# 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:** 2
**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, 3:27pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/21 "2019-05-23T15:27:24Z")
> [@Velocity](#): > > 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) I would think the state insurance is secondary to Medicare. ~Max ---
**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, 3:35pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/22 "2019-05-23T15:35:22Z")
> [@CarnalK](#): > > 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) From the summary of that case, > [@](#): > > Appellants argue that the waiting period is needed to preserve the fiscal integrity of their public assistance programs, as persons who require welfare assistance during their first year of residence are likely to become continuing burdens on welfare programs. The argument I would make is that the waiting period is needed to combat medical fraud where the individual moves to the state for the express purpose of receiving medical benefits, receives expensive medical services, and leaves the state. This is called medical tourism. The state has a compelling interest in providing medical benefits for its residents and only seeks to discriminate between new and existing residents as is necessary to further this goal. ~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, 3:43pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/23 "2019-05-23T15:43:46Z")
> [@Max\_S](#): > > From the summary of that case, > The argument I would make is that the waiting period is needed to combat medical fraud where the individual moves to the state for the express purpose of receiving medical benefits, receives expensive medical services, and leaves the state. This is called medical tourism. The state has a compelling interest in providing medical benefits for its residents and only seeks to discriminate between new and existing residents as is necessary to further this goal. > > ~Max Did you not read the bit I quoted that included part of the decision? It said reasons of “minimization of opportunity for fraud […] were not compelling enough to justify a classification that infringed a fundamental interest.” I mean, who knows how a court would decide in a state medical insurance system but you have little reason to be confident in your lawyering the matter. ---
**Author:** ![octopus](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/octopus/32/3716_2.png) [@octopus](https://boards.straightdope.com/u/octopus)\ **Post date:** [May 23, 2019, 3:52pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/24 "2019-05-23T15:52:57Z")
> [@Bryan\_Ekers](#): > > Build a wall. The Prez sez it’s a great idea. The greatest idea. Trust him. Great idea. The US has the largest immigrant population in the world and has more immigrants than Canada has people. And less land. Stop slacking up there. > [@elbows](#): > > 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! Yeah it’d be impossible to get a photo ID for all the poor people. That’d be racist! Those comments seem to be a jab at the photo ID for voting debate. ---
**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, 4:03pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/25 "2019-05-23T16:03:03Z")
> [@CarnalK](#): > > Did you not read the bit I quoted that included part of the decision? It said reasons of “minimization of opportunity for fraud […] were not compelling enough to justify a classification that infringed a fundamental interest.” I mean, who knows how a court would decide in a state medical insurance system but you have little reason to be confident in your lawyering the matter. I did read that, and I’ve been reading the case too. > [@](#): > > Similarly, there is no need for a State to use the one year waiting period as a safeguard against fraudulent receipt of benefits; for less drastic means are available, and are employed, to minimize that hazard. I don’t think there are any other less drastic means to prevent medical tourism. And I do think medical tourism would bankrupt the state insurance program. Finally I do believe the state has a compelling interest in providing coverage for its residence. If there are no alternatives that compelling interest extends to the durational residency requirement. The fraud isn’t double payments as it is in that case, so inter-state cooperation is not an alternative. I’m not sure what that court meant by saying the durational residence didn’t apply to existing residents for fraud purposes, but I would think existing residents have to show proof of 6 months (or however long) residence before they would become eligible for the state insurance. ~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, 4:18pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/26 "2019-05-23T16:18:42Z")
> [@octopus](#): > > Yeah it’d be impossible to get a photo ID for all the poor people. That’d be racist! Those comments seem to be a jab at the photo ID for voting debate. Not really a jab, but more pointing out that the same arguments against requiring photo ID for voting would necessarily have to apply equally to requiring some kind of ID for healthcare. I mean, are we really going to say that we can’t have old/infirm/poor people not voting because they can’t spare the time/effort/money to go get a photo ID, but we’re going to deny them healthcare because they can’t spare the time/effort/money to go get their state health ID card? (which would presumably involve photo ID anyway) I don’t think anyone wants to do that, so the alternative would be to take anyone who comes, regardless of the state they live in. And for the dumbasses who keep saying “Derp! Western Europe can do it, why can’t we?”, the whole crux of the OPs question is how we manage co-sovereign states within a Federal system who have DIFFERENT systems- i.e. a single payer in one, and not in another. ---
