Release 0.9: Knowledge Forces Responsibility
The Economist recently published a piece about the impact of the genome on the insurance industry.
This was all very interesting, but I felt it didn't quite tackle the real issue: Once we know a lot, we will have to be more explicit in what medical care we pay for and what medical care we do not pay for, as a society (or in each country). Insurers are simply the bearers of the bad news, because they have the data. Previously, they let us spread the ignorance; but now, they know too much. They will allocate according risks according to their knowledge, or ask us as a society to make decisions about what to pay for.
If we do not allow insurers to use the data they have, they may decide not to play. If we force them to play, they will force us to pay the costs - either in increased rates for everyone, or in restrictions on coverage... or in the knowledge that we will withhold treatment from certain diseases, kinds of people (over 80, refused to stop smoking, etc.).
Knowledge will not set us free; it will make us take on and acknowledge responsibility for what was once left to local decision-makers, chance, markets and other less explicit forces.
But the article also assumes that knowing someone's genome means knowing that person's destiny. As the author quotes Brandeis professor Dr. Stephen Cecchetti: "And once you have perfect information,....it will be the death of insurance, which depends on uncertainty and pooled risk." Fair enough, but perfect genetic information is not perfect information about people's fates.
It is, however, clear enough that it will force us to be much more explicit about what risks we will cover and what responsibilities society will force back onto individuals.
Full disclosure, of sorts: I'm part of the Personal Genome Project, run by George Church and described in this subscription-required (sorry!) op-ed in the Wall Street Journal. One reason I'm part of the project (publishing my genome and health records for all to see) is that I want people to start addressing these questions now, when we still have time to think rationally.
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Just one more reason to get for profit insurance companies out of our health care.
The premise is that once the health insurance companies have collected enough information, including genetic information, they can refuse to provide insurance to people with a genetic likelihood of certain diseases.
That's another reason why we need to either phase out the health insurance industry altogether, or limit them to some sort of "excess" coverage policies.
Health care for people does not humanely lend itself to the traditional investment analysis. If it did, of course we could just refuse to provide healthcare for old people or for anyone who is sick, then the health insurance companies could make even more money.
Healthcare should be provided to all people regardless of their genes. That's why we need national healthcare coverage. All citizens would end up paying, through taxes, a certain amount per month for this national service. For many of us, it would be about the same or less than what we currently pay in health insurance premiums.
The difference would be that we would actually receive something in exchange for our money, that being healthcare. Many of us pay a huge monthly amount as a premium, then have a high deductible so the health insurance company ends up paying nothing for us.
Also watch what happens with the economy. Insurance companies traditionally take in money, invest it, bet that they can make more in investments than they pay out for healthcare. If the market tanks, real estate is slipping, and fixed-income rates are down, the insurance companies will likely either bail on many of their responsibilities, or even become more aggressive in trying to deny coverage.
Get rid of them. They are a protection racket, like the Sopranos, and they do nothing good for any of us. We need national healthcare for all our citizens.
Unfortunately, while we are discussing the need for a humane national healthcare sys in the US, GWB is busy trying to trash it worldwide. Recently he met with Vin. Fox and the Canadian PM for a two-day summit to discuss "health" care. You can bet that wasn't good for Canadians. This is probably the plan: first tell Canadians gov. can't afford to cover all - so this procedure or that is no longer covered. That will force some to take out a pvt. ins policy. Then, it will be another.... you know the rest.
Also, I entered "Australian health care" in my search engine - guess what popped up on some of their websites - all the American parasitic "health" ins. companies. I hate to be a downer - this is such an important issue. Anyone have any ideas?
It is hard to argue against the value of more information. It is always better than less. However, no matter how you slice and dice risk, (i) high risk people don't feel that they can -- or really even should -- bear the full financial burden of their healthcare, and (ii) low risk people don't feel that they should pay for others heathcare. We need to start there before we can understand the full impact of more information and risk assessment.
The inconvenient truth in all of this is that the tough issue is not who provides the insurance (private, individual mandate, government) -- it is that costs are overwhelming. You could have single-payer tomorrow, and millions of people still are not going to get the healthcare they want or need. There isn't enough money in the world for that -- and certainly not from all of the "administrative savings" we would supposedly get from shifting from private companies to the government.
You really want to address the healthcare crisis in this country, define (i) the limits on the kind of care all people should have access to (ie. what healthcare DOESN'T everyone get), and (ii) what each person's responsibility is to pay for themselves and others. That would be real progress.
Insurance companies perform three services: expert provisioning of medical care, acturial analysis of risk, and investment fund management. These combined services are invaluable. If the insurance companies weren't competing to provide them, a government agency would have to try to do those things.
Insurance companies as they stand cause some problems. First, they are free to decline (or "price away") almost anyone who is known to be likely to draw too much from the fund. Second, they manage to deprive most insurance consumers of much choice because of things like exclusive or oligopolistic deals with employers.
