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Comment by brookst | Hacker News Reader

Playing to win is dead. Current climate is play to kill yourself, so long as your opponent also does but suffers more.

I'm somewhat hopeful with Gavin Newsom's posture making an example, I wouldn't vote for him, but I like the aggressive PR position he's taken, his willingness to gerrymander just as the other side has been doing forever. That's what I mean by bipartisanship is dead. You can't negotiate with the other side, they do not want to negotiate, they want to win at all costs for ideology, so you can only do your best to disempower them. If you try to play fair with a counterparty who does not believe in acting in good faith or playing fair, you have default lost. You can't have a functional democracy when one side rejects democracy (massive efforts to disenfranchise voters, gerrymandering, etc) because they can't win democratically. There is no reason you can't have empathy while punching down at bullies, because if the tables were turned, the bullies would put their boot on your neck ("paradox of tolerance"). So, start punching down.

Edit:

In the context of this topic and the near term, this looks like blue states implementing universal healthcare, and letting red states figure it out themselves (considering how dependent red states are on the federal government [1] [2]); Oregon is up first [3]. You can increase state taxes to fund this, reducing tax dollars sent to the federal government, if properly engineered.

[1]. https://time.com/7222411/blue-states-are-bailing-out-red-sta...

[2] https://usafacts.org/articles/which-states-contribute-the-mo...

[3] https://www.hcfawa.org/oregon_s_path_to_universal_health_car...

> In the context of this topic and the near term, this looks like blue states implementing universal healthcare, and letting red states figure it out themselves…

The risk here will be sick people (and their high costs) moving. As with how Chicago's illegal gun problems mostly come from Indiana.

We already deal with this problem in higher education by having out-of-state tuition and in-state tuition priced at different levels. A period of residency is required to access in-state tuition.

Does residency fraud exist? I'm sure of it. Despite the UC and CSU systems not publishing residency fraud statistics, such fraud is universally described as being extremely difficult to execute. I cannot overstate this point. Students routinely depict residency fraud as being more difficult to do than simply paying out of state tuition. The high cost of committing residency fraud makes cancels out any expected payoff. Furthermore, most instances of detected fraud appear to be technical and clerical errors, not intentional deception.

What are in-state residency requirements, and how difficult is the requirement? Evidence for residency includes:

- Obtaining a California driver’s license or ID card

- California vehicle registration

- California voter registration

- California state tax returns

- California bank accounts

- Employment in California

- Lease, mortgage, or property ownership in California

- Severing residential ties to your former state (e.g., closing out-of-state bank accounts, surrendering non-CA licenses)

Additionally, one year and one day of residency is commonly the required threshold to qualify for in-state tuition.

The question becomes, is this effective enough at reducing fraud rather than can fraud be eliminated. I'm sure, like with any system, fraud detection and remediation are part of the operating costs and measured in terms of recovery rate/rate of return - the KPI we're discussing.

I'm not talking about fraud, though. I'm talking about genuinely moving.

It is fraud to move to California for the sole purpose of education[1]. Likewise, genuinely moving to California for the sole purpose of benefiting from universal healthcare is also, in my opinion, fraud.

People genuinely moving to California would presumably pay out of state healthcare fees until their residency was established. Don't you agree that these fees could be set in a way that served as a barrier to doing what you suggest?

Is there a case that isn't covered by this that you're thinking about?

1. Cal. Code Regs. Tit. 5, § 54022 - Physical Presence. "Physical presence within the state solely for educational purposes does not constitute establishing California residence regardless of the length of that presence." https://www.law.cornell.edu/regulations/california/5-CCR-540...

That just means college students living off-campus don't suddenly get in-state tuition rates after a year or two.

Sick people are allowed to like California's weather enough to move there. The ADA would also apply when trying to restrict residency in a way it would not for education.

> Sick people are allowed to like California's weather enough to move there.

Perfectly fine. They shall pay out of state rates until they meet the threshold.

> The ADA would also apply when trying to restrict residency in a way it would not for education.

Can you elaborate? In the best case, it's difficult to predict how courts would rule on this. Any relevant case law? Legislation?

> They shall pay out of state rates until they meet the threshold.

I'm not arguing they'll move and obtain residency on day one. I'm arguing it may still make sense to move, pay out of pocket for the 366 days, and gain residency for some folks.

