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May 22, 2003

GENETIC SCREENING....Healthcare plans are in the news, and a couple of times lately I've made offhand statements about how national healthcare is "inevitable." But it occurs to me that the last time I explained why I believe this was about six months ago, well before I had comments on this site.

So here it is again. There's nothing original here, and my argument has nothing to with political ideology. It's entirely technical.

The problem is the increasing effectiveness of genetic screening. There's still room for dispute about how accurate this kind of testing will ever get, but let's stipulate for the moment that in the next 10 or 20 years genetic screening becomes pretty accurate for a fairly wide range of diseases.

When that happens, private insurance is no longer possible. Here's why:

  • If screening is done on a widespread basis but the results are kept confidential, people with high risks will all go out and buy more insurance. Result: this is a classic case of asymmetrical information, and the insurance companies go bankrupt.

  • Conversely, if the results are shared with the insurance company, they will decline to insure anyone with a high risk for an expensive disease. Result: very large numbers of people will be completely excluded from receiving healthcare for serious (often fatal) illnesses.

In both cases, the system fails. Either the insurance companies go broke, or else the ranks of the uninsured swell to enormous numbers. Even large group plans would start to feel some pain as people began making employment decisions based on the results of genetic screening tests.

This is why single payer national healthcare strikes me as inevitable. Only by insuring everyone and spreading the risk across the entire country do you make individual riskiness unimportant.

So the only real question left is a technical one: how good will genetic screening get? There are certainly limits to its accuracy, and it will never yield anything more than probabilistic estimates, but probability is what insurance is all about. Move the odds a bit, and the whole system falls apart.

The unfortunate thing is that this problem will creep up slowly as these tests get incrementally better over time. As this happens, and political pressures build, we will apply small patchworks to the existing healthcare system, and we will do this over and over until we have a rickety edifice that is literally the worst of all possible worlds. On the other hand, if we put away the ideology and understood the changes that technology is going to bring, we could work now to build a system that makes sense for the future. In the long run, we'd save a ton of money and a ton of anguish.

But there's not much chance of that because everyone sees this as a partisan issue, not a technological one. That's a shame.

Posted by Kevin Drum at May 22, 2003 09:28 PM | TrackBack


Comments

D-Squared actually had a post on this a while back explaining how it's not necessarily inevitable; essentially how they can weigh risk in such a way as to guarantee a profit without denying coverage, or at least that is how I read it.

Posted by: mattH at May 22, 2003 10:24 PM | PERMALINK

I had a post on this too, a long time ago. Unfortunately, I can't find it in the archives, so maybe I made it all up! In any event, I agree with Kevin that the enterprise of insurance as risk spreading is doomed by improvements in genetic testing that will tend to focus risks. I think this will get a lot worse, though, before it gets better.

Posted by: Paul Orwin at May 22, 2003 10:54 PM | PERMALINK

I'm with Paul there; it will get worse and worse before the insurance companies are forced to spread the coverage out. They will absolutely have to be forced to do it, which means legislation and probably a national insurance commission. Maybe the commission could be made up of all the employees of the 50 state insurance commissions that currently exist.

Posted by: Linkmeister at May 22, 2003 11:04 PM | PERMALINK

There are many arguments for national healthcare, but this is one of the bizarre ones. Only a minority of medical costs could be predicted by even perfect genetic information.

Already we have many lab tests that are increasingly good surrogate markers for genetic predispositions for disease (BRCA1, apoE, for example). The availablity of these markers has not really changed the insurance market, unless you are trying to purchase a $2,000,000 life insurance policy.

The majority of risk for disease (and consumption of health care resources) is going to remain from not genetic factors but environmental factors.

Posted by: Leonard Soloniuk, MD at May 23, 2003 01:00 AM | PERMALINK

What I find ironic is Bush signing into law all these federal disaster-relief bills.

What's wrong with the free market, here?

Posted by: Troy at May 23, 2003 03:05 AM | PERMALINK

This is just another sign that free-market capitalism is obsolete, killed off by corporate and federal power, and technological innovation. Genetic testing eliminates the level playing field, where buyers and sellers have roughly similar access to information. Someone is going to get shafted, either consumers or insurance companies.

