The Ethics of Adjusting Your Assets to Qualify for Medicaid
August 5, 2017 9:04 AM   Subscribe

 
It's ridiculous that our health care system requires that people have to choose between being impoverished and alive, or dead with assets.
posted by Autumnheart at 9:15 AM on August 5, 2017 [30 favorites]


This is just one of many elephants in the room of the healthcare debate, albeit one that's most indicative of the hypocrisy of most conservatives. I know a lot of Republicans who are 100% against government healthcare except of course it's totally fine for them to game the Medicaid eligibility rules so they can give their assets to their kids (who then helpfully allow them to keep using those assets).

Just like every government benefit, to the conservatives everything's awful except when they're the ones taking advantage of it.
posted by tocts at 9:17 AM on August 5, 2017 [17 favorites]


1.) "there is a large group of citizens". How many exactly? Cite?

2.) "Anyone who engages in legal Medicaid planning is attempting to qualify for a government program for the indigent". Like Walmart giving advice to employees about how to qualify?

3.) "so doing everything legally possible to get a dementia patient eligible for Medicaid is like a form of political protest". Or a heartbreaking necessity, maybe.

In conclusion, Single-Payer.
posted by Horkus at 9:18 AM on August 5, 2017 [12 favorites]


every time I think the new york times is worth a damn they go and publish something like this. Like, seriously, the frame you're going for is ethics? You're suggesting — even for a second! — that it's not ethical to shed resources to get access to a government program that you'll die without access to? You're posing this as a question in the headline?

Good lord...
posted by You Can't Tip a Buick at 9:32 AM on August 5, 2017 [46 favorites]


I have some professional experience with this. In my state, you can get the first person of a married couple eligible for Medicaid in one month, regardless of assets (I'm talking any net worth, right up until it's unnecessary because they're throwing off enough income to self-fund with no decrease in quality of life), through a combination of gifting to irrevocable trusts and promissory notes.

You can also protect between 50-100% (depending upon the asset mix) for when the second spouse (or a single person) needs care.

If you plan ahead of time (5 years+), you can get close to 100% asset protection regardless of the circumstances.

With proper planning the only inconvenience is moving the funds into the right buckets (Miller Trusts, etc).
posted by leotrotsky at 9:33 AM on August 5, 2017 [10 favorites]


like if you look at this situation and you think that the people with questionable ethics are the folks shedding assets, you are, in terms of moral development, a twelve year old. at best.
posted by You Can't Tip a Buick at 9:34 AM on August 5, 2017 [27 favorites]


If you want to make a republican feel like a failure tell them a middle class person died today with money in the bank.
posted by any major dude at 9:37 AM on August 5, 2017 [16 favorites]


Donald J. Trump explicitly acknowledged for the first time during Sunday’s debate that he used a $916 million loss that he reported on his 1995 income tax returns to avoid paying personal federal income taxes for years.

Between 2008 and 2010, a dozen major US corporations—including General Electric, ExxonMobil, and Verizon—paid a negative tax rate, despite collectively recording $171 billion in pretax US profits, according to an analysis by Citizens for Tax Justice. Taken together, these companies’ tax burden was -$2.5 billion, and ten of the companies recorded at least one no-tax year between 2008 and 2010.... over the past two years, Exxon Mobil’s net tax on its $9.9 billion in U.S. pretax profits was a minuscule $39 million, an effective tax rate of only 0.4 percent.

My mom's in a nursing home, and her care's being paid for by Medicaid. She sits in a wheelchair all day, is often clean, and gets three squares a day that look like frozen dinners.

This costs ten. Thousand. Dollars. A. Month.

I took care of her at home for a number of years, and tried to get assistance through public programs. But while Medicaid will pay huge sums to nursing homes, you can't get very much money for home care, because nursing homes lobby the government to have the lion's share of available funds earmarked for nursing homes.

Trump, and Exxon's Tillerson, the guys mentioned in the links above about rich people who don't pay taxes, are now also the supergeniuses in charge of deciding whether or not Medicaid should continue to exist.

But certainly, don't try to find a loophole that will allow you to put some money away against the possibility that these guys will destroy Medicaid, because that would be UNETHICAL.

Billionaire ratfuckers bleeding the country dry is just the beauty of the free market. But the source of our troubles is these poor people--they're all so UNETHICAL.
posted by Sing Or Swim at 9:39 AM on August 5, 2017 [103 favorites]


To be fair, virtue is its own reward so if you're not being rewarded you clearly can't be very virtuous.
posted by flabdablet at 9:43 AM on August 5, 2017 [5 favorites]


Trump, and Exxon's Tillerson, the guys mentioned in the links above about rich people who don't pay taxes, are now also the supergeniuses in charge of deciding whether or not Medicaid should continue to exist.

