So right as I left for vacation last week, JAMA posted my piece on the iron triangle of health care. A lot of you took exception with the following:
When I talk about health policy, I often refer to the iron triangle of health care. 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.
In emails, in comments, or in other blog posts, many of you asserted that we can do all three things. Many of you pointed out that other health care systems in other countries are universal, cost less, and do better in terms of quality.
Let’s start with the fact that if I could start building a new health case system from scratch, there’s no doubt in my mind we could do better than what we have right now. But my argument was more about how we make changes to the existing system. Without scrapping the current system, it really is impossible to make changes to what we have without the iron triangle coming into play.
But the larger issue is that when all of you are telling me about “quality” in other health care systems, you’re ignoring that in many ways that others find important, they are worse off in terms of “quality”. I’ve made clear how I define quality. I would imagine that many of you taking issue with my post have similar definitions. But many, many other people disagree.
Some of those other health care systems pay their physicians far less than we do. Lots of people see that as a reduction in “quality”. Some of those other health care systems don’t let you get all the screening tests you desire, regardless of their proven effectiveness. Lots of people see that as a reduction in “quality”. Some of those health care systems restrict easy access to elective procedures. Lots of people see that as a reduction in “quality”. Some of those health care systems provide much less in terms of choice, whether it be for insurance, physicians, or pharmaceuticals. Lots of people see that as a reduction in “quality”. Some of those health care systems don’t introduce new technology or drugs as quickly. Lots of people see that as a reduction in “quality”. Some of those health care systems regulate things more closely. Lots of people see that as a reduction in “quality”. Some of those health care systems do less to encourage innovation or entrepreneurship. Lots of people see that as a reduction in “quality”.
And so on and so forth.
Please know that I don’t define “quality” this way. For me, it’s hard outcomes. But I recognize that I’m willing to see changes in areas of process, including wait times, choice, profit, etc. in order to improve the things I care about. I’m willing to accept the trade offs in order to get the improvements I want. I bet lots of you are, too.
Unfortunately, lots of Americans aren’t. As long as we ignore their values, though, we will fail to engage them. Every time we say that we can reduce cost, improve access, and nothing will change with respect to quality, we are implicitly ignoring what others want in terms of quality.
A better debate would acknowledge the changes that would occur in terms of “quality” and make the case that they are acceptable losses to get better costs and get better access. We can do that.