Will Medical Compliance Ever Become Non-Voluntary?

A recent article by Dr. Lisa Rosenbaum in the New England Journal of Medicine explored both the benefits and drawbacks of Digital Adherence Monitoring. The focus was on the FDA’s recent approval of Abilify MyCite, a medicine technology that combines the medication aripiprazole, used to treat various psychiatric diseases such as schizophrenia, certain features of bipolar disorder and depression, with a digital ingestion tracking system. This voluntary digital health feedback system (DHFS) works by having the patient wear a skin patch that is triggered when the pill contacts the acid in the stomach. This event is then recorded and tracked on the patient’s smartphone. The patient can then permit their caregivers and/or physicians to access the data via a web portal. The company responsible for the DHFS, Proteus, has shown improvement in patient’s systolic blood pressure using DHFS compared with standard care. The article primarily focuses on using the technology to help doctors work with their patients to determine the reasons for non-compliance.

While this presently voluntary technology obviously can track pill ingestion and this data can certainly help doctors and patients improve medication treatment adherence, I wondered about non-voluntary uses of the technology. This particular DHFS confirms that the prescribed pill was actually ingested regardless of what the patient or their caregiver may claim. Would an insurance company be permitted to have access to this data in exchange for payment for a particularly expensive medication? Could a government agency require such a system in exchange for providing coverage for a patient for a procedure whose subsequent outcome is improved with the use a given medication?

Dr. Rosenbaum offered in her article that she thought it unethical to withhold coronary artery bypass from one of her patients with whom she was fairly certain would not subsequently take the dual antiplatelet therapy post revascularization. Using a DHFS eliminates mere suspicion. Prematurely discontinuing of thienopyridine therapy (antiplatelet drugs such as Effient, Ticlid, or Plavix) after a similar cardiac stent placement has been shown to increase the risk of both re-hospitalization and death within the subsequent 12-month period. Given the success of the Proteus DHFS in reducing systemic high blood pressure, mandating this DHFS to monitor antiplatelet therapy immediately post cardiac stent placement should reduce both patient morbidity and mortality during the following 12-month period.

A consequentialist in charge of public health care expenditures might disagree with Dr. Rosenbaum regarding the ethics of providing a revascularization procedure in an individual who is poorly compliant with beneficial post-procedure medication compliance. Bluntly, why spend the money if the patient (for whatever reason) is going to act in a manner to reduce the benefit of her procedure? Thankfully, money is not the only healthcare utility worth measuring and economists are not yet fully in charge of healthcare delivery, though they appear to have an ever increasingly important seat at the table.

So, I think DHFS technologies such as Abilify MyCite will slowly become non-voluntary.

Racial inequalities in cancer survival

Three studies published in a supplemental issue of the journal Cancer this month come to disturbing conclusions: in the United States, the survival rates for colon, breast, and ovarian cancer are lower for black people than for white people.

The news isn’t all bad: overall cancer survival rates are going up. The three studies mentioned here draw from two larger studies of worldwide cancer survival, the CONCORD study, published in 2008, and the CONCORD-2 study, published in 2015. Between CONCORD and CONCORD-2, cancer survival increased across all groups. But in both studies, the survival of black people in the United States lagged behind that for white people by about 10%.

Now there are certainly many reasons for the difference. Black people may be getting diagnosed with cancer at later stages, when survival is lower. There may be differences between the two groups, like genetic factors or the presence of other illnesses, that cause the cancers to be more aggressive in blacks. Mistrust of the health care system is more common among black patients, so they may be less likely to access care or access it early enough.

But other reasons include socio-economic status and access to health care; those who can’t access medical care because they can’t afford it or because it is not available nearby are less likely to receive necessary screening and treatment. And most troubling is the “consistent finding that black women do not receive guidelines-based treatment compared with white women, even when treated within the same hospital.”