The reason that Medicaid isn't going to get killed is because of all the middle class families that rely on it for nursing home care. AARP will crucify anyone who tries. You watch.
posted by leotrotsky at 9:43 AM on August 5, 2017 [5 favorites]


I haven't read this article but I'm going to bet it's about people suffering from major health crises who end up burning through all their savings and selling their house and assets in order to get poor enough to qualify for Medicaid.

No, it's about middle-class and well-off retirees who want the government to pay for the nursing home they expect to eventually need by appearing to become indigent without actually becoming indigent.
posted by ROU_Xenophobe at 9:48 AM on August 5, 2017 [5 favorites]


One more time: The ONLY thing that will change any of this is to get low income people and PoC to get out and vote.
posted by jeff-o-matic at 9:48 AM on August 5, 2017 [1 favorite]


THE ETHICS OF REQUIRING PEOPLE TO BE INDIGENT BEFORE THEY CAN RECEIVE MEDICAL CARE
posted by indubitable at 9:49 AM on August 5, 2017 [39 favorites]


The reason that Medicaid isn't going to get killed is because of all the middle class families that rely on it for nursing home care. AARP will crucify anyone who tries. You watch.

Keep a close watch on what they plan for Medicare, as well. For those not in nursing homes (and, at times, those who are) Medicare is a crucial support for continued healthcare.
posted by Thorzdad at 9:51 AM on August 5, 2017 [3 favorites]


As someone who has worked (on the medical side) exclusively in nursing homes for 4 years, the guidelines for anything there are a bizarro netherworld I don't wish on anyone I care about.
posted by cobaltnine at 9:53 AM on August 5, 2017 [2 favorites]


Once you need nursing home care, if you aren't indigent already, you soon will be...
posted by littlejohnnyjewel at 9:58 AM on August 5, 2017 [1 favorite]


Once you need nursing home care, if you aren't indigent already, you soon will be...

The infamous Medicaid Spend-down.
posted by Thorzdad at 9:59 AM on August 5, 2017 [8 favorites]


I took care of her at home for a number of years, and tried to get assistance through public programs. But while Medicaid will pay huge sums to nursing homes, you can't get very much money for home care, because nursing homes lobby the government to have the lion's share of available funds earmarked for nursing homes.

I helped write some pending legislation that addresses exactly this. The Disability Integration Act (S.910 / H.R. 2472) requires both Medicaid and private LTSS insurance to make home and community based services available on an equal basis as institutional services. It's been a priority of ADAPT for years and has gotten some traction in the past week after we helped stop the Medicaid / ACA repeal.

It's infuriating that this issue continues to exist because the National Council on Disability has found that it is cheaper, in some cases significantly, to provide services at home than to provide them in an institution, and people want to live at home anyway.

You can help address this problem by calling your Congresspeople and Senators and getting them to cosponsor this bill.
posted by gauche at 10:01 AM on August 5, 2017 [48 favorites]


Yup. When my father-in-law became quadriplegic, I researched this extensively. Nursing homes cost at least $75k per year. Home care costs at least $20/hour, and he needs 24/7 care. (He can't toilet -- uses diapers -- and can't turn himself in bed.) To qualify him for Medicaid, without consulting an attorney to set up trusts and things, my mother-in-law could keep at best $75k in retirement savings and about $2k/month in income (plus their paid-off house and one car). She wasn't even 65 yet when this happened. $75k isn't much in savings for someone that young.

I took her to an info session with an attorney, but once she heard it could cost up to $10k to to do the Medicaid planning, she flatly refused to pursue anything further. We had multiple conversations and then arguments about it, but she wouldn't even do a one-hour initial consultation to estimate what it would cost for them. (I doubt it would really have been $10k; their finances aren't all that complicated). My husband and I even offered to pay for the lawyer, but no.

And here is where ethics does come in: Part of her resistance was, in fact, a sense that it was fraudulent and unethical to take advantage of loopholes and set up those mechanisms to qualify. There were many other issues -- mainly the up front cost of the attorney. But ethics was one of them. It can be hard to convince someone that in this case, the law is unethical, and they are justified in finding loopholes.

So the solution was to not qualify for Medicaid. Instead, she, my husband, and my brother-in-law all worked 40-60 hour weeks at their paying jobs and took turns acting as unpaid nursing care in their off hours. It has taken a massive toll on everyone's health, marriages, and family relationships.

