Aaron Carroll repeats meme of access, cost and quality

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

By Aaron Carroll, MD, MS
news@JAMA, October 3, 2012

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.

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.


By Don McCanne, MD

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.