This month's Think Tank guests discussed the likely implications of genetic testing on the future of health insurance and protection. Alex Broad reports
Kirstie Redford: The Association of British Insurers (ABI) has already introduced a five-year moratorium, but should insurers be able to use genetic tests when underwriting life and health cover?
Richard Walsh: We are dealing with several conflicting issues here ' one is the way insurers insure in the underwriting process and the other aspect is around genetics itself and whether it should be treated differently from other issues. There is an acceptance ' and this is what lies behind the moratorium ' that this is a new technology. It is unclear how it is going to develop in the future.
Kirstie Redford: What about the ethical issues?
Richard Walsh: These are also unclear, but in the future it will be important to have a system which is acceptable to maintaining a competitive insurance industry and to protecting people from discrimination in an area where there is not yet a consensus on the way forward. The current moratorium does both because people can get insurance policies up to £500,000 even if they have a genetic test, which is approved by the Government's Genetics and Insurance Committee. At the same time, the insurance industry is protected from people taking out extremely large insurances in the knowledge they have a high likelihood of being able to claim.
Kirstie Redford: Is that sustainable?
Richard Walsh: As long as the numbers of people involved are quite small. We would get problems if the numbers were to rise significantly, or indeed the numbers of people taking tests were to rise significantly. Some kind of pooling system might be an option. What we need to do post-moratorium is look to some kind of system which can protect the most disadvantaged, maintain the costing and prudence within the insurance industry, but be flexible enough to be changed.
Alan Tyler: I agree. All we are saying is maintain that parity of information between the person who wants to be insured and the person who is taking the risk, to ensure we understand as much about the risk as they do. We are certainly not in a position of wanting to push this science, but I think we encourage it from the point of view of the health of the nation. It is something insurers should be monitoring and understanding.
Dr Helen Wallace: We do need to ensure the survival of the industry and protect people from discrimination. But I would argue that a good way forward is to have legislation to prevent the insurance industry from using genetic tests. There is a range of issues: one is that people need to be able to decide whether or not to have tests without having to worry about the implications on insurance. Second, there is a real danger that you exclude large numbers of people who in fact never get a predicted illness. We think there are real dangers in leading to a genetic underclass if you do start using those tests more widely for insurance. Finally, there is the issue of people who are currently excluded, such as people in families with Huntingdon's disease.
Mick McAteer: It is clear this is a public policy issue, it is not about insurance at all. It is about weighing up the potential advantages of allowing insurers to use genetic information. Do those potential advantages outweigh the disadvantages? I have to say, on balance, I see absolutely no evidence to suggest it will be beneficial to society overall to allow insurers to use genetic information.
Alan Tyler: Is your concern made about the accuracy of the tests in terms of how insurers would use them, or the fairness?
Mick McAteer: It is a matter for society to decide. What is a fair way to treat customers? The benefit of the moratorium is it allows us all a bit of breathing space to have this public policy debate. Once you relax that, the genie will be out of the bottle and there will be no turning back.
Kirstie Redford: So would you like to see the moratorium extended?
Mick McAteer: No, I would like to see the Government take us seriously and agree a public policy framework before it is too late.
Sue Elliott: If you look at the ABI's Code aren't there enough precautions in there regarding the use of tests?
Mick McAteer: It doesn't deal with the issues of fairness for society.
Richard Walsh: The Code of Practice actually came out before the moratorium and it deals with how insurers can use those tests they are able to use. Society, Government and the industry accepted we were not in a position to move ahead just on the basis of the Code. That is why we have a moratorium with financial limits. The Government, in its response to the Science and Technology Health Select Committee, committed itself to consulting on post-moratorium arrangements. As yet it has not launched that consultation exercise. I think the time is coming quite soon, when it needs to be moving that forward. We would certainly as an industry welcome that happening.
Kirstie Redford: Is there agreement in the insurance industry about which way things should move?
Richard Walsh: The debate can only happen if it happens across all the stakeholders because at the end of the day it is not just a business issue. The closest we have got to any consensus is that genetics is seen as different. The chances are that genetics will still be seen as different in three or four years' time, so moving back to utmost good faith and sharing information and using the Code doesn't look like a likely option to me.
Alex Broad: So what is the answer? Would legislation help?
Richard Walsh: It would be very unwise at the moment to move to any legislative basis to doing genetic tests because the future is so uncertain. The last thing we want is to have legislation which assumes a certain future and then the future turns out to be different. Legislation is very difficult to change.
Mick McAteer: I wouldn't agree that legislation isn't necessary. I think if anything, my feeling is that eventually some statutory legislation might be necessary, but it does not have to restrict things for ever.
