# 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:** 4
**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 24, 2019, 1:14am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/61 "2019-05-24T01:14:30Z")
> [@Max\_S](#): > > 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. I really don’t understand the confusion here. Right now, when you go to the doctors office, they check your insurance and will tell you that there’s a copay, deductible or whether the visit is fully covered. That is exactly how this would work, with the possibility that both private and public would contribute to paying. After you’ve paid in for long enough, you will be fully covered (or whatever max the legislation calls for). That’s not complicated at all. > [@](#): > > ETA: How is this materially different than offering multiple insurance plans based on duration of residency? > > ~Max Well, the whole point of my scheme is to get around the fact that duration of residence qualifications are unconstitutional. To make it more bulletproof, I guess you could offer it to out of state people. ---
**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 24, 2019, 1:21am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/62 "2019-05-24T01:21:32Z")
> [@glee](#): > > May I be sarcastic? > > If the US ended the War on Drugs, it would have about $51 billion annually to spend on health care. Yeah but health care is 3.6 trillion a year at this point. We spend 2x as much per capita as other western nations because our system is so poorly run. 51 billion is a drop in the bucket at this point. ---
**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 24, 2019, 3:10pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/63 "2019-05-24T15:10:19Z")
> [@Pleonast](#): > > Which will be countered by the businesses moving into the state for the lower payroll costs. Since employer provided health insurance premiums are tax deductible and wags are not, payroll costs would likely be higher in any state providing single payer. ---
**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 24, 2019, 7:51pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/64 "2019-05-24T19:51:12Z")
> [@CarnalK](#): > > I really don’t understand the confusion here. Right now, when you go to the doctors office, they check your insurance and will tell you that there’s a copay, deductible or whether the visit is fully covered. That is exactly how this would work, with the possibility that both private and public would contribute to paying. After you’ve paid in for long enough, you will be fully covered (or whatever max the legislation calls for). That’s not complicated at all. OK, say Vermont passed its single-payer system, Green Mountain Care (GMC). Vermont found a way to fund it without tanking the economy, but the only viable model involves preventing new residents with expensive medical needs from sucking the program dry. So they pass a scale-over-time system as you propose: every month after enrollment, GMC covers an additional 1⅔% of the allowed amount, up to 100% after 60 months. The remainder of the allowed amount is subject to the patient’s other insurance, or if no other insurance is available, the patient is responsible. Assume that this holds up in court. Mr. Don T. Paytenson moves from New Hampshire to Vermont on 01/01/2020 and immediately visits the local Green Mountain Care office to declare residency and enroll in GMC. At the office it is explained that his name has been entered into the GMC system, however at first he will still be responsible for 100% of medical care. Mr. Paytenson is told that he must make sure his doctor accepts GMC (most do), and if they do the charges are subject to the GMC fee schedule. He is given a website address where the fee schedule is publicly available and a printout of common charges on request. He is told that all hospitals accept GMC. He is then told that GMC will not pay for his medical expenses at first, that the state will cover a small percentage of the bill and this percentage grows by 1⅔% each month. Until 02/01 Mr. Paytenson will be responsible for the entire bill up to the amount on the fee schedule. Starting 03/01 the state will pay 1⅔% of any medical expenses incurred that month, starting 04/01 the state will pay 3⅓%, starting 04/01 the state will pay 5%, etcetera. On or after 01/01/2025 the state will pay 100% of the bill. It is explained that Mr. Paytenson, or his private insurance, is responsible for the difference between the fee schedule amount and the amount paid by the state. Then Mr. Paytenson is given his GMC card and sent off on his way. It turns out, Mr. Don T. Paytenson didn’t pay attention but he has private insurance from his previous New Hampshire job that lasts until 08/31/2020, and that coverage was very good in New Hampshire. On 02/15 Mr. Paytenson establishes care with a new chiropractor, Dr. Hayt S. Billing (Dr. Hayt). During that first visit, Mr. Paytenson presents his GMC card and asks Dr. Hayt if that insurance is accepted. Dr. Hayt said “yes, let me check how much it will cost you”, then visits [gmc.vermont.gov](http://gmc.vermont.gov) and types in the GMC ID# from the card plus a new patient CPT code. The website responds saying Mr. Paytenson