Ann Marie Marciarille has a pair of posts about Medicaid and expansion that I think bring up a very good point. The Medicaid expansion in slightly more than half the states has expanded eligibility from what is effectively a politically powerless and disenfranchised primary user base of children and poor women as well as elderly individuals in nursing homes, to a less disenfranchised and potentially politically powerful group of working poor. The working poor will never have as much power as the non-working rich, but they have some ability, especially at the local and state level, to organize and press for their interests.
A friend from Minnesota asks if I have heard of the “old” Medicaid rules on child support assignment being applied to “new” Medicaid ACA-expanded beneficiaties…..
Does this mean Medicaid’s more draconian aspects will finally see the light of day in public debate? Will the inclusion of working poor people create a constituency for a Medicaid program that does not dovetail with child support/medical support frameworks — like that found in Minnesota — apparently premised on the idea that Medicaid beneficiaries are getting something for nothing and payback is our mission?
As I have discussed elsewhere, we are conflicted about Medicaid so it is no surprise that the ACA is conflicted about Medicaid. Most particularly, the ACA does nothing to alter state discretion to seek state recoupment of Medicaid costs from Medicaid beneficiaries who received basic medical services through Medicaid at or after the age of 55.
No, I’m not talking about Medicaid recoupment of nursing home costs but, rather, recoupment of basic Medicaid medical costs. This, in some states, is old hat. California, New York, Massachusetts and others have been recovering funds from the estates of 55+ Medicaid beneficiaries who received basic health services under the program for decades. But now that the reach of Medicaid in these Medicaid expansion states is broadening Medicaid eligibility to greater numbers of citizens with assets (read: the family home) the tension between Medicaid’s historical status as a program where, to some extent, the benefit is returned to the government and its re-invented status as the health insurance provider of last resort for those too poor to shop throught the exchanges is made manifest.
These types of rules have been put in place as part of the favorite American game of determing who is and is not part of the deserving poor. Those rules applied to Medicaid when it was truly the poor person’s program and not a broad based payer of last resort. To some, anyone who qualifies for Medicaid, even with the income eligiblity expansion is a “loser” who deserves random harrassment, but beyond those assholes and sociopaths, it is harder for the American voting public (which is quite different and generally more privileged than the general public on a variety of measures) to see the value of harrassing people who they either know or could have seen themselves to be.
Phylllis
I recall when recoupment began here in SC back in the mid-90’s. Even then, it made no sense to me. Was the state going to hire real estate agents to sell all these homes? Were they going to rent them out? And considering the majority of senior citizens accessing Medicaid were folks who lived in not-very valuable homes in stagnant-growth rural communities, it made even less sense to me.
In other words, the state is going to create a entirely new agency/infrastructure to manage recoupment of assets that are not likely to even net them .30 cents on the dollar? Okay.
Citizen_X
No such thing! The JobKreaterz work 1000 X more than errbody else, they deserve that money!
low-tech cyclist
Normally, I’m ready to jump on any program that picks on the poor at the same time as it’s trying to help them, but this is one place I’ll make an exception. It seems a fair bargain to me to recover from a decedent’s estate the benefits they received during life.
It won’t hurt the beneficiary of the government program, that person is dead already. Just don’t make them jump through so many hoops while they’re still alive, and I’m good.
JPL
Well, if they had money in the first place, they would transfer ownership in the family residence to their children. Some things are only available for the wealthy though.
Bobby B.
There were a lot of “deserving poor” in France before 1790 or so.
SatanicPanic
@Phylllis: Probably just auction them off. States have to divest themselves of property all the time, so the infrastructure is in place.
Kay
I think that has done way more good than harm. It’s about the state collecting any available contribution for poor children, so I don’t kid myself that it’s benevolent on their part, but people really should pay child support. A lot of times the REASON these families are under 150% of poverty so eligible for Medicaid is they need child support from an absentee parent and they aren’t getting it. A lot of times the people who go in to get food stamps or Medicaid and are then evaluated for child support had no idea how to go about establishing parentage and applying for child support. They’re not the kind of people with access to lawyers.
