Quote-of-the-day mailing list
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Subject: qotd: Aaron Carroll repeats meme of access, cost and quality
Date: Thu, 4 Oct 2012 09:59:17 -0700
From: Don McCanne <firstname.lastname@example.org>
To: Quote-of-the-Day <email@example.com>
October 3, 2012
JAMA Forum — The "Iron Triangle" of Health Care: Access, Cost, and Quality
By Aaron Carroll, MD, MS
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
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.
Comment: We have heard for decades the meme that health care access,
cost and quality are interdependent. Any change in one or two of them
must produce a reciprocal change in either one or both of the others.
Any improvement must always be offset with one or two impairments. Yet
the single payer model shows that this is merely a replication of a
seriously deficient concept that omits consideration of many other
important health policies.
Under a properly designed single payer model, access is improved by
removing financial barriers to care for absolutely everyone. The
comprehensive design features of single payer also significantly improve
quality, simply stated, by ensuring that patients receive the care that
they need while reducing or eliminating care that is detrimental. And
costs are the forte of the single payer system. Single payer reduces
waste, redirecting those funds to patient care, and puts into place
economic mechanisms that slow the rate of increase in future health care
costs. Spending can be contained while both quality and access are improved.
It is time to retire the meme that improving access, costs or quality
can be done only by introducing impairments. Don't let the policy
community get away with that claim anymore. Aaron Carroll's integrity is
of such a high caliber that he certainly is not misleading us, but he
clearly needs to end his denial.