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Up until about 160 years ago, or the middle 1800s, the practice of medicine was for royalty and the rich. Doctors could set a broken bone, prescribe a bit of herbal remedy, bleed you, and watch carefully over the “four humors.” Otherwise, they were mere window dressing to the drama by which patients recovered or died on their own. Oh yes, surgeons could remove an irreparably damaged limb or an obvious growth. And then you recovered or died.
The mid-1800s saw a couple of real innovations. First, scientists began actively studying those little “animalcules” and linking bacteria to various illness,1 setting up the germ theory of disease and notions of communicability and cleanliness in medicine. And then surgeons began using anesthesia rather than leather straps to restrain the patient while they cut. But it would be another eighty years or so—with the discovery of penicillin by Alexander Fleming in 1928—before medicine began controlling infectious diseases with antibiotics. Until then, people with a bacterial infection either recovered or died on their own.
In the eighty years since then, we’ve seen another complete revolution in medicine with the drafting of the human genome and the discoveries it enables.2 In addition to our knowledge about bacteria and viruses, study of the genome adds the patient’s own genetic strengths and weaknesses to the questions of health and disease. Almost every week some team of researchers is finding a link between a gene group over here and a disease over there. This is opening a field called “personalized medicine,” in which the patient’s genetic inheritance is the key to almost every aspect of health: tendency toward cancer, susceptibility to infection, response to environmental insults. About the only health issue not related to a person’s genetic makeup is falling out of a tree and breaking your leg—and even then doctors will eventually find a genetic relationship with loss of balance and tendency toward acrophobia.
And on the horizon is using a patient’s own stem cells to build genetically tailored organs and repair tissues. Truly personalized medicine.
Now, I don’t want to get into a technical argument about the Patient Protection and Affordable Care Act of 2010 (popularly referred to as “Obamacare”), but this trend in medicine forces me to a conclusion about the current method of paying for health care in the United States. Taking out insurance against disease may no longer be the appropriate model.
Insurance is something you buy to protect against a risk. And risk by its nature is defined as an event or occurrence that has only a probability or likelihood of happening, not a certainty. You make a bet with the insurance company that your house might burn down this year. You pay a modest amount (compared to the cost of replacing the house) on the side of the bet that the house will burn. The insurance company takes your money (risking a much larger payout) on the side of the bet, called an “indemnity,” that the house won’t burn. You place similar bets on having an auto accident, losing a cargo to storm and shipwreck,3 and other not so likely but possibly devastating occurrences. You don’t take out insurance against a sure thing.4
Time was, when medicine was transitioning from the shaky hands of royal quacks into the more capable hands of the old country doctor, that people took out medical insurance. Called “major medical,” this bet covered the really devastating possibilities: an expensive surgery or a chronic, life threatening illness involving expensive treatments. People didn’t buy insurance to cover everyday doctor’s visits for things like checkups, minor infections, broken fingers, and other one-time occurrences. They paid the doctor themselves as needed—and in frontier days that payment might be a chicken or a calf rather than hard coin.
Wage controls during World War II meant companies couldn’t compete for workers on the basis of pay, so they competed on benefits. The practice stuck, and for the rest of the century health insurance continued as a job perk. And it covered every aspect of health, from doctor visits to treat the sniffles to that last, lingering illness. A modification in the 1970s introduced health maintenance organizations (HMOs) that emphasized paying for checkups and preventive care through a primary physician.
But it still was a kind of insurance—you pay a premium on the bet that you will need care, and the insurance organization takes your money on a bet that you’re healthy and won’t need care. And indeed many healthy people still buy health insurance and don’t visit a doctor from one year to the next. Medical insurance has thus become a social risk pool: almost most everybody pays, and then the healthy take out less in services than they actually pay for, considering it insurance against a possible major claim, while the sick take out more in services.
But what happens to this indemnity model when personalized medicine becomes the ruling paradigm? Virtually everyone, sick and healthy, will line up for a genetic screening and long-range health consultation. The goal of research in the life sciences has long been the “thousand dollar genome”—that is, the one-time sequencing of an individual’s entire genetic inheritance for about $1,000. To this, add the ongoing analysis of new discoveries in genetics to update the individual’s risk profile. And soon personalized medicine will include capturing, sequestering, and maintaining on a long-term basis an individual’s various stem cell types against the day when he or she will need to grow new organs or regenerate damaged areas of tissue.
Wide usage will certainly drive down the costs of these techniques. Growing a human heart in a bottle, on an armature of spun sugar and soluble proteins, using a patient’s own stem cells will start out as a fantastically expensive process conducted by pioneering genetic and medical artists. In time, however, it will become the province of licensed technicians operating semi-automated equipment. Heart transplants were a wonder when Christiann Barnard performed the first one in South Africa in 1967. Today, thousands of such transplants are performed all over the world—the number limited only by the availability of donor organs. If there’s no donor, except a few of your own cells, how common will cardiac replacement become?
More to the point, what limiting factor will there be when the only considerations are a bit of inconvenience and a declining actual cost of the procedure? Sooner or later, everyone who lives long enough will benefit from a replacement heart, two new kidneys, a liver, regrown eyes, bowel resections, and brain cell therapy. And each of these procedures will extend life and pave the way for the next series of treatments.
When disease, disability, and an early death are no longer “accidents” susceptible to calculation of the “risk,” what becomes of the insurance model of paying for health care? Now I am certainly not recommending “single-payer,” which is code words for a government-run medical program, as the proper or inevitable solution. There are many other ways to pay for the necessities of life, and not even a majority of them resort to government funding and control.
But within twenty or thirty years—at the outside, given the current trends in medicine—health and disease will no longer be a matter of luck, to be addressed through insurance. They will truly become the province of science and a virtual human birthright, like access to nutritious food, adequate housing, or fresh water. How then will individuals and society provide for them?
1. See Paul de Kruif’s The Microbe Hunters from 1926.
2. See my “Gene Deserts and the Future of Medicine” in Science and Religion.
3. Protecting ship cargos was one of the first uses of insurance, originating with bets made in English coffee houses in the 1680s.
4. For example, it will cost you a bundle to insure a house built in a flood zone against flood damage or in earthquake country against earthquake damage. The premium will likely equal the expected loss.