There’s quality, and there’s access

I’ve been rather bothered by the road I’ve found myself on the last few days, defending definitions of access with which I don’t agree. I think a commenter has figured out my problem:

I think the problem we are having is due to different definitions of quality. Your two examples of waiting for elective procedures and access to the latest technologies are not issues of quality. They are issues of access (which is one of the other legs of the iron triangle) so should be off the table when discussing quality.

He’s right. Many of the things I’ve seen others label as “quality” really should be labelled as “access”. Reducing the availability of screening procedures or medications is a change in access. Changing the level of providers you see is a change in access, not necessarily quality.

Point conceded.

But my larger assertion holds. If we want to hold quality constant, and reduce costs, we are going to have to reduce access by the above definition. That’s what other countries often do. They have great quality, they cost less, but by the above definition, there is some reduction of access. Yes, they are more universal in terms of insurance coverage, but that’s only one facet of access. Other countries  reduced costs come with a reduction in choice, in availability of some procedures or meds, or from some other change.

Some of my friends on the left are upset at me for believing I’m making an argument that real reform isn’t possible. That’s just not true. I would be totally fine (and in fact happy) with real reform that expanded coverage, reduced costs, kept quality as I define it constant, and reduced (covered) access to stuff evidence indicates people don’t really need. That’s a trade-off I’m willing to make. I imagine many of you are fine with it, too.

But it is a real trade-off  and we should still acknowledge it as such. I’ve long argued that Canada (as a democracy!) has chosen a health care system that sometimes (but in an overblown way) restricts access to elective procedures in a way to reduce costs. In a rational world, we’d identify that as a fiscally conservative option. We shouldn’t demonize their system, we should recognize what decisions they made to get to where they want to be. Are we willing to make the same trade-offs? If not, then we can’t complain when we get a system that costs so much yet delivers so little.


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