In most other developed countries, it is politically straightforward to spend $20,000 a year on coaxing and cajoling a patient into managing their diabetes better in order to prevent them from becoming a $70,000 a year dialysis patient. Needless to say that the benefits to this approach are greater than just a cost saving.

I agree with your basic points. But as someone who both is American and has a serious life threatening medical condition, I think there must be some deeper reason for this American quirk.

I know that a lot of "standard wisdom" concerning nutrition and the like not only doesn't work for me but is actively harmful to me. I have managed to get off 8 or 9 prescription drugs and now manage my health issues via diet and lifestyle (and herbs and supplements when necessary). But I have gotten there by following a pig-headed, asinine, "don't tread on me" sort of path. It has been really important to actively reject outside intervention in favor of home-grown solutions for my issue. I suspect something similar may be true for most Americans. America was founded by social outcasts who left their countries of origins to go elsewhere under really harsh, deadly conditions -- conditions which were, nonetheless, more tolerable than the social expectations they were fleeing.

Most people cannot fathom my choice to live without furniture and without a car. I sleep on the floor and most of the time I own only two or three outfits. I get lots of comments from people who are often just trying to make conversation but nonetheless are basically butting in to things that they know nothing about and which are none of their business. For example, I do not own a jacket. Jackets are too hard to keep adequately clean and most are not designed to be washed regularly (ie every single I wear it). I find that undershirts work better for me than jackets. I have also been known to walk to work in flip flops in 40 degree weather. People inevitably feel compelled to tell me to get a jacket or comment that my feet must be cold or something. It is usually under circumstances where I do not have the time (even if I had the inclination) to explain to them that whatever annoyance I suffer from the cold is laughable compared to the suffering it has allowed me to walk away from. It is also usually from people at work, this in spite of a company policy that no one other than my immediate boss is to offer "constructive feedback" on my appearance, and then only if I am in violation of dress code. It annoys me to no end yet I realize that if I made a big stink about it, I would most likely be the one deemed to be 'a problem' (and it would unnecessarily call attention to my medical condition, which I do not wish to do). Most of these people are well-meaning and genuinely concerned for my welfare and/or just trying to make conversation. So I try to handle things diplomatically and lightly and good-naturedly, without referencing the serious medical situation that drives my unconventional literally "remarkable" (ie worthy of remarking upon by these people) choices.

So I think it is possible that most Americans have some deep-seated reason(s) for balking at the idea of someone interceding in their diet and lifestyle choices at an earlier stage in the process. I know outside interference is one of the things that I feel most threatened by. Since I don't have a doctor's note for doing what I do, I can't really justify or defend it on some kind of "legal" grounds or some such. I'm just some lone nut-case who occasionally makes fantastical claims that most folks find unbelievable -- an issue I work very hard to keep out of my place of employment.

It is unfortunate that the results are so expensive. But I am not entirely convinced that the cajoling and convincing that works in other cultures would necessarily be such a good thing for a society of outcasts who could not conform and chose to face so much hardship in order to start over elsewhere. For me, conforming -- even in seemingly small matters like wearing a jacket -- leads to enormous suffering and would eventually kill me. So I just am unable to "go along to get along", in spite of internal wiring that makes me want very much to do that. But I just can't. Maybe a lot of Americans also just can't, yet are willing to accept intervention at a later stage of more serious crisis because at that point there is nothing to lose and a great deal to gain.