It's going to be the customers that get the reaming. Is it really likely that an individual's genetic testing results remain private, in the age of TIA?

Posted by: JLowe at May 23, 2003 03:32 AM | PERMALINK

This doesn't make all that much sense to me. People already have this sort of asymmetric information. I know that most of the women in my father's family have been diagnosed with breast cancer; my health plan doesn't. People with the kind of clearly identifiable heretible propensities you're talking about already know they have them, because that's what all their relatives die of. You might be able to be more selective at identifying the risks among family members, but on net, those people are already adversely selected into the system; their insurance might double, but it won't octuple. In fact, since their risk is currently unquantified, I've heard good arguments that they're overinsured now, and will require less insurance, not more.

The kinds of genetic screening that affect those of us without such hereditary propensities are, first of all, a long way off from being advanced enough to print out a gattaca-type list of all our vulnerabilities; and second of all, unlikely to make much difference as long as the health insurance companies continue to provide broad policies. "You have a 30% higher risk for heart disease, - 18% for cancer, +13% for diabetes, etc." is statistical noise as far as both you and the insurance company are concerned. There aren't going to be enough people at the freakazoid all negative risk factors extreme of the distribution to make an insurance business, nor will they need to. Those people might opt out, but they're likely to be a very small number, and also, they're probably not going to want to risk being uninsured if they, say, get hit by a car. I'm not worried about genetic diseases right now; I'm worried about accidents that leave me crippled.

Posted by: Jane Galt at May 23, 2003 04:12 AM | PERMALINK

The reason Jane is not concerned about what information is available from genetic testing is because she doesn't know what could be obtained that way. She knows people who have had accidents. She doesn't know anyone who has a genetically determined (or permitted) disease - yet.

How many people are familiar with the Medical Information Bureau? Any medical information obtained by a life insurance company is automatically shared with all other life insurance companies. This has been true since the 1960's that I am aware of.

As long as this country continues to be run by corporations and by the wealthy, there will not be universal health care. The media simply will not carry news that indicates that it is needed.

Posted by: Rick B at May 23, 2003 06:10 AM | PERMALINK

And of course none of this even gets into the morality (or lack thereof) of making money by denying people health care.

Posted by: John Yuda at May 23, 2003 06:30 AM | PERMALINK

If the market for health coverage were an individual market (rather than an employer provided group market), then individual risk assessment would be a big deal. Now, insurance companies ensure for estimated cost of the entire group. If the group (company) is large enough, then any extremes are smoothed over and estimates based on simple demographics such as age and sex of the employees and the occupation are adequate to make underwriting decisions.

Posted by: Ted at May 23, 2003 06:32 AM | PERMALINK

I have been thinking more about this, and I think I was probably wrong. Genetic screening is important, and will continue to be, and it will be a major predictor of large costs associated with an aging population. However, there are large looming issues in health care that cannot be significantly affected by genetic testing. Examples include epidemic disease (think SARS, only considerably worse) which is likely to strike on a large scale over the next decade, increase in hospital-acquired drug resistant infection, and spread of pandemic disease (HIV, TB, Malaria) to new areas due to a panoply of factors. All of these will stress our system, especially since infections traditionally affect the poor more than the wealthy, who are less likely to have insurance, and therefore are a direct cost to health care institutions. So, overall, I think those stresses on health care providers will outweigh the genetic stresses on insurance companies. In other words, the critical care system is in worse shape that the HMO/PPO system. Cheery thought, no?

Posted by: Paul Orwin at May 23, 2003 06:45 AM | PERMALINK

Rick B, I just told you that my family probably carries one of the easily identifiable genes for breast cancer. I know many people who have had the disease -- aunts, cousins, and my grandmother, who died of it. Read more carefully next time.

Posted by: Jane Galt at May 23, 2003 07:06 AM | PERMALINK

There are two other attributes by which one will be selected for coverage (assuming we remain under one party government): GOP party membership and a wallet full of money that was once someone's pension.