The situation is too complex for simplistic answers; one can’t say from these studies that doctors are individually practicing blatant racism, and there is after all such a thing as systemic racism. But the medical profession should take such findings seriously, and seek every available avenue of education and self-monitoring to ensure that of all the places people encounter racism, the health care system is not one of them. And Christians especially, who believe that God created all people with equal dignity because all of us are created in His image, should work towards a health care system where the value — or length — of one’s life does not vary based solely on the color of one’s skin.

Uterine Transplantation – for Men?

Susan Haack began exploring the topic of uterine transplantation in women on this blog back in February 2014. In just under 4 short years, the technology has not only successfully resulted in live births in several women who received the uterine transplants, but outgoing president of the American Society of Reproductive Medicine, Dr. Richard Paulson, is suggesting we consider exploring the technique in men. While there are certainly hurdles to overcome (need for cesarean section for the actual birth, hormone supplementation, complicated nature of the transplant even for cisgender women), Dr. Paulson does not consider these barriers insurmountable for transgender women.

Dr. Julian Savulescu, professor of practical ethics at Oxford, has cautioned that initiating a pregnancy in a transgender woman may be unethical if it poses significant risk to the fetus. The above-linked article misquotes his concern as a concern over “any psychological harm to the child born in this atypical way”. The following is his actual quote from his own blog:

Therefore, although technically possible to perform the procedure, you would need to be very confident the uterus would function normally during pregnancy. The first US transplant had to be removed because of infection. There are concerns about insufficient blood flow in pregnancy and pre-eclampsia. A lot of research would need to be done not just on the transplant procedure but on the effect in pregnancy in non-human animals before it was trialled in humans. Immunosuppressives would be necessary which are risky. A surrogate uterus would be preferable from the future child’s perspective to a transplanted uterus. Uterine transplantation represents a real risk to the fetus, and therefore the future child. We ought to (other things being equal) avoid exposing future children to unnecessary significant risks of harm.

One putative benefit might be the psychological benefit to the future mother of carrying her own pregnancy. This would have to be weighed against any harm to the child of being born in this atypical way.

His concerns are the baseline medical risks involved in using a transplanted uterus to conceive a child regardless of the sex of the recipient. None of his concerns relate to the psychological harm to the child potentially caused by a uterine transplantation in a transgender woman as opposed to a cisgender woman. Savulescu is explicit in the beginning of his blog that “[t]he ethical issues of performing a womb transplant for a [sic] transgender women are substantially the same as the issues facing ciswomen.” Is the only risk to the child “born this atypical way” just the additional need for hormone supplementation in the transgender woman compared to the cisgender woman? Can we really know, a priori, what all of the attendant risks to the child really are with uterine transplantation in a transgender woman?

Regardless, let’s assume Savulescu is correct, that there is indeed no ethical difference between carrying a child to term via uterine transplantation between a cisgender woman and a transgender woman. There certainly can be no ethical difference between carrying a child to term via uterine transplantation between a transgender woman and a cisgender man. If the foregoing is true, can there be any ethical barrier preventing a man via uterine transplantation to use his sperm to fertilize a donor egg and carry his baby to term? After all, per Savulescu, all we need be concerned about from a bioethical standpoint are the technical issues/risks of uterine transplantation regardless of the recipient’s biological sex or self-identified gender.

In Genesis, God created two complimentary sexes and stated this difference was good. We are moving toward eliminating differences between the sexes and arguing that this is good. Both of us cannot be correct.

I wonder if Dr Haack thought that we would get this far down this particular bioethical slippery slope in four short years?

Dr. Smartphone

My brother tells me my doctoring days are done. We keep up a lively, ongoing email discussion of current technologies as they relate to topics such as big data analysis, Internet of Things (IoT), and smartphone technology. He recently challenged me that due to the rapid increase in computational power and sophistication of data analysis, smartphones will soon replace doctors as the main source of medical diagnosis. He is probably correct. But will my doctoring days be over?

