Who gets hepatitis C drugs? Who pays?

The challenges of reforming the health care system seem to grow more complicated by the day. Take, for example, the new generation of specialty drugs. They often can work miracles, but they come at a high cost. And when it comes to health care, the question of cost often become the proxy for debates that range from the ethical to the political.

Who should have access to these drugs and who pays came into focus in Minnesota with news stories earlier this summer that two prisoners are suing the Minnesota Department of Corrections, demanding access to drugs that have the potential to cure hepatitis C. Meanwhile, private insurers are coming under pressure from their enrollees with hepatitis C to pay for the drug treatments.

The drugs being sought are remarkable. In 95 percent of cases, the drugs actually cure hepatitis C. But, a full regimen of treatment costs $90,000 or more. Yet the human and financial costs of not treating hepatitis C also are significant. In the worst cases, hepatitis C patients require liver transplants, a high-risk operation that can cost up to $500,000.

Unresolved, these cost dilemmas threaten the progress made in other areas. Minnesota has reduced the rate of people without health insurance to about 5 percent, and our quality of care — as measured by independent organizations — remains among the best in the world. As a result, Minnesotans are among the healthiest people in the country.

Cost is another matter. Spending on health as a share of the state budget has more than doubled since 1990, and it will continue to grow. State spending on hepatitis C drugs alone grew from $1 million to $9 million between 2013 and 2014. The same pressures are affecting the private marketplace. After a few years of relatively low health inflation, the cost of care again is on the rise.

We need new approaches. That's why, last year, North Memorial Health Care and Medica joined a group of leaders from the TwinWest Chamber of Commerce, Minneapolis Regional Chamber of Commerce and the Minnesota Building and Construction Trades Council to sponsor research and public forums on the future of health policy in our state. The initiative, Minnesota HealthBasics, is an effort to find the common ground where there is support for effective, long-term solutions.

Comprehensive research that HealthBasics conducted last year defined the political challenge of health reform. It found that Minnesotans too often see solutions to the health care cost challenge as actions for others. (Complete survey results are at www.MnHealthBasics.com.) And, when it comes to the big public-policy goals — access, cost control and quality — the positions of most Minnesotans are defined (and reinforced) by ideology.

These conversations are revealing. Go back to the hepatitis C drugs. The initial position of most of our forum participants is that insurers should pay for the treatment, regardless of the cost. But add some other information to the discussion: the New York Times cited an estimate "that treatment of hepatitis C could add $200 to $300 a year to every American's insurance premium for the next five years"; 20 percent of hepatitis C infections clear themselves naturally. What's more, in the hard economics of today's insurance marketplace, what is the incentive for an insurer (and its subscribers, who ultimately pay the cost through their premiums) to spend $100,000 to cure a patient knowing that the person may enroll in another insurance plan next year?

Minnesotans don't do an about-face on questions of ethics, cost and access in the HealthBasics forums, but they do start to look for more robust answers. Discussions turn to the value of investing in prevention, not just to reduce hepatitis C (many cases are rooted in alcohol and drug abuse), but also to cut the health costs that come from poor nutrition, tobacco use and a lack of physical activity. New care models are proposed, especially a desire to integrate alternative care — homeopathic, chiropractic and acupuncture, for example — into existing primary-care clinics. Forum participants start to discuss how information on quality and cost would be more useful — if it came from sources they trust, included incentives to use information to guide decisionmaking and was presented as guidelines, not absolutes. We still want doctors to treat every person as an individual.

We aren't naive about the challenge, but conversations at the forums leave us hopeful that real solutions to managing costs while maintaining access and quality can be found. After all, we know that the best patient and consumer is one who is informed and able to be his or her own advocate.