence, continued treatment for mental illness, or recovery from a medical condition.

Practically speaking, this outlook manifests in the substantial attention these countries pay to buttressing services pertaining to housing, the physical environment, conditions at work, supportive social environments, family allowances, income support, unemployment support, and other social services, rather than more medications, hospital days, an

nearly half of a primary care physician’s time is spent on documentation and follow-up, outside the examination room without the patient present.