The terrible execution of California’s single-payer attempt


As Republicans in the Senate are working diligently on the destruction of Obamacare, progressives in California are doggedly pursuing a distinctly opposite approach. The California single-payer bill (SB562), aims to expand health insurance coverage to all state residents regardless of income or immigration status. Just as Republicans at the federal level have tried to jam through their health care package without debate or adequate analysis of the downstream financial impact to millions of Americans and the health care system as a whole, California Democrats are eagerly moving along a bill with a projected cost more than double the state’s entire annual budget.

Like most physicians, I would love nothing more than to treat every patient without concern for how the bills get paid and whether or not a particular test or medication will be covered. I’ve seen countless patients forced to make decisions about seeking care versus paying for basic needs such as food and rent. I believe deeply that health care is a human right and everyone should have access. So why 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 establishment of a universal health insurance program, essentially enhanced MediCal, to cover every state resident. This universal coverage would replace all private insurance plans as well as existing government programs, excepting those run through the Veteran’s Administration. This means a federal program like Medicare gets wrapped in just the same as a high dollar employer-paid Blue Cross or Kaiser plan. I reference “enhanced” MediCal because the authors go to great lengths to spell out additional essential coverages, including long-term care, dental, and vision, and even reference certain alternative therapies such as acupuncture. The bill further requires that patients never be subjected to out-of-pocket expenses such as copays, coinsurance, or deductibles.

This sounds pretty great, right? Even with the most fancy pants insurance products currently available, I don’t imagine there are too many of us with coverage like that.

As much as my personal morality says universal coverage is the right thing to do, my professional ethics tell me it is absurd to prop up our existing woefully broken system with a bottomless pit of cash vis-à-vis the state government. 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. Proponents of the bill argue money will be saved by cutting out the private insurance industry and negotiating payment 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 expansive and wasteful pie that is US health care. There is an entire mentality affecting how patients seek care, and the system provides it that must be shifted to make any real gains on health outcomes and cost.

Since implementation of the Patient Protection and Affordable Care Act (PPACA a.k.a. Obamacare), health care services in the United States are increasingly delivered through very large systems. Systems bloated with administrators who contribute absolutely nothing toward patient care, yet continue to drive up costs and create incentive to bill as much as possible for every episode and interaction. In fact, reviews of quality and cost data in post-PPACA years show such giant health care 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 these giants perversely incentivized to continue their explosive growth. However, the Healthy California Act would serve to only further decimate the little guys doing it right by forcing patients to be assigned to “health care coordinators,” the responsibilities of which clearly exceed the capacity of independent primary care physicians operating on a shoestring with minimal staff.

As glorious as it seems to know that every service you could ever need will be covered with zero out-of-pocket costs, I remain suspicious of the anointed overlords of this proposal. Anointed is truly an appropriate word as the Act requires 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. Those who are behind the crafting and promotion of SB562 (largely a very vocal nurses’ union) have ensured they will get ample seats at the table. Though proud union member as I am, I can’t support 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 with medical degrees.

Insurance is a hateful burden, but it’s far from the singular obstacle to my patients universally receiving needed care. Should the Healthy 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 caregivers into further “systematization” of medicine where individuals become numbers and disease rather than humans with names and stories.

I know taking a stand against this piece of legislation will likely earn me some dirty words within the advocacy community, but my greater obligation remains to be upfront and honest with my patients. I wouldn’t deliberately lie to them or sugarcoat a grave prognosis. So let’s be honest about 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 reforms rather than chasing kudos for passing a half-baked plan that will likely never come to fruition.

Blair Cushing is a family physician.

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