Posted by: pessimist at May 23, 2003 07:20 AM | PERMALINK

We already have assymmetric information: my insurance company doesn't know that I'm a rock climber, and my buddy Rick's company doesn't know that he races stock cars on weekends.

Genetic testing will only marginally increase the imbalance here. I do not believe it will lead to disaster.

Posted by: Registered Independent Joel at May 23, 2003 07:31 AM | PERMALINK

I agree that everyone should have health care, but I'm not sure why we can't accomplish that goal with a regulated, competetive industry. There are many degrees of regulation between the free market and a government mandated monopoly. I don't see why an argument against laissez faire health care implies that the government essentially needs to take over.

Posted by: Mev at May 23, 2003 08:16 AM | PERMALINK

Kevin's right about one thing: genetic screening is going to change things. I'm not sure if he's right about how, but certainly about the fact that it will.

I've got to go for a test myself in a few weeks. I've recently learned that my father's tendency towards blood clots is genetic, and that there is a simple and cheap test for it. A test that, only a few years ago, was far too expensive. So I'll find out, and my insurance will find out, if sooner or later I'll need to go on anticoagulants for clots, and all the medical issues that entails.

Posted by: Morat at May 23, 2003 08:30 AM | PERMALINK

Well, Mev, my earlier recollection was mistaken. For an explanation of why it would be difficult, read the D-squared post I was thinking about.


Gene pools and risk pools

Posted by: mattH at May 23, 2003 08:31 AM | PERMALINK

A single-payer universal health care sytem would, in many respects, be hugely more efficient than our present system--leaving me wondering whether we could ever adopt such a system without putting millions of people out of work.

For example, if auto insurance no longer covers medical expenses, everybody's rates drop by maybe 50%--and large numbers of claims specialists and attorneys get laid off.

Posted by: rea at May 23, 2003 09:01 AM | PERMALINK

I certainly agree that genetic testing will have a big impact on insurance. I think the biggest impact will be on those who don't have insurance via their employer. I would venture that very few people who can obtain employer supplied insurance would forego it. I don't know any active risk takers, say young, fit, and unmarried males, who forego company provided insurance plans. They may select the cheapest option, but rarely forego insurance. On the other hand, those without job benefits will have a bigger problem. There will be just more more excuse to inflate their premiums.

Posted by: MyNameIsFred at May 23, 2003 09:03 AM | PERMALINK

I see the same always unanswered question in regards to school vouchers programs (and let me state for the record I am not a priori against vouchers, it is just that no proponent has ever honestly addressed the pertinent question as far as I have seen).
Some people are cheap to provide a service for and some are expensive. As a private company you have the incentive to exclude the expensive. If you are required by law not to pick and choose, but the client as the right to choose, you have an incentive to offer crappier service for the expensive clients than your competitors.

Of course, there are other issues with both healthcare and education reforms, but from a purely practical point of view the motivations of private enterprise are at odds with the structure of the entire problems. Aspects of these problems however, are ripe for free market solutions.

Posted by: theCoach at May 23, 2003 09:26 AM | PERMALINK

I've never had a post on this one before, so I can't link to it. Damn my lack of prescience.

I'd like to disagree with you on this one Kevin, because it seems to generate more traffic for my site than agreeing, but I think you're dead-on with this one.

While I'm more than a bit leery of a full-scale government takeover of the health care system, I have no philosophical objection to some sort of single payer model or some way for the government to do what many employers now do, which is offer access to group plans and thus a wider risk pool. I haven't figured out to implement that exactly, however. But, as much as I like free markets, creative destruction, and all the rest, I recognize that a pure economic model doesn't work very well for health care.

Posted by: James Joyner at May 23, 2003 10:00 AM | PERMALINK

For the past 30 or so years insurance companies have been at trying to assess risk and eliminate people they deem to be in high categories. Genetic testing will just make it easier for them.

And we also have evidence that people are eliminated or charged more if they are in a group deemed to be of a higher risk (teenage males and auto insurance come to mind).

I am waiting for insurance questionaires to come out asking psychological questions that can lead them to determine if you are of a personality type that leads to risk taking behaviors such as driving without a seat belt, riding motorcycles (especially without helmets), skiing (water or snow), etc. as these kinds of activities place a person at higher risk of accidents.

