Saturday, February 20, 2010

personal genomics and the future of health care

There was something else interesting in this Steven Pinker article I linked the other day. I don't typically find myself agreeing with Pinker because even while he admits there are problems with behavioral genomics, he sticks to his guns nonetheless in claiming that almost all our behaviors are inherited. The findings of geneticists leave me more ambivalent and agnostic with regard to such claims. Nevertheless, he's always thought-provoking, and I found the following suggestion very interesting:
"Depending on who has access to the information, personal genomics could bring about national health insurance, leapfrogging decades of debate, because piecemeal insurance is not viable in a world in which insurers can cherry-pick the most risk-free customers, or in which at-risk customers can load up on lavish insurance."
Since one of my hobbies is trying to make social and political predictions from technological developments, I got excited when I read this.

It's a plausible idea. Private health insurance in the United States is currently based on the idea that private insurance companies don't know what's going to happen in the future, so they spread their risk across a large pool and bet on an average outcome between sick and healthy. This necessarily means that if you have a prior condition, you're going to have a hard time getting coverage. All other things being equal, an HMO will take a bet on you, but if they already know you're going to get sick, that's a different story. It's also the reason why a health insurance mandate was part of one of the health care bills last year. It seems unfair to make people pay for health insurance, but assuming the system is left the way it is (with health care provided through the free market), then that's the only way to control costs. You need to have everyone in the same basic pool so that the sick and the healthy average out. That's also part of the reason why health insurance premiums are going up by 39% for so many people in California. If healthy people opt out of health insurance because they don't think they need it, that shrinks the pool and leaves more unhealthy people in it. So the premium goes up.

On the face of it, it seems like, given the parameters of the current system, making your predispositions toward certain illnesses public would be a horrible idea. HMOs already want to deny coverage to those who have conditions. If they're able to see that you're a bad bet, because you have a 30% chance of developing Parkinson's Disease or a kind of cancer later in life, they're not going to give you coverage even if you are perfectly healthy right now. They'd be able to cherry pick those they wanted to cover and leave the rest of Americans without any insurance whatsoever. A dual-caste system would develop. Like in the science fiction movie Gattaca, there would be "valids" (who could acquire health insurance and possibly other goods in life with ease), and then there would be the "invalids" (who would be denied all those things).

The other possibility—which Pinker alludes to—is that such developments would make the current system impossible. If insurance providers were able to cherry-pick who they wanted, then presumably the system would become so radically unfair that people wouldn't stand for it anymore. Many of those uninsured Americans would also be voters, and they would demand from those they elect a more rational response to these technological developments.

I think it's difficult to make a prediction here. If I understand Pinker's claim, it seems to rest on the idea that people wouldn't tolerate something so unfair and irrational as allowing HMOs to arbitrarily decide who gets health care and who doesn't. Except if you think about it, people already do tolerate that and a lot more in this country. The electorate doesn't just seem indifferent to the idea of the free market deciding who gets to live and who gets to die. Many of them feel that any alternative is actually evil. The shrill, persecuted tone of last year's protests and town hall meetings proves that. It doesn't matter to them that our neighbors to the north and our neighbors across the pond have a right to health care and haven't had to resort to howling at the moon and marrying snakes. People put up with and even seem to cheer on a lot of injustice already, even when there are rational alternatives. So I'm not comfortable with the argument that, given some technological development y, therefore social change x. You have to consider these (frankly weird) ideological factors that go into it, too.

Still, perhaps reality has a way of asserting itself after all. Good genes and bad genes are probably distributed evenly across the rich and the poor, the powerful and the disenfranchised. If a new technology has the power to impact not just those without power but also those who make decisions or can easily influence those who can make them, perhaps the irrationality of the system will translate into change in the real world. But the field of personal genomics in all likelihood will make just such a radical, all-encompassing impact. I think there are a lot of factors that will determine what the political and social upshot of all this is, but it's hard not to imagine it changing something fundamental in how we think about the distribution of health in our society.

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