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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

The “Iron Triangle” of Health Care: Access, Cost, and Quality

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.

Aaron Carroll, MD, MS

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.

Fear of Hard Truths

But politicians often seem to fear telling hard truths. They are afraid of the consequences of acknowledging reality. When that happens, they say things that simply don’t make sense.

Take Plan B, a drug to prevent pregnancy after unprotected sex. Since 2009, Plan B has been available over-the-counter in the United States to women who are 17 years old or older. Those aged 16 years or younger need a prescription. But plenty of adolescents younger than 17 years were still having sex and becoming pregnant. So the Food and Drug Administration conducted a scientific review, found Plan B to be safe and effective as an over-the-counter medication “for all females of child-bearing potential,” and ruled that it should be made available to all such individuals.

This, of course, was a difficult political decision. Plenty of people were against this policy from a “moral” perspective. But the Obama administration had argued that they would approach this from a scientific standpoint. Rather than discuss the trade-offs and admit which side they preferred, they started to make no sense. Administration officials claimed younger girls couldn’t understand its uses, when they clearly could. They portrayed it as a safety issue, when it clearly wasn’t. They denied it wasn’t a political decision, when it clearly was. And in trying to please everyone, they wound up pleasing no one.

Rep Todd Akin (R, Mo) recently made claims about the ability of a woman who has been raped to prevent pregnancy by “shutting that whole thing down.” The trade-offs with abortion come down to competing interests of protecting a fetus and protecting a woman’s right to control her body. Many people oppose abortion in this country. But many who oppose abortion in general believe that a woman should not be forced to bear a pregnancy when it’s the product of rape or incest.

When confronted with the fact that this widely held opinion conflicts with his own belief (and likely that of many of his constituents) that abortion is always wrong, rather than discuss the trade-offs inherent in his position, Akin apparently tried to pretend that the scenario wouldn’t occur: if rape never results in pregnancy, then abortion exceptions never need to be confronted. In the end, by avoiding the discussion, Akin brought on himself a load of negative publicity.

Willful Avoidance

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.

President Obama tried to pretend this wasn’t so in the Democratic primaries before the 2008 election. He attacked Senator Clinton for her “mandate.” But eventually, he was forced to recognize the hard facts. Governor Romney used to recognize these. That’s how Massachusetts got health care reform in its state. More recently, though, he has backed away from reality and tried to proclaim it’s possible to keep the good parts of health care reform while dropping the parts people hate.

That is, of course, nonsense. You have to take the bad with the good.

If you want to save money, you have to cut spending. When you do, there will be consequences. Either you’ll cut benefits or you’ll cut beneficiaries.

If you want to set up groups like the Independent Payment Advisory Board to recommend spending reductions to Medicare, they will have to recommend either that benefits get cut or that reimbursements get cut. There really aren’t many other options. Someone is going to be unhappy. Pretending that’s not so is putting your head in the sand.

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. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.
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