But if you need that level of care in this country, your options are (1) be filthy rich, so rich that you can hire 24/7 home care, or (2) plunge yourself and your spouse into abject poverty. Or (3) everyone in the family sacrifices their own entire lives to unpaid caregiving.
posted by snowmentality at 10:10 AM on August 5, 2017 [34 favorites]


The group for which this does get under my skin is the people who politically oppose a decent social safety net, who think that the government is giving too much away in entitlements to lazy people, consider themselves entitled to all kinds of government help like the mortgage interest deduction but refuse to recognize that as a government benefit akin to welfare, etc....right up to the moment that they discover their own basic vulnerability to the vicissitudes of life and aging. Then it's all "but I want to keep my house!" and "why should I have to become poor to be taken care of?"

Fuck those people. I actually think it is unethical to oppose helping others and then turn around demand the same help for yourself.

I don't know what everybody else is supposed to do. It's a brutal conundrum.
posted by praemunire at 10:27 AM on August 5, 2017 [17 favorites]


Growing old in America is a brutal, demoralizing experience unless you are unnaturally healthy and/or have a warehouse filled with cash.
posted by Thorzdad at 10:31 AM on August 5, 2017 [13 favorites]


And even worse when you don't have kids and a partner.
posted by Melismata at 11:04 AM on August 5, 2017 [10 favorites]


I was dropping in to say what praemunire did, if you have literally spent your whole life sneering down your nose at "those people" and voting to cut every single service for "those people," it IS unethical for you to pretend to be poor so that "those people's" tax dollars pay for your care - and yes, "those people" do pay tax dollars - no matter how many times you call them takers.
posted by Gyre,Gimble,Wabe, Esq. at 11:11 AM on August 5, 2017 [7 favorites]


This isn't about retirement, but I'm a lawyer who works full-time practicing law and my child is on Medicaid. Color me shocked but grateful as heck when it became apparent that we could get free health insurance for our child. And we didn't even need to hide assets!

Which is just to say, healthcare is so expensive that even what was once the middle class can't afford it. If only it covered everyone.
posted by likeatoaster at 11:14 AM on August 5, 2017 [2 favorites]


Yeah, of course nobody should have to impoverish themselves to get medical care. Nobody should have to do anything but show up at the fucking doctor's office in order to get medical care. But this is part of a bigger picture in which wealthy Americans hire an army of lawyers to game the system so that they can get access to a social safety net that many of them don't think should be available to middle-and-lower-income Americans. And that is unethical. I don't fault anyone for figuring out how to hide assets in order to get Medicaid, but they'd better be fighting like hell to make sure that there's a decent safety net for everyone.
posted by ArbitraryAndCapricious at 11:47 AM on August 5, 2017 [8 favorites]


This is a very pressing issue for my family. It is entirely reasonable to want to be able to leave money to your children, especially if you have a disabled child but also considering the diminished prospects for young people in this country today. Especially considering the miserable, low standards of care you're going to encounter - that's the kicker, you'll impoverish yourself so that you can live in an understaffed, stinking nursing home where they'll probably screw up your meds and take your stuff. I've seen exactly one nursing home that wasn't a horrorshow, and that was in a family where they could afford the best. Impoverishing your family in order to live in a flithy, crowded shared space next to people screaming with pain, dementia and fear, that's particularly unfair.
posted by Frowner at 11:49 AM on August 5, 2017 [10 favorites]


A lot of people who "hide assets" to get on Medicaid are not rich - they just have social security, a house and several hundred thousand after a lifetime of saving and working. That looks like wealth to someone who is young today because everyone's prospects have deteriorated, but it used to be very normal (at least if you adjust for inflation).
posted by Frowner at 11:51 AM on August 5, 2017 [14 favorites]


Sorry to triple-post, but this is a clarifying point: in my extended family, we have a middle class couple with a middle-aged child who is too disabled to work full time, but not disabled enough to get disability, and who therefore makes some money but still relies on the parents for help with rent, periodic expenses like replacing a phone, etc. The child lives a very, very modest life but cannot make enough money when they can work to cover all their expenses. A big priority for this couple is being able to leave some money to this child so that they are not totally impoverished and vulnerable as they age. One member of the couple has developed a debilitating condition and requires more and more care. A big concern for the couple is how to handle the eventual need for Medicaid while still being able to leave something for their child. This is, to me, a very legitimate concern, not some kind of rich people fraud. "I don't want my child to risk homelessness when I'm gone" isn't unreasonable, I think.

