One morning five years ago, my 91-year-old father took a hard fall on a tile floor. In less than a week, he was dead.

It was not a surprise. He had an abnormally slow heart rate and had just been accepted to a hospice program, where his treatment was supposed to be limited to keeping him comfortable at the end of his life.

But even under those circumstances, it’s still amazing to me how hard it is to die and how much of our medical system is devoted to prolonging the inevitable.

During another national debate about health care and how to pay for it, I can’t stop thinking about my father’s last trip through the system. While millions of Americans get sick and die without even basic care, he spent his last year refusing services, not always with success.

He was twice dragged to the hospital even though he had signed a “Do Not Hospitalize” order. On one of those trips, he refused emergency surgery to get a pacemaker installed, saying that he didn’t want to do anything until he could talk with his doctor. After the consultation, he refused the operation again.

If he had said yes, he might be alive today. But would the device that made his heart beat regularly also have brought back his hearing, the loss of which had made normal conversation impossible? Would it have made the pain in his back go away? Would he still have desperately missed my mother, who had died six years earlier?

Would the people in the nursing home – where he would almost certainly have to be living – been able to understand his thick Eastern European accent better than the EMTs who took him to the hospital when he didn’t want to go?

Or would he have been a sad, isolated guy in a lot of pain, albeit one who had a regular heartbeat?

I’ve heard worse stories: Bedridden elders who are shocked back to life and attached to a ventilator, even though they have living wills. Or people with only months to live suffering through a colonoscopy even though they would have been too weak to survive surgery if the test had found a tumor.

I don’t know what the right amount of health care is, but I do know that in this country we make sure people get the wrong amount of care in more ways than one.

Whether you get too much care or not enough depends on a lot of things that have nothing to do with how sick you are.

How much money you have matters. How old you are matters. And weirdly, geography matters, too.

Researchers at Dartmouth Medical School have been compiling Medicare payment data for decades, and have been able to compare how conditions are treated in different places. They publish the Dartmouth Atlas of Health Care, available online, which shows that there are significant differences in the kind of treatment you receive depending on where you live.

For instance, southern Maine hospitals install pacemakers for people on Medicare at about the national average rate, 4.5 per 1,000 enrollees. They are used nearly twice as often in Lafayette, Louisiana (8.4 per thousand), and half as often in Dubuque, Iowa (2.2 per thousand).

The atlas shows it’s not just pacemakers that pop up at different rates in different places. Heart specialists are not evenly distributed around the country, either, and the places with the most doctors are also the ones where the most tests are ordered and procedures performed.

That’s not a response to real-world need. Doctors don’t usually move to the places where they think they’ll find the most disease. They go where they can make a living and tend to settle where they trained, working with local physicians who have a preferred approach. It’s the culture of the hospital near you – not just your specific illness – that will determine what kind of care you get and the size of your bill.

So, is installing pacemakers at about the national average something to celebrate? Or do they do it right in Dubuque and we’re pacemaker-happy in Maine? Or is it Lafayette where they know what’s going on and we’re way behind?

I don’t know, but I do know this: At the age of 91, it would have been far easier for my father to accept much more care than he needed – all covered by Medicare – than it was for him to get the much less expensive treatment he wanted. Meanwhile, 14,000 children in this state have no health insurance and won’t see a doctor unless they have an accident or disease serious enough to land them in an emergency room.

If you’re wondering why Americans pay more for health care than any of our industrialized peers and get worse outcomes, you don’t have to look much further than that.

Greg Kesich is the editorial page editor. He can be contacted at:

[email protected]

Twitter: gregkesich

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