Friday, June 25, 2021

In NJ Spotlight News: "Affordable Care or a Loan?"

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I have an op-ed in NJ Spotlight News in support of a pending bill, A1023/S885, that would end Medicaid Estate Recovery pursued against enrollees in NJ FamilyCare (the state Medicaid program) who do not receive long-term care. The problem:

Unfortunately, in New Jersey — as in 19 other states and Washington, D.C. — efforts to make affordable coverage available to all come with a giant asterisk.

Applicants seeking health coverage on GetCoveredNJ, the state ACA exchange launched last fall, are routed either to the private plan marketplace or, if their family income is below 138% of the FPL (federal poverty level) — which is $1,482 for an individual, $3,048 for a family of four — to NJ FamilyCare, the state Medicaid program. If income qualifies an applicant for the latter, she must sign off on this disclosure:

“I acknowledge notice that the Division of Medical Assistance and Health Services (DMAHS) has the authority to file a claim and lien against the estate of a deceased Medicaid beneficiary, or former beneficiary, to recover all Medicaid payments for services received on or after age 55….” 

About 170,000 current enrollees in NJ FamilyCare are over age 55. All are potentially subject to estate recovery after their death and the death of their spouse, if there are no children under age 21.

I hope you'll read the case to end this fundamental undermining of the promise inherent in the ACA's name.

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8 comments:

  1. Good job, Andrew! (On this issue that is fundamental, that few pay attention to.)

    Just note: apparently you have checked that New Jersey will, from expanded Medicaid, estate recover only a capitation.

    In general, across the states, my understanding is that they can recover either a fixed annual capitation like NJ, or all medical bills paid out. In this latter case, it is especially cruel--there is no insurance at all.

    (I am not sure if there are conditions associated with the estate recovery of all medical bills paid out. It may be when the state pays medical bills directly, rather than paying a fixed per-person cost to an agency.)

    As I often do, let me post a link to the Wikipedia article on Medicaid estate recovery, https://en.wikipedia.org/wiki/Medicaid_Estate_Recovery_Program , which I wrote most of in 2019 after finding out about the issue.

    It contains details on the estate recovery of expanded Medicaid (and other non-long-term-care Medicaids). Note the assertions in the article can be verified from the references, which are all online.

    Also, let me link to the backup of that article, in case it gets changed: https://web.archive.org/web/20200701011813/https://en.wikipedia.org/wiki/Medicaid_Estate_Recovery_Program .

    Thanks again Andrew. You are one of the few health journalists who have an eye on this critical issue.

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    1. Norm, I wrote to your blog before. They recover EVERYTHING in NJ. Capitation, drugs, home care - everything…

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  2. Thanks Norm. I gather that billing for a fixed capitation is usually worse, as the majority of enrollees' actual costs are below the capitation rate (in all health insurance, a small percentage of enrollees account for the majority of costs). The MACPAC report recommended allowing states to base recovery from LTSS patients on the cost of care rather than capitation -- in the name of equity. https://www.macpac.gov/wp-content/uploads/2021/03/Chapter-3-Medicaid-Estate-Recovery-Improving-Policy-and-Promoting-Equity.pdf

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    1. A disagreement from me. If recovery is on the cost of care, there is no insurance at all. If you get sick with $1,200,000 in bills on expanded Medicaid (at 55-64 in the affected states), then you're estate is out $1,200,000.

      Whereas, the same person with $1,200,000 in medical bills who has an income of 142% of FPL gets free insurance (currently), and those with higher incomes get capped premiums at 8.5% of income and have real insurance. They don't owe $1,200,000. They might owe just say $15,000 (non-estate-recovered) in copays!

      The purpose of insurance is to protect people from unlikely bad things happening, like $1,200,000 in medical bills. In the affected states, people 55-64 with expanded Medicaid to not have any of this protection if recovery is of all bills.

      I thus look at the "all medical bills" scenario as the worse one, because there's no insurance and catastrophic losses are possible.

      I saw the section in the MACPAC report that you mentioned preferring capitation recovery, but I find the thinking behind that wrong.

      Of course, prevention of estate recovery of any form on non-long-term-care is the best solution, making the quibble over "what form of recovery" moot.

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  3. Really, your op-ed is brilliant and sharp, and is a definitive article on the issue.

