So here's the deal: since 1993 there has been a federal law requiring states to recover at least some of the costs of Medicaid-covered medical care for anyone 55 years old and up, from the estates of those covered.

States enforce this law, with their own laws and policies added in, differently in every state. But the general principle is there. Up until now the usual consequence has been things like this: Medicaid puts a lien on the house of someone in a nursing facility who has run out of money, and after they die, the heirs find they have to buy the house back from the state if they want it.

We haven't had lots of people younger than 65 on Medicaid, because in most states simply earning less than the Federal Poverty Level did not qualify one for Medicaid.

And we haven't had many people with lots of assets on Medicaid, because in most places you have to have less than around $2400 to your name before Medicaid will cover you. You can keep your house and your car, but Medicaid reserves the right to put liens on them and take them when you die.

But now we have the Affordable Care Act, and its expectation that everyone in the lower tier of income will end up in the Medicaid system. To accomplish this, they have dropped the asset test. So now we will have lots of people ages 55-64, who have assets but not a lot of income right now, for whatever reason, on Medicaid.

The kicker of it is, if you make the right amount to qualify for a subsidized health insurance plan, your costs are going to be shared and subsidized by the government. But if you go on Medicaid, you owe the entire amount that Medicaid spends on you from the day you turn 55.

And that amount is not just what is spent on your doctor visits and your treatments, whatever they may be. No, there is also something called a "capitation charge." For each enrollee, a base cost is assigned to the entity that administers the program. How much will that charge be? It varies by state, and as far as I can tell by other variables as well, but it could be hundreds of dollars per month, or more. (If you have specific information on this, please do share it!)

How will this play out? No one knows, as far as I can tell. But it is easy to see how this could become a real problem. If someone is low income and goes on Medicaid, will Medicaid put a lien on their house? If they need to sell their house and move, will they then lose all their equity in paying off the lien? Will people get hit with bills and liens for many thousands of dollars, even if they were healthy and hardly ever went to the doctor?

Why is it that Medicaid is pretty much cost free to use up to age 54 if you qualify, and suddenly becomes a collateral loan at age 55, for which a state agency will do its best to collect payment in full for every cost assigned? It seems clear that the Estate Recovery law did not anticipate the current circumstance with the ACA, and that putting the two laws together makes for a terribly unfair situation for some. What can we do to remedy this situation?

The fact that practically no one is talking about this makes me uneasy. (It has been mentioned a few times, for instance the comments section of the diary here.) At the very least what we are getting set up to do is implement an arbitrary, capricious, and regressive tax, that will only be paid by older, low income people. And we are putting this in motion at a time when there are lots of other difficulties to be worked out. I would like to make sure that we are not forgetting those who will find themselves stuck between their need for health coverage and the implications of the Medicaid Estate Recovery laws and programs.

Update: this diary is the first of a series on Medicaid and Estate Recovery. The next ones are Estate Recovery: It's Worse Than You Thought and Medicaid is Welfare - It's Right To Expect Repayment.