By  Stuart Henochowicz, M.D., M.B.A., F.A.C.P.

The New York Times published a fascinating opinion piece by Robin Cook on the topic of genetics and medical insurance. Much has been written about the potential sinister role that genetic information can have on a person’s employability and insurability. A dark sci-fi movie thriller called Gattaca (named after the nucleotide sequences in DNA) revolves around the protagonist effectively stealing good DNA in order to advance up the ranks of a space agency. But despite all the ink spilled on this issue already, I found Dr. Cook’s insights to be uniquely intriguing.

The thesis goes as follows: Insurance is based on concepts of asymmetric and incomplete information and applying actuarial science to assign risk. The viability of any insurance company hinges on its ability to foresee risk accurately. In a for profit environment, insurance companies systematically exclude high risk groups from their plans, in a process known as “adverse selection”, or “cherry picking”. But what if all the potentially adverse medical risk of a patient were knowable? There would be no need to assign a risk pool to a group. You could “cherry pick” with greater precision, and exclude patients with poor DNA. These patients would essentially become uninsurable.

Dr. Cook states that the advent of genomics medicine could drive the country towards having a universal single payer system, one that would place every citizen in one large risk group. Hey, whatever works. Universal health care would allow us to provide health care in a saner, more cost effective manner, and would likely improving health outcomes. So whatever argument works, I say go for it. One problem with the universal health care approach is that it does not square with our individualistic approach to life. I can hear the arguments in our not so distant future. Why should I subsidize the health care of this genetically ill person? He or she will only be more likely to transmit these genetic problems to another generation, and continually increase the costs for all the rest. One overriding principle that holds a sense of community for us is the notion that, even though we may be well now, we can become ill at any time. It is the notion of “there but for the grace of God go I”. This principle will fall apart if the risk of being ill is knowable. Those who are genetically determined to lead long, healthy lives, will become less invested, and less interested, in helping the “other”, the genetically unfortunate.

We need not descend into a Nazi-like eugenics based culture, however. We can foresee the horror of such an approach, and preclude its development. We can have a universal system of coverage. And we can continue to encourage medical science to study how genetic engineering can be used to better the fortunes of the genetically disadvantaged (such as with stem cell research).

Stuart Henochowicz, M.D., M.B.A., F.A.C.P.
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