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

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

Atul Gawande has deemed a combination of ambition and humility—ambition for the right process, and humility to recognize the limits of any one discipline.

For Americans, the rationing scheme works not through wait times but through the mechanism of price.

In her book Thinking in Systems,22 Professor Meadows highlights the need to locate accountability in a complex adaptive system so as to optimize outcomes. In the United States’ health care sector, putting Meadows’s teaching into practice would mean identifying ways by which actors (for instance, hospitals) feel the impact of their actions on other

In Sweden, for example, health services are procured by locally elected county councils that have flexibility within their mandate to provide evidence-based care at the county level. At the same time, the county councils are largely responsible for social services and general welfare as well, theoretically enabling greater coordination and more exp

Similarly, the Ministry of Health and Social Care in Denmark is responsible for establishing broad legislative and financial frameworks for both health and social policy, while responsibility for service design and provision are decentralized to thirteen counties and more than one hundred municipalities.

to balance “upstream” work to keep people healthy through adequate services in the social sphere, with “downstream” work of medical care for people after they have become ill.

This growth was fueled first by the improvement in medical education, then by an enormous expansion of hospital beds, and finally by major funding for the Medicare and Medicaid programs.

Coordinating care in this way allowed physicians to focus on what they are trained to do—provide medical care—while other staff took care of applications for disability benefits, housing, legal issues, and many more needs. The academic literature identifies this approach as enabling professionals to work at the “top of their license” and has demons