And honestly, when I consider how many young people today are hugely indebted or making so little that they are unlikely ever to have any kind of financial security, it's difficult for me to see parents who want to be able to leave them a modest amount as evil people.
posted by Frowner at 11:59 AM on August 5, 2017 [13 favorites]


But the source of our troubles is these poor people--they're all so UNETHICAL.

The ethical issue is when a wealthy person structures their affairs to qualify for medicaid rather than spend their own money on health care.
posted by jpe at 12:01 PM on August 5, 2017 [1 favorite]


From TFA:
Anyone who engages in legal Medicaid planning is attempting to qualify for a government program for the indigent when they do have at least some assets that could pay for their care.
Oh bullshit. Medical care in this country costs a fortune. Elder care is especially brutal. It's not enough to have "at least some assets," because you can either afford it or you can't. It's the same reason I know students who aren't married -- because if they got married, their financial status would change, they would get far less in financial aid, and they would no longer be able to afford tuition. This article makes it out to be this huge moral crime, but the only moral crime is the fact that it's necessary to shed assets just so you qualify for the basic care that should, under any ethical system, be available to anybody.

I actually think it is unethical to oppose helping others and then turn around demand the same help for yourself.

Where in the article does it say these people are opposed to helping others? Why assume the worst about them? We all like to imagine that this is some great moral crime being perpetrated by the least deserving people, but this article even says they're not all particularly well-off. Many of them just have enough assets to disqualify them from government programs, but not enough assets to actually allow them to pay for everything.
posted by shapes that haunt the dusk at 12:01 PM on August 5, 2017 [4 favorites]


More like "the ethics of having a health care system that is out of reach for many individuals and families."

People wouldn't need to make decisions about shedding assets to qualify for care if we provided care for all. The fact that we, as a society, put people in that position seems unethical in and of itself.
posted by evidenceofabsence at 12:04 PM on August 5, 2017


the only moral crime is the fact that it's necessary to shed assets just so you qualify for the basic care that should, under any ethical system, be available to anybody.

I've known families worth tens of millions of dollars that have engaged in Medicaid planning so that a member of the family could qualify for Medicaid. They would get care either way: the only question was whether they would pay out of their fortune or the taxpayers would pay.
posted by jpe at 12:06 PM on August 5, 2017 [2 favorites]


Part of the reason this makes me so angry is that I've seen my elderly extended family struggle to pay for basic care for years. This whole idea of "at least some assets" is so infuriating, because what are "some assets" going to cover? Will they cover the full 24-hour care that this person needs, but only if they die within the next two years? Or do we just have nurses check in every so often, and hope nothing happens in between? My family didn't do Medicaid planning because pensions were supposed to cover everything, but they don't.

On preview:

I've known families worth tens of millions of dollars that have engaged in Medicaid planning so that a member of the family could qualify for Medicaid.

I mean, there's always going to be cases like this, in any situation. I've known friends who were on food stamps, even though their parents had millions of dollars. I knew a white guy who said he was African-American on his college application because his parents were from South Africa. Are there hypocrites and people taking advantage of the system? Always. But it's really easy to overstate how many of them there are vs. how many people actually need to do this to get basic care. We can shake our fists at the millionaires all we like, but if we say that Medicaid planning is a fundamentally immoral thing because there are some egregious cases, we're leaving a lot of people out in the cold.
posted by shapes that haunt the dusk at 12:15 PM on August 5, 2017 [10 favorites]


"Some rich people abuse the system, so let's get rid of it" is the equivalent of "some people commit welfare fraud, so let's get rid of that".
posted by Frowner at 12:18 PM on August 5, 2017 [22 favorites]


Where in the article does it say these people are opposed to helping others? Why assume the worst about them?
Demographically, the people for whom this is an issue are very much the people who vote against providing a universal safety net. They are overwhelmingly white, because white people have vastly more wealth than other people and therefore are more likely to have assets to hide. (And that's partly due to conscious policymaking, such as the policies that denied black Americans access to the home loans provided by the GI Bill.) They're mostly elderly or approaching old age. Old white people are, demographically, the backbone of the conservative movement. Obviously, there are many individuals who are doing this and who aren't voting for candidates who want to roll back the Medicaid expansion, but there are a lot who are. And that's my ethical problem: not with the people who do Medicaid planning, but with the people who do that but don't realize that it's a temporary stopgap for a problem that needs a systemic solution. Or, for instance, people who do Medicaid planning and then go on about welfare cheats, as if it's somehow different when low-income people fudge an unworkable system because fudging it is the only way to survive.
And honestly, when I consider how many young people today are hugely indebted or making so little that they are unlikely ever to have any kind of financial security, it's difficult for me to see parents who want to be able to leave them a modest amount as evil people.
I don't think they're evil people at all. But all young people are struggling, not just the ones whose parents and grandparents own houses. (And it's actually only houses worth more than a number between $500,000 and $800,000, depending on what state you live in.) Lots of non-asset-having people are terrified about the future of their disabled children.
posted by ArbitraryAndCapricious at 12:20 PM on August 5, 2017 [8 favorites]


