The 'Iron' Triangle of Health Care Delivery: NOT
From the online JAMA Forum (http://newsatjama.jama.com/2012/10/03/jama-forum-the-iron-triangle-of-he...)
The 3 components of the triangle are access, cost, and quality. One of my professors in medical school used this concept to illustrate the inherent trade-offs in health care systems. His point was that at any time, you can improve 1 or perhaps even 2 of these things, but it had to come at the expense of the third.
I can make the health care system cheaper (improve cost), but that can happen only if I reduce access in some way or reduce quality. I can improve quality, but that will either result in increased costs or reduced access. And of course, I can increase access—as the Affordable Care Act (ACA) does—but that will either cost a lot of money (it does) or result in reduced quality.
Anyone who tells you that he or she can make the health care system more universal, improve quality, and also reduce costs is in denial or misleading you. When it comes to election season, those people are often politicians.
The lesson of the iron triangle is that there are inherent trade-offs in health policy. If we wanted to conduct the debates honestly, we would acknowledge these and allow the public to decide what they really want—and what they are willing to sacrifice to get it.
Most significantly, this willful avoidance of trade-off discussions has rendered much of the discussion of health care reform nonsensical. The ACA starts from a place of wanting to make sure that all individuals can obtain affordable insurance, even if they have a prior medical condition. But if you guarantee access to insurance to everyone and mandate that people with preexisting conditions can’t be charged higher rates than their healthier peers, you need to prevent adverse selection (having relatively sicker individuals more likely to buy insurance coverage rather than relatively healthy people) and people gaming the insurance market (forgoing coverage and enrolling only when they become ill)—thus, the mandate that everyone must purchase insurance or pay a penalty. And if you demand that people buy insurance, then you have to make sure they can afford it. That’s why you have subsidies.
The plus is that many more people get access. The negative is that it costs people and the government money. That’s the trade-off.
We can make the system cheaper. We can make it more expansive. We can make it higher in quality. But we can’t do all 3.
We have to choose. We’d be wise to choose politicians who are honest about that.
About the author: Aaron E. Carroll, MD, MS, is a health services researcher and the Vice Chair for Health Policy and Outcomes Research in the Department of Pediatrics at Indiana University School of Medicine.
The author of this blog entry fails to perceive that he is viewing health policy through the lens of the current for-profit, market oriented health care system. Yes, it is true, if generating profits is the ultimate goal of health care delivery (which it must be given the fiduciary duty of directors of for-profit enterprises), that there are hard trade-offs between quality, access, and cost. But there is no real fit between health care goods and services and market forces. Therefore, market-based health policy, such as that propounded by Dr. Carroll, distorts health care beyond recognition and artificially creates the so-called iron triangle.
The truth is, Americans have a highly expensive health care system because American health care delivery is inefficient and poor quality. One of our greatest inefficiencies is that we have less than universal access. One of the biggest contributors to poor quality care is the delivery of inappropriate care.
The pathway to universal care at a lower cost is through quality improvement. There is a great deal of data which supports that assertion.
Cost, quality, and access are related, but not in the way Dr. Carroll suggests. Poor quality care costs more, which in turn makes universal access impossible. The solution is not to find politicians who will bravely teach us to trade off quality or access for lower cost, but to find politicians who will bravely insist that inappropriate care be eliminated as a public benefit, thereby increasing the quality of care and making better access possible. But much of the inappropriate care is driven by market interests. Pharmaceutical companies want to sell drugs, no matter whether appropriate or not. Medical device manufacturers want their products purchased by public health programs, whether needed or not. Hospitals want beds filled, etc. We must learn to say 'no' when clinical science does not support a particular intervention. And we must eliminate the massively inefficient and wasteful health insurance business model. They want to sell insurance policies to everyone but the sick and injured and they never want to pay for health care. This is perverse reasoning driven entirely by the fiduciary duty of health insurance directors to make as much money for stock holders as possible. Where are the politicians who will say 'no' to health insurance overhead?
Time to recognized this 'Iron' Triangle as a perversion of health care delivery caused by the poor fit between the market model and what health care really is.
Dr. Joe Jarvis