Ian Morrison

There are only two issues in American health care. The first is universal access. The second is the need for a complete redesign of financing and delivery over the next 20 years. Why 20 years? In 2022, the peak of the baby boom turns 65. Fully 20 percent of the population will be over 65, compared with 13 percent today. We will have an aging white population expecting its Medicare to be paid for and delivered by an increasingly uninsured and increasingly minority working population. We will have dazzling new technologies and spineless politicians who will promise these technologies to the people without explaining who will pay for them. This does not compute. We can’t keep doing what we are doing.

The Institute of Medicine’s most recent report began the 20-year redesign process with some lofty ideals and practical first steps to cross the quality chasm, but the health care system is like a reluctant donkey, stubbornly resisting change. In health care we like to go to meetings about change, we don’t like to change.

The resistance to change is understandable. The U.S. health care system is bigger than the entire Italian economy. You would not expect the redesign of Italy to be trivial.

But make no mistake, we have no choice but change. And it has to start now.

Genomics is an important part of the redesign of health care. Randy Scott, founder and CEO of Genomic Health, wrote recently about the confluence of three powerful technology forces for change in health care: Moore’s law (the number of circuits per chip doubles every 18 months), Metcalfe’s Law (the power of the network is proportional to the square of the number of participants), and what Scott calls The Law of Finite Biology (all biological systems have a finite and thus knowable number of proteins, pathways, and so on). Together these forces will require the health care delivery system to redesign itself from an artisan delivery system of uneven quality to a system of mass customization: efficient, effective, and tailored to the individual needs, preferences, and genetic makeup of individuals.

Genomics will offer new tools of drug discovery, drug development, and customized clinical care. It will change the daily routine of all health care providers. At its extreme, the genomics revolution could lead to a health care system founded on public health, prevention, primary care, and prescription drugs rather than one centered on hospitals and proceduralists.

We need to flesh out alternate visions of a redesigned future. But more important, we need the leaders who can take us there. We need to celebrate the pioneers who drag the donkey across the chasm, who take the heat in the short run to show us the light in the long run. We have only 20 years, and it is a very big and very stubborn donkey.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. A shorter version of this editorial was published in the November/December 2001 Issue of the Health Forum Journal.