PERSPECTIVE ON PROP. 186 : All Bow to the State Health Czar : The single-payer initiative calls for one commissioner to oversee all, from doctors’ fees to patients’ choice.

<i> Sally C. Pipes is president of Pacific Research Institute for Public Policy in San Francisco, which has published a comprehensive analysis of Proposition 186</i>

The backers of the single-payer health-care initiative on the November ballot offer Californians a Faustian bargain: In return for state-guaranteed health security, we must cede all control over our health care to a powerful new bureaucracy. Californians would be wise to heed the words of Republican elder statesman Barry Goldwater: “A government that is big enough to give you all you want is big enough to take it all away.”

For those yet unfamiliar with it, Proposition 186, the ballot initiative called the California Health Security Act, promises to “fund universal coverage for all medical care services and extend benefits to include long-term care, mental health care and some dental services and increase the resources available to prevent disease, all for the same amount of money currently spent on health care.”

To achieve these utopian ends, the act would funnel all current health-care spending--private, local, state and federal--into a new state agency: the Office of the California State Health Commissioner. The government would supplant the private insurance market; new payroll taxes would replace private premiums. The act would raise the state income tax by 2.5%, levy a 2.5% surcharge on the income of wealthy individuals and place a $1-per-pack tax on cigarettes.

The health commissioner, ordained with the powers of a czar, would be charged with managing the entire system. The commissioner’s broad powers would include “all powers necessary to implement this act” and “the power to set rates and promulgate generally binding regulation on any and all matters relating to the implementation of this act.”


The commissioner, commanding a budget of more than $100 billion (nearly twice the size of California’s current budget), would direct every aspect of health care, from the fees doctors are paid to how many beds a hospital can have.

The commissioner’s broad powers are necessary, we are told, if costs are to be contained and health care made a universal right. Besides, in return for granting these extraordinary powers, backers of government health assure us, Californians would be able to retain their cherished choice of doctors, who themselves would enjoy liberation from the irritating oversight of insurance company bureaucracies.

A close examination of the measure, however, belies these assertions, revealing its guarantee of health care as a mere tautology, the promise of physician choice as a half-truth and the assurance of doctors’ liberation from bureaucracies as an outright untruth.

It’s all spelled out in the initiative: The commissioner decides what constitutes health care, and health care is whatever the commissioner decides the state can afford: “ ‘Medical care’ means all health care items and services, except for items and services not reasonable and necessary. . . . according to guidelines established by the commissioner.” More worrisome is the fact that in the face of inevitable budget pressures, the commissioner is to “identify and eliminate wasteful and unnecessary care.”


As for oversight, the single-payer system would simply replace private-sector bureaucrats with government bureaucrats armed with all the power of the law. For example, a physician “whose billing volume or distribution suggests the possibility of impropriety may be subject to investigation by the commissioner.” Penalties for billing irregularities include hefty fines and exclusion from the health system. Worse yet, state bureaucrats will tell doctors what procedures they can perform.

Promotional materials advertise that Californians will be entitled to “all medically appropriate medical care as determined by the patient’s provider of choice,” but this statement contains two major misrepresentations. First, “medically appropriate” does not necessarily mean what your doctor recommends as appropriate but procedures that fall within “the guidelines established by the commissioner.”

In any case, “the patient’s provider of choice” will probably not really be the doctor of the patient’s choosing but “a primary-care provider,” and since far less than half of California physicians are primary-care providers, this drastically narrows effective choice.

The 19th-Century French political scientist Benjamin Constant once remarked: “Every time the government attempts to handle our affairs, it costs more and (the) results are worse than if we had handled them ourselves.” If Californians are seduced by polished rhetoric of those who seek to transfer the whole health-care system to the government, we shall experience this truism firsthand. Only this time, after a stream of escalating budgets, taxes and reduced care, we all will pay for our fellow Californians’ naivete with that which is more precious than money: our health.