(4)  Many more studies by other authors have documented the extent and techniques of Medicaid estate planning.  For example: 

     (a)  Brian O. Burwell, Middle-Class Welfare:  Medicaid Estate Planning for Long-Term Care Coverage, Systemetrics/ McGraw-Hill, Lexington, MA, September 1991. 

     (b)  Joint Legislative Audit and Review Commission, Medicaid Asset Transfers and Estate Recovery, The Virginia General Assembly, Richmond, Virginia, Senate Document No. 10, November 24, 1992.  

     (c)  Burton D. Dunlop, Max B. Rothman, and John L. Stokesberry, The Context of Long Term Care in Florida:  Interrelationships of Medically Needy, Assets Recovery and Long Term Care Insurance Policy Initiatives, Southeast Florida Center on Aging, North Miami Florida, December 1992. 

     (d)  Iowa Department of Management Medicaid Task Force Final Report, December 1992. 

     (e)  Brian O. Burwell, State Responses to Medicaid Estate Planning, Systemetrics, Cambridge, Massachusetts, May 1993. 

(5)  The legal literature on Medicaid estate planning is extensive and reaches back more than ten years.  Hundreds of books, articles, training manuals, video and audio cassette programs, films, conference proceedings, etc. document innumerable medicaid estate planning techniques for professional and lay (self-help) audiences.  Some of these include: 

     (a)  Budish, Armond D., Avoiding the Medicaid Trap:  How to Beat the Catastrophic Costs of Nursing-Home Care, Henry Holt, New York, 1989. 

     (b)  Gordon, Harley with Jane Daniel, How to Protect Your Life Savings from Catastrophic Illness and Nursing Homes, Financial Planning Institute, Inc., Boston, 1990. 

     (c)  Gilfix, Michael and Mark Woolpert, "Medi-Cal Asset Preservation and Your Clients or Estate Planning is Not Enough!:  A California Elder Law Institute Continuing Legal Education Seminar," Gilfix Management Group, Palo Alto, California, 1990. 

     (d)  Budish, Armond D., "What, Me Pay for Nursing Home Costs?," Thomas & Partners Co., Inc., Westport, Connecticut, 1992; 50 minute video and workbook. 

     (e)  For several years, annual professional symposia of the National Academy of Elder Law Attorneys as well as the Joint Conference on Law and Aging have focussed heavily on the development and promulgation of Medicaid estate planning techniques.  The proceedings of these conferences are available in manuals and cassette tapes. 

     (f)  The scholarly literature in gerontology, medicine, accounting and financial planning is replete with articles on Medicaid estate planning documenting hundreds of techniques from simple asset conversions to esoteric trust maneuvers. 

     The most recent work cited above was not yet completed when GAO began its research.  All of it was underway, however.  If GAO had reviewed these studies and analyses or contacted their authors before beginning its own work, the agency could have avoided most of the methodological errors described below. 

6,iv:  "Of the 403 applicants in our sample, 54 percent converted some of their countable assets to noncountable assets and 13 percent transferred assets." 

     These findings are much higher than anyone expected.  Nevertheless, they are too low.  Anyone who has done empirical studies of Medicaid estate planning knows that most eligibility case records contain a lot of inconclusive evidence concerning income and assets.  Such clues must be followed up and verified by additional research such as contacting personal representatives of Medicaid recipients and consulting local public assessor's and recorder's records.  For example, many Medicaid applicants fail to report property ownership, transfers or conversions altogether.  Yet, GAO states that... 

23,iii:  "We did not independently test the file data nor did we determine if applicants accurately reported all their assets and asset transfers." 

     Because GAO relied only on case records and did not seek independent verification from recipients and public records, it missed cases with unreported or under-reported property, transfers, or shelters.  Although independent verification is difficult and requires considerable detective work, it is not at all unwieldy on a small sample like GAO's.  

8,i:  "Asset conversions occur frequently but not for significant sums." 

