Three Legged Stool: Shaky or Stable?


Imagine you are making a pizza. You are a beginner so you are starting with just the basics: dough, tomato sauce, and cheese. These are the three components of the pizza, but the hard part is achieving the right balance between them. Too much, or not enough, of any one ingredient and your pizza will be too dry, too wet, or too messy! 


Now, let’s compare your pizza ingredients to the three legs of a stool, and the seat of the stool to your goal: a perfect pizza. Achieving the right balance between the legs will make the stool strong and sturdy. If the legs are too long or too short, or too weak, the stool will wobble.

The three-legged stool analogy can be applied to many different concepts, like making pizza, but it is an especially helpful framework for examining healthcare systems, which are very complex and hard to understand. Through the three-legged stool framework, you can measure and analyze different aspects of the U.S. healthcare system, compare it to those of other countries, and identify areas for reform. 

Definition of Three-Legged Stool 

The three legs of the U.S. healthcare system are access, cost, and quality. Access refers to the ability to acquire and utilize health insurance and health services. The cost of the overall system includes the costs to individuals, providers, employers, insurers, and the government. Quality refers to the degree to which healthcare is adequate and acceptable, and promotes positive health outcomes. Together, these three components create a strong and robust health system where health care is accessible, affordable, and of good quality. When one or more of these legs are weak, the whole system is threatened. 

How It Works

According to the Peterson-KFF Health System Tracker, the U.S. has a comparable number of hospitals, hospital beds, and providers to other high-income countries. However, the availability of resources does not mean that they are equally distributed among rural and urban communities or that they are equally accessible to all. Only about 90% of Americans are covered by private and public insurance while in almost all other high-income countries with robust healthcare systems, coverage is practically universal. In the U.S., low-income adults, undocumented immigrants, and the unemployed, among others, fall through insurance coverage gaps. And even those who are insured face obstacles to actually seeking care because of high cost-sharing, transportation costs, language barriers, and cultural differences.

Likewise, by every measure, including the cost of scans and tests, surgery costs, prescription drug costs, general practitioner salary, and the percentage of the gross domestic product spent on healthcare, U.S. healthcare costs exceed those of other high-income countries. These costs reflect a lack of government negotiation and control and the wealth and power of the healthcare industry. And these high costs do not produce better quality healthcare. 

The same investigators found that by almost every measure, including life expectancy, maternal mortality, infant mortality, the U.S. demonstrates lower quality than other high-income countries. The only area in which the U.S. healthcare system demonstrates good comparative quality is lower smoking rates than other high-income countries. This poor overall quality of the healthcare system reflects the uneven distribution of acceptable health insurance and healthcare. Those who are poor, low-income, in rural areas, people of color, or non-English speaking are more likely to face barriers in healthcare settings that will lead to poor health outcomes and the reduced ability to seek healthcare. These issues are confounded because many of these groups are also more likely to have poor health, be low-income, and be uninsured.

Applying It

Clearly, each of these legs is weak and flawed, making it difficult for the stool to stand, and posing a threat to the entire healthcare system. The poor access and quality and high costs of the U.S. healthcare system can help us understand why health and healthcare are so uneven across the country. The U.S. system mostly benefits people who are wealthy, employed, and who live in areas with an abundance of providers. Those who are unemployed, uninsured, low-income, and impoverished face cost and access barriers and poor quality, and a disproportionate burden of these issues are faced by people of color, rural dwellers, the disabled, and the elderly.

In order to improve this system, we need to address our shortcomings in each of these categories. Improving quality without addressing cost and access will see benefits only for the wealthy and insured. And improving access without improving cost or quality will not improve health or reduce the cost barrier to healthcare. It is necessary to pay attention to all of these legs, in order to create a balance and promote health, equality, and prosperity for the most people possible.

Think Further

  1. Why might it be hard to address all three legs in a single project or program given how our healthcare system and government work?
  2. What are some reforms that would improve two of the legs, but threaten the other?
  3. Are there any limitations to this framework?


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Learn More

  1. Sanger-Katz, Margot. “In the U.S., an Angioplasty Costs $32,000. Elsewhere? Maybe $6,400.” The New York Times. The New York Times Company. 27 Dec. 2019. 
  2. Gawande, Atul. “The Cost Conundrum.” The New Yorker, Condé Nast. 25 May 2009.
  3. Gawande, Atul. “Is Health Care A Right?” The New Yorker, Condé Nast. 25. Sept. 2017.