The United States is exceptional not so much because its health care expenditure is increasing, but because of the extent of public concern about what is an international phenomenon. This article seeks to provide a political diagnosis of the causes of this concern and some political prescriptions for possible change. It suggests that current attempts to restrain spending through planning mechanisms will fail unless there are matching financial mechanisms of control, and unless ways are devised of overcoming the resistance of the constituencies for the status quo.

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