I always thought of it as pretty cut and dried, not a moral judgment at all but a practical thing, particularly because it doesn’t just apply to poor people. If you’re a parent and you’re an obligor on child support you also get a medical support order. You can satisfy that obligation with private insurance if it’s available to you, but everyone has the same obligation and that’s been true since well before the health care law.
aimai
@Kay: Isn’t this somewhat complicated by the fact that child support from a hostile or dangerous parent can lead to abuse of the custodial spouse and children? Sometimes women don’t want to identify the father of their children because of issues like that.
Matt
Unrelated, but I lol’d:
Human Fedora Hat Would Like Women He Harasses On The Street To Be Nicer To Him
Eric U.
@low-tech cyclist: I’m fighting with this now, since my brother is in medicaid paid care and is going to receive too much of my mother’s estate for the pitiful $2k asset limit. Other than the rather stark possibility that he will lose his care and be homeless, this doesn’t really matter to me. But what I have seen is that this is just another way that poor people are kept that way. Congress is supposed to be raising the limit to $50k. Would be nice, I wouldn’t be working so hard if that were the case. Not sure what the holdup is, but I’m sure it’s “deficit hawk” grandstanding.
negative 1
Not to be a cynic, but if anyone thinks that knowing a person who struggles increases sympathy towards the plight of the disadvantaged in general then I’ve got some Single Payer to sell them. From my experience, all it does is increase a person’s self-regard in comparison to that of their acquaintances.
aimai
@negative 1: Its not that people will “know someone” its that these rules will have an appreciable impact on family members–even close family members. Nothing makes American voters angrier than thinking that they might get dinged by losing money they are expecting to get on the death of a loved one. The commentary online from people realizing that their parent or siblings health insurance status may take a bite out of their inheritance makes this pretty clear.
Mnemosyne
@Eric U.:
You can set up a special needs trust for your brother. Call a lawyer right away, preferably one who specializes in Medicaid. It will cost you some money up-front, but it will prevent your brother from losing his assets. My friend at work just finished setting one up for her disabled mother.
Kay
@aimai:
It is complicated by that, but that’s a tiny portion of a large group of people who go through a fairly routine process that has done an enormous amount of good. It depends on the state of course but there are all kinds of avenues to avoid the situation you’re describing. Too, honestly, the solution for people who are afraid of other people isn’t that they give up any support for their child and hide, just as a matter of course. That’s a last resort for a dangerous situation, not the default.
The scenario I run into much more often with really young women is they don’t ask anyone for any help with the child, because they have the idea that they shouldn’t have gotten pregnant and therefore don’t deserve to “ask” for support because they got themselves into this. I see that much more often than any shaming going on at Job and Family Services, where they tend to take a much more hardheaded and practical view of these things.
aimai
@Kay: Thank you for this–and for the work you do!
Frankensteinbeck
I wish I had your faith about this. I’ve seen too much evidence that conservatives will gladly shoot themselves in the face if it even wings the black guy behind them.
Eric U.
@Mnemosyne: I’ve seen a lawyer and am working on the trust, but since everything is being held up by the fact that our mother didn’t have a will and so there is no money available now makes it less pressing. There are a couple of good organizations in Virginia that maintain pooled trusts.
His assets aren’t that important, but if he has too many it makes it really complicated
cckids
@Eric U.:
This. We’ve had to exempt our oldest son (he’s seriously handicapped) from our life insurance, had to explain to our parents that they CANNOT leave him any money, etc. Not that there’s a lot either way, but it is one more hoop to jump through. And we are educated & know about this stuff. I’m sure there are people out there to whom this comes as a considerable shock, when it is too late.
Though I agree that there should be some “look-back” period, or something, that will prevent people from just dumping Mom on Medicaid so they can get the house & a bigger estate.
My spouse does estate & financial planning, and the number of people who have a “plan” to get themselves or their parents onto Medicaid so as to have a bigger estate is just amazing. First, it is not as easy as Republicans want you to believe and second, good luck finding a decent nursing home that takes Medicaid. It is a much bleaker prospect than they think it is.
