As I have discussed elsewhere, we are conflicted about Medicaid so it is no surprise that the ACA is conflicted about Medicaid. Most particularly, the ACA does nothing to alter state discretion to seek state recoupment of Medicaid costs from Medicaid beneficiaries who received basic medical services through Medicaid at or after the age of 55.
No, I'm not talking about Medicaid recoupment of nursing home costs but, rather, recoupment of basic Medicaid medical costs. This, in some states, is old hat. California, New York, Massachusetts and others have been recovering funds from the estates of 55+ Medicaid beneficiaries who received basic health services under the program for decades. But now that the reach of Medicaid in these Medicaid expansion states is broadening Medicaid eligibility to greater numbers of citizens with assets (read: the family home) the tension between Medicaid's historical status as a program where, to some extent, the benefit is returned to the government and its re-invented status as the health insurance provider of last resort for those too poor to shop throught the exchanges is made manifest.
So, which way will we have it: urge Medicaid enrollment on the newly eligible in the 55-65 age group (what AARP calls the pre-Medicare eligibility age group) as the insurer of last resort for those priced out of the commercial marketplace but only at the cost of future recoupment or leave this group increasingly detached from employer sponsored health insurance, clinging to the family home but willing to defer care until Medicare eligibility at 65?
Interestingly, not everyone likes the choice these 55-65 year olds are being put to — hence the recent kerfuffle in Oregon and the impending one in California. But few commentators note that this is simply the application of a rule that far pre-dates the ACA to the expanded population. Of course, the expanded population is, as I have also noted, far more likely to build a consitutency for Medicaid in the way its core recipients never have. So, now it is an issue.