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[Russell Korobkin, May 2, 2008 at 1:17am] Trackbacks
The Genetic Information Nondiscrimination Act:

Today, the House of Representatives passed the Genetic Information Nondiscrimination Act (GINA) by a vote of 414-1, joining the Senate, which passed the bill last week 95-0. In addition to prohibiting discrimination in employment on the basis of genetic conditions, GINA prohibits health insurerance companies from denying coverage or determining premiums based on a customer's gentic information, which is defined broadly to include family history of health conditions.

The Act provides important protections, not only for customers in the individual health insurance market, but also for small employment groups with one or more individuals who have a high likelihood of suffering a genetically-linked illness. (Federal law prohibits health insurers from discriminating against any individual in the group insurance market, but the expected costs of covering the individual can be spread equally across all members of that group). The Act also will remove a disincentive for healthy individuals to take genetic tests because of fear that knowing the results will cause insurability problems.

In an op-ed piece in last Saturday's Los Angeles Times (here), I argue, however, that the law does not go far enough, because it still allows discrimination in coverage and pricing of insurance based on any conditions the individual customer has or has had in the past. Hopefully, GINA will be the initial step toward a legal regime in which health insurance premiums are community rated within age bands, with differential pricing allowed for risky behaviors that are individually controllable (such as smoking) in order to minimize moral hazard.

Bruce Hayden (mail) (www):
One possible downside of your proposal is that with the healthy subsidizing the unhealthy (which is essentially what you propose), the healthy will have a greater incentive not not carry health insurance, or if they do, have higher deductible health insurance.

Indeed, for your scheme to work, there would seem to have to be a move away from high deductible policies, health care savings accounts, etc., since those are ways for people to get around subsidizing those less healthy than themselves. But that would move away from attempts to move away from 3rd party payments and reimposing some market pressures in order to keep health care cost increases down.
5.2.2008 2:26am
Fearless:

One possible downside of your proposal is that with the healthy subsidizing the unhealthy


All health insurance involves the healthy subsidizing the unhealthy. That is the point. The point is to spread the cost of an unfortunate event over which the individual has not control over the society, which consists mostly of healthy individuals.

Life insurance involves the living subsidizing the families of the dead.

Car insurance involves people who haven't been in an accident subsidizing the cost of car accidents.

Basically, your criticism of Russell on the ground that it requires the healthy to subsidize the unhealthy is not a criticism at all. It just shows your complete inability to comprehend the purpose of insurance.
5.2.2008 2:31am
David Schwartz (mail):
Why do you think those with lower risks of health problems should be subsidizing those with higher risks?

And what is the policy justification for financially punishing a healthy person for living in an area that has people with genetic conditions that put them at higher risk for various diseases than he is?

And, strangest of all, why should a person who lives in an area full of heart attack survivors pay higher rates even though he has never had a heart attack?

I mean, there might be policy justifications for these oddities, but I sure don't know that are. Why not try to get insurance companies to set insurance rates to their very best estimate of the actual statistically-expected payouts, plus a reasonable profit?
5.2.2008 2:32am
Fearless:

But that would move away from attempts to move away from 3rd party payments and reimposing some market pressures in order to keep health care cost increases down.


Another effect of "market pressures" is that it prevent people from seeking diagnosis at a time when a disease could be prevented and/or treated at a much lower cost.

Our health costs are not spiraling out of control because people consume too much preventative medicine. I do not see what is gained by your proposal to decrease the amount of preventative medicine people consume.
5.2.2008 2:34am
David Schwartz (mail):
All health insurance involves the healthy subsidizing the unhealthy. That is the point. The point is to spread the cost of an unfortunate event over which the individual has not control over the society, which consists mostly of healthy individuals.
No, no no. There is a huge difference between those who *actually* suffer losses subsidizing those who do not and those who are more likely to suffer losses subsidizing those who are less likely.

Basically, your criticism of Russell on the ground that it requires the healthy to subsidize the unhealthy is not a criticism at all. It just shows your complete inability to comprehend the purpose of insurance.
No, you just misunderstand his terminology because he didn't anticipate anyone would read it in your tortured way.

