Cover: Health Care Affordability

Health Care Affordability

Iron Triangle Or Iron Curtain?

Published in: Health Affairs Forefront (2023). DOI: 10.1377/forefront.20230215.903094

Posted on Feb 28, 2024

by Bryan Dowd, Tim McDonald

The high cost of health insurance and health care services now affects not only the uninsured but also middle-class Americans with employment-based health insurance (ESI), enrollees in the Affordable Care Act exchanges, and Medicare beneficiaries. A popular concept in health policy discussions is the "iron triangle". These authors posit that it is impossible to increase access and quality of care while simultaneously reducing spending. That idea warrants further scrutiny. Because the iron triangle involves spending, it bears directly on the issue of affordability for both individuals and government units that administer public health insurance programs. Inappropriate application of iron triangle thinking could result in unwarranted pessimism regarding potential improvements in affordability, resulting in failure to test promising alternatives. However, evidence suggests that failure to improve affordability is primarily due not to a mathematical "iron triangle" constraint, but an "iron curtain" of stakeholders who are aware of promising alternatives but oppose their implementation. Below, we illustrate graphically both the concept of the iron triangle and why it does not fully capture the possible ways to reduce spending without reducing quality or access. We suggest an alternative approach--"discriminant" coverage designs--and offer real-world examples of this approach. We explore why discriminant designs have not been more widely adopted and why various health care stakeholders have not taken the lead in advocating for them.

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