     GAO found that 217 applicants, or 54 percent of its sample, converted assets totaling $1.2 million.  If GAO's one-third sample of cases for October 1992 is representative, we can estimate that total asset conversions for one month in Massachusetts approached 650 cases and $3 or $4 million in sheltered funds.  GAO concludes, however, that this is not a "significant sum," because most of it is prepayment of burial costs averaging $4,700 per case.  Consider what this means in terms of public policy.  When two-thirds of the elderly poor and half of all poor children in America are not covered by Medicaid even for acute or emergency care, is it wise to spend scarce welfare dollars to indemnify heirs for the burial costs of their parents on welfare?  Does it make any sense to pay for the relatively fancy funerals that nearly $5,000 will buy?  How much additional home care and assisted living could Massachusetts offer the frail elderly if the state stopped paying excessive burial costs for non-indigents?  If Medicaid applicants in Massachusetts really are tucking away $35 to $45 million per year in burial trusts just before they go on public assistance as the GAO data implies, the state and federal governments have a very rich source of financing for worthier causes without neglecting the decent, but cost-effective disposal of all genuinely impoverished recipients' remains. 

12,i:  "About one in every eight applicants...transferred assets within 30 months of applying for Medicaid...Transfers ranged in value from $850 to $351,300...The total amount transferred was $2.2 million, or $45,912 on average for each transfer."   

13,iv:  "Most of the $2.2 million in transferred assets did not result in increased Medicaid spending." 

     GAO reports evidence of staggering amounts of asset transfers for the purpose of qualifying for Medicaid.  Then, almost in the same breath, the agency emasculates its own findings.  Supposedly, the enormous asset transfers documented in the report do not increase Medicaid spending because most of them occur in cases denied eligibility by the state Medicaid program. This conclusion is a glaring display of naivete' and gullibility on GAO's part.  State Medicaid agencies routinely deny cases with large asset transfers or other egregious Medicaid planning gimmicks on the off-chance that the applicants will not appeal or reapply.  Usually, however, they do appeal or reapply and they do so successfully.  If an attorney was consulted in the first place, the applicant will probably win quickly on appeal.  If an attorney was not consulted in the first place, one will be consulted after the case is denied.  Then, a new application will be submitted with the help of the attorney reflecting a different, more effective transfer or sheltering technique.  As documented in the Inspector General's report on transfer of assets cited above, "fifty-eight percent of the Washington Medicaid nursing home cases that were initially denied assistance...became eligible within a few months by transferring or sheltering their assets."  If GAO were to re-review their Massachusetts sample in one year, they would find that cases initially denied Medicaid eligibility were subsequently approved and are very expensive indeed.  (By the way, the exact same thing is happening in Medicare home care and it is costing the federal government a fortune.) 

24,ii:  "Our methodology has two additional limitations.  One, it does not include people who conducted Medicaid estate planning but have not applied for Medicaid nursing home benefits...Two... [a]pplicants who conducted Medicaid estate planning sufficiently in the past [i.e. 30 months] would not have to report such data to the state and therefore may not have appeared in our review to have transferred for converted assets."  

     One of the simplest and most common Medicaid estate planning techniques is to transfer assets 30 months or more in advance.  Although not required to do so, 16 of GAO's sample cases reported having transferred assets this far in advance.  The 13 of these advance planning cases that also reported dollar amounts, transferred a total of $1.4 million.  Most people, especially those advised by attorneys, would not report transfers they are not required to report.  Therefore, this hidden loss (approximately $4 million for the review month or $48 million for the year when projected to the sampling universe) is only the tip of the iceberg.  If GAO had checked all cases in their sample against county assessors' and recorders' records going back five years (as HCFA did in its study of Idaho in 1985), it could have documented much more of this hidden loss. 

Miscellaneous Additional Comments 

(1)  GAO does not take into account the fact that the median elderly person in terms of income and assets qualifies for Medicaid nursing home benefits in Massachusetts if medically eligible without using fancy Medicaid estate planning techniques. This is true because there is no limit on how much income one can have as long as total medical costs exceed income and the vast majority of seniors' assets are exempt.  (Sixty-nine percent of the median elderly household's net worth is in a home which is exempt regardless of value.)  As long as these assets are held in joint tenancy with right of survivorship (JTWRS) as most assets in America are, they pass outside the probate estate and are free from Medicaid recovery.  Al Bove, elder law attorney and columnist, writes every other week in the Boston Globe urging everyone who does not already hold their assets in JTWRS to convert them immediately.  In other words, even when formal transfers and shelters are not employed, Medicaid eligibility restrictions are a sieve, not a safety net.  Cases in GAO's sample that involved no conversions or transfers by its definition, therefore, will nevertheless cost the state and federal governments large sums in unrecoverable benefits. 

