Arthur Caplan at the University of Pennsylvania is America's most famous bioethicist. He's unusually reasonable for that notoriously risk-averse breed. But lately he's been reverting to the rigid presumption of egalitarianism that infests most bioethical musings. Caplan is deeply concerned that in the future the rich will get better medicine and the poor worse—that more resources will allow people to obtain better quality products, an apparently unbearable situation when it comes to health care.
Caplan begins by decrying the development of "concierge medicine," in which groups of doctors contract with patients to give them 24/7 access for a fee. Patients who choose concierge medicine are, in effect, paying "bounties" so that they can get better service than other people. Caplan doesn't like this. But why? In free markets most goods and services are differentiated by quality and customers get what they pay for. The more one pays, the better one expects to be treated. But many bioethicists think that medicine is different—that "health care is a right." But this mentality leads them to the position that we only have a right to the health care the state chooses to give us—and that we ought to be, or at least will be, denied anything better.
Caplan writes: "From my point of view, health care ought to be a right for two reasons. If we are going to guarantee equality of opportunity to every American, then health is a key part of that equal opportunity. You have to have it in order to function in a market-based capitalist society. The other reason is it's a sign of communal solidarity. We care about one another. We're not going to let our kids who are mentally ill or our elderly just flounder around even if they can't, so to speak, earn it." But Caplan does think that some differentiation in health care can be, in principle, ethically acceptable, and that society merely ought to guarantee "access to a minimal package of health care."
But what's an acceptable minimum? In his column Caplan decries recent reform proposals for Tennessee's state Medicaid program. The reforms, known as TennCare, were launched with much ballyhoo 10 years ago. They involve the state government taking its allocation of federal dollars for Medicaid and using it to cover not only those residents who met Medicaid poverty guidelines, but also other poor residents lacking health insurance. As with most any open-ended government entitlement, TennCare is heading for bankruptcy. So the Tennessee legislature passed a reform earlier this year under which medical necessity would be defined as the least costly "adequate care," instead of the traditional standard of "most effective" care.
Although a bit vague, the concept of "adequate care" encompasses such things as requiring doctors to prescribe generic drugs whenever possible; limiting the number of prescriptions to no more than six per month without special permission; requiring co-payments from patients in order to cut down on frivolous visits; and an annual limit on the number of doctor visits. Instead of prescription medicines, TennCare patients will have to buy over-the-counter medications like Prilosec for controlling stomach acid and Claritin for allergies.
Tennessee's governor Philip Bredesen claims the reforms will save $2.5 billion for the state over the next four years. However, if the reforms are not adopted, then Tennessee will have to revert to traditional Medicaid programs. That would eliminate health care coverage for 260,000 of the 1.3 million residents currently on TennCare. On the face of it, it seems that the reforms are offering a minimal package of health care as a safety net for Tennessee's poorer residents, which is surely better for them than dropping them from the program entirely.
But Caplan isn't satisfied. He especially objects to the notion of "adequate care." "If a bureaucrat in the Tennessee department of health thinks a low-cost drug or treatment, or even no treatment at all, is 'adequate,' then that is what TennCare will provide," he complains.
Caplan isn't being completely consistent with his own judgments in the past. For example, in the early 1990s, Oregon adopted a plan to control Medicaid costs and extend coverage to more of the state's poor residents by imposing explicit rationing on medical care. The Oregon Health Plan uses a list of about 700 medical conditions, and the state will pay to treat the top 550 of those. So bureaucrats are making decisions about what is medically necessary for the poor in Oregon. For example, in 2000, Oregon refused to pay for an experimental lung and liver transplant for an 18-year-old suffering from cystic fibrosis.
Contra his current stance on TennCare, Caplan saw no problem with this. In a 1996 interview with the American Political Network he declared, "It was incredibly courageous what they did there. They took on the issue (of rationing) in a public way that was unprecedented and hasn't been duplicated since."
Caplan did add that Oregon's Health Plan has "a fatal flaw: the effort to think about rationing was confined to the poor." His implication seems to be that it's OK for bureaucrats to make medical care decisions, just so long as they are made for rich and poor alike. As Caplan told the Chicago Tribune in 1995, "The danger is, politically in this day and age, threadbare [insurance] will be considered enough. The poor will be asked to make sacrifices, and the rest of us can do whatever we want."
But he still hasn't come up with a convincing answer to the question: What's ethically wrong with people with means doing "whatever they want" with regard to their health care? They can already do whatever they want with their educations, jobs, housing, food, and so forth. So eager is Caplan to play class warfare by contrasting concierge care with adequate care that he actually misses the main lesson to be learned from TennCare—that any government-run national single payer system would inevitably run up against fiscal limits and impose rationing on everybody. Bureaucrats would then be making health care decisions for us all. But then at least we could share the "solidarity" of all having the same equally inadequate health care.