Suppose I have genetic factors that put me at risk for heart attack but you don't. If the law forces a health insurance company to charge us both the same rates, yours will be higher and mine will be lower than it would be otherwise. So you, the healthy (in the sense of having lower expected health costs given full knowledge) are subsidizing me the unhealthy (in the sense of having higher expected health costs given full knowledge).
5.2.2008 2:35am
David Schwartz (mail):
This is where I part company with your op-ed:
In a just society, we would all share the risks of ill health that are beyond any individual's reasonable control, such as one's genetic makeup.
This means a just society can have no lotteries. Surely being born to rich or poor parents is beyond your control -- should a just society equalize that? The risks of ill birth are beyond any individual's reasonable control.
5.2.2008 2:39am
Fearless:

Why do you think those with lower risks of health problems should be subsidizing those with higher risks?


Because the distribution of health risk is often not a factor that individuals have any control over. Also, health care is a necessity, not a luxury good.


And what is the policy justification for financially punishing a healthy person for living in an area that has people with genetic conditions that put them at higher risk for various diseases than he is?


We probably should prohibit geographic discrimination as well, so as to avoid this problem.


And, strangest of all, why should a person who lives in an area full of heart attack survivors pay higher rates even though he has never had a heart attack?


Because heart attacks are the number one killers of Americans and probably heart attacks will affect either this person or someone close to this person.


I mean, there might be policy justifications for these oddities, but I sure don't know that are.


May I suggest that your failure to think of them demonstrates a fundamental failure in your intellect. The policy justifications are not rocket science.


Why not try to get insurance companies to set insurance rates to their very best estimate of the actual statistically-expected payouts, plus a reasonable profit?


Because it is morally unacceptable to give people a financial disincentive to discover information that may save their lives.
5.2.2008 2:41am
Fearless:

No, no no. There is a huge difference between those who *actually* suffer losses subsidizing those who do not and those who are more likely to suffer losses subsidizing those who are less likely.


You are incorrect. That someone experiences a misfortune is often an indication that they were at higher risk all along. The fact is, information about probabilities that insurance companies possess is incomplete.
5.2.2008 2:44am
Fearless:

This means a just society can have no lotteries.



I don't have a problem with lotteries or gambling. I also do not think that winners of these activities "deserve" their winnings, and I would have no problem taxing such gains at a higher rate either.


Surely being born to rich or poor parents is beyond your control -- should a just society equalize that? The risks of ill birth are beyond any individual's reasonable control.


I think saying that a person born to poor parents and has health problems should not receive treatment is adding insult to injury. Ensuring that those who lose lotteries do not lose everything and maintain a basic level of human dignity does not mean I am against lotteries.

See, your problem is that you think that just because X wins the lottery and Y does not, Y should end up dead in the street from a disease that is easily treatable given current technology. That isn't pro-lottery. That is pro-inhumanity.
5.2.2008 2:48am
BU2L:
That someone experiences a misfortune is often an indication that they were at higher risk all along.

So, if I have pocket aces cracked by two-seven offsuit, because it happens, I had a higher risk of losing all along? Jigga said what?
5.2.2008 3:03am
Nathan_M (mail):

So, if I have pocket aces cracked by two-seven offsuit, because it happens, I had a higher risk of losing all along? Jigga said what?

Nope. Think about it this way. Suppose you have 200 people, and for 100 of them there is a 50% chance they will have a heart attack, and for another 100 there is a 10% chance. Further suppose everyone knows these two risk groups exist, but no one knows who is in which group.

Now, for any particular person there is a 30% chance they will have a heart attack (because you don't know if they are in the high risk group or the low risk group). But if someone does have a heart attack there is now only a 83% chance they were in the high risk group and only a 17% chance they were in the low risk group.

So, suppose one of those people has a heart attack. Before someone had a heart attack you could only say there was a 30% chance of that happening, but after you observe the person have a heart attack you know there was actually a 43% chance.

It's different from the poker situation because with poker once you see the cards you know the odds -- there's no hidden information. So what cards actually come doesn't give you any new information about the probability of someone winning. With health risks, you know everyone is at a different risk for a particular disease, but you don't know exactly what a person's risk is. So seeing who gets a disease does give you new information.
5.2.2008 3:22am
Fearless:

So, if I have pocket aces cracked by two-seven offsuit, because it happens, I had a higher risk of losing all along? Jigga said what?


