The problem with a 'each state do their own thing' solution is the very problem with health care in this country in general - the freeloader problem.
If California implements a single payer system, it would make people in other states more likely to choose not to get healthcare; if they get sick, they can just move to California.
This is the reason the ACA has the 'individual mandate' to go along with preventing the denial of care because of pre-existing conditions - without some coercive force, there is no reason to buy health care until you get sick.
This is why a national single payer system is the solution.
I'm not convinced this is insurmountable. How do countries with single payer handle this?
Surely you could require an newly established resident who wants treatment to pay a portion since they hadn't been funding it directly via taxes, and then add a further penalty if they move back out of state within a certain period of time (to discourage moving in-state just for treatment).
Countries like Germany don't have this problem because they have the power to control their borders. Accessing Germany's healthcare system requires being a German resident. That, in general, requires applying for immigration, which the government may or may not grant. EU citizens can, of course, become German residents without applying for immigration, but every EU state has universal healthcare so there is no incentive to free-ride.
And there's a push within Germany and other countries to limit access to welfare benefits for new residents, even ones from other EU countries: https://www.theguardian.com/world/2016/oct/12/german-governm.... U.S. states don't have the power to do that.
The German benefits the article talks about are not health insurance (but rather things like welfare for unemployed). It is not considered a benefit, it is considered an insurance. In fact, health insurance laws make (apart from some edge cases) no difference based on nationality or type of residence. If you become a member of a health insurance fund (which you are required to if you work in Germany) you are fully covered from day one including pre-existing conditions. Plans to change that are not even on the horizon.
But you are of course right, it's not possible to simply move to Germany just to receive treatment under health insurance. To become member of a health fund you need to fulfil certain conditions, e.g. by starting employment. This applies even to German citizens moving from abroad.
This is a really good question. The most recent case I could find here is the one Rayiner cited, Saenz v. Roe. If you read it, both the opinion and the dissent grapple explicitly with college tuition.
The reasoning goes, it seems, that only bona fide citizens of (say) California will consume welfare in California (you don't move to California to consume California welfare benefits in Ohio). But college education benefits are "portable"; you could conceivably move to California solely for the purpose of accumulating the benefits of a UC education, then take it back with you to Ohio.
Further, the way in-state tuition benefits are structured, the residency requirement is (supposedly) carefully tailored to address just that scenario, by imposing relatively short durational requirements on residency, rather than evidence of permanent residency.
It's tricky to piece out how health care would fit into this rubric. Depending on the condition, you might move to California to benefit from their health care and return to Ohio when you're cured, or you might need to stay in California indefinitely to treat a manageable illness.
This is interesting; I wasn't aware of this particular ruling. That would make running a universal healthcare program on a state-by-state basis very difficult, if it in fact applied.
It isn't insurmountable, it basically comes down to having to choose to deny care to someone.
However, it is really hard to do it in a fair and humane way; to deny care to people trying to freeload but not deny care to people who aren't.
The whole point of universal, single payer, healthcare is to avoid having to make this determination.
This isn't an issue for a country because the number of new residents (immigrants) is not a large percentage of the total number of citizens. If it was a state, though, that ratio might not work out; there is a VERY large pool of possible 'freeloaders' who are legally allowed to move to the state whenever they want.
In Canada, generally you have to be a legal resident (i.e. hold a valid immigration status, not just limited to permanent resident or citizen) of the relevant province, and actually living there for a majority of the time, before being eligible for coverage under the province's health plan.
This problem is exactly why a single payer system would fail entirely, imagine if you could easily be a freeloader without having to move at all?
I don't think the US has the same demographics as the other countries where this currently appears to succeed. There are way more people who can't pay in the US, we're far too big for this.
If California implements a single payer system, it would make people in other states more likely to choose not to get healthcare; if they get sick, they can just move to California.
This is the reason the ACA has the 'individual mandate' to go along with preventing the denial of care because of pre-existing conditions - without some coercive force, there is no reason to buy health care until you get sick.
This is why a national single payer system is the solution.