The coming explosion in health inequality

Does naming your hotel “The Capitol Hill Liaison” guarantee that it’ll be the site of many, many affairs, or absolutely no affairs? I’d guess the latter. If I were a Washington figure looking to cheat on my spouse, I’d stay far away from venues that make the story particularly irresistible to tabloid headline writers.

Of course, I’m not at the Capitol Hill Liaison to study the effect of hotel names on infidelity. I’m here for the Hamilton Project’s conference on innovation. The first panel featured Francis Collins, the physician-geneticist who led the effort to sequence the human genome and now directs the National Institutes of Health, making the case that sequencing the genome hasn’t been a disappointment: It has “utterly transformed how we study human biology,” he argued, and that means huge advances in medical treatments are coming. The fact that it didn’t revolutionize how we treat disease in its first decade doesn’t mean it won’t revolutionize how we treat disease in its first five decades.

Let’s say he’s right. As Collins sees it, what’ll be revolutionary about genome-based medicine is that we’ll be able to use the information contained in an individual’s DNA sequence to target their therapies much more precisely. If that comes true, the treatments of the future will differ from the treatments of the present in two big ways: First, they’ll work a lot better. A lot of what we’re doing right now simply doesn’t work very well. Second, there’ll be a lot more individual variation.

If that’s the path that medical advances ultimately take, one byproduct will be an immense explosion in health inequality. Right now, health inequality, though significant, is moderated by the fact that the marginal treatments that someone with unlimited resources can access simply don’t work that much better than the treatments someone with more modest means can access. In some cases, they’re significantly worse. In most cases, they’re pretty similar, and often literally the same.

But as those treatments begin to work better, and as we develop the ability to tailor treatments to individuals, we should expect that someone who can pay for the best treatments for their particular DNA sequences to achieve far better health-care outcomes than someone who can’t afford the best treatments and has to settle for general therapies rather than individualized medicine.

That’s not necessarily a bad thing. This is a future, to be sure, in which both the poor and the rich are getting much better treatment than they’re getting now. But it might have very unpredictable consequences. We’re having insanely irrational conversations about rationing at a time when the forms of rationing under consideration would probably make no difference in outcomes, and might even slightly improve them. What happens when we need to ration and that means clearly worse health outcomes for the poor and even the middle class?