Perhaps life is more complicated than a card game?
5.2.2008 3:23am
Fearless:
Nathan_M said it better.
5.2.2008 3:24am
tvk:
I know why this law is popular, but I don't understand why academics who normally know their economics are so wholeheartedly endorsing adverse selection. People who live in earthquake or hurricane zones don't have much control over that, either, short of moving interstate; but we don't bad discrimination based on that.

There are some countervailing benefits (e.g. overcoming fear of getting the tests), so the law might even be justified. But how would that justify your proposed expansion of the law to people who know they actually have the disease already (and thus no possible fear of testing)?
5.2.2008 3:29am
Nathan_M (mail):
I just realized one of my comments in my last post, "after you observe the person have a heart attack you know there was actually a 43% chance", is potentially misleading.

Now, the person didn't have a 43% chance of having a heart attack, they either had a 10% chance or a 50% chance, and you still don't know which. But you do know that 60 of the 200 people had heart attacks, and that 10 of the people who had heart attacks were low risk and 50 were high risk. So, from what you know now the person's risk of a heart attack was (1/6)*10% + (5/6)*50%, or 43%.

You still don't know with certainty which group he was in, but from the fact he had a heart attack tells you there was a 17% chance he was low risk and a 83% chance they were high risk, whereas before you observed the heart attack you only knew there was a 50% they were low risk and 50% chance they were high risk.
5.2.2008 3:36am
Fearless:

People who live in earthquake or hurricane zones don't have much control over that, either, short of moving interstate; but we don't bad discrimination based on that.


You may not have total control of whether you live in a hurricane zone. But you do have some control over whether you own beach front property. You do have some control over whether the building you are in is resistant to earthquakes.

But how would that justify your proposed expansion of the law to people who know they actually have the disease already (and thus no possible fear of testing)?
5.2.2008 3:39am
Fearless:

But how would that justify your proposed expansion of the law to people who know they actually have the disease already (and thus no possible fear of testing)?


At one time, every person who has a disease, once lived in a state when they did not know that fact.

It can be easily justified based on the idea that people should not be denied treatment for disease, which is the common enemy of humanity.
5.2.2008 3:41am
EIDE_Interface (mail):
Oh boy, since when does anything have to do with "deserve" or "just society"? Whatever happened to freedom?
5.2.2008 3:43am
Fearless:

I know why this law is popular, but I don't understand why academics who normally know their economics are so wholeheartedly endorsing adverse selection.


There is another word for "adverse selection." That word is called privacy. Economists might recognize that the thing we call privacy has some non-zero value.

Second, economists are used to cost-benefit analysis. If you really thought like an economist (and it is rather clear that you do not) you would realize that the question is not whether a particular policy increases or decreases adverse selection. The question is whether the benefits of the policy exceed the costs. Problems of adverse selection are merely one factor in that calculus. At least for those who think like economists, rather than like anti-adverse selection activists. (Also known as anti-privacy activists.)
5.2.2008 3:48am
Fearless:

Oh boy, since when does anything have to do with "deserve" or "just society"? Whatever happened to freedom?


I do not believe that people who cannot function due to easily preventable disease have very much freedom.
5.2.2008 3:50am
Lior:
Fearless and Nathan_M:

If everyone carried the same insurance then, yes, the fact that some people are at higher risk would not matter. But the crux of the matter is that you have a choice in the health insurance you buy. Any situations when insurers are not allowed to discriminate based on known risk factors is dangerous, because in that case only the people who are at risk will find it profitable to be insured.

Nathan_M: this law exactly addresses the situation when you do know the cards. In your example of the 200 people, the effect of genetic testing is to tell you to which of the two groups you belong. If the people know this, but the insurance company doesn't, then you are in trouble: if the premiums reflect a 30% risk, then only people at 50% risk will buy insurance, and the company will lose money. They will have to raise the insurance premiums based on the pessimistic assumption that every potential client is at the 50% group. At this point the people at the 10% group will go uninsured. Of course, no-one has control over their genertic make-up, but as long as they have control over buying or not buying the insurance, you still have a problem.