The ADA's Title II would seem to forbid "you can't be a resident, ever, if you've got expensive healthcare costs" sort of rules at the state level, yes? That would clearly not be equal treatment for people with medical disabilities.

> I'm arguing it may still make sense to move, pay out of pocket for the 366 days, and gain residency for some folks.

It's trivial to construct a threshold and out of state pay structure which cancels this case out. What number of days and out of state pay structure do you feel would cover these cases? How many of these cases do you suspect will occur annually and what is the projected cost? It's a relatively easy problem to solve once we get down to the specifics.

> "you can't be a resident, ever, if you've got expensive healthcare costs"

Great! I'm not arguing for "ever". I think we're in the clear here.

Edit: Let's estimate the volume of this effect using migration after Medicad expansion as a proxy. Over 10 years (2009 to 2019) we find 56,659 interstate moves after Medicaid enrollment growth[1]. In other words, 0.23 percentage points greater annual population growth in the target population. Another study found an in-migration rate(to CA) of 1.4% for medicaid recipients. Being generous and taking the higher of the two, and multiplying it by California's net immigration of 500,000–600,000 annually, gives us an estimated 7000-8400 medicaid migrants a year a fraction of which are migrating primarily for medical purposes. What would you estimate the annual medical expenditures for this group would be and if an "new arrivals" insurance pool was formed, what would the marginal monthly premium cost be to its members?

I estimate that a CA new arrivals insurance pool would have $4B in annual disbursements, and $4-20M in annual residency fraud. Using averages, we can estimate a monthly premium for this group would be about $667/month.

This is roughly on par with unsubsidized ACA premiums for adults in many states. For comparison, ACA benchmark premiums for a 40-year-old in California in 2024 are about $450–$600/month.

1. https://pubmed.ncbi.nlm.nih.gov/39893838/

2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4011649/?

I think there is a lot of time to flesh this idea out, California apparently has more people moving out than moving in at the moment.

Absolutely. While it was unsurprising to find that housing costs are now one of the biggest reasons for CA emigration. It's those who are lower income, and have just a high school education. Among high earners, working from home has a huge influence on emigration from California. Conversely, higher earners are least likely to move out of CA.

If blue states can build enough housing to welcome refugees from collapsing red states then great. Caring for people and building bigger concentrations of healthy people is a good thing, especially as the House is proportional to population.

This would be far more likely to concentrate non-healthy people, and all their costs. The needy in red states will move for access to care; the red states will see a healthier and cheaper population as a result.

I am willing to bet $10k to a 501c3 charity of the winner’s choice this doesn’t happen and that the thesis is deficient. Let me know if you want to take the bet, we’ll use Longbets.org to officiate.

Gonna gently suggest to you that someone who can go "I'll put $10k in escrow for a few decades over an internet comment" perhaps may struggle to understand the desperation of someone with a disabling chronic illness to get access to medical treatment. (And their lack of means to match such a bet, no matter their confidence in the position.)

On the contrary, I financially support several people who are disabled and will never work again (to bridge them until they qualify for age tested benefits). I bought a piece of land in the Midwest, and am building tiny homes for them one by one. I previously did a short stint as a Guardian ad Litem in Florida for disadvantaged children who needed an independent advocate, and I act as a patient advocate today for folks who need healthcare and have a hard time accessing it. My deceased mother could not claim Social Security disability while genuinely disabled, and I was first hand involved in the process to see how the system is built to prevent entitled beneficiaries from claiming disability benefits up to her early death at 60.

I am resourced (out of luck), but also high empathy and intimately familiar with the struggles you mention. The bet isn't only because I can afford it, but because I am so familiar with the data I know I'm right. This is why I am for universal healthcare, see no other path forward, and I hope this better explains the mental model my arguments in this context are based upon.

> The bet isn't only because I can afford it, but because I am so familiar with the data I know I'm right.

I mean, same position here. I just don't have $10k to sit in escrow for years. I've similarly got plenty of first-hand experience; one on Medicare and one on Medicaid in the family due to disability, and even with those and a reasonably well paying job we'd absolutely consider moving for a program as described.

Data-wise, we've already got quite a bit demonstrating that California's better-than-average social services are more attractive to homeless folks, to the point where they have ~25% of the country's population of them.