Graham Spittles: The insurance industry is not customer-focused anymore, it is customer-obsessed. Everything it wants to do is for the benefit of the customer and it looks at the totality of its customers. All the time when I speak about genetics, I talk about the people who have adverse problems. If we are doing something special for the people with a genetics history, why shouldn't we be doing special things for other customers? Why should they have preferential risk assessments?
Alan Tyler: Insurers have to write enough premiums to cover their claims. If they are treated as special cases then everybody else pays more. Every time you cross subsidise people, premiums go up and more people become financially excluded.
Alistair Kent: The question is you already have a significant group of the population who do not have access to insurance as a way of making long-term arrangements on the grounds of cost. The whole issue of genetics in insurance has been drilled down onto the question of DNA technology. Under the moratorium, insurers use family history and family history is a blunt instrument even when it is accurate. It assumes you know what your parents died of. To say DNA technology is fraught with inaccuracies is certainly true but the current system is not a perfect system.
Dr Helen Wallace: The accuracy of data is key to the discussion. One of the reasons we are so concerned about this genetic data is it is about making predictions and expanding into a much bigger constituency of people than we are currently talking about. That is where you will get terrible problems with data even if you consult the very best geneticists.
Alistair Kent: If you have had an adverse test result you are much more likely to monitor the situation and have a normal life expectancy. If you do not know and you are in that small group which go on to become symptomatic then you are much more likely to be a bad insurance risk.
Mick McAteer: Genetic information is a step towards the individualisation of risk. The original concept of insurance is basically sharing the unknown risk. You're drilling down to a better picture of the individual.
Richard Walsh: The issue is that genetics is a new technology, society does not understand it and people are worried about it. Until it beds down and until we know its true effect we need to move forward carefully.
Alistair Kent: The problem we have is misunderstanding at the level of primary care with GPs who do not understand and are giving bad advice to patients about what the actual behaviour of the insurance industry is likely to be. There is also probably an amount of bad information being given by the sales rep who is not understanding the nuances of the industry's own policy. So there is a communication problem at the point at which first think about whether to get people insurance.
Paul Robertson: If you look back at HIV and AIDS, the industry was quite happy to put up to 100% on premiums because that risk was unknown at the time and turned out to be an over-exaggeration.
Graham Spittles: We have statistical data to support the adversity. In hindsight perhaps the life assurance industry did over-react.
Bob Cheesewright: You have to put these situations into context.
Paul Robertson: So what you are saying is that the industry took the worst case scenario of a third world country and applied it to Britain?
Bob Cheesewright: Using the best information available at the time.
Dr Helen Wallace: There is a real danger you base these kinds of assessments on worse case scenarios. We do not have the data.
Sue Elliott: Then we cannot use those tests.
Richard Walsh: We have to apply for each individual type of insurance policy for each condition. The Committee has only decided on one so far which is Huntingdon's life applications. We don't anticipate any further applications during the period of the moratorium. That said, we are also waiting to hear about the terms of reference for the test. We know what the old ones are, but we are waiting to hear from the Committee what the new ones would be.
Alan Tyler: The primary test at the moment is that it has to be shown to be of significance to insurers in terms of justifying a rating. It has to be shown to be worthy in terms of its extra mortality or morbidity being reflected in the premium.
Richard Walsh: One of the things that is important for me and the IFA market is that even if a genetic test is approved by the Genetics and Insurance Committee, it is still governed by the moratorium. So, say the genetic test for BRCA1 was approved for critical illness where the financial limit was £300 000, then people will still be able to get reasonable levels of insurance.
Kirstie Redford: So what could provide a long-term solution?
Richard Walsh: For the future we need a system which operates in the commercial environment but gives insurers data they need to accurately cost their policies. That would give the people who have tests the ability to get affordable insurance so long as the insurance levels are reasonable and if necessary some kind of pooling system to protect individual companies from taking on a very large amount of the risk. Some kind of pooling system beyond the reinsurance system might be necessary. That may be a way forward.
Kirstie Redford: Would we need different policies for different products?
Richard Walsh: There are different issues for different products. So some people would argue, for example, life assurance attached to a mortgage is much more important and worthy of being pooled as opposed to a standalone critical illness policy. I do not think there is any consensus on that at the moment.
Bob Cheesewright: Do you see any difference between the NHS where everybody participates and an environment where people participate if they choose to participate and to different levels?
Mick McAteer: Part of this debate has to be that we clear up certain things. How do you provide healthcare in the most efficient manner and so on. How do you protect people against risk? The jury is out as to whether the private sector is more effective than a Government-administered social insurance.
Alan Tyler: The private sector should complement it.
Sue Elliott: They have got to work together. You have to take the good and the efficiencies of each one. You have got to bring all the parties together to debate this.
