Two weeks ago, my friend finally saw a doctor for diagnosis and treatment of her fever and shortness of breath. Concerned she had pneumonia, I'd been prodding her for days to seek medical attention.

But she was uninsured, impoverished and unwilling to accept my help. She instead planned to "hold out" until obtaining health insurance through her state's insurance exchange program that operated in concert with the Affordable Care Act.

Although given no guarantee that her application was accepted, she expected to receive coverage by May.

Unfortunately, her illness didn't wait that long. It swiftly worsened, and she finally broke down -- almost literally -- and sought medical care.

There's not enough space in this column to contain my rage over my friend's subsequent fate and that so many other Americans have likewise suffered because they couldn't pay for basic health care.

Now, as millions of such Americans await their first opportunity to be insured under the ACA, my rage focuses on anyone standing in their way.

I say this having never been a fan of the individual mandate -- the ACA's requirement that every American purchase or own a health insurance policy or risk paying penalty fees. While championing universal health care, I've viewed the mandate as a "tax wearing lipstick." And I've thought it was better to reduce, rather than expand, the presence of for-profit insurance middlemen in the system.

My views about our newish mandate-based "system" haven't changed. Still, I recognize that that system has become our reality du jour. And as a Dewey pragmatist and doctor, I've opted to work within the new reality for various reasons. First, I value sanity and rational discourse over ideological tantrums concerning health care. Second, throwing rocks at the new system means throwing them at real patients and health care workers. Third, I can imagine the system getting better by monitoring it as it stands and tending to its timely repair.

As John Lennon sagely remarked, "Reality leaves a lot to the imagination."

As of this writing, my friend still anxiously waits to hear whether she's been granted coverage that will help mitigate the looming costs for her medical care. And, like her, all of us -- as patients and health care providers -- must wait to see how we'll fare under the ACA, what costs will accrue, what fundamental values will be upheld.

Still, whatever the act's ultimate record on insuring all Americans, it's a sure bet that poverty will remain a potent cause of health disparities. Impoverished Americans will continue to struggle with insurance costs and copays. They'll still need to make health-affecting economic choices between food and utilities and rent and education.

Many will remain unable to afford transportation to clinics and pharmacies, to risk loss of jobs or wages when taking time to transact with the health care system. Having "an insurance policy in every pot" does not mean that we'll feast on equal opportunities for health.

In several years when we can begin legitimately to judge the merits of our new system, we'll need to account for poverty as an independent cause of health care disparities. The concern is formidable because, according to the CDC, a whopping 15 percent of Americans are living in poverty -- fully 46.5 million people.

In this regard, an important report was released last week by the National Quality Forum -- a nonprofit, nonpartisan organization that evaluates and endorses health care standards.

The draft report critiqued the burgeoning trend within Medicare and private insurance of paying health care providers and hospitals according to the quality -- versus quantity -- of care they provided.

But how exactly do you measure the quality of health care? What kind of yardstick do you employ? Could we be using skewed measurements that both unfairly and irrationally awarded more dollars to providers who scored high, fewer to those who didn't?

And that's precisely what the Forum found. As quoted in The New York Times, Forum President Christine Cassel concluded: "Factors far outside the control of a doctor or hospital -- patients' income, housing, education, even race -- can significantly affect patient health, health care and providers' performance scores."

That's ancient news to those of us who've been members of economically "disadvantaged" communities as patients or health care providers. But it's important to raise its visibility now if we hope to see our way to a more rational, fair, and cost-effective system. For, as the Forum report saliently noted, when you unfairly shift money away from health care providers and hospitals caring for the poor, you essentially aggravate health care disparities between rich and poor.

Still, according to The New York Times, the Obama administration "is not entirely comfortable with the recommendations" put forth by the Forum that advise adjustments for sociodemographic factors when awarding money according to perceived quality of care.

It reportedly equates such adjustments with "accepting a double standard, with lower expectations for the care provided to low-income patients."

But to me, that's impoverished thinking about poverty -- an attempt to trump common sense with ideology at the expense of patients and providers. The Forum's recommendations do not champion the creation of a lowered "double standard" of health care for poor people. To the contrary -- they aim for correction of the already established double standards that poverty sustains.

Kate Scannell is a Bay Area physician and author.