Over at Health Affairs, I argue that Medicaid is an appropriate and available back-stop for counties that don’t have an Exchange insurer:
Instead, Medicaid is better suited as a reserve parachute for bare counties. Temporary Medicaid buy-in would be a useful tool for state regulators to improve the quality of plans offered in counties that otherwise would have been bare.
Medicaid Has More Flexibility Than Medicare
Medicaid’s programmatic flexibility is much more suited to adaptation for emergency coverage than Medicare and Medicare Advantage. Its core benefit design structure is more similar to current Exchange requirements. Medicaid is required to offer all 10 Essential Health Benefits (EHBs) as well as other benefits such as non-emergency medical transportation. Medicaid has out-of-pocket limits on cost sharing. Medicare is not required to offer all EHBs nor is total out-of-pocket limited in traditional Medicare.
rikyrah
Medicaid buy in – doesn’t it work only in states with a Medicaid expansion?
Gary G
Kudos on publishing on Health Affairs – big time!
David Anderson
@rikyrah: Nope, different set of waivers
Ohio Mom
Are there any exceptions to Medicaid attaching (is that the correct verb) the estates of individuals who benefitted from it?
I know that Medicaid is keeping track of every single penny it spends on my autistic kid. When he dies, whatever money he leaves behind will go to pay back Medicaid. He won’t be leaving much behind so Medicaid will not be fully paid back.
Is this also true for everyone who is being covered under the expansion? If so, is there going to be a backlash when people see they aren’t going to be able to finish paying off the car with their share of granny’s estate?
I don’t know what made me think of this all of a sudden.
David Anderson
@Ohio Mom: those are state specific decisions and they apply to people over age 55 as far as I know.
TomatoQueen
@David Anderson: My severely disabled son has been a Medicaid waiver recipient in Florida, Connecticut, and Virginia since approx. age 9. He’s 30 now. The recoupment from the estate clause has been printed on every app I’ve ever filled out for him, which is yet another reason to do some funky estate planning (special needs trust or whatever it’s called in one’s state) with advice from somebody who knows their stuff, as well as to avoid naming him as an heir anywhere for anything.
Kelly
Oregon only goes after the estate for long term care. They changed it during the Obamacare roll out after many newly qualified folks balked when their income made the Oregon Health Plan their only choice.
Another Scott
@Ohio Mom: Anyone with an elderly parent that they’re expecting to get an inheritance from should talk to an “elder-care” lawyer yesterday. Yes, there are clawback provisions, and things like people in nursing homes on Social Security and Medicaid getting their checks confiscated (except for ~ $40/mon). But there are provisions that can be used so that everything isn’t taken – but you have to plan ahead and consider look-back periods, etc..
Cheers,
Scott.
(Who thinks it’s only fair that there are clawback provisions, and that there are some limited ways around them.)
Ohio Mom
@TomatoQueen: Yeah, we’ve paid attorneys lots of money and have set up trusts.
The rules for the new ABLE accounts, where people with disabilities get to save up to $100,000 without it affecting their benefits, clearly state that whatever is there when the account holder dies goes straight to Medicaid.
There’s lots written on coming to terms with your kid’s disability (e.g., Welcome to Holland) but nextvto no warnings that this new status means you have to take up being a tax attorney as a hobby.
@Kelly: Ah ha! That is the answer I was looking for. Wonder how other states are handling this.
Who knew this stuff could be so complicated? ; ^ )
Elisabeth A.
This is a little off topic but here it is. What would do if I could just wave my wand would be: 1. Move Medicare down to age 62 to cover people who take early retirement. 2. Change the ACA so that the government handles catastrophic coverage. People would purchase coverage that would cover the first $25,000 of medical expenses. Anything over that in any given year would be covered by the government.
I don’t want single payer because if the government is paying for everything they are the ones who decide what is covered. And, if that happens I believe that women would not only lose coverage for abortion but all reproductive services (birth control and childbirth). They would argue that these services aren’t necessary as they are a personal choice and they shouldn’t have to pay for something that was a personal choice and which violates their moral beliefs.
Insurance companies on the other hand see the economic benefits of women not getting pregnant when they weren’t planning on it. The insurance companies also act as a brake on the medical establishment pushing up prices too quickly. Using this approach would also eliminate the economic shock of suddenly losing all the jobs in the medical insurance industry.
I also think that this would an easier sell than single payer. If insurance companies are only covering the first $25,000, prices should be down around where the old junk insurance policies were. Also, I think most people would agree that it makes sense for the government to cover medical catastrophies just like FEMA covers weather related ones. And really, most people won’t have anywhere like $25,000 in expenses most years. I am a 60 year old women with a number of chronic conditions and even with twice yearly lab work and a number of prescriptions, my total expenses (before insurance) are under $8,000.
While it would still be necessary to subsidize people with low incomes, the amount of that subsidy would be much lower and you wouldn’t have that large price difference with people that earn just a little too much.
There may be reasons why this wouldn’t work but I really think that this would have a more realistic chance than single payer.
Another Scott
@Elisabeth A.: Excellent points all around. Thanks.
Cheers,
Scott.
Brachiator
@Ohio Mom:
Wait? What. I thought that these were the rules:
I don’t know that this is an iron clad guarantee that a state would move to take any funds.
Ohio Mom
@Another Scott: I have a couple of friends from working class families who didn’t have parents who were going to consult lawyers — they didn’t consider it in their budget, and the idea of talking to a lawyer was intimidating.
