Critics of the US health system argue that a higher proportion of the health dollar should be spent on public health, both to improve outcomes and to contain costs. Attempts to explain the subordinate status of public health in America highlight such factors as distrust in government, federalism, and a bias toward acute care. This article considers these assumptions by comparing public health in the United States, England, and France. It finds that one common variable is the bias toward acute care. That the United States has such a bias is not surprising, but the similar pattern cross-nationally is less expected. Three additional findings are more unexpected. First, the United States outperforms its European peers on several public health metrics. Second, the United States spends a comparable proportion of its health dollar on prevention. Third, these results are due partly to a federalism twist (while all three nations delegate significant responsibility for public health to local governments, federal officials are more engaged in the United States) and partly to the American version of public health moralism. We also consider the renewed interest in population health, noting why, against expectations, this trend might grow more quickly in the United States than in its European counterparts.

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