Corrections could be as simple as requiring the disaggregation of private risk pools (e.g., employee pools), capping the *spread* of insurance rates, allowing insurers access to information such as genetics, and finally: an earned income tax health care credit for families to be able to make the median price of insurance while requiring that insurers proportionately accept (at that median rate) all who qualify for that tax credit (resolving cases of over-demand by lottery). This would put insurance companies in a fourth useful business: fair medical expense redistribution.
The other thought: the genomics research isn't all that good yet and I fret about forming social policies around what will later be found, I've little doubt, to be a morally significant number of forseeable false positives. People don't understand gene expression very well therefore we lack a solid metric for the error rates in sequencing techniques. On top of that, in my experience (e.g. at the Church lab), people are frighteningly unclear about how to measure the error rates in even the computations they're doing. We're at the stage of alchemy where there are speculative taxonomies and recipes and noticed correlations but, other than at the level of single cells, we aren't much beyond that and won't be for decades. People are prematurely leaping from a fairly sound understanding of some very low-level molecular dynamics to thinking they can easily draw conclusions about organisms. Where is Santa Fe when you need them....
-t
JUST MAKE PRIVATE INSURANCE COMPETE WITH GOVERNMENT HEALTH INSURANCE OR OUTLAW IT ALL TOGETHER.PROBLEM SOLVED.
Interesting! Contrary to popular belief, and media hype, the private sector is rarely as efficient or cost effective as government.
That is, with the possible exception of the military which just does not know how to be efficient.
A few self-sacrificing teachers have made a very few private schools as cheap as public schools, however, most private schools pay teachers less and still cost more per student to run. (Caveat: parochial schools, especially Roman Catholic, are subsidized by parishes or dioceses, and rarely offer a living wage to teachers).
Dyson, you argue perfectly for the expansion of the risk pool for insurers to the entire country, thereby averaging out the risks of bad genomes by birth. It is either that or run a genetic profile at birth and brand anyone with defective genes un-insurable at birth.
I know what will help the happless insurance companies, socialized medicine, where the entire country averages out the risks, just like Social Security.
Esther Dyson is correct, but events won't transpire as she hopes. There are too many possible economic and political futures for what she is proposing on the genome project in, in which she is one of ten, if I remember correctly, participants.
If one were to borrow the language of Donald Rumsfeld, there are known risks, and then there are unknown risks, and a range of possibilities between the two. A market that works well should make it possible for the insured and the insurer to decide which end of that range they want to operate in, and at what prices. I would agree with the broad conclusion, though, that insurance premiums in the future will reflect the wide variations in individual health status far more accurately. People will probably depend less on insurance and more on specific remedial steps/behaviour to grapple with their health risks, as more of that risk becomes “knowable”.
I think Lewzealand makes an excellent point in that epigenetics have a significant impact on our practical health. There will still be accidents and exposures to deleterious conditions and the genetics add to that complexity. And it seems that the standard model applied to genetics is still not perfectly understood, with emerging evidence of a more complex set of interaction than the mendellian understanding most of us have from our education, is shedding light into the way the genetic code is expressed in regards to degree and intensity of expression. Systems this complex are by nature hard to predict..or impossible,actually...and so sharing risk will always be an option, though as the biological revolution continues, everything else is speculation.
If the private insurers decided not to play, this wouldn't necessarily be a bad thing. If health care was universal and not based on the probability that a sick or genetically predisposed person would cost more money and cut into somebody's profits wouldn't it be better that the mess you have now?
Dear Ms. Dyson,
Thanks for being a part of this study, I saw your interview with Charlie Rose, it was a wonderful interview.
As far as this subject goes on the genome, we have a long way to go, epigenetices and the epigenome are also very important, especially in illness, and body chemistry changes that flick the little switches on and off in the cells.
This science gets my mind going a mile a minute, well really at light speed but, ya know what I mean.
Thanks for sharing with us. Agape.
merely knowing the data about a single individual is meaningless so far as social risk in concerned; the individual's data may be known, but the social risk covers a continuum, like all other social factors.
personally i would be delighted if insurance companies, those repositories of knowledge, declined to play. i am tired of playing their game anyway and would much prefer a health plan where risk would be spread over all of the society, not merely those lucky enough to have insurance.
not in knowledge, but in dreams begins responsibility....
Just another reason for Nat'l healthcare. We don't need more reasons to NOT provide care to everyone that needs care. DUH
"I want people to start addressing these questions now, when we still have time to think rationally."
The rich tend to think rationally, and they are always looking for new ways to make a profit. Certainly this info opens up some possibilities. A single payer system would doom this info to being used only to treat people rather than profit from them, so the rational thinkers will have to invest heavily in pundits to counteract the full disclosure intellectuals. That always works.
How about we just take the power away from the insurance industry and set up a national healthcare plan with the money we throw away for insurance?
Exactly. Why doesn't this author even broach the inevitable questions that have been hammered home in Michael Moore's movie Sicko? Namely, 'what does the insurance industry contribute to health care and why do we tolerate the medical insurance industry sucking money out the system, period? And of course the inevitable solution to ridding ourselves of this parasitic industry, nationalized healthcare, is still being treated as a taboo subject by mainstream writers like Dyson.
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