Tuesday, November 14, 2006

Genomics and socialized health care   posted by p-ter @ 11/14/2006 07:38:00 PM

On this site, we often refer to public genomics resources like the HapMap project when making an argument about population differences in one thing or another. The reason for this is simple-- there is a vast quantity of information freely available that allows, in the words of H. Allen Orr, "any bright graduate student working in his parents' garage [to] ask and answer any awkward question he likes." Come to think of it, that's not a bad description of this site, though bright graduate students thankfully make enough money to live on their own these days.

It's worth keeping in mind, though, that these excellent resources have not been assembled for the pedantic pleasure we get from skewering uninformed opinions about race. Millions of dollars have been spent in the hope that these resources will lay the framework for large-scale medical genetic studies--essentially studies that make robust correlations between particular genetic variants and disease outcomes. These studies are only now starting to appear, and the inital results are promising-- new variants have been found for obesity, diabetes, and heart disease. One goal of these studies is to discover new disease pathways which may be future therapeutic targets, but another is possibly more worrying-- the creation of a "risk engine" which will predict, for a given genome (i.e. your genome), the probability of developing any of a number of diseaes.

To be blunt-- our insurance system is in for a major overhaul. As a general approximation, we (Americans) are now charged for medical insurance based on how likely it is we're going to get sick and how costly that's expected to be for the insurance company. Non-smokers pay less. Obese people pay more. If your dad died of a heart attack, that's probably not something you want to mention when you apply for coverage. But with a full view of your genome, your expected eventual cost to an insurance company will be predicted even more precisely. There's no doubt that insurance companies will want this information, and under our current system, it's a perfectly legitimate request-- if you accept a priori that higher risk people should pay more for health insurance, you should certainly want to include genetic information in your risk calculations to increase the "efficiency" of the system.

Poltically speaking, this will be rather problematic. Essentially, there is a "genetic underclass" (to phrase this provocatively) more prone to disease, and you might well be part of it. Importantly, this categorization cuts across traditional boundaries of class-- while certain diseases might be associated with poverty, there will be people in all classes of life who are genetically prone to obesity, for example, and who will be forced to pay more for insurance. This will seem, to most people, "unfair". A couple possible political responses are as follows:

1. Make it illegal to use genetic information in determining health care coverage. This is possibly feasible, though I'm skeptical. Within a couple decades, your genotype might be on your chart from birth, and insurance companies will absolutely make use of it. Family history is already used; this would be a simple step further. And as I noted before, this is perfectly logical-- the more information available to them, the better their calculations, and the more efficient the insurance system.

2. I'm willing to advocate the alternative: strict, government-enforced indifference to genetic information-- that is, some version of socialized health care. Your genotypic information will be available, but all will be charged equally. The details need to be worked out, but other models are out there, including (dare I say it?) the French one-- a percentage of all costs covered by the government via a co-pay system, with supplementary insurance available on top of that.

The genomics revolution in biology will soon be showing some effects socially; a number of institutions will have to be questioned. Now seems like a good time to throw out some ideas of what comes next.