In a future world where you can test every baby and get an accurate prediction of their future medical risks, insurance can only work in one of two ways: either everyone gets insurance based on their personal risks (so if you are at greater risk you pay more), or everyone gets exactly the same insurance -- probably through the government.
5.2.2008 4:32am
Roger Schlafly (www):
Russell Korobkin makes a good point when he says that Amy, Beth, and Cindy may have the exact same cancer risk, and yet GINA forces insurance companies to discriminate between them. This seems unfair and economically inefficient to me.
Exceptions should be permitted to allow insurers to surcharge customers who engage in risky activities within their individual control, such as smoking.
This is the really insidious part of Korobkin's ideology. He wants the govt to decide what behavior you ought to be correcting.

There is no consensus about what is under your individual control. Recent research has shown that some smokers may have a gene that makes it very difficult for them to quit. Likewise, some obese people seem to be unable to lose weight. Many physical conditions can be ameliorated by actions that people are unable or unwilling to do. Does Korobkin really want the govt or the insurance company to distinguish "unable" from "unwilling"? It just cannot be done, with today's medical knowledge. It is like trying to separate nature and nuture; you can do it for a few things, but you cannot do it for most things.
5.2.2008 4:37am
David Friedman (mail) (www):
The piece mentioned moral hazard but not adverse selection, the other form of market failure commonly associated with insurance. Was that because the author was unaware of the problem or did he have some reason to think it wasn't important? Almost all of his arguments seem to relate to moral hazard, which is an entirely different issue.

To what extent does he want to limit individual choice? Can I and a hundred (healthy) friends form our own mutual insurance company, covering only ourselves? Can I choose to buy insurance only against very large costs, self-insuring against small ones? Both of those are ways in which it will pay healthy people to get out of a system in which they are being taxed to subsidize less healthy people--and have nothing to do with whose fault being unhealthy is.
5.2.2008 4:45am
Nathan_M (mail):
Lior, that's obviously a danger with this proposal, but I think you overstate it. Given the bankrupting cost of a major illness if one does not have insurance, people will be willing to buy medical insurance even if they are at a lower than average risk. Of course, how much lower than average a person can be is an empirical question.

In the example I gave you're probably right that adverse selection would drive all the healthy people out of the market. But in the real world it's probably only a small percentage of the population that is at a markedly high risk. This might mean everyone would stay in the market.

My understanding of the current situation is that presently insurances companies do not discriminate based on genetic risk factors. (I base this on a NY Times article I read about people who weren't getting genetic tests. It said that they could still get insurance now, but they were worried policies might change in the future.) That suggests the vast majority of people with better than average genes are still willing to buy health insurance, even though they might know they are not getting a particularly good deal.

Of course, there is a potential trade off here as technology gets better. It's conceivable that adverse selection might become a serious problem. I don't think it's as dire as you suggest.

I'd also note that most people get their health insurance through their work, and they do not pay premiums based on their individual risk factors. In the aggregate, already observable risk factors such as obesity, smoking, and family history (which is really an imperfect genetic test) are far more important than genetic testing will be at least for the foreseeable future. Despite this, the health-insurance-though-work market survives. (Of course, there are serious problems with this way of getting health insurance, but that's another issue.)
5.2.2008 4:57am
Roger Schlafly (www):
Here is an article suggesting that smoking may be genetic: Genetic link tied to smoking addiction.

What if my cholesterol is high, but I have genetic evidence that I am at low risk for heart disease? Should I have to get cholesterol-lowering drugs just to pacify an insurance company that is forbidden from using the evidence that I am at low risk? I think that GINA is really bad.
5.2.2008 5:18am
David Schwartz (mail):
Supposed that I am apparently overweight, but have genetic evidence that such a weight is actually healthier for me. Should I lose weight and increase my health risk to lower my insurance rates?

Suppose genetic evidence shows that I have a tendency to get some disease that can be warded off mild smoking, outweighing their health costs. Should I still get a lower insurance rate for being a non-smoker?

But it seems the people on opposite sides of this issue just have a very different notion of what is fair.