(2)  GAO does not deal with the possibility that Medicaid nursing home recipients simply spent their money rather than transferring or sheltering it based on advice like this from prominent Medicaid planners:  

"...a common misconception among applicants is that excess resources must be spent only on doctors, hospitals, nurses, medication, and nursing homes.  Nowhere in the law is this indicated.  Quite literally, an applicant could spend all of his or her assets on something 'frivolous,' such as a 90th birthday celebration of Ziegfield Follies proportion and this should not be cause for denial of Medicaid, because the applicant received 'value' for his or her money." (Ira S. Schneider and Ezra Huber, Financial Planning for Long-Term Care, Human Sciences Press, Inc., New York, 1989, p. 142) 

"While there are rules against giving away most assets, there are no prohibitions against simply spending money... options might include travel to visit relatives or see the world, or one last tour of Reno's finest establishments."  (Michael Gilfix and Mark Woolpert, "Medi-Cal Asset Preservation and Your Clients or Estate Planning is Not Enough!:  A California Elder Law Institute Continuing Legal Education Seminar," Gilfix Management Group, Palo Alto, California, 1990, p. 42) 

(3)  GAO fails to capture the outrage of Medicaid eligibility workers who are compelled to work as unpaid paralegals for private and legal services attorneys who badger them for methods to qualify affluent clients for Medicaid.  For example, this is what Medicaid eligibility workers told me when I interviewed them in Massachusetts:  "long-term care units are barraged by [Medicaid planning] attorneys...it goes on all day...the system leaks all over the place...the laws and policy set us up for failure...the workers feel intimidated...it gets outra-geous...it is morally terrible."  (Page 5 of enclosed report.)  Sterile case record reviews fail to evoke the anger and frustration eligibility workers feel when they are unable to qualify genuinely needy people for Medicaid, but must grant the program's most expensive benefit to the well-to-do clients of clever attorneys. 

     In conclusion, GAO provides ample evidence of widespread Medicaid estate planning in the Massachusetts nursing home caseload, but fails to capture anything approaching the full magnitude of financial impact on state and federal finances. 

Section II:   Comments on Senate/House Conference Language on Transfer of Assets and Estate Recoveries 

     Senate and House conferees have come under pressure to dilute or eliminate proposed statutory language designed to close Medicaid estate planning loopholes and require recovery from estates.  I believe it is critical for conferees to keep the goal of this legislation constantly in focus.  These bills were not designed simply, or even primarily, to save money.  Their objective is to make better use of scarce public resources.  Their main goal is to protect our government's ability to provide quality long-term care to people who could not otherwise afford it.  Their effect will be to encourage those who can afford to pay their own way or to buy insurance to do so and leave the welfare programs to those who have no other option.  We must remember that two-thirds of the elderly poor and half of all poor children are not covered by Medicaid even for acute or emergency care.  Public policy makers must concern themselves with these truly needy citizens first before spending public dollars to indemnify middle class heirs of affluent seniors for ignoring the risk of long-term care. 

     Although its main focus should be to eliminate perverse incentives in existing Medicaid rules which discourage private pay and private insurance, this legislation will also save billions more in tax payers' dollars than anyone has so far estimated.  This is true because, in addition to hard dollar estate recoveries and direct cost avoidance from loophole closures, people will change behavior if this legislation passes. They will buy insurance, pay privately for top quality care, stay off Medicaid in the first place, and raise the quality of care in nursing homes by increasing the cash flow (i.e. higher private payments) to nursing homes available for cost shifting to support the remaining Medicaid patients.  (See the enclosed draft article entitled "Of Floods, Insurance and Long-Term Care.  Scheduled for publication in the September issue of LTC News and Comment.) 

