" “Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ” "
The narrative continues:
"To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice which has three decades of expertise in examining regional patterns in Medicare payment data.
Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things."
The L.A. Times article on which you base your conjecture is itself based on data from the Dartmouth Institute for Health Policy and Clinical Practice, whose publications paint an entirely different picture (from yours) of why Medicare costs differ enormously from region to region. As a matter of fact, if you visit the site, you will find several of Dr. Gawande's articles listed there - including this one.
So the answer is pretty clear. Medicare costs differ from region to region - not because of differences in the income or "life styles" of local populations - but rather, the differences in the approach by medical professionals and administrators in different areas towards how and how much health care is to be delivered. Furthermore the choice of McAllen as a case study is particularly significant, since another commonly held view is that doctors prescribe more tests and procedures to avoid malpractice complaints, and Texas is one of the few states in the union which caps non-economic damages in malpractice suits.
I think we're going to get into trouble if we start making broad assumptions about health care reform by using stereotypes. When you proceed on the assumption that income is a central determinant in how much care an individual is going to require in later life, what you are really doing is just laying the blame for high costs on "poor" people - while ignoring the real problem. Any free society is always going to have its poor and rich - and everything in between. There isn't much we can do about that. But we can, in the real world, develop more effective guidelines for doctors to rely on when considering treatment options. This concept, by the way, is precisely why the original reform bill proposed by Democrats mandates the creation of an advisory board to do that.