# If a US state enacts single payer, how do they stop out of staters from bankrupting the system **URL:** \ **Category:** Great Debates\ **Created:** [May 23, 2019, 1:05am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384 "2019-05-23T01:05:03Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [May 23, 2019, 1:05am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/1 "2019-05-23T01:05:03Z")
I don’t know the details but I believe a US state can’t say ‘we won’t cover you if you’re out of state and move here for our health care system’. I could be wrong. But anyway, that is used as one criticism for a state enacting single payer or meaningful health reform, all the sick people will move there to get health care. But is that really a risk? It was my understanding that places like Canada & Australia had universal health care in certain provinces and states before their universal health care plan went national (Saskatchewan and Queensland respectively). It didn’t seem to bankrupt them, but then again health care was much much cheaper back then. I’m assuming a lot of people who desire universal health care crave it more for the security, not because they have expensive medical conditions. Just knowing you won’t lose everything you’ve worked your whole life for if you get sick is appealing, even if you aren’t sick. A lot of people are mostly healthy for most of their lives, and by the time they do truly get sick they’re usually on medicare. People who truly get sick before age 65 tend to end up on medicaid (I would assume as the truly sick may lose their ability to work and end up poor). So I’m guessing the 5% of Americans who make up 60% of all medical expenditures are mostly already on medicare or medicaid, and as a result wouldn’t see much appeal in moving to a state with UHC. But how is this risk balanced? ---
**Author:** ![Bryan\_Ekers](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/bryan_ekers/32/183_2.png) [@Bryan\_Ekers](https://boards.straightdope.com/u/Bryan_Ekers)\ **Post date:** [May 23, 2019, 1:20am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/2 "2019-05-23T01:20:48Z")
Build a wall. The Prez sez it’s a great idea. The greatest idea. Trust him. Great idea. ---
**Author:** ![jasg](https://avatars.discourse-cdn.com/v4/letter/j/f0a364/32.png) [@jasg](https://boards.straightdope.com/u/jasg)\ **Post date:** [May 23, 2019, 2:28am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/3 "2019-05-23T02:28:44Z")
Maybe the same way they control tuition at state colleges and universities? ---
**Author:** ![elbows](https://avatars.discourse-cdn.com/v4/letter/e/b3f665/32.png) [@elbows](https://boards.straightdope.com/u/elbows)\ **Post date:** [May 23, 2019, 2:29am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/4 "2019-05-23T02:29:29Z")
An identification card. The Canadian system is by province, not national. (The provinces have reciprocal agreements in place though!) We all have an ID, with photo, that we show whenever we access services. Every Dr visit, etc. It’s not that hard a hurdle to clear, it’s quite easily managed. ---
**Author:** ![Northern\_Piper](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/northern_piper/32/5304_2.png) [@Northern\_Piper](https://boards.straightdope.com/u/Northern_Piper)\ **Post date:** [May 23, 2019, 3:19am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/5 "2019-05-23T03:19:57Z")
Residency requirements. You can’t just show up and get health care. You have to be a resident of the province, I think for at least three months. That’s under the current system, where you’ll be covered by the province you came from for the three month period. I’ve never looked into how it was managed by Saskatchewan prior to Medicare being brought in at the federal level, but I would imagine it was a residency requirement. That’s the origin of the long wait lists you keep hearing about. Three months to see a doctor… 😉 ---
**Author:** ![Broomstick](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/broomstick/32/246_2.png) [@Broomstick](https://boards.straightdope.com/u/Broomstick)\ **Post date:** [May 23, 2019, 10:41am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/6 "2019-05-23T10:41:07Z")
People who aren’t sick and move into a state for the “security” of such a system aren’t going to bankrupt the system, they’ll be holding it up by paying (via taxes or premiums). People who are seriously ill are less likely to move their residence because it’s even harder to move when you’re seriously ill than when you are well. They’ll either be on medicare/medicaid, so they’ll likely have very little money to move anywhere, or have private insurance and already be covered (although a lot of people find out the hard way their coverage is crap). ---
**Author:** ![glee](https://avatars.discourse-cdn.com/v4/letter/g/b5a626/32.png) [@glee](https://boards.straightdope.com/u/glee)\ **Post date:** [May 23, 2019, 11:29am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/7 "2019-05-23T11:29:05Z")
Here in the UK we have the wonderful NHS. I recently had two treatments (gallstones removal / liver sepsis), which involved ambulance trips, stays in hospital, operations, tests including MRIs, ultrasounds etc. US friends estimate the cost in the US would have been $500,000 plus. Having paid my taxes, it cost me nothing. At the hospital I was required to show evidence that I was eligible (passport / driving licence / utility bill etc.) ---
**Author:** ![Lightnin](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/lightnin/32/180_2.png) [@Lightnin](https://boards.straightdope.com/u/Lightnin)\ **Post date:** [May 23, 2019, 11:35am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/8 "2019-05-23T11:35:07Z")
> [@Northern\_Piper](#): > > You have to be a resident of the province, I think for at least three months. Here in Alberta, I was able to get my health card as soon as I got my SIN, which was about two weeks. I did have to show my work permit, though, to get my SIN. ---
