Since I published my previous diaries on Medicaid Estate Recovery and its implications for those of low income ages 55-64 who sign up for coverage through the Affordable Care Act and end up on Medicaid, I have received email with personal stories and state-specific information from people across the country who are being affected by this. Thanks to everyone who has written me.
Thanks to these fine folks who are doing their best to track down what is really going on with estate recovery, I can report that so far, at least 2 states have taken action to prevent estate recovery from going after the estates of newly-eligible 55-64 year olds enrolled in Medicaid through the ACA: Oregon and Washington.
Unfortunately I have to report that so far, I have not gotten any meaningful responses at all on this subject from my Congressperson, my Senator, or the White House, despite having contacted them about this issue some months ago.
In one news story, it was reported that the administration would issue some kind of clarification about estate recovery - "after January 1st."
That's pretty distressing, in that millions of people were having to make decisions about their participation in these programs before January 1st.
Also of course it is now January 20th and to the best of my knowledge, nothing has been heard on this yet from the federal government.
So let's get into the questions this raises:
Medicaid Estate Recovery is not terribly effective as a way to pay for Medicaid. According to factcheck.org, "The total recovered was 0.13 percent of total Medicaid spending for the year."
The most frequently given reason for why we should have estate recovery at all is not that it is a good method of cost recovery, but that we must prevent people from "gaming the system." People concerned about this ask: why should some very rich person get Medicaid and be able to shelter their assets? The logic is that that person's assets should at least be able to be collected against when they die.
However, with the ACA and the end of the asset test for enrolling in Medicaid, there is no longer any element of "gaming the system" for many people who have assets but have a low income. The intent and structure of the ACA is that these people should be enrolled in Medicaid.
But the ACA did nothing about estate recovery. So now, if you are low income, and 55-64, and have assets, and live in a state whose estate recovery rules include recovering for all health care expenses the state spends on you, including monthly "capitation charges" just for being enrolled - you may have just been swept into a system that entitles the state to your assets upon your death.
This is profoundly distressing to a lot of the people who are affected. If you have lived in poverty or on the edge of poverty, you know that the presence or absence of those assets of yours, in the lives of your heirs after your death, can make a profound difference to their health and safety, not to mention their choices in life.
And if you have worked for health care reform, and watched your friends and neighbors, who may make only slightly more money than you do, get subsidized health coverage without endangering their assets, your sense of betrayal may be profound.
So there are reasons to fight for fairness here. And fairness is exactly what we do not currently have.
We know that Oregon and Washington have issued "emergency regulations" saying that estate recovery will not apply to new Medicaid recipients enrolled through the ACA.
(Why this was an "emergency" when the laws were all on the books years before they issued these regulations last month, I don't know, but at least they did the right thing.)
Not so, according to my correspondents, in California. There estate recovery applies.
Let's also point out that if you are married, the Federal Poverty Level (per person) is lower. Thus people who are married can qualify for subsidized coverage they could not get if they were single. A couple in WA state got married for this reason last month, and their story made a splash in the news.
So single people are penalized in this system. Especially, I suspect, single women, since women still enjoy disproportionately low pay.
So: Why isn't this being addressed by the federal government? Why is it OK to take the house of a woman in CA but not her sister in Oregon, although they may have received the same kinds of medical care, all of it paid for by the same federal program?
And another question: where will the money go? From what I have read, states are supposed to pass on to the federal government the portion of money recovered that is due to money spent by the federal government. If the ACA has the federal government paying for 100% of Medicaid expansion for 3 years, slowly moving down to 90%, then the lion's share of money recovered by these states for ACA Medicaid enrollees actually should go back to the federal government.
That means it really should be up to the federal government to say: no, we don't want you to do estate recovery on people enrolled through the ACA.
Or is there some exception somewhere, do the states get to keep the "capitation charges" or some other portion of the money? And a larger question: will any of these agencies really be able to keep track of people's assets and who paid what and which entity should be reimbursed for what out of whose estate and why - for decades?
So those are tonight's questions. Thanks for sticking with me through this!