There is a romantic view of America as a homogeneous nation – a nation that is flat. But the real America has high peaks of affluence and deep valleys of poverty and a varied landscape of health care spending. It is a hilly terrain of income inequality. 

The Affordable Care Act was based on homogeneity. Not only would its provisions be disseminated equally, but smoothing the peaks and valleys of health care utilization would liberate the funds necessary to finance it. Under reform, Newark would come to resemble Grand Junction CO, and Mayo would be the model for Manhattan. No longer would Los Angeles, home to the nation’s largest concentration of poverty, consume more resources than Green BayWI, where poverty is infrequent. Regional variation in income and poverty could be ignored all together. The problem is “practice variation,” and health care reform will fix that.

Of course, the US  is not homogeneous, and poverty cannot be ignored. In fact, the principal cause of geographic variation in health care utilization is geographic variation in poverty. And now the hilly terrain of health care is coming more sharply into focus.  Over the course of a few short days, from December 15^th to 18th, that message sprung from three separate sources.

First was an observation in the New England Journal by David Blumenthal, the most qualified member of the Obama health care team and the first director of its health information effort. Dr. Blumenthal noted that “good legislation does not guarantee successful implementation. Never before had a country as large, complex, politically decentralized and diverse as theUnited Statesattempted to create a nationwide electronic health information system.” The nation is too varied.

On the same day, the Wyden-Ryan plan for Medicare was announced. While defined contribution plans, including this one, have the potential to skew benefits away from the poor, a Wall Street Journal editorial endorsing it correctly noted that one of its benefits is that “it relies on local information and adjusts with the behavioral and organizational responses that will vary from region to region.”

And the very next day, HHS Secretary Sebelius announced that the Obama administration would no longer insist on defining a single uniform set of essential health benefits for the nation because “coverage that works inFloridamay not work inNebraska.” The New York Times observed that “the move would allow significant variations in benefits from state to state.

The consistent message is that there is a great deal of geographic variation in America. Its hilly terrain includes peaks and valleys of costs, outcomes, preferences, poverty and needs. Reforming health care in an imagined nation of sameness must give way to reforms for an economically and demographically varied nation, and real solutions must be sought not only within the system but within the structure of the terrain in which our patients live.