Geographic variation in health care and the affluence-poverty nexus

Almost 50 years ago, John F. Kennedy told Yale's graduating class that "what is needed today is a new, difficult but essential confrontation with reality, for the great enemy of truth is very often not the lie-deliberate, contrived and dishonest-but the myth-persistent, persuasive and unrealistic." Today's myth is the belief that 30% of health care spending is due to supplier-induced demand and that this amount could be saved if high-spending regions could more closely resemble low-spending regions. The reality is that, while quality and efficiency remain important goals, the major factors driving geographic differences are related to income inequality. Yet, following the road map of the Dartmouth Atlas, the Affordable Care Act includes penalties for hospitals with excess preventable readmissions (which are mainly of the poor), incentive payments for providers in counties that have the lowest Medicare expenditures (where there tends to be less poverty), incentives for physicians and hospitals that attain new "efficiency standards" (ie, costs similar to the lowest), and a call for the Institute of Medicine to recommend additional incentive strategies based on geographic variation. This scenario iscoupled with a growing bureaucracy, following the blueprint laid out by Brennan and Berwick in the 1990s, but with no tangible measures to increase physician supply. Meaningful health care reform means accepting the reality that poverty and its cultural extensions are the major cause of geographic variation in health care utilization and a major source of escalating health care spending. And it means acknowledging Bertrand Russell's admonition that a high degree of income inequality is not compatible with political democracy, nor is it compatible with health care that this nation can afford. As solutions are sought both within and outside of the health care system, misunderstandings of how and why health care varies geographically cannot be allowed to deter these efforts, and the pervasive impact of poverty cannot be ignored.