**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, 4:30pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/27 "2019-05-23T16:30:12Z")
> [@Max\_S](#): > > I don’t think there are any other less drastic means to prevent medical tourism. And I do think medical tourism would bankrupt the state insurance program. Finally I do believe the state has a compelling interest in providing coverage for its residence. If there are no alternatives that compelling interest extends to the durational residency requirement. The fraud isn’t double payments as it is in that case, so inter-state cooperation is not an alternative. Nitpicking the differences can be fun, but like I said there’s more than a few precedents of striking down durational residential requirements and that Cornell article notes that where it has been upheld, such as with in-state college tuitions, the reasoning is murky. So while us randos on the internet can imagine that none of that applies to a state insurance plan, the reality is they’d be on shaky legal ground. ---
**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, 4:42pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/28 "2019-05-23T16:42:43Z")
In fact, here’s a challenge for you Max: instead of trying to find differences in the cases I cited, try to find a case where durational residency requirements were ultimately upheld and tell us how it’s similar to a state medical insurance scheme. ---
**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, 5:01pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/29 "2019-05-23T17:01:25Z")
> [@CarnalK](#): > > In fact, here’s a challenge for you Max: instead of trying to find differences in the cases I cited, try to find a case where durational residency requirements were ultimately upheld and tell us how it’s similar to a state medical insurance scheme. I’ll admit that I am acting rather apologetic. The case law indicates that any durational residency requirement will see a tough fight in court. I can’t find case law supporting my position in this thread. That’s not enough to shoot down the idea in theory, but perhaps politically. I suppose a locality (eg: city) could make a test case before the whole state gets behind the plan. ~Max ---
**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, 5:13pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/30 "2019-05-23T17:13:05Z")
> [@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. I gather the problem isn’t the requirement for the card, but the acquisition\* of\* the card. We have provincial agencies that are specifically set up to distribute health insurance cards and in my province at least, it can be tied in with your driver’s license so you renew both at once and have the same picture on each, easy-peazy. Compare that to American calls for voter ID that were coupled with efforts to make that ID more difficult for some citizens to get, or for forms of ID that some citizens were less likely to have. Bureaucracy isn’t your problem; partisan dishonesty is. ---
**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, 5:25pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/31 "2019-05-23T17:25:10Z")
> [@bump](#): > > And for the dumbasses who keep saying “Derp! Western Europe can do it, why can’t we?”, the whole crux of the OPs question is how we manage co-sovereign states within a Federal system who have DIFFERENT systems- i.e. a single payer in one, and not in another. This is an unfriendly and overly confident remark. We may have to discuss this further in the Pit. ---
**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, 5:33pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/32 "2019-05-23T17:33:00Z")
> [@Max\_S](#): > > I’ll admit that I am acting rather apologetic. The case law indicates that any durational residency requirement will see a tough fight in court. I can’t find case law supporting my position in this thread. > > That’s not enough to shoot down the idea in theory, but perhaps politically. I suppose a locality (eg: city) could make a test case before the whole state gets behind the plan. > > ~Max I think it might just take some imagination to form it in a way that can’t be defined as a residency requirement and/or a benefit. The first thing that springs to mind would be to make it an insurance plan where the longer you’ve been paying premiums, the more coverage you get. So first year, 1% of your medical expenses are covered and by year five 100% are covered. Premiums would be paid out from a salary or payroll tax. For unemployed or disabled people, they can make a purely paper bump in their benefits that is simultaneously deducted as a premium. Dependents get the same care as the one paying the premiums. So you’d go through a transition initially where private and public were both being used then you have a de facto residency requirement. ---
**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, 6:09pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/33 "2019-05-23T18:09:54Z")
> [@CarnalK](#): > > I think it might just take some imagination to form it in a way that can’t be defined as a residency requirement and/or a benefit. The first thing that springs to mind would be to make it an insurance plan where the longer you’ve been paying premiums, the more coverage you get. So first year, 1% of your medical expenses are covered and by year five 100% are covered. Premiums would be paid out from a salary or payroll tax. For unemployed or disabled people, they can make a purely paper bump in their benefits that is simultaneously deducted as a premium. Dependents get the same care as the one paying the premiums. So you’d go through a transition initially where private and public were both being used then you have a de facto residency requirement. That’s too complicated. I understand it, but it is just too complicated to roll out. Doctors and patients both want a clear line - either the doctor will get paid or not / either the patient has coverage or they don’t. ~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, 6:34pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/34 "2019-05-23T18:34:20Z")