If I'm born with genes for good health and you're born with genes for good saxophone playing, why should you get to benefit from yours and I don't get to benefit from mine? There is nothing fair about leveling natural advantages and disadvantages.
5.2.2008 5:32am
Roger Schlafly (www):
David Schwartz raises some good questions. Even if you think that insurance companies are supposed to look at things like weight and not genes, how are they going to get the physicians to separate out the genetic info in their reports? Before long, the genetic info will be inseparable from the other info.
5.2.2008 5:47am
Brian Mac:
I don't normally like the screams of "this is supposed to be a libertarian blog," but this comment pretty much calls for it:


"the law does not go far enough, because it still allows discrimination in coverage and pricing of insurance based on any conditions the individual customer has or has had in the past."

On that logic, why not just introduce socialised medicine?
5.2.2008 7:39am
Alan Gunn (mail):

On that logic, why not just introduce socialised medicine?

Indeed. What the politicians seem to be doing is enacting law after law that increases the cost of health insurance for most people, then asking for a national health system on the ground that private insurance has become too expensive. The government has been fouling up health care ever since it started encouraging the tie between insurance and employment. So now we should think it can run the whole system?
5.2.2008 9:20am
Serendipity:
I haven't read the bill yet, but what's going to happen when the "gay gene" is discovered? How about the "fat gene"?
5.2.2008 9:27am
A. Zarkov (mail):
Suppose someone undergoes genetic testing and he finds that he's at extremely low (but not zero) risk of disease. He then advertises for others with similarly low risk to join him in a voluntary pool. The insurance premiums for this risk pool would be much lower than a pool with anyone in it. Would GINA deny people the opportunity to do this? Of course this creates a problem. All the low risk people are going to start joining these pools effectively leaving all the high risk people to enroll in regular insurance pools. Thus premiums will more realistically reflect the underlying risk. Congress obviously doesn't want this. It wants the votes of high risk people who want to keep their premiums low.
5.2.2008 9:56am
TruePath (mail) (www):
This law can only hope to work because we don't have a very advanced system of genetic testing yet. At the point the amount of genetic information becomes significant we will have the choice of repealing such a law or effectively moving to socialized health insurance.

Given widespread knowledge of genetic risk virtually any greater coverage by one plan than another of some condition or treatment will cause it to become highly subscribed by those with the condition thus imposing FAR greater costs. This creates a race to the bottom for insurance companies since greater converage disproportionatly attracts the sick. Hence all insurance will become nothing but the government mandated minimum coverage (which will naturally expand to counteract this force). At this point we should just go to full on government managed insurance since what's the difference.

Well that's probably what we should do anyway (and government run insurance doesn't have to be government run healthcare).
5.2.2008 10:07am
H Tuttle:
One of the most pernicious aspects to discussion in this area is that in no way is "health insurance" any longer a form of traditional "insurance." Rather today it's simply and starkly a method of spreading costs, whereas traditionally insurance, of course, was a means of spreading and allocating risk. We'd do much better with this debate if we stopped calling health coverage health "insurance".
5.2.2008 10:08am
Prufrock765 (mail):
Can anyone think of another area of the economy where the government (apparently unanimously) thinks that the market will work better with LESS information?
I always thought that the reason the free market worked better than socialism in allocating scarce resources is that the free market is able to process information and send (more nearly) accurate signals on pricing.
5.2.2008 10:18am
Aultimer:

Fearless:


Surely being born to rich or poor parents is beyond your control -- should a just society equalize that? The risks of ill birth are beyond any individual's reasonable control.


I think saying that a person born to poor parents and has health problems should not receive treatment is adding insult to injury.


The original poster's point goes unanswered, perhaps because you purposly misread it.

If justice requires that no one suffer in life from any factor beyond their control (as you seem to say), shouldn't the government tax the wealthy to take every dollar above the mean and redistribute the money to those below? Certainly those below the mean can't control the genetics and early environment that gave them their intelligence, personality and values.
5.2.2008 10:25am
MDJD2B (mail):
BTW, the one NAY vote in either house was Ron Paul.
5.2.2008 10:45am
Pon Raul (mail):
I thought that this was a Libertarian blog! Russell Korobkin sounds more like a Marxist.