Added to the common questions about height and weight and smoking, these kinds of questions will further winnow those who are deemed to be acceptable risks from the rest of us who are flawed human beings.

Insurance no longer uses a model of setting your rates high enough to cover the costs of all group members. Once market forces enter into the equation you start the process of shaking the tree to get rid of the rotten fruit.

Posted by: Mother of Blog Baby at May 23, 2003 10:06 AM | PERMALINK

Kevin wrote: Result: very large numbers of people will be completely excluded from receiving healthcare for serious (often fatal) illnesses.... In both cases, the system fails.

This may seem obvious, but aren't very large numbers of people already excluded from recieving healthcare (apart from emergency room care)? The system has already proved able to deal with large masses of uninsured people; I don't think this'll change in the future.

Your argument seems very speculative and over-optimistic; it assumes that people will eventually react sensibly to a problem created by technology. I'm not sure that people are so sensible.

Posted by: Ampersand at May 23, 2003 11:15 AM | PERMALINK

This may seem obvious, but aren't very large numbers of people already excluded from recieving healthcare (apart from emergency room care)? The system has already proved able to deal with large masses of uninsured people; I don't think this'll change in the future.

I'm not sure what "deal with large masses of uninsured people" is supposed to mean. The system doesn't "deal with" those people very well. Emergency care is not an effective substitute for routine and preventive care. That's why U.S. health statistics compare so badly with those of other countries, and why some form of universal health care is needed.

Posted by: Don P at May 23, 2003 11:23 AM | PERMALINK

"Already we have many lab tests that are increasingly good surrogate markers for genetic predispositions for disease (BRCA1, apoE, for example). The availablity of these markers has not really changed the insurance market, unless you are trying to purchase a $2,000,000 life insurance policy."

Odd. I had a 3mm melanoma removed when I was 37; after five years of full body scans that all came up clear, I discovered that I am denied coverage by all individual plans offered in Arizona, including the alumni plan from my university alma mater. Money was not an issue, all the companies simply declined to quote a plan, and I could get only two to admit why.

This would have forced me to abandon an entreprenurial venture, had my wife not serendipitously obtained coverage through a group plan.

When "Total Information Awareness" gets airplay, medical information is the sort of thing I think of.

Posted by: Russell L. Carter at May 23, 2003 12:53 PM | PERMALINK

I've been mulling it over, and I think the best way to fix health insurance is to destroy it completely; scrap the entire insurance model and replace it with something that almost all Americans are intimately familiar with... financing. Just like buying a house or a car or a dining room set, you buy medical care and pay for it on the installment plan.

If you break your leg or you need gall bladder surgery, you simply go to the hospital, sign a promissory note, and get it done. The bank or whoever pays the hospital and you pay back the bank or whoever on a set schedule. Depending on your credit rating, your interest rate would be in a range pegged to the prime rate and your monthly payment would be capped at a certain percentage of your income. If you die before you pay the note off, it becomes a debt to be collected from your estate. The *bank* would buy insurance against the risk of you defaulting or discharging the note via bankruptcy, perhaps as a medical equivalent to the FDIC. You can get as much or as little health care as you want to pay for eventually, and you cannot be turned down.

I'm sure there are some holes in this, so I'm asking the rest of you to find them :)

Posted by: David Thompson at May 23, 2003 02:06 PM | PERMALINK

David Thompson:

It's absurd. People with major medical problems would be bankrupted. Why do you think people buy insurance in the first place?

Posted by: Don P at May 23, 2003 02:31 PM | PERMALINK

"It's absurd. People with major medical problems would be bankrupted."

Go back and read it again, and this time pay close attention to where and in what context bankruptcy appears.

"Why do you think people buy insurance in the first place?"

Because right now they don't have any other option except to pay cash out of pocket.

Posted by: David Thompson at May 23, 2003 03:47 PM | PERMALINK

David Thompson:

Go back and read it again, and this time pay close attention to where and in what context bankruptcy appears.

I did. As I said, people with major medical problems would be bankrupted.

