Medicaid Estate Recovery imposed on Medicaid enrollees


Andrew writes on healthcare, mostly the PPACA plan and the various metal plans, and the latest gig (ARPA) resulting in lower costs for anyone under 250% FPL and lower costs for anyone higher than 400% FPL.

All made possible due to Biden and Democrat’s American Rescue Plan Act of 2021. It will expire EOY 2022 and I doubt Manchin will help with it. Without it and other aid, This all could have been a 2008 Redux. Mostly, what you will catch me writing about is prices versus costs. How can you set a price or accept one if you do not know costs? The same applies to healthcare. Eighteen percent of GDP appears to be kind of high. . .


John Roberts, James Joyce, the individual mandate, Medicaid Estate Recovery, and “affordable” care

Andrew Sprung, XPOSTFACTOID, May 9, 2022

So it was that I caught one lightning round of associations at lunchtime today:

—  John Roberts — trying to moderate Roe strike-down?

— Roberts — headed off one radical conservative decision by saving the ACA’s individual mandate “as a tax.” 

— The mandate — justifiable? — if insurance were truly affordable for all, but under the ACA as written, it wasn’t.*

— RBG: mocking Scalia’s broccoli horrible — mandates to buy all kinds of stuff…

— mandating that people buy private insurance — ok?

— not always private — the mandate could land you in Medicaid. Public! Free!

— But… Medicaid Estate Recovery!  — for applicants over age 55 in 20-plus states, the mandated coverage is a long-term loan… 

And there I was brought up short by an actual thought. I have written before or several times, Medicaid Estate Recovery imposed on Medicaid enrollees not in long-term care undermines the ACA’s promise of “affordable” care — and the mandate to obtain it. What struck me, as I enter the marketplace myself — is no one is threatening to come after my estate for the gargantuan subsidy which my wife and I are getting. Medicaid is cheaper than marketplace coverage. In 20-plus states, people over 55 accessing it (or rather, their heirs) are ultimately on the hook for paying back premiums from the government. In New Jersey, an adult made eligible for Medicaid by the ACA costs the state and federal government $416 per month (in 2019). My wife and I will cost the feds $700/month or so. We get the benefit free and clear; the Medicaid enrollee’s children may have to pay the state back after the enrollee’s death.

Put another way, if you’re over age 55, lack access to other insurance and earn $17,775 per year, under the ARPA subsidy schedule you qualify free silver marketplace coverage with Cost Sharing Reduction that bumps the actuarial value to 94%.

If you earn, $17,773, you get Medicaid — also free, but with an effective lien on it. ???

That’s ridiculous. One generation’s legislative priority was to avoid giving people with assets free long-term care (though estate recovery most commonly falls on low income people). So the 1993 omnibus budget package required states to recover from the estates of those whose long-term care was funded by Medicaid. That 3rd Way legislative aim ran smack dab into the next generation’s intent: to make affordable health coverage available to all non-seniors. States, given the option to extend Medicaid Estate Recovery to all enrollees over age 55, most often opted for the extra revenue opportunity.  Thus, “affordable” coverage is a long-term loan for a significant subset of near-elderly beneficiaries of the ACA Medicaid expansion, or other pathways to Medicaid eligibility.

Okay, it’s not a new thought. It’s the same obvious injustice. But the stark contrast with the way marketplace coverage — more wasteful, more expensive, available only at higher incomes — is granted struck me afresh.—

* I somehow skirted the usual follow-on thought: the ARPA subsidy boosts brought the ACA a lot closer to living up to its name, and it will be  policy disaster and political suicide if Democrats fail to extend them.