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Comment by hagy | Hacker News Reader

I think the best approach is for the US to move more concerns to the state level. E.g., it would be great if states would start implementing their own universal healthcare for their residents.

States commonly have more internally aligned political goals and therefore can move quicker. It also has the benefit of allowing different states to experiment with different solutions and all states can learn from the results.

Lastly, inter-state mobility is much higher than inter-country and this will allow residents to congregate in a state that matches their political desires. E.g., if someone doesn't like the tax burden of states that provide more services then they can move to a state that provides fewer.

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Trivial inter-state mobility is a big obstacle for states doing grand social programs individually.

If a state provided universal healthcare for residents, it'd quickly be overwhelmed with "hard cases" from other states where coverage is a problem. Which would drive up costs, and taxes, and drive productive/healthy people out.

See the current inter-state shipping of homeless people, especially those who suffer mental illness, that is often done via bus tickets paid for by local governments looking to shed those people.

People also want trivial inter-country mobility.

Canada it is a "state"/provincial system. All provinces manage their own. Canada doesn't get inundated with Americans because if they do come, patients will be charged like private health care. If the patient's home province has universal health care, both province's will just work it out.

In general, we don't dump problems on to other provinces. It's bad form and federal courts will fix that quick especially with so much money on the line. If Florida state sends patients to a universal health care NY state for care, you can bet, NY State will be suing either residents of Florida for medical bills or Florida State directly.

Americans going to Canada for care is a totally different thing, and not relevant to my prior point.

All of Canada has universal healthcare, which again makes Canada a completely different discussion from my earlier comment. There isn't the kind of huge discrepancy between provinces as we'd have if some US states had universal healthcare and some had the status quo.

To your argument about states suing one another - we literally already have localities giving mentally ill people bus tickets out of state, and that's been unable to be stopped via the court system. I'm not dealing in hypotheticals here, I'm talking about things that already happen.

> In general, we don't dump problems on to other provinces. It's bad form and federal courts will fix that quick especially with so much money on the line. If Florida state sends patients to a universal health care NY state for care, you can bet, NY State will be suing either residents of Florida for medical bills or Florida State directly.

That was kind of the point OP was trying to make - in the US there are quite a few states that would do this without blushing. Without the Federal government instituting a framework and legal mechanism to prevent it, there is no way any individual state can do it on their own.

The system here only works because the Canada Health Act requires every province to have a universal health insurer for provincial residents and mandates each province accept the insurance of the others. If only Ontario had a provincial insurer or the provinces didn't have to accept each other's programs there would be a ton of game theory style manipulation.

Any state trying to implement a single payer system would get crushed as tons of individuals and even other states tried to milk the system (like putting homeless people on a bus with a one way ticket).

States would need a "suicide pact" of sorts to ensure a bunch of states made the leap at the same time. There actually is such a plan to subvert the electoral college to ensure the popular vote winner always wins the presidency, but that's a relatively simple pact around single law. Health care laws a incredibly complex and rather than try some kind of weird multi-state pact you're better off fighting for a national law.

it would be great if states would start implementing their own universal healthcare for their residents

This isn't really feasible because residents of one state with no universal healthcare + lower taxes could easily move to another state with universal healthcare + higher taxes when they get a serious illness.

Full benefits could phase in over time. You could get increasing discounts on public services until you reach full state membership. This would be no different than out of state school fees.

The Supreme Court has ruled ideas like this unconstitutional.

https://www.latimes.com/archives/la-xpm-1999-may-18-mn-38325...

Just another example of the failures of the Constitution in the modern era. The Federal government is the only one that can reasonably do Universal Healthcare, or any kind of economic stimulus in crisis, but it fails. States are powerless to try to fix it on their own.

Durational-residence requirements still exists. E.g., paying in state vs. out of state tuition at a state university, which commonly requires a year of residency. [0, 1] State-provided healthcare could be provided in a similar fashion through state-administrated health insurance that has different rates for in state and out of state. There could be a durational-residence requirements for in state pricing.

[0] https://repository.law.umich.edu/mlr/vol104/iss3/5/ [1] https://www.law.cornell.edu/constitution-conan/amendment-14/...

From footnote [1] which you generously provided:

"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"

It's obviously hard to know for certain what SCOTUS will do, but under that standard it sounds like having health care benefits only available to long term residents would be on very shaky legal ground.

The trivial solution is to tie residency to property ownership or property lease, and payment of property tax. Then use the prop tax to pay for the health care, because almost all health care is local anyway. Have the hospital or clinic or whatever bill the municipal taxing authority wherever you live; for most people the house you live in.

Determining residency is not rocket surgery; could steal the entire system from state income tax codes.

Accounting details like that do not address the Constitutional concerns.

You can have residency requirements. In Canada you have to be present in most provinces for half the year and live there for a certain amount of time before you get free health care.

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