There are two types of discrimination. Rational and irrational. Irrational is self-punishing. Therefore, we should not make any type of discrimination illegal.
5.2.2008 12:03pm
Pon Raul (mail):
I should add, except for when the government is doing it, because government discrimination is punishing us all.
5.2.2008 12:03pm
Childermass:
"If I'm born with genes for good health and you're born with genes for good saxophone playing, why should you get to benefit from yours and I don't get to benefit from mine? There is nothing fair about leveling natural advantages and disadvantages."

Surely your good health is a benefit, no? And, being in good health opens many more doors for you than not being so, so I fail to see how you don't benefit.
5.2.2008 12:14pm
David M. Nieporent (www):
One of the most pernicious aspects to discussion in this area is that in no way is "health insurance" any longer a form of traditional "insurance." Rather today it's simply and starkly a method of spreading costs, whereas traditionally insurance, of course, was a means of spreading and allocating risk. We'd do much better with this debate if we stopped calling health coverage health "insurance".
Indeed; I've been trying to explain that point to leftists for years. The problem is that people think health insurance is a way to pay for health care, rather than a way to pool risk. That's where people get the bizarre idea that health insurance should be forced to pay for contraception. That's where people get loony ideas that insurers shouldn't be able to charge more or deny coverage for pre-existing conditions.

Nobody would suggest that a person whose house is presently on fire should be legally entitled to buy homeowners' insurance, let alone that he should be able to buy this insurance for the same rate as everyone else.

Nobody would suggest that a guy with 10 auto accidents on his driving record should be charged the same rate as a guy with none.

Nobody would suggest that earthquake insurance ought to cost the same in California as in Nebraska.

Nobody would suggest that auto insurance cover gasoline and wiper fluid.

But when it comes to health insurance, people mistakenly think that it should cover the analogous things.
5.2.2008 12:23pm
Duncan Frissell (mail):
I'm sick and tired of our mentally and morally defective rulers designing our, cars, light bulbs, toilets, and insurance contracts. If they were any good at those jobs, they would do them instead of sucking at the public tit.

If I want to discriminate against a genetic defective, I have a natural right to do so and I will simply ignore anyone who tries to stop me. Coprophagous cretins.

differential pricing allowed for risky behaviors that are individually controllable (such as smoking)


Including, I presume, risky behaviors like, sodomy, fornication, staying out after 9:00 pm, failure to marry, failure to attend church regularly (-7 yrs longevity), failure (by women) to give birth to and nurse children under modern medical conditions (increased cancer risk), etc.

Lots of avoidable risks out there.
5.2.2008 12:35pm
David Chesler (mail) (www):
My understanding of the current situation is that presently insurances companies do not discriminate based on genetic risk factors.

I am heterozygous for Factor XI deficiency. I had a subtly higher clotting time even before my doctors told me I should take a baby aspirin per day to decrease my chances of having a heart attack. (It's like calories -- unlike our ancestors, the risk of a heart attack killing us is greater than the risk of bleeding to death, so most of us clot too readily.) About the only thing that one can determine from this deficiency is that I am probably either an Askkenazi Jew or a Kerry Blue Terrier, and I don't see no tail on me. (There's probably an increased likelihood that I lived near Albert Einstein College of Medicine, home of one of the researchers into this oddity, even greater than could be predicted by ethnicity.)

But ten years ago SBLI, the "No Nonsense" life insurance company, wanted to "rate" me for this condition. I don't know if it meant they were improperly discriminating on the basis of ethnicity, but I didn't push it, because I had an equally good offer from CNA/Valley Forge that I took. (It's not all good - since then my health declined, as happens to some of us as we enter middle age, so their odds look better; also since then my wife's health declined, and the declined to zero, so what would have been enough to let her get back on her feet after my death would not now suffice to take care of my kids, even ignoring inflation.)

That is an interesting moral hazard question: if ignorance is cheaper, 'tis folly to be wise. One might be tempted to add a level of indirection: insurers can charge what they want, but genetically defective people get a government cash subsidy to offset, but that would no doubt go the way of government college financial aid and medicare, where costs would rise to exactly what the subsidy covers.
5.2.2008 12:53pm
Hans Bader (mail) (www):
The GINA law reflects baseless fear of new technology, is a solution in search of a problem, could dry up insurance options for consumers, and could negatively affect public safety.

