Discriminating Our Way to Universal Health Care

When libertarian bloggers hear about rationing by the British National Health Service, they get quite distressed. But I rarely hear the same level of outrage over stories like this:

One of California’s largest for-profit insurers stopped a controversial practice of canceling sick policyholders Friday after a judge ordered Health Net Inc. to pay more than $9 million to a breast cancer patient it dropped in the middle of chemotherapy. . . . “Health Net was primarily concerned with and considered its own financial interests and gave little, if any, consideration and concern for the interests of the insured,” [a private arbitration judge] wrote in a 21-page ruling. . . . When Health Net dropped her in January 2004, [the patient] was . . . forced to stop chemotherapy for several months until she found a charity to pay for it.

A few years ago, a doctor/novelist (Robin Cook) suggested that private insurers may eventually provoke adoption of a universal health care system if they use new technologies of genetic discrimination to avoid sick patients.

The argument is worth quoting in full, because it points out some deep difficulties in a “market” for private insurance that provides “tailored” policies in response to individual needs:

[A] negative consequence of [a] new ability to predict illness is the potential for discrimination in one form or another if confidential health information is released. Unfortunately the chances of such a breach of privacy occurring, despite lip service by politicians to prevent it legislatively, are probably inevitable. Not only is microarray technology easily accessible, but for-profit private insurance companies have strong incentives to use it to protect their bottom lines by denying service, claims or even coverage.

It is precisely this danger, however, that may lead to a great breakthrough: the inevitable movement to universal health care. In this dawning era of genomic medicine, the result may be that the concept of private health insurance, which is based on actuarially pooling risk within specified, fragmented groups, will become obsolete since risk cannot be pooled if it can be determined for individual policyholders. Genetically determined predilection for disease will become the modern equivalent of the “pre-existing condition” that private insurers have stringently avoided.

As a doctor I have always been against health insurance except for catastrophic care and for the very poor. It has been my experience that the doctor-patient relationship is the most personal and rewarding for both the patient and the doctor when a clear, direct fiduciary relationship exists. In such a circumstance, both individuals value the encounter more, which invariably leads to more time, more attention to potentially important details, and a higher level of patient compliance and satisfaction – all of which invariably result in a better outcome.

But with the end of pooling risk within defined groups, there is only one solution to the problem of paying for health care in the United States: to pool risk for the entire nation. (Under the rubric of health care I mean a comprehensive package that includes preventive care, acute care and catastrophic care.) Although I never thought I’d advocate a government-sponsored, obviously non-profit, tax-supported, universal access, single-payer plan, I’ve changed my mind: the sooner we move to such a system, the better off we will be. Only with universal health care will we be able to pool risk for the entire country and share what nature has dealt us; only then will there be no motivation for anyone or any organization to ferret out an individual’s confidential, genetic makeup.

Cook’s argument is a powerful counternarrative to a dominant theme of “medicine & technology” discourse. Usually, technological advance is Exhibit A for the logic of a tiered medical system–if only the comparatively wealthy can afford something new, it’s fine to allow them to get better technology than others because it incentivizes the development of technology that all can afford. But if technology makes existing markets for private insurance obsolete by rendering risk more transparent, it may well catalyze more egalitarian methods of pooling risk.

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