California’s soaring costs hide a surprising distinction: it has become one of America’s most carefully built places to face the end of life.
California has long carried a reputation for sky-high living costs, yet many people still choose to spend their later years there. According to data from the Centers for Medicare & Medicaid Services, states like California consistently rank high in end-of-life healthcare access and quality.
They offer a broad availability of specialized care and support services. For some, that level of care outweighs the financial strain of living in one of the most expensive places in the country.
This contrast highlights a deeper reality about what people value as they age. Beyond housing prices and taxes, factors like climate, healthcare, and overall quality of life begin to matter more. California offers a combination of mild weather, strong medical infrastructure, and lifestyle appeal that can make it an attractive place to settle down long-term. For many, the high cost becomes easier to justify when comfort and care take center stage.
You can legally choose your exit
In California, terminally ill adults can request medical aid in dying. This is written into the End of Life Option Act. The law took effect in June 2016.
The California Department of Public Health publishes annual reports on the Act. The 2023 data report covers all prescriptions and deaths from 2016 through 2023. In 2022, 341 physicians submitted aid-in-dying prescriptions. For patients who qualify, the choice itself becomes a form of medicine. Knowing there is a controlled exit eases fear long before the medication is used.
The rules around aid in dying are tight, on purpose
Access is not casual. To qualify under the End of Life Option Act, a person must be 18 or older. They must have a terminal illness with a life expectancy of six months or less. They must be mentally capable of making medical decisions.
They must make two separate oral requests for the medication. The second request cannot be made until at least 48 hours after the first. The patient must be able to self-administer the drugs. This structure slows things down. It filters for persistence, not impulse. For many families, that care with the boundary is part of what makes California feel safe for a final choice.
Hospital palliative care is widely available
Relief in California is not only legal. It is clinical. The Center to Advance Palliative Care’s 2024 state scorecard estimates that 94.5 percent of hospital inpatients in California have access to a hospital-based palliative care program. That number is based on total admissions in the state.
Among 356 acute care hospitals in California, researchers validated 202 active inpatient palliative care programs in earlier statewide work. CAPC’s scorecard shows that 70.3 percent of urban hospitals in California reported palliative care. So did 85.5 percent of suburban facilities. So did 96.2 percent of rural hospitals. That spread means serious illness care is not only for big coastal systems.
Community palliative care capacity has been growing
Palliative care has also stepped outside hospital walls. The California Health Care Foundation’s report “Palliative Care in California: Narrowing the Gap” estimated that inpatient programs could meet between 43 percent and 66 percent of statewide need. The midpoint estimate was 52 percent.
For community-based palliative care, capacity was estimated to meet between 33 percent and 51 percent of demand. The prevalence of community programs more than doubled in the study period. Many hospice organizations now offer palliative services alongside traditional hospice. That blend means more people can receive symptom relief and family support while still pursuing treatments or living at home.
The state scores well on serious illness care
California’s end-of-life infrastructure is tracked nationally. CAPC’s Serious Illness Scorecard reviews each state across five domains. These domains include the availability of specialty palliative professionals, payment structures, education, and caregiver support.
Hospice News reports that in the 2024 scorecard, six states earned a four-star rating for serious illness care. California was one of those six. No state reached five stars. That means California is not perfect. But it is near the top of the current American curve for serious illness readiness and palliative access.
Long-term services and supports are relatively strong
Dying is not just about medicine. It is about the scaffolding around frailty. California’s long-term services and supports environment is captured in the national LTSS Scorecard, produced by AARP and partners. That scorecard ranks states on metrics like affordability, access, safety, and family caregiver support.
In the most recent LTSS Scorecard cited in California’s palliative scorecard, the state ranked 11th out of 51. That position sits near the top fifth. It signals a system with relatively better infrastructure for home care, nursing facilities, and family support than much of the country. For many older Californians, the hardest part is paying the rent while alive. The support becomes more visible once illness sets in.
Pediatric palliative policy has pushed hospice quality
California has also experimented with palliative care for children. A study in the journal “Cancer” evaluated California’s pediatric palliative care policy and its effect on hospice use. The analysis followed 979 children who died with complex chronic conditions.
More than 10 percent enrolled in hospice. The average hospice stay was less than three days. But in counties covered by the pediatric palliative policy, the rate of hospice length of stay increased by a factor of 5.61. That figure is an incidence rate ratio. The policy did not change how many children reached hospice. It changed how much meaningful time they had there. That same logic shapes adult reforms.
California tracks hospice use in detail
The state has data on how people actually use hospice. California’s open data portal hosts hospice utilization datasets from the Department of Health Care Access and Information. One dataset covers patient demographics. Another track’s length of stay and patterns of care.
In addition, statewide analyses have looked at hospice use among adults with serious illness, including Medicaid populations. The goal is simple. To understand who reaches comfort care and who does not. That transparency allows advocates and policymakers to argue that dying well should not depend on zip code or insurance type.
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The aid in dying program has served thousands
Medical aid in dying remains a small part of California’s deaths. But for those who use it, the impact is outsized. The California Department of Public Health’s 2023 report aggregates all data since the End of Life Option Act began. It counts each person who received a prescription and each person known to have died after ingesting the prescribed drugs.
Advocacy group End of Life Choices California notes that by 2023, the law had helped thousands of terminally ill Californians. That figure is cumulative. For a minority of patients, this path is chosen. For a larger group, simply knowing the option exists is described as a comfort. It turns a feared “California good life” slogan into something more layered. A good life that includes a shaped ending.
The culture talks about death out loud
Policy exists because culture allows it. When then-Governor Jerry Brown signed the End of Life Option Act in 2015, California became the fourth U.S. state to legalize medical aid in dying. That placed it in a small group with Oregon, Washington, and Vermont.
Organizations like Compassion & Choices and Death with Dignity have active operations in California. They help patients navigate requirements. They train clinicians. They push for equity in access. This openness around death is part of why national media sometimes use the phrase “a great place to die” about the state. Here, the end of life is not a taboo corner. It is a policy arena.
Serious illness care is being measured and upgraded
California’s serious illness infrastructure is not static. CAPC’s ACT Index tracks states on 26 measures. Those measures sit in four domains. Care. Costs. Community and caregivers. Communication.
In the ACT Index, California placed 27th out of 51. That mid-table ranking shows that even with strong palliative and LTSS scores, there is room to improve how seriously ill people move through the system. For residents, that steady measurement means reforms keep coming. Home-based palliative teams. Telehealth. Better caregiver training. For writers, it underlines the idea of a state obsessed with the mechanics of dying as much as living.
The irony is the point
California is still one of the most expensive places to be middle-class in. Housing costs press. Taxes pinch. Many retirees quietly leave the state to stretch their savings. Yet those who stay, and those who return when they are sick, are often doing a different kind of math.
They weigh access to hospital palliative care in over 70 percent of urban hospitals. They notice the four-star serious illness rating. They know that if their body fails, there are hospice programs, pediatric policies, aid in dying laws, and caregiver supports waiting. In that calculation, California becomes something strange. A hard place to live in. A carefully engineered place to die in.
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Disclosure: This article was developed with the assistance of AI and was subsequently reviewed, revised, and approved by our editorial team.
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