Musings on genome medicine: the slow but inexorable process of medical care reform in the United States

The current struggle to achieve a rational healthcare system in the United States (US) may well have a profound effect upon the future of genome medicine and all advanced biomedical science. The current system is all but unsustainable, but if, in a poorly conceived attempt to improve it, the budgets of academic teaching and research hospitals are damaged, advances in medicine of any kind will be slowed to a crawl. Worldwide discoveries in medicine depend on the biomedical research productivity of Western Europe, Great Britain, Australia, Japan and North America, with growing contributions from Southeast Asia, China and India. The US effort is the largest in that group. A budget crisis in clinical care within leading US academic hospitals will imperil their capacity to do research because it is impossible to do meaningful research and break even financially in the process. It is axiomatic that institutions will lose at least 10% of research budgets because grantors either cannot or will not support the infrastructure that enables research activity. The gap between cost and revenue is made up by donations and/or by a surplus on the clinical side of the budget. If the clinical budget enters a red zone, donations will necessarily be directed to shore up that vital function. Unless donations can be markedly increased, this shift will inexorably weaken the research program and force it into mediocrity. This says nothing about the teaching and training budget, the remaining obligation of an academic hospital and one that is notoriously under-reimbursed. Clearly, a collapse of the clinical budgets of major academic hospitals in the US will have a very deleterious effect on worldwide medical progress, and genome medicine will suffer along with other critically important fields. Despite the obvious risk to academic medicine, reform must occur, but it must be achieved wisely.In order to develop policies, governments must first ask the right questions. It is abundantly clear to