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Regulation and Compliance > State Regulation

5 creepy thoughts about interstate LTC migration

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The United States is one big happy country — but a public college in one state can charge students from another state a high out-of-state tuition rate.

Domestic travelers may have trouble getting hunting and fish licenses outside their home states.

Other countries have imposed famous limits on internal migration, especially by poor people. When Adam Smith wrote Wealth of Nations, the bible of capitalism, one of the villains in the book was an 18th century system that required poor people in England to stay in their home parish.

A team recently looked at the relationship between interstate migration and public long-term care (LTC) in a report prepared for the executive office on aging at the Hawaii Department of Health.

The team looked at interstate migration in connection with an analysis of the feasibility of setting up a limited-benefit long-term care (LTC) benefits program. Hawaii has been considering the idea of setting up its own public LTC program since at least 2012. 

A lawmaker in California recently introduced a bill that calls for his state to conduct a similar public LTC program feasibility study.

The analysts described the pros and cons involved with setting up a public LTC program, and they also talked about an issue that faced major medical insurance regulators before the Patient Protection and Affordable Care Act (PPACA) commercial health insurance market requirements took effect: The difficulty of offering either richer benefits or lower costs than other states.

Concerns about the effects of migration across state lines could help shield insurers in the market for setting up their own public long-term care insurance (LTCI) programs.

For some of the details about what the analysts said about LTC-related moves from state to state, read on.


1.  The Constitution limits state efforts to shut newcomers out.

“The privileges and immunities clause of Article IV of the Constitution states: ‘The citizens of each state shall be entitled to all privileges and immunities of citizens in the several states,’” the analysts in Hawaii note.

In an 1868 case, Paul vs. Virginia, the U.S. Supreme Court ruled that the provision relieves citizens moving from one state to another “from the disabilities of alienage in other states.”

See also: 12 worst pieces of tax advice from financial planners 

Man with a big fish

2. Interpreting the privileges and immunities clause is complicated.

The analysts say there have been many court cases involving the provisions. “The sense of these cases is that the clause protects the basic rights of a person who goes from one state to another to travel, transact business or live,” the analysts say. “It does not necessarily protect ‘non-basic’ rights such as the right to a hunting or fishing license.”

Because a long-term care program meets a basic need, it “is not likely to be seen as a fringe program or one in the realm of recreation or conservation,” the analysts say. “There are grounds for legitimate concern that any program created which dramatically restricts benefits to persons who came to Hawaii from elsewhere in a way not parallel to the provision of benefits to Hawaii residents would be subject to a serious challenge on the basis of denial of fundamental rights. In principle, any policy provision intended to deter migration for purposes of claiming long-term services and supports should treat old residents of the state and new residents the same.”

See also: Top 10 states with improvements in older people’s independence


3. Experts aren’t sure whether any differences in welfare benefits, let alone LTC benefits differences, affect interstate migration

In Hawaii, the analysts note that some authors see little welfare gap effect on migration, and that others see substantial evidence of welfare-driven migration. 

Newer, better-designed studies “showed very substantial attraction from welfare differences,” the analysts say. 

See also: 5 ways the state (might) help your older client stay home

Nice young couple

4. Interstate migration patterns already differ from state to state.

Hawaii can be an isolated, expensive place to live. From 1995 to 2000, it lost 201,293 residents to out-migration and gained 125,160, for a net loss of 76,113 people. Now, the state is attracting about 17 people more than it loses per day, and many of the newcomuters have high socioeconomic status.

Some young people move to Hawaii for jobs, but many older people retire in Hawaii, and about 69 percent of those people say they would prefer to stay in their homes as they age, the analysts say. 

See also: Home care planning: 4 things LTC planners should know about the new regs


5.  The analysts believe a state can use a vesting period to control access to a public LTC benefis program.

If anyone who participates in the program stays in it, and earns a “stipulated share of a program benefit for each year the individual has been a ‘member’ of the program, that procedure should be consistent with federal equal treatment standards, the analysts say.

The vesting period protects both against predatory benefits migration and constitutional challenges, the analysts say.

See also: Obama administration working to save CLASS


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