Luckily, neither of them had parents who ended up in nursing homes. One inherited enough money to yes, pay off her car ahead of schedule, and the other bought new furniture for her bedroom. She jokes, “You can pretty much tell how much I inherited the minute you walk into this room.” I think barely in five digits would be s good guess.
I think there are a lot of families like that out there.
I think it’s unfair that a retiree starting with a fair amount of money can spend all of it on wine, women/men and song, and then be accepted into a Medicaid nursing home without question, but someone of more modest means, who has given their kids or grand kids a relatively small amount of money for something like a new water heater, to help cover an unexpected medical expense, or just a little money they can have a cushion — those people hit a snag when they need to enter a Medicaid nursing home.
I think we all benefit when families of modest means can help their members build a little bit of intergenerational wealth. But those are the families who are ill-equipped to find the loopholes.
And then there is my kid’s third grade teacher’s dad, who did indeed spend all his money having “fun in Florida” (as she described it) and then deposited himself on her doorstep, flat broke. She was not happy, and I can be a little irritated at the thought that my taxes are now bailing him out when he did not do his share.
But how to translate this into policy, and get rid of the perverse incentive to spend all your money on yourself on frivolous things? That is above my pay grade.
chopper
what about the fact that many docs don’t accept medicaid? tho i would think this is less of an issue in bare counties.
David Anderson
@chopper: It is a problem, but a bad network is better than no network
Ohio Mom
@Brachiator: When I say that Ohio counts every penny they spend on my kid, I am not kidding. I got an audit notice over the summer that asked me to let them know if any of the listed charges were incorrect, and among the charges were two for $1.79 made by CVS (Ohio Dad’s insurance is the primary, Medicaid picks up whatever is left).
I was not surprised because our special needs attorney had already told us that the state tracks every cent in the hopes of eventually recouping what they can.
Now most people with disabilities live in poverty once they leave their parents’ home, so the odds of any state government coming out even is remote. But the ABLE account set-up means that there is a new set of pots for them to salivate over.
I don’t have a problem with this, especially if the money essentially recirculates to help another family with a disabled member.
I think it’s worth noting that although the Medicaid money Ohio distributes is a 50-50 match, Ohio-Feds, all the recouped money will go to Ohio. I think that’s fine, I’m for anything thatbencourages states to do well by their disabled citizens.
Another Scott
@Ohio Mom: How to do this stuff fairly is difficult.
I understand where you’re coming from.
Most of J’s parents money was in their house (went up in value ~ 10x over 30 years). They did Ok, but they weren’t even upper middle class despite being fortunate enough to buy in the right neighborhood when the subdivision was new. When her parents got to be too old to live on their own, they sold their house and moved in with us. We talked to an elder care lawyer to make sure their will was Ok (it was drawn up in their previous state and there can be state-to-state differences in the “preferred” way to write them), that we had the various powers-of-attorney, advanced directives, etc. for when their health declined further, etc. They paid a nominal “rent” with us to help with their expenses (a few hundred a month), and they gave their kids a few thousand dollars a year (not even hitting the limit).
But with paying for in-home health aids and all the rest, and then private-paying for a decent nursing home (around here few if any will take new patients unless they private pay for some extended period (a year + IIRC) before they go on Medicaid), even with 3-years of long-term-care insurance, the money ran out before her mom died (of Parkinson’s and Alzheimer’s) – her father had died ~ ~2 years before. It’s the “private pay” requirement that should give frivolous spending a second thought, but it won’t if people don’t know about it.
They lived with us ~ 6+ years. It’s easy for us to rationalize that “we saved the government a lot of money” doing things the way we did (though we wouldn’t have done it any other way because of the expense and other issues), so we don’t feel guilty about doing what we did before the “look-back” period. And I don’t have any problems with the various claw-back features for those who were fortunate enough to have a big nest-egg that lasted longer than they did. I think we have a responsibility to help support the systems that make life as good as it is here in the USA, so that those that come after us have it as least as good. If someone is having their bills paid by Medicaid or other public insurance, then the more fortunate really do need to pay their fair share out of their estates. Defining “fair share” is left as an exercise for the reader.
I understand that far too many people can’t afford a few hundred/low thousands to talk with a good lawyer and make sure they understand the issues and get the right paperwork in place in time. But it really is necessary to understand what’s going on and to handle things legally if you want to pass-on an estate. Places like Nola are a good starting point, but I don’t know if they’re comprehensive enough to totally eliminate the need for a live lawyer…
We don’t have kids, so it’s not as much of an issue for us as for many (at least not yet – things may change once we win the PowerBall!).
I hope this lets you know better where I’m coming from.
Good luck!
Cheers,
Scott.
catclub
@Elisabeth A.:
what taxes pay for that $25k and up coverage?
Elisabeth A.
Responding to catclub:
I don’t know exactly what tax would pay for it. I am not someone who would know how large a figure it would be. I know that it would be paying for a much lower number of claims but that the claims it would cover would be the expensive ones. It would probably end up being a program similar to Social Security and Medicare where employers and employees both make payments. I think it would work out to considerably less than what people and companies are currently paying, because the current situation requires all the insurance companies to hold cash reserves to cover these catastrophic situations. Also, since this would be covered by the country as a whole, you wouldn’t have the situation we currently have in Iowa where rates (at least on the exchanges) are extremely high because there is a person (a child I believe) who has an extremely expensive condition.
I do think the charge to the companies should be more than to the employees since they would be getting the larger price break since I believe that the cost breakout between the companies and employees is usually 75% to 25%.
If there is someone who has back of the envelope figures for this type of program I would be happy to here them.
Sorry to be so late to respond. I actually headed out to work after my posting.