Talk:Health insurance coverage in the United States/sandbox

In interpretation of insured rates within the US, care should be taken that most presentations count people as insured who have any form of Medicaid, including ACA expanded Medicaid. However, depending on the state, the insured in the statistics may include people one might not consider truly insured, because of estate recovery of medical expenses. These are people 55 and older, in certain states only, who receive Medicaid or expanded Medicaid.

Effect of Medicaid Estate Recovery
Certain states exercise their option to do Medicaid Estate Recovery for all medical expenses, not just long-term-care-related expenses. (States are required to recover long-term-care-related expenses by the Omnibus Budget Reconciliation Act of 1993, but are also given the option to recover all medical expenses paid out for people 55 and over.  ) The estate recovery of Medicaid extends now to the Affordable Care Act's expanded Medicaid.

Estate recovery of non-long-term-care-related expenses results in people counted as insured in tables prepared by the U.S. Census Bureau and elsewhere, who are subject to estate recovery of all Medicaid medical expenses at the time of the person's death. A number of states took the option of recovering non-long-term-care-related expenses prior to the ACA, and have not adjusted laws and regulations post ACA to undo it. These states include (but are not limited to) MA, NJ, IA, NV, NH, ND, OH, RI, IN, ID, UT, and MD, as well as in the District of Columbia.

The effect, in states that exercise that option, is that people counted as "insured" in the statistics, those 55 or older with some form of Medicaid, including ACA expanded Medicaid, will have their medical bills paid for now, but, when they die, their estates can be made to pay all expenses back. This can be all medical expenses, and not just some form of premium equivalent, so there is a view that these people are uninsured, with just a loan.

Since, generally, about 20-25% of people in a state counted as insured are counted as such because of their Medicaid, an approximate estimate as to the proportion of people 55 and older counted as insured because of their Medicaid would be about 4%.

So, for example, MA reports a 97% rate of health insurance coverage. However, the state implemented non-long-term-care estate recovery pre-ACA, and has not adjusted its laws and regulations since. So, in one view, those insured are only about 93% of the population.

A number of states, such as NY, CA, OR, WA, CT, CO, and MN have done away with non-long-term-care related estate recoveries, so in all views, the insured rate would be the reported rate.