Sequencing the Insurance Genome

If you build it, they will come.

The classic Field of Dreams tagline seems to be—perhaps unconsciously—informing the new Precision Medicine Initiative announced by President Obama as he heads into his lame duck period.

If you build it, they will come.

The classic Field of Dreams tagline seems to be—perhaps unconsciously—informing the new Precision Medicine Initiative announced by President Obama as he heads into his lame duck period.

Those in the field may recognize this as a next-generation re-branding of personalized medicine, the not-quite-new idea that treatment can be more targeted, more effective, and more personal than current best practices typically entail.

The White House’s Precision program builds on the premise of personalized medicine to specifically target cancer. The multi-million dollar investment is intended to move cancer treatment beyond management—which responds to symptoms and is decidedly reactive—and into prevention. Large-scale genetic sequencing will enable doctors to identify cancer in patients long before they exhibit symptoms, advancing screening to the point that proactive, lifesaving measures become the norm, and a cure is finally feasible.

If—and it is, at this point, still a Mount Everest of an ‘if’—the new initiative succeeds in overcoming all of the scientific, organizational, and practical challenges inherent in this undertaking, there remains a significant policy hurdle that no one involved has yet begun to address: access.

The Affordable Care Act (ACA—or Obamacare, if you prefer) came under fire during its initial implementation for denying patients access to the best cancer treatment hospitals in the country. In fact, this was not so much a feature of the new ACA as it was an integrated failure of the insurance marketplace.

The ACA hinges on getting more Americans covered by health insurance. As the name suggests, this requires many to purchase the most affordable—and therefore limited—coverage available on the new marketplaces. Making these plans affordable requires some cost-cutting on the part of the providers, achieved in part by severely limiting provider networks.

The most modern, cutting-edge hospitals are expensive to add to networks, and so are excluded from many of the entry-level (bronze, in the parlance of the marketplace) or even higher-premium plans (silver and gold).

So even without the next generation of medicine on the table, access to the best treatment available is, at best, extremely limited.

A miracle cure for cancer won’t go far unless the precision screening being developed is provided under more than a minority of hospital networks. More accurate, early screening alone would be worth some celebration. But the President’s allocations also specifically include the FDA, a clear sign that a cure is expected to accompany the genetic risk-analysis being developed.

The ACA failed to stop insurers from top-loading their tiered drug formularies to avoid paying to expensive patients and their treatments. There is no reason to expect that any forthcoming precision cancer drugs will somehow escape this profit-minded tactic.

For personalized care to be truly revolutionary, it needs to do more than take the best elements of scientific knowledge, technology, and virtual connectivity; it needs to be available to the general public who stand to benefit most. With all of the focus on the tech and modernity of personalized care, the importance of the policy challenges seems to be missing—undermining the very significance any potential success the new initiative might have enjoyed.

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