The Economist blog suggests it could doom private individual insurance in the future, as people who test negative for genetic risk factors for diseases refuse to buy health insurance policies that are priced the same for them as for riskier people who test positive for those genetic risk factors, effectively forcing those with lower risks to subsidize those with higher risks. Such adverse selection would cause the market for such insurance policies to dry up.

Last year, I criticized the GINA bill in the National Law Journal for lacking a "direct threat" exception that would allow employers not to use people with hazardous conditions (like a genetic tendency to seizures) for jobs where they could unintentionally cause harm to the public (like a person prone to seizures driving a bus). Existing laws such as the Americans with Disabilities Act contain such an exception. Greg Conko, who studies biotech law and policy, pointed out that there was no need for the GINA bill. He noted there is no pattern of insurers or employers misusing genetic information.
5.2.2008 1:56pm
Bruce Hayden (mail) (www):
If everyone carried the same insurance then, yes, the fact that some people are at higher risk would not matter. But the crux of the matter is that you have a choice in the health insurance you buy. Any situations when insurers are not allowed to discriminate based on known risk factors is dangerous, because in that case only the people who are at risk will find it profitable to be insured.
This was part of my earlier post. When I was paying for my own insurance, I ran with a very high deductible catastrophic medical policy as well as an accident policy to plug the deductible in the case of an accident. Because I was healthy and a low user of health care, this worked well for me, saving me a bunch of money. And I am sure that any number of other self-insuring low health care usage people are doing the same in order to keep their costs down.

But if it becomes illegal to rate based on past health, then more and more will be pushed into this sort of policy in order to keep their costs down, as I did. But that would leave a smaller, more self-selecting, insured base for the lower deductible policies, and that would essentially defeat Russell's proposal. The only way I see around that would be to eliminate choice as far as deductibles, etc., which I would expect to be the next step.

One problem with that though is that high deductible policies provide an incentive to keep one's health care costs down, in particular, by not overconsuming, and possibly by shopping for price. The alternative, which would be the likely ultimate next step here, with the push to a standard policy, would be to not penalize overconsumption, since there would be a less direct connection between supply and demand.
5.2.2008 2:11pm
Alex S. (mail):

...with differential pricing allowed for risky behaviors that are individually controllable (such as smoking) in order to minimize moral hazard.


There heritability of nicotine dependence is about 0.60, which means that 60% of the variation in people's propensity to become addicted to cigarettes is explained by genetic variation. Other unhealthy lifestyle "choices" like alcoholism and obesity have similarly high heritabilities, and it's doubtful that any choice or personal attribute affecting health is completely within a person's control.

If a person doesn't bear the costs and responsibilities of their chance genetic endowment, we really can't expect anyone to be responsible or accountable for very much at all (and we should equalize literally everything to obtain a "just" society).
5.2.2008 4:22pm
Bleah:

I haven't read the bill yet, but what's going to happen when the "gay gene" is discovered?


Well, I suspect that will be both fun AND sad to watch if it happens. You'll see a lot of people quickly switching views on things that they've held opposition to for years, just on the basis of a singular (or dual) item. For instance, perhaps some pro-life people who might internally view homosexuality as a worse thing than abortion, may begin to promote this as a case where abortion is OK. In another instance, we might see gay rights groups trying to get laws changed to say that when a fetus is found to have that gene, they can't be aborted just because of that.

"May you live in interesting times"
5.2.2008 11:21pm
Bleah:

Hopefully, GINA will be the initial step toward a legal regime in which


I should hope not. I don't really mind GINA, because I think some people beat some of the worst parts out of it before it passed. I'm fine with it being applied to our existing system and leaving it at that. Any time discussions start focusing on "just" and "fair", it's a good sign the outcome will be neither (much like when someone suggests something is "clear" or "obvious", it rarely is).
5.2.2008 11:52pm
Mary Katherine Day-Petrano (mail):
"All health insurance involves the healthy subsidizing the unhealthy. That is the point. The point is to spread the cost of an unfortunate event over which the individual has not control over the society, which consists mostly of healthy individuals.

