Every economist who studies health care knows about the "iron triangle."
Here's how it is sometimes explained:
"In health-care reform, three goals matter: increase access; improve quality; reduce cost.
In other words, you can't do it all; whichever two goals you choose as your focus, the third will suffer.
So, anyone who promises to cover more people at less cost while improving quality is either ill-informed, delusional, lying - or a little bit of all three.
Barack Obama did choose two goals, but had a hard time admitting it. This got him into some trouble for misleading voters.
The Affordable Care Act, AKA Obamacare, aims foremost to increase access to care.
Its second priority is to speed the long slog to better quality by investing in strategies such as evidence-based medicine and accountability metrics for hospitals.
But expanding the percentage of covered Americans as successfully as the ACA did . . . well, it costs more, a lot more.
That said, you have to ask a key follow-up: "Cost to whom?"
Despite much-hyped premium spikes recently (often in the states that spent more energy resisting Obamacare than implementing it), the act did put health coverage within reach for millions who previously could not afford it. So, for them, it reduced their most pertinent cost.
The law also strived, in its backers' phrase, "to bend the cost curve" - that is, to slow (not end) the long, upward spiral of overall health spending. Don't expect Paul Ryan to mention this anytime soon, but the ACA had some success there, too. The Urban Institute and Robert Wood Johnson Foundation estimate that Americans health-care spending in this decade will clock in at $2.6 trillion below the estimates made in 2010, when the ACA went into effect. Many reasons exist for that, but the wonks credit the ACA as one.
Cost-saving ACA reforms also helped the Medicare Trust Fund gain 11 extra years of solvency.
Still, for all that, Obamacare does entail a lot of extra spending - by the government - to help people gain coverage. Where does the money come from? Higher taxes on affluent people, mostly. Also, from fines on the freeloaders who used to go without coverage they could afford, confident the rest of us would pay for their care when they needed it.
Republicans in the U.S. House simply couldn't stand that people with healthy incomes were paying more to make sure people of lesser incomes stayed healthy.
I never can tell how much of their pro-wealth, anti-tax stance stems from principle and how much from simply doing the bidding of the rich donors who finance their careers. (As a wise man once said, never underestimate the degree to which a man - and they're almost all men here - will believe something that's untrue if his livelihood depends on him believing it.)
Either way, the mess that Ryan and the Freedom Caucus just deposited on the Senate's desk does not, despite presidential shtick to the contrary, even try to expand access coverage or improve care. It goes backward on both fronts.
It zeroes in only on cutting costs - not for the mass of Americans - but for the plush cohort of taxpayers whose tax dollars fueled the ACA's useful deeds.
The most outrageous thing about this escapade is how grievously their bill hacks away at Medicaid.
Medicaid - here's one thing that annoys me. Even well-informed reporters sometimes refer to it in shorthand as "the insurance program for the poor."
Medicaid has never just been about "the poor." Under Obamacare, it is even less so.
Obamacare offered states a pile of federal tax dollars to extend Medicaid to more of their residents. Governors with a clue said yes; Pennsylvania arrived late to the dance, when Tom Wolf replaced Tom Corbett and embraced the full deal.
Now, in participating states, families earning up to 138 percent of the poverty line are eligible for Medicaid. For a family of four, that's $33,600. In Pennsylvania, a person working 40 hours a week, 52 weeks a year, at the state minimum wage makes . . . $15,080. So, far from being reserved only for lazy, unemployed leeches (which is what many people think when they hear "the poor") Medicaid now enrolls working people who make more than twice the minimum wage. Pennsylvania has enrolled 700,000-plus additional people since Wolf took over.
Beyond that, Medicaid helps thousands of middle-class grandmas and grandpas. The second-biggest chunk of Medicaid spending in Pennsylvania, more than $4 billion, goes for long-term nursing care; Medicaid (not Medicare) pays for most (66 percent) nursing home days across the state. Also, under a generous provision in Pennsylvania, Medicaid covers the immense health costs of children with serious, long-term chronic conditions such as cancer - without regard to family income.
All of this - decent coverage for working people, a decent nursing home bed for your parents, life-saving care for the unluckiest of children - would be put at risk by the sloppy, selfish bill passed by the U.S. House.
That's not grappling with the iron triangle. That's beating Americans over the head with it.
Chris Satullo is a former Inquirer editor. email@example.com