To pay or not to pay? Conservatives grapple with Medicaid estate recovery issues

December 23, 2013

By Matthew E. Milliken
Dec. 23, 2013

Last week, I looked at how the expansion of Medicaid under Obamacare might be changing the scope and reach of Medicaid’s estate recovery provisions. As the Democrats’ Patient Protection and Affordable Care Act continues taking effect, I suspect we’ll hear a lot more people raising questions about how these two programs interact with one another. 

Of course, some conservative writers have already expressed their thoughts on the matter, and they’re rather dire. At Breitbart, Debra Heine wrote ominously that “enables the Federal government to go after your estate after you die in order to pay for the healthcare expenses you have incurred while on Medicaid.”

Dr. Jane Orient, a conservative physician, offered this: “Expanding Medicaid to persons with modest assets will enable estate recovery to become a cash cow for states to milk the poor and the middle class.”

Blogger Alex Gimarc rendered this verdict: “I cannot think of a better way to impoverish the young and keep them impoverished for all time.” Gimarc then went on to quote George Orwell’s 1984: “If you want a vision of the future, imagine a boot stamping on a human face — forever.”

Summing up, Heine, Orient and Gimarc seem to be arguing that it’s wrong for the estates of deceased individuals to pay for the health care that they received while they were alive.

Now, maybe I’m oversimplifying. Maybe these writers’ argument is a bit more nuanced; maybe they’re trying to say that it’s OK for the government to seek reimbursement for estates, as long as the amount sought is commensurate with the value of services rendered. That seems somewhat sensible.

(To be candid, I can’t discern from Orient’s rhetoric whether her main problem with estate recovery is that it enables government to get revenue or that that revenue is funneled to “multibillion-dollar, managed-care companies.” Perhaps she’s objecting to both things — or would everything be better if all of these companies billing the government simply didn’t reach the multibillion-dollar threshold? At any rate…)

What struck me about these pieces is how starkly they contrast with a principle that über-successful conservative radio host Rush Limbaugh offered the day after President Barack Obama won re-election in 2012. Take a look:

Conservatism, in my humble opinion, did not lose last night. It’s just very difficult to beat Santa Claus. It is practically impossible to beat Santa Claus. People are not going to vote against Santa Claus, especially if the alternative is being your own Santa Claus.

Now, everybody is jumping on Romney’s chain today, getting in his chili. Look, he may have not been the most optimal candidate, but he’s a fine man. He would have been great for this country. Mitt Romney and his family would have been the essence of exactly what this country needs. But what was Romney’s recipe? Romney’s recipe was the old standby: American route to success, hard work. That gets sneered at. I’m sorry. In a country of children where the option is Santa Claus or work, what wins? And say what you want, but Romney did offer a vision of traditional America. In his way, he put forth a great vision of traditional America, and it was rejected. It was rejected in favor of a guy who thinks that those who are working aren’t doing enough to help those who aren’t. And that resonated.

Got that? One key conservative principle is that government shouldn’t take money from private citizens, even for services rendered. But here, El Rushbo is basically saying the opposite — that success is earned through hard work, and that unearned benefits are immoral.

The truth, of course, is that while some degree of poverty may be inevitable, it’s bad for citizens to be impoverished, whether by government or the private sector. It’s also true that, beyond a certain point, offering free benefits on a wide scale does have deleterious effects. There’s a very important question raised by estate recovery and Medicaid expansion under Obamacare, and it’s this: Bearing in mind that Medicaid recipients are by definition low income, how much responsibility should older Medicaid enrollees have for their health care costs?

There’s no single simple answer to this. But I’m confident of one thing.

Finding the best solution won’t come from elevating one principle at the expense of another. Instead, it will come from finding the best balance among competing principles.

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