Obamacare: The Final Payment

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Introduction

Since writing "Obamacare: Devils in the Details" posted on this site on February 3, 2013, I have investigated in detail other aspects of the insurance industry's program to bring health care to Americans. In this article I explain estate recovery to which poorer Americans herded by Obamacare into Medicaid are subject. In violation of moral philosopher John Rawls' second principle of justice, some of the poorest Americans will pay the highest cost of health care as they, and they alone, are subject to having the family home and any other assets they might possess confiscated by the state in order to reimburse Obamacare for the cost of their medical expenses. The compassionate rhetoric aside, Obamacare makes the poor pay the most.

Under what was deceptively named the Affordable Care Act (ACA), commonly known as Obamacare, which is unaffordable for the patient in more ways than one, beginning January 1, 2014, citizens without health insurance must pay a tax penalty to the Internal Revenue Service (IRS). Qualified individuals and families with incomes between 138 and 400 percent of the Federal Poverty Level (FPL) can shop for commercial insurance policies at a Health Insurance Marketplace (an exchange) and may be eligible for a subsidy from the government to help pay for a plan. Those with incomes at or below 138 percent of the Federal Poverty Level will be tossed into Medicaid unless there are specific reasons why they would not be eligible.

The Federal Poverty Level incomes for different family sizes for 2014 established by the Department of Health and Human Services can be found here. To determine whether you will be put into Medicaid, find the Federal Poverty Level annual income that applies to your family size for 2014 from the HHS tables and multiply the amount by 1.38. If your annual income is not larger than this amount, into Medicaid you go. For example, to avoid being put into Medicaid by Obamacare, a single individual in the 48 states and D.C. needs an income that is more than 138 percent of $11,670 (more than $16,105). A family of four needs an income that is more than 138 percent of $23,850 (more than $32,913). Poverty level incomes in Alaska and Hawaii are higher due to the higher cost of living in those states.

You won't find estate recovery in the ACA. It's in the Omnibus Reconciliation Act of 1993 (OBRA 1993) -- a federal statute which applies to Medicaid, and, if you are enrolled in Medicaid, it will apply to you.

Estate Recovery

OBRA 1993 requires all states that receive Medicaid funding to seek recovery from the estates of deceased Medicaid patients for medical services received in a nursing home or other long-term care institution, home- and community-based services and related hospital and prescription drug services regardless of age. It also allows, at state option, recovery for all services used in the Medicaid state plan at age 55 or older. At minimum, states must pursue recovery from the probate estate which includes property that passes to heirs under state probate law, but states can expand the definition of estate to allow recovery from property that bypasses probate. This means states can use procedures for direct recovery from bank accounts and other funds. The state keeps a running tally, and even if you have a will, your heirs are chopped liver. Estate recovery can be exempted or deferred in certain situations after your death, but the regulations for this are limited and complicated with multitudes of conditions.

Your estate is what you own when you die -- your home, other real estate in which you have a legal interest, personal property, bank accounts, annuities and so on. For cash-strapped states, recovery provides an income stream, and with the expansion of Medicaid states will be in dire need of money, particularly in the current economy.

You must first understand that if an exchange determines you are eligible for Medicaid, you have no other choice. Code for exchanges specifies that an applicant is not eligible for a subsidized plan to the extent that he or she is eligible for coverage under Medicaid. Therefore, when you apply, if you are found eligible, you will be tossed into Medicaid. You can also be auto-enrolled in Medicaid if you are presumed eligible through a database such as SNAP (food stamps). If you are enrolled in a subsidized private plan through an exchange and your circumstances change making you eligible for Medicaid, in you go.

Obamacare revises Medicaid regulations in order to make more Americans eligible for Medicaid. Revised regulations include an increase in age and income limitations, and the asset test no longer applies. Prior to these revisions, applicants were not eligible for Medicaid if they had more than a specific dollar amount in assets. But, under Obamacare, those who likely own a home or have savings set aside -- for example, early retirees or people who have lost their jobs and, as a result, are in a low income bracket -- will find themselves in Medicaid, and their assets will be looted by the government when they die for medical services used at age 55 and up.

Estate recovery can have a damaging impact on low-income and poor Americans. It is a pernicious death tax on those who have the least and are the most vulnerable. Often, the only asset they have is the family home and what's in it, and, for some, this has been the family home for several generations. The threat of losing the home causes people to forego health care.

Home equity is part of a deceased Medicaid recipient's estate and except under certain circumstances is subject to estate recovery. Surviving family members may either sell the home and use the proceeds to satisfy the Medicaid claim or, if they wish to keep the home in the family, they can satisfy the claim with their own personal funds. This Medicaid clawback not only confiscates family property but also robs people of their dignity as Medicaid allows only an amount it considers reasonable for services provided by a funeral home and burial costs. In some states, funeral homes are responsible for notifying Medicaid if there is excess money in a burial trust fund so it can also be pillaged.

Some might think it fair that those who are enrolled in Medicaid pay back the benefits they received. However, under a mandate that requires all Americans to be covered by health insurance or pay a tax penalty to the IRS, estate recovery is unconscionable since Obamacare offers no other viable option for this income-segment of the population. It also discriminates by age since only Medicaid enrollees who use benefits in the state plan at age 55 and up are subject to estate recovery, but those who use benefits at age 54 or less are home free unless they receive long-term care. Under federal law, discrimination is not permitted on the basis of age, but, obviously, the U.S. government turns a blind eye to to its own law. Perhaps, when states need more money due to the Obamacare expansion of Medicaid, and as the jobless economy continues causing more people to be eligible, age discrimination will be broadened to 45 and up.