# 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:** 3
**Author:** ![Grim\_Render](https://avatars.discourse-cdn.com/v4/letter/g/a87d85/32.png) [@Grim\_Render](https://boards.straightdope.com/u/Grim_Render)\ **Post date:** [May 23, 2019, 7:23pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/41 "2019-05-23T19:23:24Z")
Canada reportedly has a problem with Americans filching free health care through forged documentation though. Then again, healthcare isn’t actually that expensive for a Beveridge-type UHC system -that is, setting it up can be expensive, as can running it, but when everyone is on a salary and the supplies are bought in bulk, the costs of treating an extra patient can be very low. ---
**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, 7:25pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/42 "2019-05-23T19:25:46Z")
> [@DrDeth](#): > > 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. Actually, now that I think about it, maybe a mere residency requirement would prevent that behavior. ~Max ---
**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, 7:30pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/43 "2019-05-23T19:30:58Z")
> [@Grim\_Render](#): > > Canada reportedly has a problem with Americans filching free health care through forged documentation though. They should build a wall to keep us pesky Americans out. ---
**Author:** ![PastTense](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/pasttense/32/14550_2.png) [@PastTense](https://boards.straightdope.com/u/PastTense)\ **Post date:** [May 23, 2019, 7:38pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/44 "2019-05-23T19:38:08Z")
We already have a comparable situation: Medicaid expansion–where there are a substantial number of states–mostly Southern–who did not expand Medicaid. Is there any evidence the relevant sick people are moving to Medicaid expansion states? ---
**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, 7:48pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/45 "2019-05-23T19:48:34Z")
I think I get it. The issue isn’t determining if someone is in the plan but the legality of excluding someone access to care due to the equal protection clause in the 14th amendment? Do I have that right? Well the easy answer would seem to be to not restrict access to the system. Those in the system get care and those from outside of it get care and then get charged outside of system rates. Hell an influx of out of system patients could actually help mitigate costs for those in system. ---
**Author:** ![Buck\_Godot](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/buck_godot/32/6573_2.png) [@Buck\_Godot](https://boards.straightdope.com/u/Buck_Godot)\ **Post date:** [May 23, 2019, 7:52pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/46 "2019-05-23T19:52:39Z")
> [@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. There is also a difference in motivation. Suppose comprehensive healthcare is provided to those who have an ID, and acquiring that ID requires a modest expense of time an effort that is equivalent to say $20/year. Then I imagine most residents would see it as a worth the effort to get it since the direct benefits to them would far outweigh the cost. However the actual direct benefit to an indvidual of casting a vote is much lower. Those of limited means look at spending $20/year so that every 2 years you can add one to an enormous tally with a near negligible chance of actually affecting the outcome, and each individually reach the rational conclusion that its not worth it. So they stay home en-mass tilting the election and fulfilling the design of those who wrote the legislation. So, yes, if they wanted to bad enough most people could probably get a ID, But the question is whether its discriminatory to purposefully put up a barrier that is just high enough so that the “wrong” sort of people won’t want to vote bad enough. ---
**Author:** ![puddleglum](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/puddleglum/32/137_2.png) [@puddleglum](https://boards.straightdope.com/u/puddleglum)\ **Post date:** [May 23, 2019, 7:53pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/47 "2019-05-23T19:53:44Z")
What will bankrupt any state that enacts single payer is not that people will move to that state, most people already have coverage. What will bankrupt the state is people moving out who don’t want their taxes doubled. ---
**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, 8:13pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/48 "2019-05-23T20:13:12Z")
> [@Grey](#): > > I think I get it. The issue isn’t determining if someone is in the plan but the legality of excluding someone access to care due to the equal protection clause in the 14th amendment? Do I have that right? > > Well the easy answer would seem to be to not restrict access to the system. Those in the system get care and those from outside of it get care and then get charged outside of system rates. > > Hell an influx of out of system patients could actually help mitigate costs for those in system. It would be doctors offices deciding who does and does not get care (unless it is an emergency). Not legislation. You can’t just tell doctors to treat every patient without a guarantee of payment, or the doctors will have to spend time and money pursuing bankruptcy claims to stay afloat. So doctors check with the state: “are you going to pay me if I treat member #12345?” or “are you going to pay me if I treat John Doe with date of birth 1/1/1970 and address 111 something street, state+zip US?” The constitutional issue is whether it is OK for the state to restrict who is on the state insurance rolls based on duration of residency. ~Max ---
