Sharing the cost of insuring those with health risks

BY RUSSELL KOROBKIN

Amy carries the BRCA1 gene, associated with an elevated risk of breast cancer. Beth has an aunt and a sister who had breast cancer. Cindy had breast cancer, which is now in remission.

What these three women have in common is a much higher risk of developing breast cancer than the average woman. Should a health insurer be allowed to charge them higher premiums or deny them coverage altogether?

Last month, the U.S. Senate passed the Genetic Information Nondiscrimination Act (GINA), prohibiting both insurers and employers from discriminating against individuals on the basis of their genetic makeup. Last week, the U.S. House of Representatives joined the Senate in passing GINA and President Bush has indicated he will sign the bill.

GINA offers protection for Amy and also for Beth (by defining family health history as "genetic information" that may not be used in insurance decisions), but not for Cindy.

From an actuarial viewpoint, all three women are more expensive to insure than the average woman. If the premiums they are charged are not commensurate with their health risks, the extra costs must be paid by others: their fellow workers, if they have employer-based insurance, or the rest of us, in the form of higher insurance premiums or taxes.

Is it fair to spread these costs to others? Well, yes. In a just society, we would all share the risks of ill health beyond any individual's reasonable control, such as their genetic makeup. Because GINA promotes this result with regards to Amy and Beth, it deserves applause.

But if Amy and Beth should not be charged health insurance premiums that reflect their true risks of illness, it's hard to see why Cindy is less entitled to protection. She's not any more at fault for the possibility that she will suffer a relapse than Amy and Beth are responsible for their risk profiles.

What's more, by prohibiting consideration of any genetic or family information, GINA increases insurers' incentives to discriminate against individuals who have modest health problems weakly related to expected future illnesses, because this is the only information they can use.

The only way to solve the problem is to extend federal law to prohibit what is known as medical underwriting — basing coverage and pricing decisions on any indicators of health status — and require instead what is called community rating of all people within an age category, with exceptions for people who engage in risky activities within their control, such as smoking.

One fear is that without medical underwriting, more healthy people would choose to go without coverage rather than pay the added costs to subsidize the less healthy. But it would be better to have a few more healthy people choosing to go without insurance than many people with serious or even very modest health issues unable to afford it or find it for sale at any price.

Korobkin, a law professor and faculty fellow at the Center for Society and Genetics, is the author of "Stem Cell Century: Law and Policy for a Breakthrough Technology (2007)." A longer version of this op-ed recently appeared in the Los Angeles Times.