Competing Agendas: Health Insurance Reform and Precision Medicine

By Emily Hammad Mrig

When she was diagnosed with breast cancer, Christy was suddenly confronted with numerous decisions about what to do next. Among the many decisions she had to make, Christy had to choose between a breast conserving surgery or a more invasive bilateral mastectomy to remove the cancerous tissue. Fearing a future cancer reoccurrence, but hoping to preserve as much breast tissue as possible, Christy felt uncertain about which surgical option was best. To help her make a definitive decision, Christy’s oncologist recommended BRCA genetic testing – if she tested negative for a hereditary breast cancer, she would be less likely to have a cancer reoccurrence and could feel more confident choosing the less invasive surgical option. Unfortunately, when she received the news that her health insurance would deny coverage of BRCA testing, Christy was taken aback. She was eager to undergo testing so she could make a timely and educated decision about her breast cancer surgery; however, Christy knew she could not afford to pay for the test out-of-pocket and was frustrated by the lengthy coverage appeals process involved before her insurance would reconsider coverage for the test.

Precision Medicine: The “Future” of Medicine

The recently announced U.S. Precision Medicine Initiative promises to usher in a new era of medicine by using an individual’s unique characteristics, including their genome, to develop tailored treatment and prevention strategies. Christy’s story is an example of how preoperative genetic testing among newly diagnosed breast cancer patients is being used as a form of “personalized” approaches to cancer treatment.

Proponents of precision medicine claim this approach is an opportunity to foster precision public health by providing the right intervention to the right population at the right time. The concept of individualized medicine is alluring, but the technology associated with precision medicine is costly and would require most Americans to obtain access to these interventions through their health insurance plan. Yet, despite the key role of health insurance as a gatekeeper to this promising technology, the topic of health insurance is curiously absent from much of the discourse around the Precision Medicine Initiative and the potential future of biomedical innovation and discovery.

The Mismatch Between Payer Coverage and Newly Available Medical Technology

Historically, U.S. policies and laws designed to assuage health disparities, including the Affordable Care Act (ACA), have done so through the expansion of health insurance coverage. Shortly after the implementation of the Affordable Care Act, anthropologists pointed out that health insurance coverage was essentially serving as a “stand in for health itself” and warned that, although the ACA aims to mitigate systemic inequalities in access to care, not all populations would benefit equally. In other words, even with more individuals covered by some form of health insurance, new categories of health disparities would likely be introduced. As predicted, this problem is emerging within the context of health insurance coverage for the new medical technologies associated with precision medicine approaches to health care.

My current research substantiates previous work indicating that health insurance coverage of new medical technology is highly variable across plans; Christy’s experience with her health insurance and her initial denial of BRCA testing coverage is illustrative of how coverage variability in new medical technology plays out for many patients seeking access to these technologies. This is in part due to health insurance payer requirements that new medical treatments demonstrate that they are medically necessary, efficacious, and clinical guidelines are available before payers will revise their coverage policies to include new medical technology. As a result these requirements, the use of new medical technology is rapidly diffusing into clinical practice, but reimbursements by insurers are increasing slowly, resulting in a mismatch between payer coverage policies and the availability of new medical technology.

This mismatch between payer coverage and available new medical technology produces disparities in access to new medical technology based on a person’s specific health insurance plan. Further exacerbating these disparities is our knowledge that individuals covered by higher quality health insurance plans also tend to have higher levels of socioeconomic status (SES). An implication of inequitable access to new medical technology is that efforts to alleviate health disparities through access to health insurance coverage will likely fall short of their goal unless insurance reform includes policies to increase equitable access across all types of health insurance plans. This means redesigning health insurance plans to support the principles of equity rather than focusing only on equal access to health insurance coverage.

The future of the ACA may be uncertain, but regardless of what happens next, we need research to inform health insurance policies that transcend health insurance expansion and make significant improvements to population health. Current health insurance reform is preoccupied with providing Americans with more “choice” as a vehicle for reducing the cost of health care; however, this focus on a free-market system of medicine will bring us further from our goal of making meaningful improvements to health disparities. As Jessica Mulligan points out, our current obsession with increasing choice of health insurance plans is eclipsing our goal of ensuring adequate health care for all Americans. Anthropological research on health disparities associated with health insurance coverage is needed more than ever to ensure that this narrative of addressing U.S. health disparities is not lost in the discourse around health insurance reform.

 

Emily Hammad Mrig is a lecturer and mixed-methods social scientific researcher in the Department of Health and Behavioral Sciences at the University of Colorado-Denver.

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