I'm also for universal healthcare. I just don't think doing it unilaterally at the state-level is likely to work very well with freedom of movement between states, as with gun control.

Most people cannot afford to move. 60 percent of Americans cannot afford a basic quality of life. Those who can move will move to states that can afford this, and are the economic engines of the US economy (California is the world's fourth largest economy, for example). Those who voted for this and don't believe in subsidized healthcare should stay where they are, as I presume they believe universal or subsidized healthcare is "socialism" they don't want. I support the rapid reduction of healthcare services in those areas [1].

I pay taxes (>$100k/year total state and federal tax burden), I support universal healthcare, and I am willing to pay more for everyone to be covered.

[1] https://ruralhospitals.chqpr.org/Overview.html

> Most people cannot afford to move.

That calculus gets a little different for some folks if the move comes with subsidized universal healthcare and better social services.

> Those who voted for this and don't believe in subsidized healthcare should stay where they are, as I presume they believe universal or subsidized healthcare is "socialism" they don't want.

We agree, but "The Only Moral Abortion is My Abortion" rule applies. https://joycearthur.com/abortion/the-only-moral-abortion-is-...

If you can’t change their mind, and you can’t change their vote, and rural voters die faster than urban voters because of lack of access to healthcare services, state universal healthcare is the best we can do until electorate turn over through rural age out can improve political outcomes. Until then, we are held hostage by the irrational and unsophisticated with votes, which is unfortunate but the reality of the situation.

It’s exhausting being dragged by low empathy unsophisticated humans frankly, I am personally over it. I was naive about human nature, hard lessons learned.

"and rural voters die faster than urban voters because of lack of access to healthcare services, state universal healthcare is the best we can do until electorate turn over through rural age out can improve political outcomes."

Is there any evidence that universal healthcare would address the facility and physician shortages in rural areas? It won't make much difference if you give people coverage if they still can't exercise that coverage, or just get subpar care in many rural facilities. It seems that many rural hospitals have turned into glorified helipads to transport many patients to bigger cities.

For example, the uninsurance rate for urban vs rural is only 1-2%. It seems like that wouldn't explain the larger gaps in health outcomes. It seemsbother factors would be more important.

Rural hospitals close because they lack funding. When they have funding, they can stay open and continue to retain medical staff. When they close, mortality rates increase. Can I prove universal healthcare would keep these hospitals open? Highly speculative based on what that solution would look like. I can only prove stripping Medicaid funding is going to close them, with the consequences enumerated.

https://www.nbcnews.com/news/us-news/rural-hospital-closings...

https://www.nber.org/papers/w26182

https://pmc.ncbi.nlm.nih.gov/articles/PMC9633454/

https://ruralhospitals.chqpr.org/

https://www.aha.org/fact-sheets/2025-06-13-rural-hospitals-r...

https://www.kiplinger.com/taxes/medicaid-cuts-and-your-local...

Medicaid reimbursement rates tend to be lower than the cost to treat in many instances. Only preserving Medicaid funding will not prevent hospital closures. We already know that with or without Medicaid, rural hospitals continue to close. The only difference is the speed at which they do.

The question was about some universal system preventing rural deaths. If the coverage difference is only 1-2%, then coverage doesn't seem to be the driver. If it's a provider and facility shortage, then we would need some strategy to address the provider shortage, even if we assume we can fix the facility issue by providing higher reimbursement rates or grants.

Can I give my perspective as a Canadian? In our political system, we rarely talk about bipartisanship. First, because we don’t only have two political movements. Second, because we do nonpartisan politics. Examples include judges and district boundaries. Those two things are qualified as nonpartisan in Canadian politics. Another very telling example: parliamentary tour guides. The US Congress hires tour guides that are meant to reflect the political party that is responsible for their hiring. The Canadian Parliament insures their guides are nonpartisan.

Of course if you dig you will find problems, it’s far from perfect. However, the fact that what is collectively outside the realm of partisan politics is not decided by two partners who need to agree is what’s important here. There is a collective tradition. With our judicial system able to give binding decisions on unwritten parliamentary traditions, you even have legal protection for nonpartisan politics.

The US system counted way too much on the kindness of political adversaries. You need to find a new way to do politics, because American conservatives have decided that they will abandon democracy rather than give up power.

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