By George J. Annas

The Olsen family had been coming to the Minnesota State Fair for almost 3 decades, and they had seen some changes. Blue ribbon cows and pigs, for example, were now all clones, virtually identical to the previous year's winners except for their markings. The lack of variety had reduced the number of contestants (and barns) to a mere handful. The food, including the pronto pups, cotton candy, snow cones, and walleye-on-a-stick was much the same as it had been before 9/11. What now drew most people to the fair was the lottery. 

That's why Ollie Olsen continued to bring the family. All of the citizens of the state are eligible, not just those qualified for subsidized health insurance, and all of their names are automatically entered into the lottery.  Only in its fifth year, the kinks were still being ironed out, but even Ollie Olsen (known more for his hard work on the farm than his intellect) understood the basic concept. Health care expenditures now made up more than 80% of the federal budget, forcing downsizing to all but a skeleton military made up mostly of robots, and the elimination of all federal agencies not directly involved in healthcare.

Ollie's son, Jon, was a big believer in the lottery as a way to reduce health expenditures on the elderly. He also liked the idea of doing national experiments at the state level.  The idea was to try to cap (use of the word "rationing" was prohibited by law, as was the term "death panel") the total number of Americans who used the most expensive treatments in medicine.  

Jon and his twenty-something sibling, Alice, had freely "donated" their DNA for banking at the fair in 2010, and knew exactly what "the most expensive treatments" meant. The great human genome adventure had succeeded far beyond anyone's wildest dreams. Now when anyone was sick, the first thing federal physicians did was to have the patient's genomes sequenced (or re-sequenced, if their genome was already in their EHR). Treatment would be entirely determined by the structure of the patient's DNA; medical care was thus "personalized" (the preferred term to describe genomic medicine). Sequencing itself was dirt cheap, but analysis of the sequence could involve hundreds of physicians and mathematicians. No wonder it was so expensive, and multiple ways had already been tried to reduce costs. Perhaps the most promising was to task the National Security Agency, which already stored the medical records and genome sequences of every American and most of the world's population, as well as their social networks, finances, and educational backgrounds, to take over all electronic health record storage for the country's physicians, hospitals, and health plans.

But even eliminating information generation and storage duplication could not reduce the average cost of personalized medicine to under $2 million per person per year ($4-5 million for cancer cases that required multiple tumor sequencing, and the creation of individualized drugs). The lottery was the solution. One lucky person from each state would annually win the prize of a federal certificate good for a lifetime of personalized medicine. The certificate was good for any family member, but could also be sold (the going rate last year was $20 million). Once treatment began, the certificate could not be transferred. If two family members were sick, only one could have their treatment personalized.

Waiting for the drawing, Ollie decided to get pronto pups for him and his wife, and elk jerky and Dr. Pepper for the kids. Then he remembered that his cousin had signed up on three waiting lists before he finally got a liver transplant. Shouldn't he and his family be able to go to as many state fairs around the country as they could manage? There was obviously no constitutional right to medical care, but wasn't there still a constitutional right to travel?

George J. Annas, JD, MPH is Chair of Health Law, Bioethics & Human Rights at Boston University School of Public Health.

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