INDIANAPOLIS -- The American health care system may have a myriad ofproblems, but health care expert Aaron Carroll said we sometimesmake the issue more complicated than is needed.

Carroll, who is the director of the Center for Health Policy,Indiana University School of Medicine, served as the openingkeynote yesterday at the BenefitsPRO BrokerExpo in Indianapolis.

“Think about health care as the iron triangle,” saidCarroll.

That iron triangle draws its strength (and weaknesses) in theanswers to three questions: how much coverage costs; how good isthe coverage; and, how well do people get access.

“If anyone promises they can improve all three, they are eitherlying or a politician or both,” said Carroll.

The three-legged stool of health care

The U.S. did not invent universal health care out of thin air,Carroll said. “The vast majority of developed countries offeruniversal coverage. The U.S. remained alone in not offering italong with Chile, Turkey and Mexico.”

The Affordable Care Act made its promise on theidea of a three-legged stool, stated Carroll.

1. Everyone should be able to get insurance even if they have apre-existing condition.

2. To prevent people from gaming the system. They need to buyinsurance even if they are healthy.

3. To make sure everyone can afford the insurance, many people willbe given tax credits to help offset the costs.

“For it to work,” said Carroll. “We need all three legs of thestool. This is how all of the countries with universal health caremake it work. They all start with a similar model in mind.”

In making his case about America’s woes, Carroll submitted aseries of slides comparing the U.S. health care system to othercountries who are members of the OECD (Organisation for EconomicCo-operation and Development). After looking at the results, let’sjust say, thank you, Canada.

Access to health care

At least in one measure, the ACA has worked. “We have reducedthe number of uninsured to an all-time low,” Carroll said.

But that’s only one way to measure the success of the ACA. A2016 Commonwealth Study looked at a myriad of health topics thatoften placed the U.S. in an unfavorable light.

Take the percent of people unable to get a same day appointmentwhen sick. The U.S. was second last, just above Canada. Halfof Americans cannot get a same-day appointment when sick.

Cost, however, is the biggest barrier to access, and thatbarrier stretches across socioeconomic lines. About one-third ofall Americans neglect care because of costs. The richer half ofAmericans are more likely to forego filling a prescription or goingto a doctor when compared to the poorest people in other OECDcountries.

While health care spending growth has slowed in the U.S. thelast few years, it remains two to three times above what othercountries spend.

“The U.S. is off the charts,” said Carroll. “Access is not greatand much of that is because costs are sky high.”

Quality of health care

“How do we define quality of care?” asked Carroll. “One way islooking at the number of doctors per 1,000 people.”

The U.S. has a below average number of doctors when compared tothe OECD members. Only Greece and Hungary fall below the U.S.numbers. Carroll said we’re turning out fewer graduates andbecoming more and more reliant on foreign-educated doctors to fillour health care needs.

Another way to measure the quality of care is by looking atmortality rates and how we treat disease.

“We fare well when talking about the U.S. mortality rate frombreast cancer and prostate cancer,” said Carroll. “But we areterribly low when looking at lung cancer. We are also very low whenlooking at heart disease.”

The U.S. also falls well below the average when looking at lifeexpectancy versus health care spending. “We should be the best inthe world at health care based on our spending,” he said. “Butwe’re not. We’re not even close and we’re stuck with an irrationalsystem where we pay a lot of money and are not getting a return onour investment.”

Outlook for health care reform

According to Carroll, we knew the direction, for better orworse, of where we were going under the ACA. With the recentpresidential election, now, he said, all bets are off.

The GOP controls the House, the Senate and the White House andchange of some kind seems certain. Carroll said one of four optionscould be coming down the pike:

• Option 1: Repeal through reconciliation

• Option 2: Repeal and replace

• Option 3: Executive action

• Option 4: Cassidy-Collins Bill

Option 3, Carroll said, is not gaining enough coverage from themedia, but the option that may have the best chance to make wavesthis year.

“The ACA isn’t as prescriptive as people think,” he said. “Birthcontrol is one example. The ACA doesn’t demand that it be covered.It delegates that decision to the HHS secretary.”

Carroll added that other factors fall into this grey area. “Whatexactly is an essential health benefit? What is a preventativeservice? When you begin digging into health care issue, there’s alot of leeway and a lot of room where Trump could enact changeswithout changing the whole thing.”

But anyone who thinks they know what will happen is foolingthemselves, said Carroll. “There is still so much in flux. Anyonewho tells you they know what will happen is lying.”