**Author:** ![nearwildheaven](https://avatars.discourse-cdn.com/v4/letter/n/90db22/32.png) [@nearwildheaven](https://boards.straightdope.com/u/nearwildheaven)\ **Post date:** [May 23, 2019, 8:13pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/49 "2019-05-23T20:13:59Z")
> [@Max\_S](#): > > I would think the state insurance is secondary to Medicare. > > ~Max When people are dual-covered, Medicare or the private insurance pays first, and then Medicaid picks up the balance, in most cases. When I worked at the grocery store, we just ran our Medicaid patients through that because we weren’t set up to do otherwise (for example, a child with divorced parents has private insurance, say Blue Cross, through his father, but the family’s income is low enough that he’s eligible for Medicaid). That was almost 20 years ago; I’m guessing they’re set up for that now, especially since Medicare Part D(isaster) came online in the mid 00s. If a Medicaid patient needs treatment out of state, whether the state will pay varies for more reasons than I could think of now. In many cases, they will authorize it because they can’t get it in their state. This is especially true for children with rare diseases. ---
**Author:** ![Pleonast](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/pleonast/32/1183_2.png) [@Pleonast](https://boards.straightdope.com/u/Pleonast)\ **Post date:** [May 23, 2019, 8:16pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/50 "2019-05-23T20:16:02Z")
> [@puddleglum](#): > > What will bankrupt any state that enacts single payer is not that people will move to that state, most people already have coverage. What will bankrupt the state is people moving out who don’t want their taxes doubled. Which will be countered by the businesses moving into the state for the lower payroll costs. ---
**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, 8:18pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/51 "2019-05-23T20:18:27Z")
> [@Max\_S](#): > > It would be doctors offices deciding who does and does not get care (unless it is an emergency). Not legislation. You can’t just tell doctors to treat every patient without a guarantee of payment, or the doctors will have to spend time and money pursuing bankruptcy claims to stay afloat. So doctors check with the state: “are you going to pay me if I treat member #12345?” or “are you going to pay me if I treat John Doe with date of birth 1/1/1970 and address 111 something street, state+zip US?” > > The constitutional issue is whether it is OK for the state to restrict who is on the state insurance rolls based on duration of residency. > > ~Max Again why? The doctors provide care and submit the cost to the state department tied to healthcare. They go and chase down the insurance company/individual to get money back. No doctors involved at all. ---
**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, 8:28pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/52 "2019-05-23T20:28:28Z")
> [@nearwildheaven](#): > > When people are dual-covered, Medicare or the private insurance pays first, and then Medicaid picks up the balance, in most cases. > > When I worked at the grocery store, we just ran our Medicaid patients through that because we weren’t set up to do otherwise (for example, a child with divorced parents has private insurance, say Blue Cross, through his father, but the family’s income is low enough that he’s eligible for Medicaid). That was almost 20 years ago; I’m guessing they’re set up for that now, especially since Medicare Part D(isaster) came online in the mid 00s. > > If a Medicaid patient needs treatment out of state, whether the state will pay varies for more reasons than I could think of now. In many cases, they will authorize it because they can’t get it in their state. This is especially true for children with rare diseases. Well first of all Medicaid doesn’t “pick up the balance”, doctors write off the remainder. Medicaid rates are usually _lower_ than 80% of the Medicare rate, which means as far as Medicaid is concerned there’s nothing left to pick up. Here’s an example. The Medicare rate for a mid-level followup visit in my region is $74.41 (CPT 99213). Medicare pays 78.4% (80/20 split minus 2% sequestration) which is $58.34, and says the patient is responsible for 20% or $14.88. The patient is on Medicaid so Medicaid gets a copy of the Medicare remittance which says charges=$74.41, $58.34 has been paid, $1.19 has been written off, and $14.88 is left over for Medicaid to pay. Medicaid looks at their fee schedule, which says the rate for 99213 is $25.76. Then Medicaid figures, $25.76 was charged and $58.34 was paid by other insurance. Medicaid promptly returns the bill with $0 enclosed. ~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, 8:40pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/53 "2019-05-23T20:40:33Z")
