For those who receive a blood-thinning agent called warfarin, that day has already arrived. One third of people who receive warfarin, known by the trade name of Coumadin®, metabolize the drug differently from the rest of the population. A genetic screening test can identify those individuals who are more prone to bleeding when taking warfarin.

Earlier this year the Food and Drug Administration required a change in drug labeling to advise patients and doctors that a genetic test could identify that subgroup of people at greater risk for bleeding after taking warfarin.

So what does this advance in genetic screening have to do with the current debate about health care reform? A commentator in the Dec. 12 issue of the Journal of the American Medical Association argues advances in genetic screening and genetically directed treatment are pushing health insurance to a moral precipice.

James P. Evans, MD., Ph.D, a professor of genetics at the University of North Carolina at Chapel Hill, writes that modern health insurance is premised on the assumption that you can accurately predict aggregate risk, but not as easily predict individual risk. As scientists develop more sophisticated genetic tests, the prediction of individual risk will become easier. Insurance companies then would be able to cherry pick those at greatest risk and either deny them coverage or make coverage more expensive.

To prevent that, the U.S. House of Representatives passed the Genetic Nondiscrimination Act of 2007 (GINA) in April. The legislation has yet to pass the Senate. Even with passage of this act, Evans argues that individualized medicine will shift the burden of inequity back onto insurers by allowing individuals to choose coverage based on their specific risks. “Either way, the foundation of the system is undermined: the solution is for all to pool their risks,” Evans writes.

Without a universal health care system, the uninsured will not benefit from genetic screening and individualized treatment. That will lead to even greater disparities in health care delivery between the haves and the have nots. Pharmaceutical companies will have incentives to develop genetically engineered drugs (in a process scientists call pharmacogenomics) for those who have the means to pay for them. Those without insurance or with second-tier insurance won’t have the benefit of the latest advances in drug therapy.

So, advances in pharmacogenomics combined with inequitable distribution of treatment options will result in a rationing of genetically derived drugs. Evans argues that this disparity will lead to a genetic underclass. To prevent that, Evans writes, “… it will be necessary to share risks and pool resources to ensure that, regardless of genetic makeup, a humane and basic level of medical care will be available to all.”

For those who don’t have a family history of diabetes, heart disease or cancer, don’t think individualized medicine won’t benefit you. Evans reminds us that every individual has mutations in his or her genetic code. You may just need to wait until you’re old enough for that mutation to manifest itself.

“This inevitable bad news for individuals is actually good news for the common lot and represents a compelling inducement to share risk,” Evans writes. “Because all are flawed at the level of the genome, all people need each other.”

Take Dr. William W. McGuire. He’s the former United Health CEO who reached that settlement with the Securities and Exchange Commission and UnitedHealth shareholders. According to the New York Times, Dr. McGuire will still be allowed to keep stock options valued at more than $800 million.

I assume Dr. McGuire worked hard to make UnitedHealth the largest health insurer in the country, but you have to question the equity of a system that gives Dr. McGuire stock options worth $800 million, an amount that would pay annual health insurance policies for about 69,000 families of four, assuming an annual premium of about $11,500.

Why does the American health care system generate huge profits for the few and exclude the many from reasonably priced health care services? The answer is that the United States has lost its sense of community. Politicians give lip service to the concept of the common good, but the reality is that most America’s politicians and business leaders place self-interest above all else.

The individual has run amuck in American society. As Forbes magazine reports, we are in the gilded age with more than 400 American billionaires. True, a few billionaires like Bill Gates, Warren Buffett and Ted Turner have pledged billions for philanthropy, but the U.S. health care system can’t depend on handouts to serve the needs of its citizens. In 2005 health care expenditures in the U.S. represented 16 percent of our gross national product. Each year we’re spending more and getting less for our health care dollars. Public health is suffering. For example, a recent study in the New England Journal of Medicine revealed that only about 50 percent of children from 12 metropolitan areas in the U.S. were fully immunized by age two.
So what do we do? Eliminating the influence of big money from the political process would help, but that’s not going to happen overnight in the United States. The insurance industry will not willingly give up the golden goose that laid an $800 million egg for one former CEO and smaller but significant eggs for many others. Nor is the pharmaceutical industry going to loosen its grip on Washington. We all remember how big pharma lobbied Congress in 2003 to pass the so-called Medicare Modernization Act of 2003 that, among other provisions, prohibited Medicare from negotiating drug prices with pharmaceutical companies. The legislation turned out to be a multibillion-dollar windfall for the pharmaceutical industry. As Congresswoman Louise Slaughter wrote in the New England Journal of Medicine, “The final legislation, heavily influenced by drug-company and health insurance lobbyists, focused mainly on the needs of those industries instead of those of the seniors it should serve.”

So if we can’t turn to Congress and if we can’t expect the health care industry to kill its golden goose, what can we do? The coming election provides an opportunity to elect a Congress and a President who could put common good above private gain. Most of the candidates have shared at least an outline of their plans. You can view their positions on YouTube. The question I ask is will the U.S. electorate recognize the exigency of the moment and elect representatives and a President who put the health and welfare of all its citizens ahead of the financial interests of the rich and powerful? It’s that simple.