is enrolled and is responsible for 98⅓% of the GMC allowable amount while GMC will pay the rest. Dr. Hayt says “you just started out on GMC so they are hardly paying anything, and today’s visit will cost you $98.67”. Mr. Paytenson is shocked for a second before remembering that he still has his old insurance. He whips out his Anthem NH card and asks Dr. Hayt to check that. Dr. Hayt then calls the BCBS of Vermont provider line to verify benefits and eligibility for the Anthem NH coverage (that is how BCBS works, you call the local BCBS for benefits of an out of state plan). BCBS of Vermont tells Dr. Hayt that he is out-of-network provider and it will be a $50 out-of-network specialist copay, plus Mr. Paytenson has a $4000 out-of-network deductible for the rest of the year. Dr. Hayt in turn relays this to Mr. Paytenson by saying “it’s all going to your Anthem deductible, so this visit will cost you $98.67”. Mr. Paytenson becomes choleric as he has great difficulty understanding how come he has to pay almost $100 just to see the doctor when GMC is supposed to cover everything and even if it didn’t he only ever paid a $20 copay for his chiropractor in New Hampshire. Evidently Mr. Paytenson wasn’t paying attention when he signed up for the Anthem NH plan, either. Eventually Mr. Paytenson pays the $98.67 and sees the doctor. Later that day, Dr. Hayt goes to submit the electronic claim to GMC. I assume he does this from [gmc.vermont.gov](http://gmc.vermont.gov), puts in the member ID#, CPT, ICD-10, charged amount, and patient payment, hits submit, then calls it a night. Now there’s two ways the billing can go from here. Option 1) is that GMC pays the full amount upfront (minus patient payments at the time of service) and collects from the patient/insurers themselves. In that case, the claim also needs to include other insurance information. Dr. Hayt gets paid $1.33 within two weeks and GMC forwards the claim to BCBS of Vermont, who in turn forwards the claim to Anthem of New Hampshire, who marks $98.67 off Mr. Paytenson’s deductible. The whole process runs again backwards as Anthem of NH sends a remittance for $0 to BCBS of Vermont, who forwards it to GMC, who puts it in MR. Paytenson’s file. Option 2) is that GMC only pays what they have to and lets Dr. Hayt collect the rest. Within two weeks Dr. Hayt is paid $1.33 and the remittance says the patient is responsible for the $98.67 they paid at the time of service. Dr. Hayt S. Billing, who hates billing, must then make a CMS1500 claim form for $0, attach a copy of the GMC remittance, and send it all to BCBS of Vermont. BCBS of Vermont in turn forwards it to Anthem of New Hampshire, who marks $98.67 off Mr. Paytenson’s deductible. Anthem of NH sends a remittance for $0 to BCBS of Vermont who sends it to Dr. Hayt, who promptly throws it away and muses about how much time and paper was wasted and how little attention Mr. Paytenson paid. Things could be even more messy - if it were later in the year or Mr. Paytenson’s deductible might be met by the costs of this or a recent visit, Dr. Hayt would have to collect the $50 copay and _wait_ to collect the rest until Anthem of NH decided whether to pay. And if Anthem of NH decided the patient has an additional responsibility past the $50, under option 1) GMC would have to collect that amount from Mr. Paytenson, and under option 2) Dr. Hayt would have to bill Mr. Paytenson directly. My point is that this is complicated, and in my experience patients usually don’t pay attention to the details of their health insurance plans. > [@CarnalK](#): > > Well, the whole point of my scheme is to get around the fact that duration of residence qualifications are unconstitutional. To make it more bulletproof, I guess you could offer it to out of state people. I thought the state insurance was being funded by state taxes. How can you _afford_ to offer insurance to out of state people? ~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 24, 2019, 8:34pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/65 "2019-05-24T20:34:09Z")
You purposely made it sound as complicated as possible. I mean seriously, you decided a monthly increase of 1⅔% was the way to go in describing the imagined system? How about months 1-4 has 1% coverage, 5-8 is 25%, 9-12 75%, after a year 100%. Or something like that, rather than your needlessly complex formula. So when Mr P moves to Vermont, he is informed that there is mandatory enrollment in Vermont Health Co-op which phases you into full coverage over the course of a year so you should probably maintain your private insurance until then or try not to get sick. When he goes for his first doctor’s visit after being in state for 6 months, the receptionist runs his name and informs him that Vermont Health will cover 25% of his bill and asks whether he has other insurance to cover the balance or will he pay cash. That’s it. Once he’s been going to the doctor for a year, they won’t even have to look up the fact that he’s fully covered. Eta: I shaved it down to a year as that’s what most of those overturned welfare benefits waiting periods were. Same principles apply though. ---