See, here's what happens: you have a couple, they have a house. One person gets really sick and needs medicaid. They do the spend-down. The ill person dies and the other ages. As the other ages, they can't afford to keep the house. They sell the house. They have to do a spend-down. And that's the end of that - no money for a child. End of life care can blow through a hundred thousand dollars in a year, even leaving out things like surgeries. It's easy to die with literally nothing left at all, even if you start from a middle class position.

Also, let's remember that this is a very large country - you can have, say, 70% of white baby boomers be right wing and you still have a very, very large absolute number who are not, so saying "ha, the only people doing this thing are selfish assholes who hate POC and want to get rid of the safety net except themselves, etc, so it doesn't matter what happens to them" is still leaving out a very large absolute number. My family, for example, even the Indiana ones, is rife with white liberal and left voters.

Lots of non-asset-having people are terrified about the future of their disabled children.

Yeah, but look, unless you have an actual way to support the current generation of disabled adults that is going to sub in for getting money from family, what you're saying still boils down to "statistically, regardless of what the actual people are like, these people are probably morally bad, so it is important to make sure that they do not figure out a way to leave money to their kid, and it's important to make sure that this particular child joins the ranks of the semi-homeless disabled because, statistically speaking, people like their parents are bad people". I mean, what good does that do? It's like when people say to me, "some union members are conservative, so it's a bad thing that they get these pensions and make fancy wages - other people don't get them, so we should take them away from union members."
posted by Frowner at 12:32 PM on August 5, 2017 [15 favorites]


I am perfectly fine with millionaires having access to medicaid, in fact, I think everyone should have access to medicaid.

If you don't like that the state is paying private companies for the nursing home care of a few millionaires, the solution isn't to reduce their access to medicaid. The solution is to nationalize the nursing home industry.
posted by You Can't Tip a Buick at 12:34 PM on August 5, 2017 [28 favorites]


also if at any point my comments on any thread have more favorites than Frowner's comments, that means that you should all go read Frowner's comments more closely and then favorite them.
posted by You Can't Tip a Buick at 1:04 PM on August 5, 2017 [4 favorites]


Yeah, but look, unless you have an actual way to support the current generation of disabled adults that is going to sub in for getting money from family
I think that everyone should be working on an actual way to support the current generation of disabled adults who don't earn enough to live on and don't have family money to support them. I think that is a real moral crisis for our country, not a glib throwaway. (This is something I have thought a lot about, because my uncle was severely disabled and relied entirely on Medicaid-provided care. And my grandmother didn't have a lot of money or assets, but her ability to work the system was massively important to his quality of life, in ways that made me really question how people survive if their parents don't live into their 90s and aren't really good at dealing with bureaucracy.) And I do think it would be nice if people who were doing "Medicaid planning" would think about why they were committing legal welfare fraud and whether framing it that way should change their views about the social safety net that we provide to people who don't have wealth.

(And just so we're clear on how racialized this disparity is, the median white household in the US has a net worth of $141,000, while the median Latino household has a net worth of $13,000 and the median black household has a net worth of $11,000.)

Like I said, I'm not faulting people for doing it. I'm faulting people for doing it and then not asking any hard questions about what it means and how it should affect their views about public policy. And anything that gets people thinking about that stuff is a positive in my book.
posted by ArbitraryAndCapricious at 1:26 PM on August 5, 2017 [4 favorites]


I've known families worth tens of millions of dollars that have engaged in Medicaid planning so that a member of the family could qualify for Medicaid. They would get care either way: the only question was whether they would pay out of their fortune or the taxpayers would pay.

