The health care ‘iron triangle’ and the Patient Protection and Affordable Care Act

Abstract

H ealth care economists have long understood that the Patient Protection and Affordable Care Act (PPACA) could never function as intended. The reasoning behind this bold statement is simple. The PPACA aspires toward an end point that no law, system, or intervention has been able to accomplish: breaking the health care "iron triangle."According to the concept of the health care iron triangle, health care is a tightly interlocked, self-reinforcing system of three vertices-access, quality, and cost-and improvement in two vertices necessarily results in a worsening in the third. 1 Interventions in health care inherently require trade-offs, which prevent simultaneous improvement in all three components.The PPACA is explicitly designed to disrupt this paradox, ambitiously aiming to increase access and improve quality while lowering costs. 2 Emerging evidence suggests, however, that the practical implementation of the PPACA will trump its intended benefits. Though there are numerous ways in which the PPACA could paradoxically decrease access to care, lower the quality of care, or raise costs, the outcome is almost certain that the PPACA may bend-but will never breakthe health care iron triangle.

The Affordable Care Act

“…Some policy researchers suggest that the iron triangle may bend but will not break. 4,5 They argue that this ambitious law will not be able to overcome economic realities, but an integrative approach might ''bend'' the cost curve and maintain quality and access. 5 Unquestionably, the ACA expands access to coverage to millions of Americans by imposing individual mandate, employer mandate, expanding public programs, and eliminating preexisting conditions.…”