**Author:** ![Kearsen1](https://avatars.discourse-cdn.com/v4/letter/k/3d9bf3/32.png) [@Kearsen1](https://boards.straightdope.com/u/Kearsen1)\ **Post date:** [May 23, 2019, 12:00pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/9 "2019-05-23T12:00:29Z")
> [@elbows](#): > > An identification card. The Canadian system is by province, not national. (The provinces have reciprocal agreements in place though!) > > We all have an ID, with photo, that we show whenever we access services. Every Dr visit, etc. > > It’s not that hard a hurdle to clear, it’s quite easily managed. Think of the hardship getting such an ID would require! ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [May 23, 2019, 1:39pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/10 "2019-05-23T13:39:09Z")
> [@Northern\_Piper](#): > > Residency requirements. > > You can’t just show up and get health care. You have to be a resident of the province, I think for at least three months. That’s under the current system, where you’ll be covered by the province you came from for the three month period. > > I’ve never looked into how it was managed by Saskatchewan prior to Medicare being brought in at the federal level, but I would imagine it was a residency requirement. > > That’s the origin of the long wait lists you keep hearing about. Three months to see a doctor… > 😉 I agree with **Northern Piper** , residency requirements are the way to go. The state would probably set up offices where residents can bring in two forms of identification and proof of residency, give their bank account #, and get their new health insurance card. ~Max ---
**Author:** ![bump](https://avatars.discourse-cdn.com/v4/letter/b/7c8e57/32.png) [@bump](https://boards.straightdope.com/u/bump)\ **Post date:** [May 23, 2019, 2:05pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/11 "2019-05-23T14:05:13Z")
> [@Kearsen1](#): > > Think of the hardship getting such an ID would require! You jest, but that’s probably the biggest flaw in the system. If we can’t require ID for voting (arguably THE most important civil thing we do), how are we going to require someone to get some kind of state single-payer card? Presumably the same hurdles apply to either sort of card, after all. So we’re back in the same boat where we’d have single-payer with cards for most people, and then some sort of provision where hospitals, etc… would have to let anyone in anyway, because they _might_ be one of these un-carded citizens. ---
**Author:** ![Slash1972](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/slash1972/32/6461_2.png) [@Slash1972](https://boards.straightdope.com/u/Slash1972)\ **Post date:** [May 23, 2019, 2:06pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/12 "2019-05-23T14:06:58Z")
> [@bump](#): > > You jest, but that’s probably the biggest flaw in the system. > > If we can’t require ID for voting (arguably THE most important civil thing we do), how are we going to require someone to get some kind of state single-payer card? Presumably the same hurdles apply to either sort of card, after all. > > So we’re back in the same boat where we’d have single-payer with cards for most people, and then some sort of provision where hospitals, etc… would have to let anyone in anyway, because they _might_ be one of these un-carded citizens. It seems like the cards would only be provided to meet the “resident of this state” requirement, and not “US Citizen”. Probably easier to get. ---
**Author:** ![Grey](https://avatars.discourse-cdn.com/v4/letter/g/b782af/32.png) [@Grey](https://boards.straightdope.com/u/Grey)\ **Post date:** [May 23, 2019, 2:17pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/13 "2019-05-23T14:17:20Z")
> [@bump](#): > > You jest, but that’s probably the biggest flaw in the system. > > If we can’t require ID for voting (arguably THE most important civil thing we do), how are we going to require someone to get some kind of state single-payer card? Presumably the same hurdles apply to either sort of card, after all. > > So we’re back in the same boat where we’d have single-payer with cards for most people, and then some sort of provision where hospitals, etc… would have to let anyone in anyway, because they _might_ be one of these un-carded citizens. Holy hell. The rest of the bloody world has managed this and yet to Americans it’s some sort of unsolvable problem. Free health cards to residents (and various secondary groups) and and honest attempt to get them to everyone. ---
**Author:** ![elbows](https://avatars.discourse-cdn.com/v4/letter/e/b3f665/32.png) [@elbows](https://boards.straightdope.com/u/elbows)\ **Post date:** [May 23, 2019, 2:24pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/14 "2019-05-23T14:24:24Z")
Sheesh, y’all managed photo ID driver’s licenses, without the world ending. How hard is it to understand why this is needed? So, you’re saying, the very same people, who would loose their shit if someone undeserving got covered by fraud, won’t hear of a photo ID requirement to access services? Because FREEDOM ??? Universal health care is just not worth this infringement !!! America gets weirder every day, I swear! ---
**Author:** ![Red\_Wiggler](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/red_wiggler/32/13190_2.png) [@Red\_Wiggler](https://boards.straightdope.com/u/Red_Wiggler)\ **Post date:** [May 23, 2019, 2:40pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/15 "2019-05-23T14:40:14Z")
Those last two posts are pretty embarrassing. Why indeed can’t we manage relatively simple bureaucratic stuff that western Europe does with ease? ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [May 23, 2019, 2:57pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/16 "2019-05-23T14:57:38Z")