     Medicaid estate planning attorneys have offered self-righteous and self-serving recommendations to weaken this legislation and preserve existing loopholes.  Medicaid planners prosper under existing law and want it to change as little as possible.  They prefer the most lenient treatment of divestiture and the weakest estate recovery provisions possible.  This is because they represent seniors (whether rich or poor) to the exclusion of the general public interest.  Private attorneys charge $100 to $200 per hour to qualify affluent seniors for Medicaid nursing home benefits.  The more effective trusts, transfers and other tricks are in short-circuiting eligibility rules, the more money these private attorneys make.  Legal services' attorneys absorb millions in federal tax revenues to provide free legal services to poor seniors.  What is less well known is that they also refer middle income and wealthy seniors or heirs who contact them (and many do) to private Medicaid estate planning attorneys.  Studies by the Inspector General of the U.S. Department of Health and Human Services found that private and public attorneys work hand-in-hand to insure that everyone, regardless of income or assets, qualifies as quickly as possible for Medicaid nursing home benefits.  Is it any wonder that Medicaid costs are skyrocketing? 

     If one keeps these principles in mind, it is not hard to distinguish between provisions in the proposed legislation which would make good law and alternatives which merely cater to the Medicaid planning attorneys and their well-heeled clients.  Therefore, I will not address every specific clause in the bills, but limit my comments to the more important provisions. 

(1)  Look back periods of 30, 36, or even 48 months are insufficient.  

     The Medicaid estate planning attorneys are already gearing up to push their clients to plan much further in advance to divest.  Sooner or later, we will have to go to a minimum of 60 months (5 years) as recommended by the Inspector General of the U.S. Department of Health and Human Services.  Why?  The average time from onset to death in Alzheimer's Disease is eight years.  If heirs act at the first sign of confusion or frailty to appropriate their parents' assets, they can do so with impunity. This is precisely what the Medicaid planners advise their clients to do.  Transfer of assets will increase rapidly if other loopholes are closed without extending the look back period.  

     The objection that longer look back periods would create administrative hassles for state Medicaid agencies is specious.  The vast majority of states do not verify asset transfers on a case by case basis.  Most Medicaid planning attorneys will respect the law regardless of how strongly it is monitored or enforced.  Few people will plan five years or more in advance without the advice of an attorney.  Therefore, a longer look back period will have a strong chilling effect on asset transfers without requiring any extra work.  

     Furthermore, we must keep in mind the reason for having a look back period in the first place.  Nine percent of seniors will spend five years or more in a nursing home at an average cost exceeding $30,000 per year.  Given this high probability of catastrophic loss, any transfer of assets no matter how far in advance by an older person is suspect as to whether it is done in contemplation of avoiding a future possible creditor, i.e. Medicaid.  If done to avoid paying for long-term care costs, any transfer may be a "fraudulent conveyance" and may leave the transferor, the transferee, and the facilitating attorney liable to legal action for recovery brought by the defrauded creditor.  Many courts are now so holding.  This risk of malpractice or even prosecution under the common law of fraudulent conveyances is a major worry to Medicaid planning attorneys today.  Extending the Medicaid look back period enforces the message that divesting assets to shift the highly probable financial burden of long-term care to public programs is inappropriate no matter how far in advance it is done.  

(2)  The penalty period should begin at Medicaid eligibility.  

     The reason the Medicaid estate planning attorneys want to retain current provisions under which the penalty begins at the date of transfer is to protect the "half a loaf" gambit.  When this legislation eliminates the pyramid or multiple divestment strategy, the only trick left will be to give away half of the client's assets and spend down the rest while the penalty period elapses.  This allows someone to get rid of $100,000 while only triggering a penalty for $50,000.  By starting the penalty at the date of eligibility, this legislation would encourage people to use their wealth for their own care instead of giving it away to qualify more quickly for Medicaid.  Policy makers must decide whether the purpose of our welfare programs is to help poor people or to protect the inheritances of heirs.  

(3)  It is critical to apply the transfer of assets penalty to home care as well as nursing home care.  

     Medicaid estate planning attorneys often advise clients to transfer their assets and use Medicaid home care for 30 months whether they need it or not in order to qualify for nursing home care without a penalty period whenever the higher level of care becomes necessary.  The explosion in Medicare home health costs, aided and abetted by the same legal techniques refined in Medicaid planning, is another reason to include home care in the transfer of assets penalty.  As long as people can obtain free home care from Medicaid and Medicare, we cannot expect them to pay privately or purchase insurance for this risk.  We must decide as a nation whether we can afford to provide everything to everyone at any cost.  In the meantime, however, we should reform the current system so that it helps those in genuine need and encourages others to take care of themselves. 

(4)  It is very important to define the hardship exclusion narrowly.  