These people already pay their share through our progressive taxation system (or should). There should be no means testing whatsoever in the provision of healthcare.
posted by indubitable at 1:27 PM on August 5, 2017 [11 favorites]


A lot of people who "hide assets" to get on Medicaid are not rich - they just have social security
I got kicked off Medicaid when I went on disability. Even though I live below the poverty line and have no assets, my monthly payment is "too high" to qualify for Medicaid.
posted by xyzzy at 3:21 PM on August 5, 2017 [6 favorites]



If you don't like that the state is paying private companies for the nursing home care of a few millionaires, the solution isn't to reduce their access to medicaid. The solution is to nationalize the nursing home industry.

I don't mind that medicaid is paying for their nursing home care, I mind that they AND their children, will continue to vote to block access to the social safety net for those that don't have their privilege. I hate that the thread keeps framing it that I'm mad that millionaires are getting health care. I'm mad that millionaires who don't think brown folk or poor folk should get health care are gaming the system to make sure Muffy and Buffy inherit the goods that they gained by denying brown/poor folk from getting. If you're a millionaire that votes for the social safety net, avail yourself of it as well. If you vote to deny me of it? Then I have unkind thoughts for you.
posted by Gyre,Gimble,Wabe, Esq. at 5:12 PM on August 5, 2017 [2 favorites]


I mean, sure, it bugs me too that some petit bourgeois twerps get to pretend they're not the same as everyone else who needs help from others to stay afloat. but attacking the little bourgeoisie, in this case, would do nothing but benefit the big bourgeoisie who'd most benefit from the dismantlement of non-market-based assistance programs.
posted by You Can't Tip a Buick at 5:29 PM on August 5, 2017 [2 favorites]


While we're all mad, I'm mad, frankly, that my family members, who are lifelong left voters, who are not rich, get tarred with all this "Muffy and Buffy" garbage by people who sound extremely unfamiliar with arranging and paying for end of life care. Millionaires? I fucking wish we had millionaires in the family. I'm mad that everyone in this thread who has talked about their personal/family experience with this gets either brushed aside or assumed to be - as I can only assume you think of me - the lying liar relatives of wealthy people.

This whole thing reminds me of the run up to Obamacare, where my immediate thought was "a lot of people are going to make ~$40,000 a year and not get any subsidies, but not be rich enough to find it easy to pay an extra $500 out of pocket every month, and this is going to be a problem for the popularity of the plan." Which is what has happened. But back then, everyone loved to pretend that the only people who had any financial qualms about this were millionaires who hated the taxes.

I know it is difficult to believe - partially because most people under about 40 have a much worse time of it than older people did - but it is not incredibly uncommon for someone who is about seventy to have worked, bought a small house and have retirement savings in addition to the house and social security that total somewhere in the $200,000 range. That doesn't put you in the Buffy and Muffy class, and it does not make you financially secure when you're no longer working. Those people are far, far more common than multimillionaires.

And while we're on the anger thing - I get so, so tired of all the "statistically white boomers are conservative so let's talk as if they all voted against Obamacare and every good thing" bit. It is a slur on my union elders, it is a slur on my activist elders, it is a slur on the members of he otherwise rather dull but generically liberal church I grew up in. I get so tired of people - often young people in the tech industry, oddly enough, who are far richer and more respected than any of the white boomers I grew up with - talking about how terrible the older generation is. All I can think is "this is the garbage people will talk about me when I'm old, because just as everyone in American hates their mother, everyone in American hates old people".
posted by Frowner at 6:41 PM on August 5, 2017 [20 favorites]


I apologize for commenting once more, but as I made some toast, I came up with a policy solution that we in theory could implement. I mean, this assumes that healthcare is not free to all - if that is too big an ask, I propose:

First, much more substantial estate taxes, exact details to be worked out later.

Second, a more generous process for creating trusts for disabled children.

Third, Medicaid requires a sliding contribution based on income. In retirement, people with up to X amount of income (presumably Social Security plus some amount) pay nothing; people with more income pay a "Medicaid tax" which increased with income administered via quarterly estimates like capital gains taxes are. Rather than requiring people to get rid of assets on the front end, assess a contribution on an ongoing basis.

The estate tax plus the contribution system should allow the preservation of the kind of estate where people leave their kids relatively small amounts (which, FTR, is what people I know tend to do if they leave estates at all - the kids come out of it with a downpayment for a house, maybe, or if they're lucky enough money to supplement a low annual income by a few thousand dollars a year if they just flat out spend their capital) We're basically talking estates below $100,000, usually much below.

The contribution system would recognize that people with a high income should pay something while still not leaving people vulnerable to the kind of $100,000 a year costs that even fairly well-off people can't pay.

Very rich people would still attempt to reduce their income through tax dodges, but that's what the estate tax is for, and average people would have much less access to that type of accounting.

