“Give me a lever long enough and a fulcrum on which to place it and I shall move the world.” —Archimedes (287-212 BC)

The forces for change impinging upon the laboratory industry are great. These include a host of economic, demographic, and political influences as well as scientific advances. Mergers, acquisitions, consolidations, competitive bidding, and government regulations all are contributing to a re-sculpting of the laboratory landscape. Which of these forces has the greatest possibility for impact on the laboratory world, and what effect would that impact have? Likely, the force most powerful is the one that will eventually change the face of medicine in America: The looming health-care crisis. The current government administration, led by President Obama is trying to create a health care system which addresses this crisis and at the same time provides universal health care coverage.

However, in response to this pending crisis, a revolution is quietly brewing in the far northwest of America, led by former Oregon Governor John Kitzhaber, M.D. This is a revolution, "not of arms and violence, but of vision and ideas". The health-care crisis potentially is of dramatic proportions, and it requires immediate significant bipartisan action on the Congress’s part.

Some history: The financing and delivery of healthcare in America is based on programs that were created in response to the economic and demographic environment that existed 50 to 60 years ago. The country has changed dramatically since then, yet we are still attempting to use an antiquated health-care delivery system, a system that was built around “categorical eligibility” (Medicare and Medicaid), not “universality.” Today, more than 45 million Americans lack health-care coverage. Economic and demographic realities are now such that Medicare will not be economically sustainable in the future. In 2004, Medicare accounted for 8 percent of all federal income from taxes. This figure is estimated to rise to 19 percent in 2015 and to 32 percent by 2025. Medicare’s total liability (unfunded) is estimated at more than $65 trillion. At this rate, America faces economic collapse in a fashion analogous to the Soviet Union when it bankrupted itself by trying to outspend the United States militarily.

This staggering weight of debt casts an ominous shadow over our children’s future, and suggests that healthcare is quickly becoming an issue of economic security. Our financial stability as a nation is at risk, and we are transferring power and influence to countries like China and others, which, at some point, may refuse to underwrite U.S. deficit spending. Refusal on the part of these countries to underwrite U.S. deficit spending could precipitate a currency crisis, soaring interest rates, and a stock market collapse.

The Archimedes movement, by generating opportunities for public engagement, is proposing a solution by creating a fairer fair, more equitable, and more sustainable medical system. The political process cannot, by itself, solve this problem as it is inherently biased toward inaction.

Americans need medical coverage to which all citizens have access. We need a system that produces health or wellness, not one that simply reacts to sickness: a system that organizes the delivery of care efficiently and effectively and pays for what works. We need a system that is fair to all and does not pit citizens against one another; the old against the young, the rich and middle class against the poor.

The Archimedes movement vision statement is as follows: “To maximize health by creating a sustainable system that reallocates the public resources spent on healthcare in a way that ensures universal access to a defined set of effective health services.”

This vision is elegant in its simplicity. The adoption of a policy of universal coverage for a defined basic group of effective health services subsidized with public resources. All citizens paying taxes, regardless of their economic circumstances, would contribute to the subsidy, and all Americans would be covered for the same basic benefits. Citizens who want access to health services not covered by the basic package would be free to purchase them at their own expense. This creates two standards: One for that part of our health-care system that is financed with public resources and a second standard for that portion that is financed with private resources. This proposal is not a Canadian-style, single-payor system.

Consider a similar situation: In the United States, because of the widespread recognition of the importance of education, we have a policy that entitles all children to a publicly financed education from the first grade through high school. This is of value not just to individuals, but to society as a whole. Our schools are publicly subsidized with general tax revenues, ensuring availability to all. Everyone who pays taxes contributes to this subsidy—rich, poor, people with children, people without. All children receive the same basic benefit, everyone is included, and the public pays for the same benefit for all. However, parents who wish to give their children additional educational opportunities, in the form of private school, can do so, but the cost is not subsidized by the general public.

General Principles Proposed by the Archimedes Movement

1. Universality/inclusiveness 2. Equitable/fair/just
3. Population benefit (greatest benefit for the largest number of people) 4. Value (lowest cost for highest possible quality) 5. Efficiency (use of fewest resources necessary for highest quality) 6. Effectiveness (outcomes measured by unbiased, objective evidence) 7. Economically sustainable
8. Explicit decision-making 9. Transparency 10. Community-based (unless outcomes better elsewhere)

Within the previously proposed Oregon Health Act, 10 categories of health conditions were created with priorities ranked within each category from most important to least important. This ranking will be based upon the comparative health benefit of the treatment of each condition for optimizing the health of the entire population. These prioritized conditions (medical care for which society deems necessary for the general good of all) would be funded to the extent financially possible. Consumers with elective, discretionary, or lower-priority conditions would share in the cost. These proposed categories are as follows:

1. Prevention 2. Pregnancy and childbirth 3. Acute life-threatening conditions 4. Acute non-life threatening conditions 5. Catastrophic conditions 6. Chronic life-threatening conditions 7. Chronic non-life-threatening conditions 8. End of life 9. Rehabilitation 10. Elective conditions

Major reform of our health-care system requires definitive action by the U.S. Congress. But action by Congress will not occur without pressure. We the people must pressure Congress.  In order to drive this process, three steps are necessary, as stated by the Archimedes movement:

1. A vision of a new health-care system must be clearly defined. 2. The contradictions and inequities of the current system must be exposed. 3. A “tension” must be created between the vision and the status quo.

The success of this strategy depends on the capacity of people to come together around a common vision and to build a clear, compelling, and broadly supported vision of what a more equitable and sustainable health-care system should look like. The Archimedes movement has articulated that vision.

So…should this revolution, or one like it, succeed and actually change American medical care, what would be the direct impact on the laboratory industry? With a two-tiered system (basic coverage for all, optional coverage for those who want it and are willing to pay for it), what economic forces will come into play and how will these forces reshape the scope, delivery, and cost of laboratory services? Speculate. A train is coming. Get on board, or get off the tracks.

One can only hope that Congress, the President and the people of the United States will do the right thing and do it now.

"There is a tide in the affairs of men, which taken at the flood leads on to fortune. Omitted and all the journeys of their lives are bound in shallows and in miseries. On such a full sea are we now afloat and we must take the current or lose our ventures."

     - William Shakespeare

Use of materials and information provided by, and excerpted from, the Archimedes movement and Dr. John Kitzhaber are gratefully acknowledged in the preparation of this discussion.

References:

Oregon Better Health Act (Oregon Senate Bill 27) www.archimedesmovement.org www.wecandobetter.org The Archimedes Movement  -Vision and General Principles  -On the Road to Revolution: Fear and Loathing in the U.S. Health Care System -Rebuilding the Ladder of Opportunity  John Kitzhaber, M.D.