**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 24, 2019, 8:54pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/66 "2019-05-24T20:54:23Z")
> [@CarnalK](#): > > You purposely made it sound as complicated as possible. I mean seriously, you decided a monthly increase of 1⅔% was the way to go in describing the imagined system? How about months 1-4 has 1% coverage, 5-8 is 25%, 9-12 75%, after a year 100%. Or something like that, rather than your needlessly complex formula. > > So when Mr P moves to Vermont, he is informed that there is mandatory enrollment in Vermont Health Co-op which phases you into full coverage over the course of a year so you should probably maintain your private insurance until then or try not to get sick. > > When he goes for his first doctor’s visit after being in state for 6 months, the receptionist runs his name and informs him that Vermont Health will cover 25% of his bill and asks whether he has other insurance to cover the balance or will he pay cash. > > That’s it. Once he’s been going to the doctor for a year, they won’t even have to look up the fact that he’s fully covered. > > Eta: I shaved it down to a year as that’s what most of those overturned welfare benefits waiting periods were. Same principles apply though. Yeah, cutting it down from 5 years to 1 year reduces the potential confusion; however, patients who didn’t pay attention will still have problems during the initial year of residency. I still think it’s more complicated than a simple 1-year residency requirement, and I don’t see a substantial difference between this and that. You are still conditioning 100% coverage on 1 year of residency, but now you are conditioning 75% coverage on 9 months residency and 25% coverage on 5 months residency. You are effectively offering three tiers of insurance and discriminating against citizens by the duration of their residency. Wouldn’t it be easier to just leave it at 1 year residency required? ~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 24, 2019, 8:54pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/67 "2019-05-24T20:54:46Z")
> [@Max\_S](#): > > I thought the state insurance was being funded by state taxes. How can you _afford_ to offer insurance to out of state people? Well, the idea there is to make it seem even less like a durational residency requirement. The coverage would only be for in-state medical expenses and the target customers would be people who frequently vacation in or plan to soon retire to the state. It would probably be legally kosher to charge them a little more than whatever the public health insurance premiums are being deducted from in-state payrolls. ---
**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 24, 2019, 8:56pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/68 "2019-05-24T20:56:41Z")
Of course it’s more complicated than a 1-year residency requirement! But as I thought you understood, that’s illegal! ---
**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 24, 2019, 8:57pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/69 "2019-05-24T20:57:31Z")
> [@CarnalK](#): > > Well, the idea there is to make it seem even less like a durational residency requirement. The coverage would only be for in-state medical expenses and the target customers would be people who frequently vacation in or plan to soon retire to the state. It would probably be legally kosher to charge them a little more than whatever the public health insurance premiums are being deducted from in-state payrolls. I don’t know… state residents wouldn’t have premiums and out-of-state residents would. That sounds like a clear violation of the equal protection clause to me. Taxes are exempt because states have the enumerated right to tax within their own jurisdiction. ~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 24, 2019, 8:58pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/70 "2019-05-24T20:58:41Z")
> [@CarnalK](#): > > Of course it’s more complicated than a 1-year residency requirement! But as I thought you understood, that’s illegal! If that is illegal, so is your more complicated proposal. You are doing the same thing three times over. ~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 24, 2019, 9:06pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/71 "2019-05-24T21:06:24Z")
No, you don’t know that. If my proposal was seen as a threadbare screen for durational residency requirements then yes, a judge would likely turn it down. But if it can be framed as a structure meant to buffer the economic viability of a health care project, which does not rely on residency at all, then it could get through. ---
**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 24, 2019, 10:16pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/72 "2019-05-24T22:16:39Z")
> [@CarnalK](#): > > No, you don’t know that. If my proposal was seen as a threadbare screen for durational residency requirements then yes, a judge would likely turn it down. But if it can be framed as a structure meant to buffer the economic viability of a health care project, which does not rely on residency at all, then it could get through. I could just as easily put in a 1-year waiting period from application to enrollment, and require mandatory applications for all residents starting 01/01/2020. ~Max ---