     Early indications are that the Medicaid planning attorneys intend to pry this loophole wide open as soon as possible.  We need to remember that Medicaid planning, especially the use of divestiture and guardianships, is sometimes only a euphemism for financial abuse of the elderly.  Oregon enhances its adult protective services program by retaining private attorneys on contingency to invade abusive trusts, reverse illegal transfers, and partition undivided property (when the property is improperly withheld from Medicaid recipients to assure their eligibility).  This procedure not only protects seniors and generates non-tax revenue, but it also has a chilling effect on the use of Medicaid planning techniques by heirs to impoverish and disenfranchise their parents.  It is far better public policy to help financially abused seniors recover assets taken from them than to interpret "hardship" provisions so liberally that they protect the people who took the assets from legal actions for recovery. 

(5)  The estate recovery provisions must be broad and strong.      

     Under current law, anyone can evade estate recovery by placing assets in joint tenancy with right of survivorship.  All of the Medicaid estate planning treatises urge this gambit.  Many other similar techniques permit affluent seniors who have access to professional financial and legal advice to avoid recovery.   Furthermore, Medicaid state agencies are adept at giving money away but they have a dismal record for recovery programs including child support enforcement, third party liability, and fraud recovery.  Properly managed, estate recovery alone can recoup five percent of a state's Medicaid nursing home budget.  Oregon has proved this year after year.  Therefore, this legislation should contain a broad definition of "estate;" it should require HCFA to provide extensive technical assistance; and it should encourage states to use private estate recovery contractors working for contingency fees that reward success and penalize failure.  

     House and Senate proposals to discourage divestiture and mandate estate recovery occupy a seldom-articulated moral high ground: 

            We have very limited dollars available for public assistance; we must take care of the truly poor and disadvantaged first; the middle class and well-to-do should pay privately for long-term care to the extent they are able without suffering financial devastation; prosperous people who rely on Medicaid for long-term care should reimburse the taxpayers before giving away their wealth to heirs; seniors and their heirs who wish to avoid such recovery from the estate should plan ahead and purchase private long-term care insurance. 

If members of Congress keep these principles in mind, they will sweep aside the self-serving arguments of misguided advocates and reform the system to benefit taxpayers and vulnerable seniors alike.                       

APPENDIX 

DRAFT        Of Floods, Insurance and Long-Term Care        DRAFT
by
Steve Moses
Director of Research, LTC, Incorporated 

     This year's sodden catastrophe in America's heartland is a perfect analogy for the crisis in long-term care financing.  The "flood of the century" swamped thousands of homes, dislocated millions of people, and destroyed countless farms and businesses. Costs may reach $10 billion or more.  State and federal governments acted immediately to provide emergency aid.  Politicians inundated the media with promises that tax-financed indemnification would follow.  Although most of the damaged property was located on flood plains, few property owners had private insurance to cover the risk of flooding.  Why? 

     "My home-owners' policy will protect me," some claimed.  "The water could never reach me here in a hundred years," many affirmed.  "Flood insurance is too expensive," most said.  Local officials and bankers frequently bent the rules to approve building permits and bank loans without the technically required flood insurance.  No one said "I'm not going to buy insurance, because the government will pay if the worst happens."  But, vaguely and evasively, everyone knew it was true.  If the floods came, the political compassion combine would replace any natural harvest lost.  

     Now compare the crisis in long-term care financing.  Nine percent of seniors will spend 5 years or more in a nursing home at an average cost exceeding $30,000 per year.  People over 85 who are the most vulnerable to long-term institutionalization are the fastest growing population cohort in America.  Nursing home costs tripled between 1980 and 1991 (from $20 to $60 billion) and they are projected nearly to triple again between 1990 and 2000 (from $53 to $147 billion).  Clearly, long-term care risk dwarfs flood risk. Predictably, the government response has been commensurately large.  Two-thirds of all patients in America's nursing homes receive Medicaid.  Although Medicaid pays only 48% of nursing home costs directly, Social Security pays another 18% indirectly as the Medicaid patients' contribution to cost of care.  Medicare and the Department of Veterans' Affairs picked up another 6% or so in 1991 bringing the government's nursing home contribution to well over 70% of total costs.  Finally, Hillary's health care honchos are promising even further expansion of public benefits for long-term care.  Although nursing home institutionalization is the single biggest financial risk senior Americans face, only 4% of them have private long-term care insurance and private insurance contributes less than 4% to national nursing home costs.  Why? 