> [@Bryan\_Ekers](#): > > I gather the problem isn’t the requirement for the card, but the acquisition\* of\* the card. We have provincial agencies that are specifically set up to distribute health insurance cards and in my province at least, it can be tied in with your driver’s license so you renew both at once and have the same picture on each, easy-peazy. Compare that to American calls for voter ID that were coupled with efforts to make that ID more difficult for some citizens to get, or for forms of ID that some citizens were less likely to have. > > Bureaucracy isn’t your problem; partisan dishonesty is. Yes, it’s the acquisition of the card; basically when some states tried to enact a requirement that registered voters show a photo ID when voting, there was a great outcry of injustice about how many people don’t have photo IDs, and the usual reason was that they couldn’t afford to take off work, had health problems precluding them from going to get the ID, or that whatever fees and/or requirements (i.e. birth certificate primarily) and/or transport costs involved with getting the IDs were too onerous. Basically the contention was that there are people who, for whatever reason, can’t get drivers’ licenses or the equally free So what I’m saying is that those reasons are equally valid for why someone might not be able to have a health care ID card, or really any sort of mandatory card/identification at all. ---
**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, 6:45pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/35 "2019-05-23T18:45:53Z")
> [@Max\_S](#): > > That’s too complicated. I understand it, but it is just too complicated to roll out. Doctors and patients both want a clear line - either the doctor will get paid or not / either the patient has coverage or they don’t. > > ~Max How is it any more complicated than the current system? As you said earlier, the doctor’s office checks your insurance benefitse regardless. ---
**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, 6:48pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/36 "2019-05-23T18:48:40Z")
So make the cards very easy to get and don’t freak out when some dumbass tries to start a moral panic about fraud or abuse, because the greater good is more important. ---
**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, 6:49pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/37 "2019-05-23T18:49:12Z")
> [@CarnalK](#): > > How is it any more complicated than the current system? As you said earlier, the doctor’s office checks your insurance benefitse regardless. By scaling coverage over time you are partially counteracting one of the major selling points of a single-payer program: that it will be easier for doctors to handle and for patients to understand. ~Max ---
**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, 6:55pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/38 "2019-05-23T18:55:50Z")
> [@bump](#): > > Yes, it’s the acquisition of the card; basically when some states tried to enact a requirement that registered voters show a photo ID when voting, there was a great outcry of injustice about how many people don’t have photo IDs, and the usual reason was that they couldn’t afford to take off work, had health problems precluding them from going to get the ID, or that whatever fees and/or requirements (i.e. birth certificate primarily) and/or transport costs involved with getting the IDs were too onerous. Basically the contention was that there are people who, for whatever reason, can’t get drivers’ licenses or the equally free > > So what I’m saying is that those reasons are equally valid for why someone might not be able to have a health care ID card, or really any sort of mandatory card/identification at all. Forgetting an ID card shouldn’t be a problem so long as they are enrolled and “in the system”. Getting an ID card (and thus being enrolled), just like registering to vote, can and should require positive identification. ~Max ---
**Author:** ![DrDeth](https://avatars.discourse-cdn.com/v4/letter/d/b487fb/32.png) [@DrDeth](https://boards.straightdope.com/u/DrDeth)\ **Post date:** [May 23, 2019, 7:16pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/39 "2019-05-23T19:16:56Z")
> [@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 think many of us are more talking about residents of say, AZ, driving over for a day to get free Health care in say CA. ---
**Author:** ![DrDeth](https://avatars.discourse-cdn.com/v4/letter/d/b487fb/32.png) [@DrDeth](https://boards.straightdope.com/u/DrDeth)\ **Post date:** [May 23, 2019, 7:19pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/40 "2019-05-23T19:19:02Z")
> [@bump](#): > > … > And for the dumbasses who keep saying “Derp! Western Europe can do it, why can’t we?”, the whole crux of the OPs question is how we manage co-sovereign states within a Federal system who have DIFFERENT systems- i.e. a single payer in one, and not in another. Well, I wouldnt call them dumbasses but, yeah the whole _"Western Europe can do it, why can’t we?_" argument, repeated endlessly- is a very poor one. [Previous 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=1) [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=3)