Steeplejack
Misspelling in the title (and throughout). Five points off your usual excellent post.
Phylllis
@Kay: At least in SC, if the parent opted not to cooperate with child support enforcement wrt Medicaid, the penalty was to exclude them from the household count when calculating their income for eligibility. @ 185% of poverty, I can recall maybe a handful who ended up not eligible because of it.
Corner Stone
@low-tech cyclist:
I completely disagree with this assessment, and can not state forcefully enough how wrongheaded I think this view is.
Eric U.
@cckids: the organizations in Virginia we talked to that do special needs pooled trusts charge something on the order of $1000-$1500 to set up a trust. Then if it’s not funded, you can keep the trust in place for a small yearly fee. If it is not funded by the person themselves, the fund can be passed on to others when the beneficiary dies. This has been federal law for a couple of decades now. I assume some people just leave instructions in their will to set up the trusts and don’t bother to do it ahead of time.
It was like pulling teeth getting this information. In fact, my father went to a lawyer that didn’t know about these trusts and so he didn’t leave my brother anything. It’s really frustrating now that I know about the trusts. My mother made my brother a beneficiary on anything she could, so that’s just another complication.
Mnemosyne
@Eric U.:
I think the dollar amount of the inheritance for my co-worker’s mother was something like $10K, but it would have been just enough to screw everything up with her current benefits, so they ended up having to put it in trust.
Kay
@Phylllis:
Thanks, they all know about it so there’s probably a portion who avoid the whole issue by not going to get food stamps or Medicaid but I do see the sense in it. As far as the parentage, making a decision NOT to determine parentage should at least be a decision and not just “I don’t know how to do it or who to ask”. I don’t know if it just appeals to my sense of order or what, but it seems like we could figure out who everyone’s parents are without turning it into a big shaming session.
This stuff is important. There’s a whole side of the family there, relatives, history for the child, not to mention when he or she wants to be President and has to produce a birth certificate with a raised seal and field all kinds of questions on the father :)
Matt McIrvin
@low-tech cyclist:
What?!!!! You do realize that these are families who have essentially nothing? Nobody’s socking that money away. It’s a recipe for eternal debt peonage.
PhoenixRising
In my state at least, CHIP Medicaid has no asset test–children whose parents can’t afford private insurance are presumed not to have a yacht they can sell, I’m guessing.
It’s been astonishing to hear the replies when we tell people that our kid is Medicaid-eligible due to the ACA. (Income from the year I had cancer was the determining income, there is no asset test, and the Blues plan that covers both parents isn’t allowed to accept a child who is eligible for a state-funded plan for an additional premium, which would have been financially better for us because 1 deductible amount.)
The process is designed to be demeaning, intrusive, extremely inconvenient and inscrutable. State workers have told me that we’re required to apply for welfare to get the coverage, that there is an asset test, and that our neighbors may be asked to verify our household’s members (none of which are true).
Dragging as many small business owners through the door of the welfare office as this does–it’s got unlimited political upside, and while I’m personally inconvenienced by it I think it’s a good trade.
Groucho48
I’d be interested to see how much it costs to run this Medicaid recoupment thing vs. how much is actually recouped.
low-tech cyclist
@Eric U.:
My wife and I are in the same boat with her 90 year old grandmother who’s on Medicaid and in a nursing home, and it really is a pain.
But again, that’s a hoop we have to help her through while she’s alive, just like with your brother, and I agree that there are too damned many of those. We don’t have a problem with Medicaid claiming what few assets she leaves behind once she dies, in exchange for ~$85K a year of nursing home care.
@Matt McIrvin:
How’s that? If these families have essentially nothing, then they lose essentially nothing when Medicaid claims the essentially nothing that the deceased Medicaid beneficiary left behind. And that’s the end of it. Where’s the debt peonage?
@Corner Stone:
OK, but can you explain the reason you disagree? Otherwise, we’re in Argument Clinic territory here.