Consider the linked article by Madhunita Murgia in The Financial Times (you may get one view of this unless you have a subscription or Google “Murgia smartphone”). Murgia lists a fairly exhaustive list of both current and looming smartphone apps and smartphone attachments that are – frankly – amazing. A fair number of these are backed by technical and clinical staffs, as well as massive computational clouds, that provide analysis of what you and your smartphone observe – about you. By keeping track of the number of calls you initiate, your movements (or change in that number), the quality of your voice, the results of heart EKG sensors on the phone cover and voluntary responses to personalized texts, your smartphone can instantly analyze your current physiology and often correctly identify any pathophysiology better than some (most?) physicians. Given the IoT technology trajectory, the smartphone will only get better and do so at a far faster and broader pace than the average MD during his or her limited 30 years of solo or group practice experience. It is the medical “Wisdom of the Crowd”, to borrow from a current TV show. Read the above linked article (if you can) just to get a glimpse of what is already here and what is quickly going to be available.

Security and privacy issues may be the one limiting factor in this technological progress. Consider one example of current technology in the area of smartphone post-partum depression diagnosis and management. A company called Ginger.io has developed a smartphone-based tool for patients to use to identify depression by a series of interactive text questions with a company coach as well as raw data from your phone checking the number and length of phone calls to friends, as well as an analysis of quality of your voice (no actual content – yet). Joseph Walker at the Wall Street Journal (subscription needed) offered one patient’s experience:

Tara Dye, who participated in Novant’s postpartum program, said she wasn’t aware of the extent to which her smartphone data was tracked. Ms. Dye says she was told the app would record her location and how far she traveled, but she didn’t realize that her behavior was being probed for a link to depression. She says she doesn’t mind the extent of the tracking, because it was in service of her health care, but she wishes there had been greater disclosure.

Finally, Andy Kessler, also at the Wall Street Journal, argues we are too worried about all this smartphone monitoring. He believes that eventually courts will rule that use of our personal data (heart beats, facial recognition, voice quality, etc…) will be determined to be a property rights issue and eventually companies such as Ginger.io and Apple will have to pay you for the use of your personal data. That may well be. But it does not currently put the “data horse” back in the privacy barn.

I am not sure where that leaves me or the other average doctors as smartphones eclipse us in diagnostic acumen. Like most technological advances during my practice lifetime, I have worked to embrace the ones that work and sifted through and discarded the ones that did not. Will there still be a place in the practice of medicine for one-on-one, patient-doctor relationships? An 87 year-old patient of mine recently commented to me that although I had not significantly improved her chronic back pain, she appreciated the time I took, the education I provided, and the reassurance that her problem was not more severe. Perhaps she was just being nice.

My brother would argue the smartphone would have been faster, cheaper and avoided the risk of her traveling to my office. I’m not sure. Let me ask Dr. Siri…

Mental Health ERISA Law for Dummies

My son is an ERISA attorney whose present work requires him to make sure that large group insurance plans offered by companies comply with various federal statutes, such as the various regulations surrounding the PPACA (i.e. ObamaCare). In one of our recent discussions about healthcare access, he made me aware of some federal laws regarding the provision of mental health benefits, which I was heretofore completely ignorant. In my practice, I have frequently been frustrated by trying to get mental health care for some of my patients, some of whom appeared to have reasonable health insurance, which turned out to have rather minimal mental health coverage, a condition ERISA nerds refer to as lack of coverage parity between mental health benefits and covered medical and surgical benefits. This is thankfully changing. Without getting into the tedious minutia of ERISA law (and it is very tedious), let me take you on an abbreviated tour of these mental healthcare federal statutes.