    (The New York Times and Washington Post are put to shame in comparison, with the omission of the critical issue. As well, the Health Affairs blog is put to shame, with the exception of the 2014 Tim Jost post on the issue: https://www.healthaffairs.org/do/10.1377/hblog20140224.037390/full/ )

    One thing to add: I see you have indicated that New Jersey does have notice of the recovery. (Hopefully, this is conspicuous and on the ACA Application, and not delivered at a point when a person has already enrolled in expanded Medicaid through the ACA application and been exposed to the recovery.)

    The Federal ACA application, at least on the .pdf version here, does NOT have the notice of the recovery. (https://marketplace.cms.gov/applications-and-forms/marketplace-application-for-family.pdf -- Medicaid conditions are on paginated page 7, and we see there is no mention of the recovery.)

    Otherwise, I point out that a person/family eligible for expanded Medicaid is not eligible for a SUBSIDIZED on-exchange plan, but can get a non-subsidized one. (It requires using a different "no help from the government paying" .pdf application, or, on exchanges, selecting "I want no help from the government paying".)

    Of course, the problems are, this can be expensive (premiums might be as high as $1500 a month per person), and this is unaffordable for most who have incomes to 138% of the Federal Poverty Level. (Some people affected, early retirees and decently-off people with temporarily-low incomes will be able to afford unsubsidized on-exchange. However, the other problem here is that they often don't know of the potential recovery of all medical expenses or capitations, because of inconspicuous or missing notice, as on that Federal .pdf application. Without the fix, the ACA can be a dangerous contraption, wiping out the estates of the unsuspecting.)

    Once again, congratulations. Your article is clear, sharp, and definitive. The clarity is partly by your being careful to distinguish non-long-term-care (we're supposed to have the ACA for that) from non-long-term-care (which we don't have a national program for). People trying to follow issue often aren't making that critical distinction--I see that in responses to my NY Times comments on the issue.)

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  4. Medicaid expansion only covers under 55 years old. Age 55 to 65 must pay back under medicaid recovery in NJ . Not all states do this. some find it discriminatory. I was paying $80 per month for health benefits until my heart attacks at 56 years old. Because my income dropped I was forced on Medicaid. I owe Approximately 58 THOUSAND Dollars + ONLY because I was a senior citizen between 55 & 65 years old. To make matters worse The agency that handles this Has new employees & NOW says I owe $163,000. Seniors are paying for the Medicaid expansion. It is CLEARLY age discrimination & some states refuse to collect it. If someone can bring this up with Governor Murphy I would appreciate it. He claims he against discrimination of any kind. We will see!

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  5. Andrew, thank you for the article! I previously wrote to Norm’s blog. This Medicaid “loan” is totally unfair. My Mom didn’t even use Medicaid much. But after her death, NJ put in estate recovery consisting mostly of “capitation fees”. She didn’t even use it, and she didn’t spend a day in long term care. But New Jersey wants every penny Medicaid spent, whether my Mom wanted them to spend it or not. They put a lien on her modest apartment- on one end NJ affordable housing hit the apartment with retroactive sales price restriction, and on the other end NJ Medicaid recovery comes in!
    I am aware of the two bills in the Legislature. I wrote to Senator Cryan. Didn’t hear back. What needs to be done to get those passed? Why so much apathy? Why NJ is the worst of them all? Medicare spent a lot more on my Mom - no recovery.

    I guess until people don’t experience Medicaid estate recovery personally, they will just not know about the consequences.

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  6. On this issue as it affects Massachusetts, rather than NJ, I was actually notified by a nearby MA State Senator Jo Comerford that a bill to stop the estate recovery on non-long-term-care Medicaid has been submitted by her and a Rep. Barber, and will be at a joint committee next week.

    (As here https://senatorjocomerford.org/wp-content/uploads/2021/07/h.1246s.749-fact-sheet-estate-recovery.pdf )

    (I was asked to submit testimony, and I did submit written testimony, in favor of course, with the usual cogent arguments. Let's hope it goes, and the ACA gets a little more fixed.)

    (Meanwhile, to my last knowledge, the removal of the 400% Federal Poverty Level "subsidy cliff" needs to be brought from just temporary, for 2 years, to permanent. I think that's in the giant bill in Congress, by reconciliation. Let's hope it makes it!)

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