Life insurance involves the living subsidizing the families of the dead.

Car insurance involves people who haven't been in an accident subsidizing the cost of car accidents.

Basically, your criticism of Russell on the ground that it requires the healthy to subsidize the unhealthy is not a criticism at all. It just shows your complete inability to comprehend the purpose of insurance."

Thank you Fearless for setting things straight. People with autism LOVE this new law. Another way to make *normals* stop denying autistics every conceivable opportunity because the *normals* irrationally fear autism is somehow contagious.
5.3.2008 2:31am
theobromophile (www):
How about an alternate proposal?

If someone wants non-discrimination based upon (or in spite of) genetic conditions, he must be continuously insured (or not uninsured for more than, say, 63 days at a time, just to pick a number) from a time prior to taking the genetic test to the time he seeks non-discriminatory pricing. Insurance that one is seeking on a non-discriminatory basis must be comparable to that carried before the genetic test was performed.

That way, there is no moral hazard in taking a genetic test, realising that you're very likely to get some expensive, horrific disease, and then insuring against it when you're old enough to get it. In fact, if you want non-discriminatory pricing, you have to pay into the system for years.

Alternatively, some enterprising person could develop an insurance specifically aimed at those with genetic markers and the associated diseases, so a person could insure himself (prior to taking a genetic test) against an adverse result and any diseases that may arise from that, years down the road. Normal insurance companies would then insure for everything BUT that disease, and could price on a non-discriminatory basis and still make money.

I found out a few months ago that I have a high risk of developing breast cancer. I have the option of taking a genetic test to see if I also have a genetic risk as well. It doesn't feel like I have any control over this - any more control than I would have over getting, say, mono or a broken leg - but insurance companies may not see "losing the genetic lottery" as an insurable risk. It doesn't make too much sense that an insurance company could look at a genetic predisposition to breast cancer (if I have one) and charge me more, but would not look at my propensity for getting hit by cars and attacked by wild animals when calculating my premiums.
5.3.2008 2:48am
Mary Katherine Day-Petrano (mail):
"If I'm born with genes for good health and you're born with genes for good saxophone playing, why should you get to benefit from yours and I don't get to benefit from mine? There is nothing fair about leveling natural advantages and disadvantages." --->

This, ultimately, is exactly what the current A-B-C-D standardized bar examinations do -- level the playing field for people who DO NOT have autism to eliminate their competition from autistics with higher intelligence genes.

But, the question about changing these bar examinations to performance testing is, why shouldn't an autistic perons benefit from his/her superior intelligence genes, rather than have the mediocre thinkers all become licensed attorneys by virtue of the very structural access barriers they have erected to cheat their way to the top?
5.3.2008 2:59am
Zoe E Brain (mail) (www):
This law is a disaster for a small group of people, perhaps 100,000 in the USA.
I'm talking about the Intersexed and the Transsexual.
The law specifically excludes data about sex and age. As there's no genetic test for age, that can be ignored.

The legislation says, in effect:

It shall NOT be an unlawful employment practice for an employer--

(1) to fail or refuse to hire, or to discharge, any employee, or otherwise to discriminate against any employee with respect to the compensation, terms, conditions, or privileges of employment of the employee, because of genetic information with respect to the sex of the employee (though it is for all other genetic information); nor

(2) to limit, segregate, or classify the employees of the employer in any way that would deprive or tend to deprive any employee of employment opportunities or otherwise adversely affect the status of the employee as an employee, because of genetic information with respect to the sex of the employee (though it is for all other genetic information).

(b) Acquisition of Genetic Information- It shall NOT be an unlawful employment practice for an employer to request, require, or purchase genetic information with respect to the sex of an employee or a family member of the employee (though it is for all other genetic information).
See the problem?

Ettsity vs Utah Public Transport already established in that circuit that Transsexual people are neither entitled to Title VII protection as men, nor as women. The recent Employment Discrimination Act excluded TS and IS people at the last moment, so it only protects Gays and Lesbians.
5.3.2008 3:33am