Prior to 1996, coverage for mental health care was unambiguously less generous than for physical illness. In 1996, the Mental Health Parity Act (MHPA) passed, which required parity of annual and aggregate lifetime limits compared to med/surg benefits. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) expanded parity to include treatment limitations, financial issues such as co-pays, and in- and out-of-network coverage. However, and this was and continues to be a major “however”, neither of these federal statutes mandated any specific mental health coverage but simply required insurers who chose to provide mental health coverage to do so with parity with other medical and surgical benefits. I like to think of this like Title IX established parity between the sexes, MHPA and MHPAEA tried to establish parity for mental health with other medical coverage. If you want to get into the minutia, begin HERE and HERE.

With passage of the PPACA in 2010, both MHPA and MHPAEA suddenly developed some teeth. The PPACA mandated coverage of certain mental health and substance abuse disorders. Now the benefits for those covered services must have parity with other medical and surgical benefits. For a deeper dive, see HERE. But oddly, the sharpness of MHPA’s and MHPAEA’s new teeth varies by state. For technical reasons that only an ERISA attorney may understand, there remain variations in state-by-state interpretations of the coverage minimums of the PPACA 10 ‘required’ Essential Health Benefits (EHB), so see HERE for more details (particularly chart at bottom of linked article listing benefits by state).

Nonetheless, armed with these statutes, mental health advocates are demanding their parity. Recently, the 2nd US Circuit Court of Appeals allowed an ERISA lawsuit to proceed against a large health plan group administrator for their alleged reduction in mental health benefits for services provided to patients. Whether this encourages other legal challenges for more parity, time will tell.

What does foregoing mean from a bioethics standpoint? This blog has frequently discussed the problems of healthcare access for some our most vulnerable members of society, many of these related to mental health struggles. While I am no fan of the PPACA in general, this is one result that I applaud. More work needs to be done to determine exactly what mental health issues get covered and perhaps who gets to decide. Until we all behave like the Good Samaritan toward all of our neighbors, it may take statutes like these to nudge us along the way.

Ethical Health Care Reform

Recently I heard a Christian TV personality refer to Obamacare as “iniquitous.” This started me thinking, What would make a health care funding reform scheme “iniquitous”? Or, although the words aren’t synonymous, what would make such a scheme unethical? What should go into ethical health care reform?

The answers to these questions are legion and conflicting. There are some who see government intervention as inherently wrong; for them, the free market is the key to ethical health care reform. There are others who distrust the free market, and consider some degree of governmental control to be the only ethical option. Some see personal mandates to buy insurance as unethical; others understand the mandates as ethical solidarity with our neighbor. Some ardently believe justice means everyone gets exactly the coverage or treatment they pay for; others just as ardently believe justice means everyone gets the same coverage and treatment.

What is ethical health care reform? There are many possible answers. I am not sure that Obamacare is any more or less ethical than the versions of Trumpcare that have been put forward. I am not sophisticated or smart enough to pontificate about the free market or theories of justice.

One thing I am certain of, however: Whether the system relies on markets or government regulations, whether there are more or fewer mandates or taxes, whether everyone gets the same coverage or not, one final measure of whether or not a health care system is ethical is how it treats those who are the poorest and most disadvantaged among us. If those who are least able to provide for themselves are not provided for and granted access to the system, then it is an unethical system.

More about Charlie Gard

Dr. Robert Truog, the bioethicist and transplant physician who has pushed the envelope on the definition of death, has weighed in on the Charlie Gard case in a “Perspectives” piece that is generally available (i.e., without a subscription) from the Journal of the American Medical Association (JAMA).   By all means read it.

