California Single Payer Bill: Ethical intention, terrible execution

As Republicans in the US Senate are working diligently on the destruction of Obamacare, progressives in California are doggedly pursuing a distinctly opposite approach. The California single payer bill, originally introduced by Senator Ricardo Lara (D-Bell Gardens) in March, aims to expand health insurance coverage to all Californians regardless of income or immigration status. Just as Republicans at the federal level have tried to jam through their healthcare package without debate or adequate analysis of the downstream financial impact to millions of Americans and the healthcare system as a whole, California Democrats are just as eagerly moving along a bill with a projected cost that would be more than double that of the entire annual state budget.



Like most physicians, I would love nothing more than to be able to care for each and every one of my patients without any concern for how the bills will get paid and whether or not a particular test or medication I need to order will be covered by their health plan - if they have one at all. As a student, I learned that the numbers are undeniable: the United States spends far more on health care in every respect than the rest of the developed world and gets far less for it. As I've progressed through my personal training, I've seen countless patients in the unfortunate position of having to make decisions about seeking care for themselves or a family member versus paying for basic needs such as food and rent. From a morality standpoint, I believe deeply that health care is a human right and everyone should have access. So why, given all of this, am I so adamantly opposed to California's latest attempt at a single payer bill?



Well, for starters, I read it.



The Healthy California Act proposes the state establish a universal health insurance program, essentially enhanced MediCal, that would cover every individual residing in the state. This truly universal coverage would replace all private insurance plans as well as existing government programs with the exception of those run through the Veteran's Administration. This means a federal program like Medicare gets wrapped into this new coverage just the same as a high dollar Blue Cross or Kaiser plan paid for by an employer. I reference "enhanced" MediCal because the authors go to great lengths to spell out all of the additional services that must be provided, such as coverage for long-term care, dental, and vision, and even reference certain alternative therapies such as acupuncture. Going even further, the bill requires that patients never be subjected to out-of-pocket expenses such as co-pays, co-insurance, or deductibles. And to make medical providers happy, there is even language specifically referencing that I should always be able to substitute my own reasoning and clinical judgment about caring for individual patients over any guideline or consensus about standard of care.



This sounds pretty great, right? Even with the most fancy pants insurance products currently out there, I don't imagine there are too many of us who can say we have insurance coverage like that. So what's not to love? All of my patients should get covered for absolutely everything and I do mean EVERYTHING.



As much as my personal morality says universal coverage is the right thing to do, my professional ethics tell me it is absolutely absurd to continue to prop up our existing woefully broken system with a bottomless pit of cash vis-à-vis the state government. Proponents of the bill argue that money will be saved by cutting out the private insurance industry and negotiating payment for care differently once the state has full authority to do so with all providers. What they fail to recognize is that the insurance industry is behind only one slice of the bloated and wasteful pie that is the US healthcare system. There is an entire mentality affecting how patients seek care and the system provides it that must be shifted in order to make any real gains on health outcomes and cost savings.



Since the implementation of the Patient Protection and Affordable Care Act (PPACA a.k.a. Obamacare), health care services in the United States are increasingly being delivered through very large health care systems. Systems that have become bloated with administrators who contribute absolutely nothing toward actually caring for patients, yet continue to drive up the cost of care and create further incentive to bill as much as possible for every episode and interaction a patient may have. In fact, reviews of quality and cost data in post-PPACA years show that such giant healthcare systems are not only failing miserably when it comes to cost control, but the only bright spot in truly improving outcomes related to both quality and cost come from small physician groups - the exact same groups which are largely being gobbled up by the health care giants in all their perverse incentives to continue their explosive growth. However, the Healthy California Act would serve to only further the decimation of the little guys who are doing it right by forcing patients to be assigned to a "health care coordinator," the responsibilities of which clearly exceed the capacity of your independent primary care physician operating on a shoestring with minimal staff.



Furthermore, as glorious as it would seem on face to know that every service you could ever need or desire will be covered with zero out-of-pocket costs, I have to remain suspicious of the anointed overlords of this proposed system. Anointed is truly an appropriate word as the Act takes literally multiple pages to describe the make-up of the Healthy California board, most of whom will be appointed at the behest of top elected officials to include designated appointees for each the governor, speaker of the Assembly, and president pro tem of the Senate. Those who are behind the crafting and promoting of the bill (largely a very vocal nurses union) have ensured that they will get ample seats at the table. Though as much of a proud union member as I am, I can't say that I'm entirely supportive of the idea that a group responsible for such weighty decisions on the provision of health care for the entire state would ultimately be composed of just as many labor representatives as people who actually have medical degrees.


When I really step back to consider, what are the things that I most detest about my day-to-day in attempting to provide quality care for my patients? Insurance is a hateful burden, but it's far from the only burden nor is it the singular obstacle to my patients universally receiving the care that they need. When I read this bill and consider the energy behind it and the political backlash at anyone who isn't supporting it, I became angry. Should the Health California Act become law, progressives will pat themselves on the back for having finally proven universal coverage is possible in the United States. But what those same supporters aren't talking about is that there is absolutely zero guarantee that California will ever have access to the federal funds that are necessary to make the whole thing work. And should the Centers for Medicare and Medicaid Services (CMS) presently staffed by Trump appointees grant the incredibly broad based waiver to finance the whole thing, this bill offers little to no solutions in the way of future cost containment to make such a program viable for the long-term if said funding doesn't also increase substantially year over year.


I want coverage for my patients and I don't think anyone should have to defer necessary care for worry about whether or not they can personally afford it. But I also want us to be smarter about how we are collectively utilizing health care services in the first place. I don't want to perpetuate the bloat and continue driving care further away from meaningful relationships between patients and care givers into further "systematization" of medicine where individuals become numbers and disease rather than humans with names and stories.


As much as I know that taking a stand against this piece of legislation will likely earn me some dirty words within the advocacy community, my greater obligation remains to be upfront and honest with my patients. Few people would actually request that I deliberately lie to them or sugarcoat a grave prognosis. That is exactly how I perceive the end game of the Healthy California Act which is sucking up all the oxygen in the room and preventing us from moving forward on transforming health care in meaningful ways. Let's devote the same energy to pursuing real reform rather than chasing kudos for passing a half baked plan to get everyone an insurance card that will likely never come to fruition.