The idea that you should not get a benefit unless you are basically broke derives from the old poor laws - where you would have to, eg, sell your winter coat before you could get charity assistance. The problem with the poor laws on a practical level was that insisting that people be in total poverty before they could receive help made it harder for them to find work, care for kids and get off of assistance.
posted by Frowner at 7:37 PM on August 5, 2017 [8 favorites]


The thing that really bothers me about this whole situation is that the expense of elder care functions as something like a massive inheritance tax, but one paid to the market (which sucks) rather than to the state (which is despite it all at least nominally subject to some measure of democratic control). If you're middle class, or just regular wealthy rather than .01%er wealthy, whatever you've saved up to pass along to the next generation gets eaten by scoundrels — like, the 70k a year or whatever that people pay to nursing care facilities? that money does not go to the the people who take care of them. It gets skimmed off by the owners, who then give crumbs to the overworked staff.

The middling-well-off get their money taken by end of life vultures, but the real rich, the .01%, the people in danger of setting up a dynasty, the people who are threats to democracy, they can afford end-of-life care without blinking, and also they know how to dodge state-imposed inheritance taxes.

It's abominable.
posted by You Can't Tip a Buick at 8:29 PM on August 5, 2017 [16 favorites]


While we're all mad, I'm mad, frankly, that my family members, who are lifelong left voters, who are not rich, get tarred with all this "Muffy and Buffy" garbage by people who sound extremely unfamiliar with arranging and paying for end of life care.

Yeah, seriously, anecdata, but my grandmother has been a communist since at least the 40s, if not earlier. I hate the automatic assumption that this is just rich people demanding to get free stuff, based on assumptions about demographics. It only serves to dominate and shut down the conversation with righteous fury instead of engaging with the actual problems at hand. I'm sure there are people abusing this, but there are only so many millionaires in the country (they're not even the 1%), and the cutoff for this sort of benefit is always far lower than people imagine.
posted by shapes that haunt the dusk at 9:19 PM on August 5, 2017 [2 favorites]


"ha, the only people doing this thing are selfish assholes who hate POC and want to get rid of the safety net except themselves, etc, so it doesn't matter what happens to them"

Yes, it would be terrible if someone said such a patently untrue thing. Good thing nobody did, instead identifying such people as a subgroup of the larger group facing a "brutal conundrum" for whom it would be an ethical issue to engage in that practice.

is not incredibly uncommon for someone who is about seventy to have worked, bought a small house and have retirement savings in addition to the house and social security that total somewhere in the $200,000 range. That doesn't put you in the Buffy and Muffy class

No, but it does make you significantly better off than both most people and most people your own age. Honestly, don't lecture me about economic reality when this example person is the same age as my mother, who worked hard all her life and has no house, small or otherwise, and has only a fraction of that supposedly not-very-meaningful $200K in savings. "I'm only middle-to-upper-middle-class, that's not so great, why don't people understand I want to keep my assets and then give them to my kids?" is ... well, it's not all that far off in tone from the NYC professionals complaining that they aren't rich at salaries of $300K/yr when you're talking about one of the poorest American demographics.

I think that everyone has a right to access health care and elder care, regardless of income. I also think that no one has any particular right to or interest generally in leaving assets to their adult children such that they have some kind of ethical dispensation to preserve those assets in contravention of universal rules just so that they may do so. I would, for instance, be perfectly happy funding a non-means-tested nursing-home benefit with 100% inheritance tax on all assets over a very modest amount (with appropriate lookbacks, etc.).
posted by praemunire at 10:59 PM on August 5, 2017 [4 favorites]


It is insane.

And actual liquidation of assets leaves one living on the 30 (yes, you read that right) stipend per month one gets from the nursing home to cover all outside needs (shampoo, new underwear, a cell phone, snacks, toenail clippers, whatever you get the idea) you will live in nursing home gowns with no access to anything that you once enjoyed on the outside. A movie? Never again.

Then there is just stuff not covered by Medicaid. Like dental. You can get dentures and extractions. Have good teeth and just need a filling? To bad, all they will do is pull the tooth.

The DME is IL is terrible. Have brand of daipers that doesn't irrate the skin? Too bad. Walkers fall apart way faster than they'll replace them. My MILs rolling walker is a year old and the tires have lost their rubber so the brakes don't catch. Getting extra seating covers?

My MILs assisted living made her pay for her ensures on her 90 dollar a month stipend because the food they provided should have been enough. Even with a prescription and a low BMI. (This was most likely illegal, but we moved her to another facility)

One will end up spending money on care if you want quality of life in a nursing facility. There are things that are worth it to do that aren't frivilious.

