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Sue Lani Madsen: Health care shifting toward individualization; coverage should as well

Sue Lani Madsen (Jesse Tinsley / The Spokesman-Review)
Sue Lani Madsen (Jesse Tinsley / The Spokesman-Review)

“Stick out your tongue. Now firmly grasp it with your teeth.”

A group of health care leaders and policymakers gathered Wednesday afternoon at the Inland Northwest State of Reform Healthcare Policy Conference for one last breakout discussion. The topic was “Building a Post-ACA System in Washington State.” As a panelist, I asked for audience participation as a reminder it’s time to set aside partisan blame-shifting.

The State of Reform conferences draw participants from health insurance companies, health care providers, government agencies and elected officials with a broad variety of viewpoints.

My fellow panelists were Pam MacEwan, CEO of the Washington Health Benefit Exchange, and MaryAnne Lindeblad, Medicaid director for the Washington Healthcare Authority. MacEwan and Lindeblad presented on where their organizations are now and what they see as future challenges. My role was to be the Eastern Washington wild card.

There was life, death and health care before the Affordable Care Act passed and before the American Health Care Act didn’t. In the past hundred years, the death rate per 100,000 population has dropped by roughly 45 percent. Instead of tuberculosis and pneumonia, the leading causes of death are now cancer and heart disease.

In 1917, patent medicines were widely advertised. They were usually not patented and mostly not medicine. If you were lucky, all you got was a buzz and a hangover. Prescription medications were individually compounded. The earliest health insurance plans were developed and sold through employers, because holding a job meant you were healthy. Average life expectancy at birth was 48 for men and 54 for women.

By 1967, we had mass-produced medications tested for effectiveness on at least 80 percent of the population. Medicare was passed to cover the elderly, Medicaid was for indigent children or the disabled who couldn’t work. Both had bipartisan support. Average life expectancy at birth was 67 for men and 74 for women, primarily because childhood diseases like diphtheria had dropped out of the top 10 causes of death and antibiotics had conquered infections.

Our systems of insurance are based on historical data predicting future developments. Progress on life expectancy has been less dramatic in the past 50 years, now averaging 78.8 for the total U.S. population, according to the Centers for Disease Control and Prevention. But diagnoses like diabetes and AIDS, which were once fatal, are now chronic conditions.

A hundred years ago, victims of a shark attack on the New Jersey shore bled to death while they waited on a train platform. Now we’d land a helicopter and they’d be in surgery within an hour. It’s not just medical breakthroughs changing the conversation on health care. Transportation, communication and data sharing have all changed our society in transformational ways.

In health care, we’ve seen the least predictable changes. The big medical breakthroughs in 1917 were the development of accredited medical education and hospital standards. Treatments, but not cures, were found for infectious diseases. And hand-washing in health care was just becoming mainstream.

Then the first successful heart and liver transplants came in 1967. Science-based medical education paid off and antibiotics made it possible.

Now we have personalized immunotherapy treatments for cancer. Gene mapping is pointing to individual rather than mass-produced drug therapy. CRISPR genetic engineering techniques will soon make it possible to cure diseases like cystic fibrosis, hemophilia and muscular dystrophy. Genetic engineering could also “cure” Down syndrome. We have hard conversations ahead on what a cure is and who makes the decisions. And we’re back to emphasizing hand-washing as bacteria adapt to critical antibiotics.

Our panel agreed we all want effective care, delivered efficiently. We need to pay for it sustainably, without relying on more federal debt. State-by-state solutions are one way to simplify issues on a systems basis.

We also need simplicity on an individual basis. Shifting away from employment-based coverage to improved association-based health plans would provide choice and portability. Not everyone wants to shop individually for health care, but we do want to choose whom we associate with.

An era of personalized medicine requires particular attention to who makes the choices. The hardest outcome to accept is not everyone will choose wisely. There is no scheme of regulations, no system of health care that can assure everyone lives happily ever after. And that’s the hardest pill to swallow.

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