There is a lively (and somewhat depressing) debate between academics about America’s health care delivery system. Do poor health care outcomes reflect improper health care utilization, inadequate access due to societal inequities in access, or  poverty itself?  In other words, does  poor health cause poverty, or is it caused by poverty? A report out today once again implicates the system, not the patient . The report, by the Commonwealth Fund, compares seven countries (US, Australia, Canada, Germany, New Zealand, Germany, The Netherlands, and the UK) on the basis of quality, access, efficiency, equity, longevity in a healthy state, and cost. Once again we were last in all categories except cost (there, we’re #1). In an interview, one of the investigators pointed out that “We [the US] do particularly poorly on going without care because of cost. And we also do surprisingly poorly on access to primary care and after-hours care.” People who delay access come in sicker, and unlike mechanical devices, they are not able to be overhauled once brought to the shop.

Why is this more than an academic exercise? If poor people are just sicker, then it is important to continue to place sophisticated (and expensive) Academic Health Centers near poor people. But if sick people are poorer, then we need to give them access to average (cheaper per patient but possibly more expensive in aggregate) primary care and specialty care as needed. As of today, the evidence continues to suggest that access beats out any bizarre poor-sick illness connection. Reform anyone?