     "My Medicare supplement policy will protect me if I have to go to a nursing home," some claim.  "It won't happen to me; I'm too healthy,"  many affirm.  "Long-term care insurance costs too much," most say.  Elder law attorneys and many Medicaid eligibility workers bend the rules to qualify prosperous people for the welfare program's nursing home benefit.  No one says "I'm not going to buy insurance, because the government will pay if the worst happens."  But, subconsciously, everybody knows this is true.  The reality is that if nursing home care becomes necessary, someone else usually pays.  Who knows or cares whether the payer in fact is Medicare or Medicaid, Uncle Sam or Santa Claus? 

     The main purpose of private insurance is to replace a small risk of catastrophic loss with the certainty of an affordable premium.  In a free market, private insurance also performs another vital function; it prices risk.  Voluntary exchanges between willing sellers (insurers) and willing buyers (insureds) determine actuarially sound premium levels.  Premiums tell the public as accurately as humanly possible what the precise danger is of living on a flood plain or "going bare" for long-term care. Given this information, rational people who are free to choose can make intelligent decisions in their own best interests. 

     Ironically, for all its good intentions and altruistic justifications, government distorts this risk calculation and dangerously misleads the public by providing tax-financed grants or subsidies to indemnify the uninsured.  By reducing or disguising actual risks, the government discourages responsible people from buying private insurance and rewards the irresponsible for failing to do so.  This is the real reason why so few people have flood, crop, earthquake or long-term care insurance, self-serving evasions ("it won't happen to me" or "insurance costs too much") to the contrary notwithstanding.  When insurance truly costs too much, it means the risk is too great to take, by definition!  If the government rebuilt every home that burned down, no one would buy fire insurance either.  

     If this assessment of the marketplace is correct, the solution to the long-term care financing crisis is simple:  stop giving away free care to people who can afford private insurance. If we do this, everyone who can will buy long-term care insurance, stay off Medicaid, and leave the welfare program to the poor people who need it.  The humane way to achieve this goal is to end Medicaid divestiture and require estate recovery of sheltered wealth.  That way, we deny care to no one who needs it, but neither do we reward people who fail to insure.  Miraculously, this is exactly what the government intends to do if legislation restricting Medicaid planning and mandating estate recoveries, which is now pending in Congress, passes.  We are on the verge of a revolutionary breakthrough in long-term care financing! 

     Curiously, however, the government has not yet figured this out.  President Clinton's economic plan estimates savings of $395 million over 4 years by closing Medicaid loopholes and recovering from estates.  The Senate Finance Committee puts the figure at $1.1 billion over 5 years.  The Congressional Budget Office bumps the estimate to $1.8 billion, increasing in the out years.  All three vastly underestimate the potential savings.  They take into account only the projected revenues from estate recoveries and the direct cost avoidance from closing loopholes.  They completely miss the big impact of the pending legislation--the change it will engender in consumer behavior.  

     When Medicaid is harder to get and has to be paid back out of the estate in the long run anyway, i.e. when there is no more free ride, people will plan ahead, buy insurance and avoid Medicaid.  In Wisconsin, we found that a 10% drop in the Medicaid census of the state's nursing homes (from 65% to 55%) would save $106 million or 20% of the Medicaid nursing home budget.  A comparable drop in Medicaid census nationally, all other things being equal, would save $4.1 billion per year!  But a 10% drop in Medicaid census is an extremely conservative goal.  When the choice is "pay me now" for long-term care insurance, or "pay me later" for estate recoveries, people will search for creative ways to afford private insurance and the access to quality care that it assures.  Research shows that 57% of homeowners can afford long-term care insurance with nothing more than the proceeds of a reverse annuity mortgage, but Medicaid currently exempts the home regardless of value so there is no incentive to tap this resource.  Heirs get a windfall from Medicaid now for ignoring long-term care risks, but with their inheritances at stake, they will help their parents to purchase private insurance.  When unleashed by the new restrictions on Medicaid nursing home benefits, these two potential financing sources will make long-term care insurance affordable for the vast majority of seniors in America.  Then, we will finally see the full impact of private insurance on the long-term care financing problem.

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