Dr. Truog approaches the case from the standpoint of limiting medical research—indeed, that’s in the title of his article.  He says the case is about “the best interest of the patient, financial interest, and scientific validity.”  On the first point, he is cautious about the British courts’ assertions that it can assess how much pain and suffering Charlie is experiencing, and whether the courts know this better than the baby’s patients.  This caution seems wise.  As I have reflected further on this case it strikes me that I may be missing a legal distinction between Britain and the US; frankly, I am not well-versed on British law in these cases.  I do tend to think of the Gard case in terms of substituted decision-making in the case of severe or terminal illness.  My thought process runs through the checkpoints.  First, the patient’s wishes are paramount.  In this case, the patient cannot express wishes and may not be able to form them.  In that case, second, a surrogate decision-maker should speak for the patient using “substituted judgment” or “substituted perspective” to express how the patient might have approached the case if able to express wishes.  Here, the parents are available to speak for the patient.  It would be only in the absence of a decision surrogate that “the best interests of the patient,” as judged by the physicians or the courts, would control.  Apparently British law grants rather more primacy to third parties, other than the patient and any surrogate decision-maker.  Under the rubric I’m used to, the parent’s wishes would control.  Here, the British authorities argue, they do not.

The columnist William McGurn took exception to this attitude in The Wall Street Journal earlier this week.  “This is our call, [the doctors and courts] say,” he writes.  And this is the necessary attitude of single-payer healthcare, he claims: “at the heart of single payer is single authority.”  The hospital, McGurn charges, “even wants the last word on love: ‘In one respect, Charlie is immensely fortunate” to have such loving parents, but that respect apparently has nothing to do with this decision, for which their love apparently disqualifies them.  (BTW, perhaps you have seen the report that the court-appointed “guardian” for Charlie chairs an organization that is a sister organization to one that promotes doctor-assisted suicide.)

Dr. Truog’s second point is that distributive justice trumps (my word, no political pun intended, honest) the money Charlie’s parents have raised for his experimental care.  In fact, justice demands we disqualify that fundraising effort, because to allow them to pay is to elevate their ability to pay over others who may be in need of scarce resources.  He says that public funds have stood up the hospital and British health system overall, so the Gard family does not, as it were, “own” it or lay privileged claim to access.  I find this argument of Dr. Truog’s specious.  There is no certainty at all that Charlie would block other needed care—unless, I suppose, it is allowed that Britian’s National Health Service already rations care to the point of extreme scarcity!—and they harm no one by possibly paying for experimental care.

That leaves the third issue—is treatment, admittedly experimental in this case, ethical?  Dr. Truog says no, because the chance of success is so low and “does not meet a threshold of scientific plausibility.”  He argues that the rationale is theoretical only, and complains that the proposed experimental treatment has not been tested in animals or humans before.  But again, this is at least partially specious.  Charlie suffers from an extremely rare condition, animal models may be lacking or entirely unpredictive (medical researchers operate with this general conceit that animal studies DO predict—boy can I tell you how often we are wrong about that!), and when a condition is rare, EVERY individual case provides the opportunity to learn something.  Medical history is replete with work based on the careful observation of clinicians, even apart from the randomized clinical trial, which could never be done in such a rare condition as Charlie’s.

It is of course possible to object that the risk-benefit ratio for giving Charlie the experimental treatment is a judgment call that should be made against treatment.  If the doctor is truly being reckless with the proposed treatment, is profiteering, or if there is no reasonable possibility, at acceptable risk, for direct benefit to Charlie or for useful knowledge to be gained, then the proposed treatment should be deemed unethical.  In the U.S., that would be a call for an IRB and the FDA.  And again, they might say “no,” in which they would be speaking more to the doctor than the patient’s parents.

But in this case I think the British courts should defer to the parents and allow them to pursue that question in the U.S.

Healthcare Insurance vs. Healthcare coverage?

Kimberly Strassel wrote an interesting piece in the WSJ entitled “The Simplicity of a Health Deal” (Link here – subscription required). I don’t think she was saying that crafting legislation to resolve all of America’a healthcare issues was easy, she was making the political point to Senate Republicans that, like it or not, no future legislation will be possible unless they agree to continue the ObamaCare provision of eliminating insurance proscriptions for pre-existing conditions. She cited a YouGov poll that showed 77% supported protections for those with pre-existing conditions as an example of the public support for this provision.

