Californians Can Choose to Die – With the Help of Taxpayers

The law carves out religious and other exemptions for doctors and hospitals who don’t want to participate.

By Kimberly Leonard, Staff Writer
By Kimberly Leonard, Staff WriterMarch 21, 2016, at 7:33 p.m.
U.S. News & World Report

State Funds to Help Californians Die

Debbie Ziegler, mother of aid-in-dying advocate Brittany Maynard, speaks after the California state legislature passed an aid-in-dying bill in September.Carl Costas/AP

California’s aid-in-dying law contains a provision allowing doctors and hospitals to opt out of helping terminally ill patients access medications that would help them hasten their deaths, but that same exemption will not be carved out for state taxpayers, U.S. News has learned.

The state government plans to assist in the cost of providing life-ending medications and doctor visits using $2.3 million already quietly tucked into Democratic Gov. Jerry Brown’s proposed budget in January, according to a spokesperson for California’s Department of Health Care Services.

Of five states that offer aid-in-dying options, California will be the second, after Oregon, that covers the prescriptions using public funds. The program covers a third of California residents, and state officials haven’t yet announced whether private health care plans will also be obligated to participate.

The move represents a major victory for aid-in-dying advocates who say that the law allows terminally ill patients, regardless of their means, to choose to die rather than undergo unbearable end-of-life suffering.

But opponents criticized the move, saying that the aid-in-dying law was passed during a special session designated specifically so lawmakers could plug deficit holes in Medi-Cal, the joint state-federal program for low-income people, and is therefore invalid.

Brian Johnston, former commissioner on aging in California and spokesman for Seniors Against Suicide, accused the state of having more nefarious motives for passing the aid-in dying bill.

“When you’re willing to legalize the intentional killing of patients in order to save Medi-Cal money, there’s something a little bit utilitarian about that,” he says. “We have a law that isn’t really designed for those we care for, but for those we don’t wish to care for anymore, that’s why Medi-Cal is paying for this.”

Federal funds cannot be used for aid-in-dying, so state money was routed to that purpose. Budget projections anticipate that some 443 Medi-Cal recipients will obtain the drug over the course of the first year the law is in effect.

A lethal dose of secobarbital, the drug most likely to be prescribed and known by its brand name of Seconal, often costs between $3,000 and $5,000. Another drug that had been used for aid-in-dying, called pentobarbital, had cost about a tenth of the price, but because it has also been used to carry out the death penalty, its Illinois-based manufacturers limit its distribution, including to hospitals that use its liquid version as a sedative before surgery.

For medically assisted dying, another option is a three-part drug cocktail that costs $400, but it is not as widely available as Seconal and requires the use of compounding pharmacies, which aren’t as heavily regulated by the government. The mixture contains chloral hydrate, a sleeping pill; morphine sulfate and phenobarbital. Dr. David Grube, a retired family physician and medical director for Compassion and Choices, says the mixture has been used more than 100 times for more than a year in Oregon and showed no significant complications.

Under aid-in-dying laws, patients must ingest the medication to show that they are voluntarily choosing to end their lives; the drug cannot be administered through a needle as is done in euthanasia in some countries in Europe.

California’s End of Life Option Act, signed into law last fall, is set to go into effect June 9. The bill includes protections from abuse, including specifying that people who choose this option must be mentally competent and must have a diagnosis from two separate doctors showing that they have six months or less to live. Every year, the law specifies, the state must collect data about people who use aid-in-dying to see that these principles are being followed.


But as detailed as the law is about certain provisions, language about how the drugs are covered is vague. The Department of Health Care Services was left to implement the law, including determining whether state funds would cover the medication.

Supporters of the bill had said they expected state funds would cover the medications and that legislation should not be needed to clarify this. Still, Assemblywoman Susan Eggman, D-Stockton, who helped introduce the aid-in-dying law in California, in February introduced a bill of intent that would require Medi-Cal to pay for drugs used in aid-in-dying.

David Stammerjohan, Eggman’s chief of staff, says the bill was introduced out of an “abundance of caution.”

“It’s not clear the bill is necessary,” he says. “We introduced it as a contingency. We’ll know in the next few weeks whether we need to proceed or not.”

But the decision had already been made, according to budget projections and an email from the Department of Health Care Services to U.S. News.

The agency does not oversee private health insurance companies. The law provides some guidance, saying that an insurance company may not tell a patient that an aid-in-dying medication is covered unless a patient asks. It also may not include denial of treatment and mention the availability of aid-in-dying drugs in the same communication.  

“We are doing everything possible to ensure access, regardless of an individual’s income or health coverage,” says Democratic Sen. Lois Wolk, a co-sponsor of the aid-in-dying law in California.

According to the Death With Dignity National Center, individual insurance companies determine whether the procedure is covered under their policies and as required by state regulators, just as they would with any other medical procedure.

The California Association of Health Plans says its members plan to abide by the guidance from the state. “Health plans are preparing to comply with the law,” says Nicole Kasabian Evans, a spokeswoman for the group. “As such, the plans have reviewed the law and looked into how it was implemented in others states to help with compliance.”

Kat West, national director of policy and programs for Compassion and Choices, says the group is launching a campaign so that “everyone who wants and needs medical aid-in-dying has access to it.” The campaign includes asking doctors and health insurance companies whether they will participate in medically assisted dying.

Dr. Michael Amster, a pain specialist at North Bay Hospital in Fairfield, California, says he is prepared to prescribe Seconal in tablets that patients will open, pouring the powder into water or juice. Prior to taking the mixture, they will ingest Zofran and Reglan to keep from vomiting.

Amster gets questions about the aid-in-dying option from patients about two to three times a week. He has checked with a pharmacy in a large grocery chain in California, whose pharmacists assured him they could fill any prescription for Seconal within one or two days. The hospital where he works is crafting its policies and procedures and identifying which doctors will be willing to prescribe the medication.

“After I write that first prescription, I think I will take a moment to pause to understand the magnitude of this privilege doctors have of providing medical aid-in-dying for our patients,” he says. “I think it’s a right patients have been seeking for many years. … Some patients died miserable deaths for people to have this option.”


Corrected on March 23, 2016: Dr. Michael Amster is a pain specialist at North Bay Hospital in Fairfield, California.

Kimberly Leonard, Staff Writer

Kimberly Leonard is a former health care reporter for the News division at U.S. News. Previousl... READ MORE  »Kimberly Leonard is a former health care reporter for the News division at U.S. News. Previously she worked in Health Rankings as a multimedia producer and reporter. You can follow her on Twitter, connect with her on LinkedIn, circle her on Google+ or email her at kleonard@usnews.com

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