> [@Grey](#): > > Again why? The doctors provide care and submit the cost to the state department tied to healthcare. They go and chase down the insurance company/individual to get money back. No doctors involved at all. This is an entirely different idea then what I was thinking of, where I was thinking of single-payer as a synonym for a publicly funded health plan. A single-payer setup like that would be entirely exempt from the concerns I mentioned in this thread. In regards to the original post, I suppose the number of people who actually _move_ to the state just to leech off the public welfare are small enough to be a non-issue. Even if we include people who stay just long enough to establish legal residency\* then move away. A basic investigation as to whether an enrollee is actually a resident of the state should suffice. \*the same legal residency as required to vote, and in this process the state should check with other states to make sure there isn’t a double entry ~Max ---
**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, 9:09pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/54 "2019-05-23T21:09:48Z")
> [@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). > [@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) Yeah, I knew there were court cases but I didn’t know the names of them that could be an issue. I believe with medicaid there is no residency requirement when you move between states, you can apply the day you move. With in state college tuition I believe there is a one year waiting period before you quality for in state tuition, but I’m not sure why one holds up in court and not the other. In a large state it may not be an issue, but for a small state it can be a huge problem. Vermont has a GDP of 27 billion, which means they spend about 5 billion on health care. The most expensive 1% of medical patients use roughly 300k a year in medical care. If 5,000 of them move there it’ll bankrupt the system. Of course many of them are on medicare and medicaid, but a true single payer system would have more choices than medicaid and less copays than medicare. ---
**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, 9:12pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/55 "2019-05-23T21:12:47Z")
> [@Max\_S](#): > > 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 And it will be easier. After the transition period, all your regular patients will be fully covered. New patients will have to be checked against the government’s enrollees database and a note placed in their file. ---
**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, 9:24pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/56 "2019-05-23T21:24:40Z")
> [@Wesley\_Clark](#): > > In a large state it may not be an issue, but for a small state it can be a huge problem. Vermont has a GDP of 27 billion, which means they spend about 5 billion on health care. > > The most expensive 1% of medical patients use roughly 300k a year in medical care. If 5,000 of them move there it’ll bankrupt the system. Of course many of them are on medicare and medicaid, but a true single payer system would have more choices than medicaid and less copays than medicare. I feel like that shouldn’t be a problem if Medicare pays first. But I don’t have any cites. ~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, 9:33pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/57 "2019-05-23T21:33:33Z")
> [@CarnalK](#): > > And it will be easier. After the transition period, all your regular patients will be fully covered. New patients will have to be checked against the government’s enrollees database and a note placed in their file. I’ve never heard of an insurance plan that pays 1% of the bill one day after enrollment, 20% of the bill after so many weeks, 100% of the bill after so many months… this “transition period” is complicated. Patients won’t be able to say I’m covered or I’m not covered, they will have a card but the card does not mean they are covered. Doctors won’t be able to lay off their benefits staff who need to figure out whether the patient is “really” covered or not. Even if the state pays upfront and collects from the patient on their own, the patient still might have a false sense of how the system works until suddenly they have a hefty bill. ETA: How is this materially different than offering multiple insurance plans based on duration of residency? ~Max ---
**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, 9:54pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/58 "2019-05-23T21:54:08Z")
May I be sarcastic? If the US ended the War on Drugs, it would have about $51 billion annually to spend on health care. ---
**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 24, 2019, 12:35am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/59 "2019-05-24T00:35:58Z")
> [@Slash1972](#): > > 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. We have those already. They’re called “driver’s licenses” and, for those who don’t/can’t drive, “state ID” which is the same thing minus the bit that says “authorized to drive vehicle”. ---
**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 24, 2019, 12:56am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/60 "2019-05-24T00:56:10Z")
> [@Broomstick](#): > > We have those already. They’re called “driver’s licenses” and, for those who don’t/can’t drive, “state ID” which is the same thing minus the bit that says “authorized to drive vehicle”. True, but I’ve never been one to say that getting one of those IDs is some onerous burden. [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=2) [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=4)