The problem with pre-existing conditions is that they cost more money to insure than not-yet-existing conditions. This fact is the primary reason for the unpopular provision of Obamacare – The Mandate (or tax, if you like). If you delay buying insurance until your not-yet-existing condition becomes an exiting condition, what exactly are you insuring? This “gaming the system” is illegal and for good reason. Without the mandate (that everyone buy some minimal level of insurance), insuring pre-existing conditions is very expensive. Insuring pre-existing conditions has turned out to be more expensive than anticipated, even with the weak mandate/tax, and insurance providers have been and are continuing to leave Obamacare, further reducing insurance options in many states. Failure to make significant changes in the present law (i.e. leaving Obamacare as is) would likely result in further reduction in the number of insurers and the cost of their products.

I find it odd that we continue to refer to ObamaCare or whatever the new Republican iteration will be as health insurance. Wikipedia describes insurance as a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Life insurance and car insurance are good examples. Premiums charged for these types of insurance policies are based upon one’s risk or lack thereof, as well as how much risk an individual wished to mitigate. Essentially, these are catastrophic risks we are taking about. Healthcare insurance has morphed into healthcare coverage. We expect our health insurance to pay for everything that has to do with accessing a healthcare provider: routine office visits, medications, emergency/trauma care and end-of-life support, to name but a few. That would akin to asking our car insurance to not only handle major accidents but also gas and oil purchases.Of course, taking the car insurance analogy to its logical conclusion suggests that just as there are some people that have such a terrible driving history that they simply are not insurable, there are similar people who are not insurable based upon their terrible health history. Eliminating pre-existing condition proscriptions effectively turns the insurance model on its head as a means for risk mitigation.

If we are going to eliminate pre-existing conditions, we are essentially agreeing healthcare insurance isn’t the way to pay for healthcare, at least the essential aspects, whatever those are. We are also agreeing that those essential aspects are basic rights, without an open and honest agreement on exactly how to pay for those rights. We need to have the discussion of what exactly constitutes basic or minimal healthcare rights and then we need to have the discussion about how to obligate those providing those rights (required as part of licensure, reforming malpractice, adjusting reimbursement, etc..).

My “Happy Fourth of July” daydream is that Congress would have such a debate, aided perhaps by many bioethicists from many persuasions. Tomorrow, I will wake up and go back to work.

Two Random Thoughts about Health Care Policy and Justice

I haven’t yet read the Senate Republicans’ draft health care bill, just out today.  Until I do I’m not going to comment about it directly.

The matter is a bioethics concern solely from the perspective of justice, really.  What is the wisest, most just policy?  And here one is forced, I think, into a fairly utilitarian assessment of what approach provides the best outcome for the country overall?  In that, we can allow for a “priority concern” for pool or relatively poor folks, allowing a weighting of factors in their favor.  In fact, I’m all for that.

But two thoughts.  First, I and others tend to argue that we should reform Medicare and Medicaid and not just leave them as they are, because to do so is to ratify their demise into bankruptcy or unaffordability.  That argument is open to two charges: that it assumes that forecasts of rapid demise are reliable, and that preserving the programs, in a sustainable form, favors future generations at the expense of the current ones.  On the latter, to wit:  Most people would agree that “my” (i.e., someone’s in general) duty to people close to them (like spouse, children) is greater than to a stranger.  But can we not say the same thing about generations?  Isn’t our duty to people already among us greater than, say, our envisioned duty to our grandchildren and great-grandchildren, even if they are ours and not someone else’s?  I suppose that one might argue that.  Then my longer-term argument would lose force.

Second, we hear so much about people who will be harmed if the Affordable Care Act is significantly touched, much less repealed.  (I don’t think any minimally serious observer of the political scene would suggest that true “repeal” of the ACA is even a remote possibility.)  But ANY change is called disastrous, mean, evil—pick your pejorative.  On the other side of the leger are working-class or middle-class people who can’t afford insurance and don’t qualify for subsidies now.  An accurate calculation of the two groups and what they stand to lose seems impossible.  Which group to favor?

