Solutions to problems are generally sought from within the problems themselves. Two recent examples are health care and finance. In both cases, the solutions are believed to be better-structured and regulated systems. In blogs, articles and speeches, I have stressed that, while there are myriad ways that health care can be improved, the real solutions to high health care spending lie outside of health care. Poverty and its associated manifestations are at the core of the health care spending crisis. The high costs of caring for the poor will continue to overwhelm the system, no matter how it is structured and improved. Rather than looking for solutions through changes in process and regulation, the major solutions to health care’s excessive spending reside in areas such as K-12 education, neighborhood safety and the creation of jobs that can lift low-income families from the cycle of poverty.  Simply stated, the US does not and will not have the resources to provide equitable care for those among us who confront inequitable circumstances in every other aspect of their lives.

Now Raghuram Rajan, a distinguished professor of finance at the University of Chicago and former chief economist at the IMF, has come to the same conclusion about our financial system. In his new book, Fault Lines: How Hidden Fractures Still Threaten the World Economy, he describes how cheap credit was a mistaken remedy for the consequences of poverty. In addressing its financial future, the US will have to place greater emphasis on educating its young and creating a safety net for its poor.

Neither cheap credit for those who are too poor to pay it back nor costly health care for those whose poverty creates the demand for more, nor even more primary care physicians to treat their woes, can hold our society together. Commenting in the BMJ on similar circumstances in England, Iona Heath said, “It has been much too easy and much too convenient for governments to locate the task of lessening health inequalities within their health services, as if a brief contact with the health service could compensate for a lifetime of disadvantage and deprivation, with the resulting almost inevitable attenuation of opportunity and hope.” Here, as there, the fault lines of income inequality are the nation’s greatest challenge.