Benefit management is important. We deserve to be able to leave a legacy if we are lucky enough to have money. And more importantly, some of that money will be used on care by choice of family if they care .

As a millennial with a disabled parent, I know at some point I will creating debt to make my moms life better. There is nothing for her to give.

When I hear my friends who get income from the passing of a parent, aside from the serious grief there is relief. I can pay off my credit card debt. I can make a dent in my student loans, I have a down payment on a house.

Medical care taking everything you have is unethical.
posted by AlexiaSky at 11:10 PM on August 5, 2017 [12 favorites]


I don't think I'm wealthy enough to afford this type of planning. But if I needed care, my retirement savings wouldn't last long. This type of planning is most likely to benefit people who are wealthier than I am. I'm 62, pretty much debt-free, own my house, with modest retirement savings. I figure I'll rely on Social Security for @ 2/3 of my retirement income. Like many tax regulations (mortgage interest deduction), this ends up benefiting the wealthy. As long as we have a Congress that is focused on assisting the wealthy and doesn't care about people who earn less than 100,000 a year, this isn't going to change. If you are poor, you'll get Medicaid and Social Security. You'll land in a nursing home and if you're very lucky, you'll get good care. If you're lucky, you'll get adequate care. If you're not lucky, well, that sucks. If you are wealthy, you'll have the income to ensure that your care is good, and the assets that produce that income will be protected. Just like everything, your wealth will protect you and your government will enable that. I don't begrudge anybody getting good health care; I just think everybody should be able to get good care without being impoverished.

The US is practicing extreme capitalism. The results are predictable.
posted by theora55 at 7:28 AM on August 6, 2017 [3 favorites]


I got kicked off Medicaid when I went on disability. Even though I live below the poverty line and have no assets, my monthly payment is "too high" to qualify for Medicaid.

It seems, unfortunately, that you live in a Republican state that refused federal funds for Medicaid expansion. In states that implemented the Obamacare Medicaid expansion, everyone below 138% of the poverty income level, regardless of assets, gets free or nearly free Medicaid automatically. There are still 19 Republican controlled states that haven't expanded Medicaid even though the federal government covers 95% of the cost.
posted by JackFlash at 6:44 PM on August 6, 2017 [5 favorites]


I live in one of those states. Fuckers.
posted by yesster at 7:39 PM on August 6, 2017


Remember, Republicans WANT TO END EVEN THIS.

They proposed capping Medicaid reimbursement rates at a rate that would end the program in under two decades.

Republicans think even the indignity of throwing off your life savings to die in squalor is too good. They want to take even that away.

Every single Republican in Congress except John McCain voted to do exactly that.
posted by T.D. Strange at 9:09 PM on August 6, 2017


I don't think I'm wealthy enough to afford this type of planning. But if I needed care, my retirement savings wouldn't last long. This type of planning is most likely to benefit people who are wealthier than I am. I'm 62, pretty much debt-free, own my house, with modest retirement savings.

You are the perfect demographic for this type of legal services. You have assets, a house to protect if nothing else. Contact an estate planning lawyer with elder planning and medicaid experience. They're not all for the 1%. There's Mitt Romney level offshore "I have 100 million in my IRA" estate planning; and then there's retail lawyers that can help you plan for getting the care you may need in the future without losing your life savings. Plan before you need it. Medicaid clawback provisions can be up to 5 years, so waiting saves you nothing.
posted by T.D. Strange at 9:16 PM on August 6, 2017


In states that implemented the Obamacare Medicaid expansion, everyone below 138% of the poverty income level, regardless of assets, gets free or nearly free Medicaid automatically.

It's worth noting that 138% of the federal poverty income level is still less than $17,000/year.

Since no one has quoted any numbers, I've been doing some research (admittedly, I'm far from an expert on this). For an individual over 65, the medicaid asset limit is $2,000. In some states it's more generous, so maybe $3,000 (in California) or even $14,000 (New York). The numbers for couples are a little higher.

I'm still figuring out how community assets work. A community spouse is someone whose spouse enters nursing care. They are allowed half of the couple's shared assets, with an upper limit of about $120,000. There's restrictions on how much can be spent per month, and there are often penalties for transfers of wealth.

Incidentally, there are about a million websites offering legal advice for asset planning, and these websites are very depressing. What a shitty country to live in.
posted by shapes that haunt the dusk at 9:49 PM on August 6, 2017 [3 favorites]


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