PNHP

Universal health care and the Iron Triangle myth of U.S. policy makers

Donald Light on the Iron Triangle Myth

By Donald Light

Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (https://pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-access-cost-and-quality):

In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)

Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.

The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.

Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.

In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.

The Iron Triangle is an American myth for lazy and unobservant policy leaders.

Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania

Comment:

By Don McCanne, MD

As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”

Universal health care and the Iron Triangle myth of U.S. policy makers

Donald Light on the Iron Triangle Myth

By Donald Light
Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (https://pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-acce…):
In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)
Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.
The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.
Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.
In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.
The Iron Triangle is an American myth for lazy and unobservant policy leaders.
Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania

 
As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”