> [@bump](#): > > You jest, but that’s probably the biggest flaw in the system. > > If we can’t require ID for voting (arguably THE most important civil thing we do), how are we going to require someone to get some kind of state single-payer card? Presumably the same hurdles apply to either sort of card, after all. > > So we’re back in the same boat where we’d have single-payer with cards for most people, and then some sort of provision where hospitals, etc… would have to let anyone in anyway, because they _might_ be one of these un-carded citizens. Any reasonable insurance plan should keep a centralized database and give doctors free access to check eligibility and benefits by ID, name, address, date of birth, etcetera. An online interface plus automated phone system would do the trick, with an option to speak with a state employee for unusual circumstances. Missing an ID card necessarily makes it harder for the doctor’s office to verify that you are covered, but it should not prevent you from getting health care so long as you still know your name, date of birth, address, and the phone number or website of the insurance plan. Strictly speaking though, a state cannot actually create a single-payer system where there is only one payer. They don’t have the authority to shut down federal insurance programs and if the state conditions their “single-payer” coverage on residence, as would be necessary to prevent medical tourism, other private insurance plans must be allowed to fill the gap in coverage. Plus it is likely that the single-payer plan still allows for supplemental coverage. So all of this means doctors still need to verify benefits, preferably with an online or phone system. In case you didn’t realize, doctors offices check benefits for every single patient before their first appointment. With reliable insurances such as Medicare we might not check before each subsequent appointment. The only exception is emergency rooms, who might check after the services are performed. ~Max ---
**Author:** ![CarnalK](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnalk/32/486_2.png) [@CarnalK](https://boards.straightdope.com/u/CarnalK)\ **Post date:** [May 23, 2019, 2:59pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/17 "2019-05-23T14:59:23Z")
Not sure why you guys are going on about residency cards when the whole question of the OP is about sick people moving to the free healthcare state, ie. they’ll be residents. And the answer to that isn’t “hey, nobody is going to move just because they require $900k medical procedure”. It also probably can’t be solved a length of residency requirement as those have been [struck down by the courts](https://caselaw.findlaw.com/us-supreme-court/457/55.html). ---
**Author:** ![Max\_S](https://avatars.discourse-cdn.com/v4/letter/m/46a35a/32.png) [@Max\_S](https://boards.straightdope.com/u/Max_S)\ **Post date:** [May 23, 2019, 3:07pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/18 "2019-05-23T15:07:08Z")
> [@CarnalK](#): > > Not sure why you guys are going on about residency cards when the whole question of the OP is about sick people moving to the free healthcare state, ie. they’ll be residents. And the answer to that isn’t “hey, nobody is going to move just because they require $900k medical procedure”. It also probably can’t be solved a length of residency requirement as those have been [struck down by the courts](https://caselaw.findlaw.com/us-supreme-court/457/55.html). I was talking about insurance cards, not residency cards. (Is there such a thing?) And that Alaskan constitutional amendment was struck down because it gave existing residents a _permanent_ advantage over new residents. People who were there longer would get more money than people who weren’t, _every_ year, _forever_, on the sole basis of residing in Alaska for longer. That’s an “I’ve got mine”. A residency requirement is different, it is just saying anyone gets a fixed benefit so long as they have resided here for say 6 months. ~Max ---
**Author:** ![CarnalK](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/carnalk/32/486_2.png) [@CarnalK](https://boards.straightdope.com/u/CarnalK)\ **Post date:** [May 23, 2019, 3:16pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/19 "2019-05-23T15:16:08Z")
Alaska is not the only case law on residency requirements. I think you are incorrect if you think one for medical benefits would stand up in court. [Cornell Law: Durational Residency Requirements.](https://www.law.cornell.edu/constitution-conan/amendment-14/section-1/durational-residency-requirements) > [@](#): > > Thus, in Shapiro v. Thompson,2090 durational residency requirements conditioning eligibility for welfare assistance on one year’s residence in the state2091 were voided. If the purpose of the requirements was to inhibit migration by needy persons into the state or to bar the entry of those who came from low-paying states to higher-paying ones in order to collect greater benefits, the Court said, the purpose was impermissible.2092 If, on the other hand, the purpose was to serve certain administrative and related governmental objectives—the facilitation of the planning of budgets, the provision of an objective test of residency, minimization of opportunity for fraud, and encouragement of early entry of new residents into the labor force—then the requirements were rationally related to the purpose but they were not compelling enough to justify a classification that infringed a fundamental interest. ---
**Author:** ![Velocity](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/velocity/32/18006_2.png) [@Velocity](https://boards.straightdope.com/u/Velocity)\ **Post date:** [May 23, 2019, 3:23pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/20 "2019-05-23T15:23:13Z")
So maybe this was answered in some sub-text but I missed it, but couldn’t elderly retirees (who aren’t earning much or paying much in taxes, if at all) move to a single-state system for treatment for expensive medical conditions - and fulfill the 6 month residency first - and still represent just about as much burden on the single-payer system as if they hadn’t fulfilled their residency at all? (especially if it’s a small state like Vermont) [Next page](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384.md?page=2)