Getting past denial--the high cost of health care in the United States.

10.1056/nejmp0907172 nejm.org 1 since doing so would require taxes to be raised beyond the level the public can sustain. Others believe that we can slow spending growth only by rationing needed care. Neither option is attractive. Evidence regarding regional variations in spending and growth, however, points to a more hopeful alternative: we should be able to reorganize and improve care to eliminate wasteful and unnecessary services.1 But not everyone is convinced. Some physicians, hospital administrators, and legislators appear to have succumbed to a behavioral bias. They know that their patients are sick and that sick patients need more care than relatively healthy ones. They therefore conclude that the reason their hospital or region spends more is that their patients are sicker and poorer than those cared for by institutions in other regions. Given this reverse “Lake Wobegon” effect that renders all U.S. patients below average (in Garrison Keillor’s fictional town of Lake Wobegon “all the women are strong, all the men are good-looking, and all the children are above average”), they argue that any efforts to rein in costs will cause harm to the people we most want to protect. And it’s not hard to find examples of places where this explanation might appear to make perfect sense: in Los Angeles, where Medicare spends $10,810 per capita, a somewhat higher percentage of the population (15%) is at or below the poverty line than in Minneapolis (10%), which spends $6,705 per capita. This is too important a moment to allow physicians or policymakers to be confused by behavioral biases or distracted by one-off examples. Health is indeed the most important determinant of health care spending, but differences in health explain only a small part of the regional variations in spending.2 We illustrate by updating our earlier Dartmouth Atlas study2 with 2004 and 2005 data from the Medicare Current Beneficiary Survey, a nationally representative sample of 15,487 Medicare enrollees that provides detailed information on individuals’ health status, income, health care utilization, and Medicare spending. MedGetting Past Denial — The High Cost of Health Care in the United States