Then again, maybe single-payer would conquer all.  As I have written 2 weeks ago and in the past, I’m not so sure.

In the meantime, I am at the annual meeting of the Multidisciplinary Association for Supportive Care in Cancer (MASCC) this week.  Discussions today centered on “financial toxicity”—the negative effects of high drug prices—and on the coming changes in how doctors are paid.  Bottom line: it all has to cost less.  The outcome may not be that public health will be worse—I’m not at all sure it will—or that rich doctors or industry executives will make less money (they will, but they’ll be OK).  But we don’t have a purchase on how many people of more modest current income will be out of work as a result—e.g., the chemists, regulatory folks, administrative assistants in industry.  I have no idea what that effect will be.  Maybe significant, maybe not so much.

But we are about to “conduct the experiment.”  One way or another, we have to.

Single-Payer in California?

I’m not sure that even advocates of single-payer health care will find the spectacularly overreaching “Healthy California Act” (California Senate Bill 562) a good idea.  Follow the link and read the text yourself—I link, you decide.

While the bill appears at points to read like a re-assertion of current federal programs, and perhaps some related private insurance (e.g., Medicare Advantage), in fact it looks to me like it would replace all current public and private health insurance for California residents, whether citizens or not, with a state run, state financed (how is yet to be determined) single plan called “Healthy California.”  This is how it is described in the general press.

Under it, no California resident would have to pay a dime for any aspect of health care.

As I read it, no other insurance plans would be allowed to pay for anything that Healthy California covers.  Just about anything and everything health-care related—including, it appears, skilled nursing and long-term care—would be “covered.”  Of course, any extra billings outside the coverage would be illegal.  Practitioners could opt out of the program but that means they couldn’t get paid—except, I suppose, on some sort of black market. 

Healthy California would be run by an independent 9-person board with no clear accountability.  This board would set coverage range and payment rates; certify doctors, hospitals, and other providers (including out of state, in case a Californian gets sick while traveling); oversee the collection and management of not only claims payments but also health and health-payment statistics, and do just about everything else that Medicare or your (evil?) insurance company currently does.  It would be advised by a separate 22-person advisory panel.

The legislation calls for any and all federal payments that otherwise would come into California for health care to be made to Healthy California.  It is argued that additional monies would be needed to pay for everything.  The bill says only that the legislature will come up with a plan for funding, and that the program would not go live until the funding is in place.  News reports have estimated the costs at up to twice the current total California state budget.  Estimates for how it would be paid for include things like a 15% payroll tax on everyone, and other measures.

I can accept that access to medical care should be a duty of human society.  I don’t think that means first-dollar coverage for everything, for all.  I also fail to see why reforms can’t be made within the overall structures of a market economy.  I read that Britain is having trouble with its National Health Service, and that people there try to “go private.”  And I don’t know whether anything will come out of the current Congress, or what it will look like.  I AM fairly sure that without substantial reform of Medicare and Medicaid, the money for them will start running out in my likely lifetime.  I don’t think the Affordable Care Act put us on a stable path.

But I also must say that I have wearied of trying to figure it all out, and I think the nation is on something of a ratcheting path toward national single-payer.  So we will carry out the experiment, as it were, perhaps before long.  (Then we’ll all “have coverage.”  I hope we will all be able to get in to see a doctor.) 

While we wait for that, the “Healthy California Act” looks to me like childish fantasy.  Any readers of this blog who read the bill and can explain how it will be workable are invited to do so in the comments section.

For my part, my wife is on Medicare, which is working reasonably well for her, and I like my current employer-sponsored insurance.  I would like the choice to stay with those, not have them replaced by fiat by the single-party California government.

The California bill passed the state Senate, and awaits action in the Assembly.  If it passes there, my guess is the current governor will veto it.  The likely next governor probably will not.