Because right now they don't have any other option except to pay cash out of pocket

Of course they do. They could take their chances, and take out a loan (if they qualify) or declare bankruptcy if they are faced with crippling medical expenses. The fact that they tend to choose insurance over those other alternatives illustrates the absurdity of your proposal.

Posted by: Don P at May 23, 2003 03:59 PM | PERMALINK

OR

You will get gentically screened and give the data to insurance cos and get coverage for everything but your genetic defect at regular rates and be offered AFLAC style coverage for the problem.

OR

You parents will get genetically screened and your genetic defects will be known before hand for modification PLUS your parents chose to have you anyway.

OR

The defects you are genetically screened for will be offered at preferred rates IF YOU REALLY WANT IT by agreeing to aggressive preventative lifestyle commitments.

OR

The statistical averages gleaned from publicized screening will lead to better mating patterns and better private medical R&D.

The answer is never the government. Nationalized healthcare will lead to overall reduced tech advances, overall reduced health of wealthy, and overall reduced life expectancy 20 years from now.

Posted by: not for publication at May 23, 2003 04:30 PM | PERMALINK

"I did. As I said, people with major medical problems would be bankrupted."

Why? Their payments are capped at a percentage of their income. They wouldn't be bankrupted by their medical bills alone.

Posted by: David Thompson at May 23, 2003 04:40 PM | PERMALINK

David Thompson:

Why? Their payments are capped at a percentage of their income. They wouldn't be bankrupted by their medical bills alone.

Because they might not be able to secure a loan on those terms. Even if they were, they would be saddled with potentially crushing repayments for the rest of their life. Your proposal would not and should not be accepted because it forces people to shoulder enormous and unforseeable economic burdens rather than protect themselves from such burdens by sharing the risk through insurance.

Posted by: Don P at May 23, 2003 05:05 PM | PERMALINK

"Because they might not be able to secure a loan on those terms. Even if they were, they would be saddled with potentially crushing repayments for the rest of their life."

Those terms would be enforced by legislation, and without running the numbers, I'm thinking of a payment cap in the 10-15% range. Your payment *term* would vary depending on the expense of the care you received, but the payments aren't going to break anyone by themselves. Under that system, you could see a 15-year-old repaying their bone-marrow transplant for the next 40 years, but that's not functionally different than that kid paying for insurance for those 40 years.

"Your proposal would not and should not be accepted because it forces people to shoulder enormous and unforseeable economic burdens rather than protect themselves from such burdens by sharing the risk through insurance."

It "forces" people to pay for their own medical care at a reasonable and sustainable level without the income hurdles and bureaucratic regimentation of the current insurance model. If "single payer" is what I think it is (I've never seen a coherent explanation of the term), then my model is basically private, multiple-source single payer.

Posted by: David Thompson at May 23, 2003 05:39 PM | PERMALINK

"Those terms would be enforced by legislation..."

So you're basically proposing a price control. The problem is that this does not work any more than NYC rent control. I won't waste my time explaing why.

And what if someone dies before they can pay the loan back? Many people with the biggest expenses have a fairly high chance of dying soon. What if that person's estate has nothing? No insurance company would want to insure this without very very high premiums, which would have to be paid for by very high interest rates. And what about older people who don't have many years left to work? The companies that give out these health care loans would have to charge extraordinarily high interest rates to compensate for the people who die or stop working before their loans are paid off, or to pay the super high insurance premiums that cover those people. So anybody who does take these loans would be forced into debt peonage, with stratospheric interst rates.

Ridiculous.

As for Kevin's idea, while I support single payer, I don't think this is very good reason for why it's necessary. If genetic screening becomes as big a deal as he says, you could simply force everyone to buy health insurance. Then those who have good genes must subsidize those who don't. Nearly everyone ends up having the standard minimum level of insurance required by the government. People too poor to afford this get government subsidies. I think that single payer would be more efficient than any other system, including what I just described, but I don't see why the system I just described couldn't work, even after genetic screening becomes important. The main thing is that healthy people need to be forced to pay for the insurance of the less healthy, or else adverse selection destroys the system. The insurance could be public or private.

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