In the DC parlor game of comparing the Clinton health reform debate to the current one, here's our favorite entry. In 1993 we had Betsy McCaughey infamously trashing health reform in The New Republic. In 2009, thank goodness, we have Gawande's piece on the extraordinary high costs of medical care in McAllen, Texas, which has reverberated all the way to the White House, and naturally it's come under attack. Gawande responds on The New Yorker's website, with words and numbers. He addresses three common critiques:

1. People in McAllen are poor. So are people in El Paso, which spends much less and has comparable or better health outcomes.
2. Snowbirds (elderly northerners winter in McAllen—who knew?) distort the health spending data. No they don't. Their Medicare costs are calculated in their home community.
3. It's all about malpractice. No it's not. And even if it was, it wouldn't explain why doctors in McAllen practice more "defensive" medicine than just about anyone else on the planet. 

As Gawande noted in the original article and in his follow up post, perverse financial incentives, and the local medical practice patterns and culture are the main reasons that McAllen spends $14,946 per Medicare enrollee.
That's more than the local per capita income. It's the second-highest Medicare spending in the United States and essentially double El Paso's cost of $7,504 per enrollee.

McAllen's doctors do more pacemaker insertions, knee replacements, carotid operations, coronary artery stents and just about everything else you can think of. Except hospice (which typically doesn't earn the doctors much money, even though it can be very good for the patients). McAllen has more hospital beds than four out of five American cities. And as we've learned in the past, once the hospital bed is made, patients end up lying in it.

We all know Gawande can do words. Here he also does numbers:

He adds:

One last point worth remembering here: McAllen's spending was almost identical to El Paso's in the early nineteen-nineties. By the late nineties, however, it had become one of the most expensive regions in the country for Medicare and it has continued that way. Yet, public data show no sudden decline in health status or income for the McAllen population.

 

As we look across the enormous differences in health-care spending in our country, what we are witnessing are enormous differences in the way medicine is practiced. There are lessons to be learned from examining what the positive outliers do differently to prevent themselves from going McAllen's way. Studying what they have accomplished, and changing the financial incentives in our system to replicate it, could make care far better for patients in McAllen. Indeed, it could make care far better for patients across the country.

So to go back to the parlor game. Gawande has inspired us to update that Clinton era slogan for the heatlh debate of our times:  "It's the incentives, stupid."

P.S. This was actually Gawande's second terrific piece on health reform this year. An earlier one describing other countries' gradual paths toward covering everyone got noticed but didn't make as big a splash. We blogged on it here, and we've also covered Gawande's work on quality, safety and surgical checklists (here, here, here, here, here, here, here and here)

Gawande also chatted recently with Ezra Klein about some other aspects of the health reform debate.