**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 24, 2019, 10:21pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/73 "2019-05-24T22:21:43Z")
> [@puddleglum](#): > > Since employer provided health insurance premiums are tax deductible and wags are not, payroll costs would likely be higher in any state providing single payer. Only by the payroll taxes on the former insurance withholding. The company is worse off only if it has been contributing little to nothing to its employees’ plans. I don’t know what the national norm is. ---
**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 24, 2019, 10:38pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/74 "2019-05-24T22:38:09Z")
> [@Max\_S](#): > > I could just as easily put in a 1-year waiting period from application to enrollment, and require mandatory applications for all residents starting 01/01/2020. > > ~Max See, now you’re actually addressing the question in the OP. Yes, that is simpler than my idea but might be a little more obviously a threadbare veil. “What is the purpose of the wait period?” a court might ask. ---
**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 24, 2019, 10:46pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/75 "2019-05-24T22:46:54Z")
> [@CarnalK](#): > > See, now you’re actually addressing the question in the OP. Yes, that is simpler than my idea but might be a little more obviously a threadbare veil. “What is the purpose of the wait period?” a court might ask. As far as I am concerned, the rationale is the same: > [@Max\_S](#): > > 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. In my opinion, if it fails on this ground, it is indeed impossible for a state to enact single payer and stay afloat. ~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 25, 2019, 12:03am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/76 "2019-05-25T00:03:59Z")
Well, you are clearly not a lawyer so maybe dial back the absolutes? Do you not think distributing other welfare benefits is a compelling interest of the state? You think medical care is more compelling than food? ---
**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 25, 2019, 1:30am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/77 "2019-05-25T01:30:04Z")
> [@CarnalK](#): > > Well, you are clearly not a lawyer so maybe dial back the absolutes? > > Do you not think distributing other welfare benefits is a compelling interest of the state? You think medical care is more compelling than food? I do think distributing other welfare benefits are compelling interests of the state. But unlike other benefits, medical benefits can involve very high costs within a short amount of time. One cancer patient could easily cost the state over $1,000,000.00 in medically necessary treatment within one year. There are _hundreds_ of people in this country who _need_ that sort of treatment _to survive_, but can’t afford it and are thus _dying_. If we introduce a system where people can move to a state and their medically necessary expenses are immediately covered, it is within reason to say the system must be prepared to accommodate or exclude such people. It is not within the means of small states to accommodate such people, not on their own. Thus they must exclude them, or fail to satisfy a compelling interest. ~Max ---
**Author:** ![Sitnam](https://avatars.discourse-cdn.com/v4/letter/s/6a8cbe/32.png) [@Sitnam](https://boards.straightdope.com/u/Sitnam)\ **Post date:** [May 25, 2019, 5:33am UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/78 "2019-05-25T05:33:02Z")
Despite obstacles and opportunities for fraud the private system is so corrupt I would bet (and Vote) for a chance to change it. If it’s even half as efficient it will be a change for the better. As a candidate I would DARE opponents to stand in my way. ---
**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 25, 2019, 8:45pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/79 "2019-05-25T20:45:00Z")
> [@Sitnam](#): > > Despite obstacles and opportunities for fraud the private system is so corrupt I would bet (and Vote) for a chance to change it. If it’s even half as efficient it will be a change for the better. As a candidate I would DARE opponents to stand in my way. Vermont did in fact pass a law authorizing the creation of a publicly financed insurance system. Unfortunately the government of Vermont under Gov. Shumlin, who spearheaded the thing, couldn’t work out a way to fund the program and gave up. ~Max ---
**Author:** ![elbows](https://avatars.discourse-cdn.com/v4/letter/e/b3f665/32.png) [@elbows](https://boards.straightdope.com/u/elbows)\ **Post date:** [May 25, 2019, 8:51pm UTC](https://boards.straightdope.com/t/if-a-us-state-enacts-single-payer-how-do-they-stop-out-of-staters-from-bankrupting-the-system/834384/80 "2019-05-25T20:51:14Z")
Why can’t you just set it for 25% coverage in the first two years of residency, and then graduating from there. After, say, five years you’re up to 100%. I still don’t get why all this stuff is SO, SO hard for Americans. Y’all show a card to collect air miles or shopper/loyalty points without a second thought! [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=3) [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=5)