Reader Response – How about we start here?

A reader writes:

I am writing to disagree with a claim I’ve heard you make a few times, and have now seen on your blog, most recently in the “How about we start here?” entry.  In particular, I strongly disagree with:

“Anyone who tells you that they can increase the number of people with coverage, improve quality, and reduce cost is lying – or a politician… Do you want to improve access?  Then you need to admit that it’s going to cost money, and you have to discuss how we are going to raise that money.  You may also want to address how this will affect the quality of everyone’s care, because it might.”

and especially:

“Do you want to bring costs down?… It’s going to have to come in the form of either covering less people or spending less on health care.  That can negatively impact quality.”

Given that you yourself have often noted that many or even most developed countries have close to universal access and their overall health and health outcomes are generally superior to the US, yet they spend between one third and one half of what the US does, doesn’t it seem self-evident that the US could do so as well, if only it chose to?

I think the reader missed my P.S. at the bottom, where I say:

P.S.  Alternatively, we could scrap the whole system and start over, doing better in all three domains.  Pretty much every other comparable country in the world does so.  Seems pretty rational, so it’s ironic that not doing that is the one thing everyone in this fight seems to agree on.

This is an important point, so I’m going to say it again.  The iron triangle* of health care applies when we try and make incremental changes to the system.  I can’t take what we have – right now – and increase access without somehow affecting costs and/or quality.  Nor can I cut costs in the current system without somehow decreasing access or decreasing quality.  It’s common sense.  We could start over, but no one seems to be talking about that at all.  So if you are committed to “keeping what works and changing what doesn’t”, the rules of the iron triangle apply.

*My first exposure to the “iron triangle” came in a medical school class taught by William Kissick.  I’m embarrassed to say that the class was graded on attendance, so I might not have paid as close attention as I should have.  Especially given what I do now….

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