“A Major Landmark In American History”

That's what renowned Penn bioethicist Art Caplan calls the health-care bill. But whether it's boutique practices for the rich or end-of-life care, he says our discussions about health have only just begun

For nearly two decades Arthur Caplan, PhD, director of Penn’s Center for Bioethics, has been one of America’s leading voices on health and medicine. I talked to him on Wednesday and got his take on the pros and cons of Obamacare, plus where we’re headed next in the great health-care debate.

How do you feel about the new health care reform bill?
Well, I would like to begin by saying I am really pleased that this passed. I think it’s a mish-mash of a bill, a product designed by many, many hands and it kind of came out looking like the proverbial elephant — you know, no one could quite figure out who designed the thing. But it has number of [good] features. First and foremost, it’s making a dent in the uninsured problem, the single greatest ethical scandal of American health care. We were the only developed country that hadn’t brought everybody in under the safety net for health care insurance, and it’s time we did that and I think it will go down as a major landmark in American history. [SIGNUP]

What are some of the major changes we’ll be seeing?
It’s getting rid of preexisting conditions as a way to toss out people [from health care insurance], so that’s a big plus. Making sure every child is covered through basic health care, and that’s a big plus. Mandating health care for everyone, and I know that’s controversial in some circles, but you have to do it if you’re going to pay for the whole thing, you have to have everybody contributing, so to speak. It’s also pushing more towards primary and preventive care, rather than specialty care. I think that it’s important, we can’t afford to wait to treat people’s emerging health care problems, we need to catch them early. You want me to tell you the downsides?

Yes, definitely, let’s go there. What are some of the problems with the bill?
Well, there are three major downsides. None of them are addressed by the lawsuits and the sort of pouting the Republican opposition is doing right now. One, [the bill] still doesn’t have an effective cost-containment mechanism. There is some talk about using evidence-based medicine [to save costs], but it is yet to be clear who is going to set limits on what the basic package of health care is that everybody has to have.

We’ve got a huge challenge from demography, we’ve got an aging population, plus new technologies are appearing that are expensive — there is nothing in this legislation that grapples with the reality that we have to set limits down the road on who gets what. There may be bigger co-pays, but I think it’s inevitable down the road that we are going to wind up having a basic plan for many and a boutique plan for the upper-class and the rich. And if we don’t want that, then we better start talking about that now, because that is absolutely where we are headed.

What else is missing from the bill?
There is nothing in here about malpractice reform. That was one idea that Obama’s critics had that I thought was worth something, and it has to be addressed because the malpractice system is very costly in terms of defensive medicine. And the bill really doesn’t address that we are short on primary care providers. When you bring all these people in, bring the uninsured out of the ER where they don’t belong and give them an insurance card to see a primary care people, there aren’t enough primary care people [to see them]. So, those I think are the downsides. And they are significant, they are not small.

What about capping the coverage when you get sick? You get cancer, and your bill sky rockets and you know….
Most plans are traditionally capped at $1 million dollars, but that may not turn out to be true. But what I do suspect is that the basic plan that they sell will have limits, but you will be able to go into a special government-sponsored pool down the road if you really get above the million-dollar caps. So that is what I meant when I said that we haven’t really talked about serious cost containment or who gets what.

So what changes will the average American who already has health care see immediately?
Ironically, not so much in the next year or two. I think they’ll notice there are more people waiting in line at the pediatrician or internist because more people have insurance. I think they’ll notice some quicker treatment at the ER because there are fewer people there that don’t belong there because they have chronic medical problems. I think the average person may see a little better access to mental health care, because that’s buried in this bill, but it’s there. I think the average person will not worry so much about changing jobs if they have a child, or they themselves, have a preexisting condition because they know they won’t get dropped.

And I think the average person will see more emphasis on prevention and primary care everywhere from where they eat to the doctor’s office. More calorie counts and different types of taxes on bad behavior. That’s started, but I think that will keep going.

Down the road do you think we’ll be paying less than we’re currently paying?
It’s impossible to pay less. With an aging population — think of your father-in-law or your uncle who’s heading into retirement — these people consume three to five times more health care than people under the age of 65. Right now, about 60 percent of the budget for Medicare goes to people in their last year of life, and there’s going to be more of those. And there’s more technology coming. There’s better brain science work coming with scanning that can detect early Alzheimer’s or early depression rather than waiting for symptoms. If you add the demography to the emerging new technology it will cost more no matter what—if they passed this bill or not, we’re going to be paying more.

Will the reform limit the new technologies we have access to?
The battle in the future is going to be who gets access first to the new emerging technologies, and I expect that will be the wealthy. They’re gonna have better plans and access to new and emerging technology sooner. If you want to feel better about that, it also means that the rich are going to get experimented on first.

What do you think will be the differences between the regular and boutique plans?
I think the poor-person plan will be heavy on prevention and primary care. Blood-pressure control, get your asthma under control, try and give you counseling for diet and nutrition, get you to comply better with taking diabetes medicine, fix your broken bones, give you a transfusion …. I think the bells and whistles high-end plans are going to be beyond that, but we haven’t had that debate yet. But that’s what’s coming.

Another thing you can expect down the road is managing end of life, getting people into their homes, getting them into hospice. Those are cheaper settings and probably just as effective for nearly everybody. You may even see further pressure to expand assisted suicide, but I expect that’s not going to be as big as people think. I think people don’t trust the health-care system enough still to really be pushing assisted suicide at a time of cost containment.

So what would you like to see happen?
What would be nice would be if we could all have discussions, some hearings in Congress, and maybe discussions in our churches, synagogues and mosques, and civic groups about the health-care cost crisis, and then act reasonably and make some decisions about whether we want to limit who has access by money, or who has access by age, or who has access by saying if a procedure doesn’t get to a certain level of effectiveness—say if it’s not 30 or 50-percent effective—we’re not going to put it in insurance plans.

But we’re not going to do that, I fear. What I fear is that we’re going to keep muddling along until we get to a huge cost crisis. I think five, seven years out we’ll hit that wall and we’ll have to think on the issue of how to settle this. It doesn’t have to be that way, we could start talking about that now until we reach a social consensus of what’s fair and just. But politicians don’t like that. As soon as you utter the “rationing” word every politician heads for the bomb shelters and gets into an ostrich-like stance.

But still, despite all of this, you feel this reform is going to be good in the long run?
Yes, it has three other unintended side effects. One, it puts us all in the same boat, rather than rationing health care by keeping 40 million people outside of the system. Now, everybody is in, and that’s good. Everybody has a ticket. We now have to decide how we’re going to divvy up the seats, but at least we’re all on board. Some may go to first class, some may go to coach, but at least we’re all on the plane, so to speak.

Second, I think it starts to make it a community thing for health care—everybody heals it together, you start to be aware of what health care costs. Third, it’s going to make us finally address the issue of what we are [collectively] paying for. Do we want to limit access to things by who we are? Meaning, are we poor, are we engaged in bad health behavior, are we old, are we disabled? Or are we going to do, to me, what makes more sense and is much more fair, and start to ration procedures and tests by how well they work? So, we’re going to have to start asking that hard question. But it won’t just be the rich having access while the poor stare through the window at the CAT scan machine.

JENNA BERGEN is Philly Mag’s health and fitness editor.