This time they almost got me. I couldn’t really figure out why McAllen spends more than El Paso. But give me some credit. I figured out (1) why states with more specialists have poorer quality (they don’t; it’s phony statistics); and (2) why states with more Medicare spending have poorer quality (because many states with the most Medicare spending have low total spending, which is the determinant of quality); and (3) why nothing was necessarily better among the Medicare quintiles (because they were distributed randomly with respect to total spending); and (4) why there are more knee replacements in Minnesota than in Massachusetts (rather interesting because it’s backwards – Minnesota is supposed to be the land of sky-blue spending, but it’s in the bowl of high knee replacements) and (5) why health care outcomes in the US are the poorest in the world (because the Union won the Civil War and got the Confederacy, where health care spending is low and outcomes are poor); and (6) why women in Lewiston, Maine had more hysterectomies than women in nearby Wiscassett (because Lewiston is heavily Catholic, while Wiscassett is almost entirely Protestant, and the ladies of Lewiston used hysterectomies as a form of birth control that was acceptable to the Church.); and (7) why there are such great differences in resource use among academic health centers (because the ones with lowest use are in college towns, while the high-users are in major urban centers); and (8) why California’s academic medical centers differed so widely in resource use (because their patient populations had such different risk and income levels); and (9) why Medicare spending in Miami is not like Minneapolis (because Miami is as poor as the wards in Chicago where President Obama worked, and expenditures among the poor are vastly greater); and (10) why the use of oxygen equipment is higher in some states (because the higher use states are at higher altitudes, where folks with COPD need more oxygen); and (11) why Birmingham spends more than Grand Junction (because Birmingham has a 55% higher prevalence of major illness, double the poverty and 76% blacks, while Grand Junction has 0.6% – – in fact, Grand Junction is pretty much like Green Bay, the most recent poster child of efficiency); and (12) why mortality is lower in states with more family physicians (because they’re mostly in the upper Midwest, where there are fewer blacks, low poverty rates and longer life expectancy). But I couldn’t quite figure out (13) why McAllen spends more than El Paso, although others have made interesting suggestions. And then along came Dan Gilden, who showed that it’s simply a matter of disease burden. Sicker people use more care. So it’s 13 for 13 — not bad (with a little help).