The “Dartmouth Honorary Clause” (Section 1123) of the House of Representatives discussion bill provides an incentive payment of 5% for suppliers of medical services in the 20% of counties that have the lowest Medicare expenditures.  Are these counties distinctive in any other way? Well, yes. While they spend 40% less per enrollee on Part A services and 25% less on Part B than the highest-cost 20%, they have smaller populations (only ¼ as many Medicare enrollees as in the high-cost counties) and much less poverty (60% lower DSH payments per enrollee than in the high-cost counties). So there’s not much chance that the high-cost 20% will get that 5% boost. They just have the wrong demographics. Darn, all those poor people.