Gawande’s New Yorker article has become required reading. But is McAllen a microcosm of American health care? Or is it a curiosity. I’m afraid it’s the latter. McAllen is unique. Read what McAllen’s physicians have to say about it. It’s at the most southern tip of Texas in a county with 725,000 people, 90% of whom are Hispanic – one of the poorest counties in the nation. But because of NAFTA, McAllen is the fastest growing community in the nation. People and money are pouring in from the north and across the border, and there’s also a great deal of cross border activity – working in one place, living in the other and shopping in McAllen on the way back. The in-pouring of wealth has fostered high-tech medical facilities – cancer centers, heart institutes, psych units, rehab units – big city medicine in the middle of nowhere. Entrepreneurism abounds, in retail, real estate and medical care. Yet 36% of the population is below the poverty line, including almost 25% of the Medicare population, whose outcomes are poor, not just in McAllen but everywhere. So, there a collision of abundant health care resources related to burgeoning wealth and massive utilization related to profound poverty — an extreme example of the affluence-poverty nexus. A Monty Python version US health care.
Possibly unaware of the connection, Gawande described the poverty effect in a previous New Yorker article, about the “Checklist.” That project took him to Detroit’s Sinal Grace Hospital, which the Dartmouth group had criticized as a hotbed of waste and inefficiency due to an overuse of supply-sensitive services. What Gawande stumbled into was quite different: “Occupying a campus of red brick buildings amid abandoned houses, check-cashing stores and wig shops on the city’s West Side, Sinai-Grace is a classic urban hospital. It has eight hundred physicians, seven hundred nurses and two thousand other medical personnel to care for a population with the lowest median income of any city in the country.” It is little wonder that its patients consume more resources, but such consumption is unlikely to result from “the overuse of supply-sensitive services.” Indeed, what the suppliers desire most is fewer demands on their already overworked lives. As in Chicago, poverty matters.
One last word, and it’s for the President. Health care reform is on a failure course because ideologues are twisting anecdotes into policy. I want you to succeed. I want the nation to succeed. Making McAllen required reading is not the way to do it.