Geography Is Destiny: Differences in Health Care Among Medicare Beneficiaries in the United States and California

Dartmouth Institute for Health Care Policy and Clinical Practice


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When it comes to health care it’s not just who you are that matters, it’s also where you live. While income and race have an impact on both the health of patients and the care they receive, there is often greater difference seen in the amount and quality of care patients receive in various parts of California, and in the rest of the nation.

The California HealthCare Foundation, as part of its continuing support of the Dartmouth Atlas Project, commissioned research on variation in care delivery among Medicare beneficiaries, both nationally and in California. This 2008 report offers a window into the underlying causes for the poor state of our health care system and identifies opportunities for reform. Major findings include:

  • For services such as mammography and diabetes testing, differences across states and regions are greater than differences by race. In other words, while race matters when it comes to whether or not you receive appropriate preventive services, where you live can matter even more. Furthermore, there are some regions where African Americans receive equal or better care than whites but where care for all patients is less than ideal.
  • Nationwide, the rate of leg amputation — a treatment needed in severe cases of diabetes and peripheral vascular disease — is four times greater in African Americans than in whites. Even this disparity is different based on location. Within California, rates in different regions vary by a factor of two.
  • Regions differ dramatically in their rates of hospitalization. Although African Americans in most regions are somewhat more likely than whites to be hospitalized for conditions that could be treated outside the hospital, the differences are much greater across regions. These conditions include such chronic illnesses as heart disease, lung disease, diabetes, and high blood pressure.

These findings and other Dartmouth Atlas reports underscore the importance of the local delivery system.

The complete report is available under Document Downloads.