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4. Get the hell out of Texas, Granny
As bad as it is now and has been lately for financially strapped families in Texas to deal with nursing-home costs, it was much worse not long ago.
Just four years ago, the income cap was $780. Anyone whose income exceeded $780 per month did not qualify for Medicaid.
Perlin remembers his advice during that time to one man who received just over $800: Move to Florida, where the cap was slightly higher. The man did, and has been living ever since in a Florida nursing home.
"Is that what we're going to tell the citizens of Texas, [that] if you need to go to a nursing home, you need to go to another state?" Perlin asked.
Mayo vividly recalls an incident in which he talked to a woman in the Heights some years ago. Her husband had Alzheimer's disease and was in a nursing home.
"She was about $30 over the cap and she asked me what I could do for them," Mayo says. "I said, 'Ma'am, what you can do is take this wonderful house you've lived in and raised your kids in and sell it and pick your husband up and move to a non-income-cap state and you can get him on Medicaid. You'll have money left to buy you a place to live and then you can survive. Otherwise there's nothing that can be done.'
"That's a hell of a thing to have to tell a 68-year-old woman. Paid her taxes all her life, worked hard, raised her damn kids and did everything she was supposed to do, and just because her husband becomes ill with something as horrible as Alzheimer's, we in turn come in and say, 'Sorry, you're going to get screwed, everything you have left in the world is gone.'"
One problem with moving out of Texas is that adjacent states such as Oklahoma and Louisiana have income caps too -- so people must move farther away.
Wherever the destination, there is little quarrel over why Texas had the $780 income cap and why it now limits coverage to those below the federal level of $1,302 per month.
"Texas doesn't want to spend any money," Perlin says. The acceptance of an exempt trust "would make a lot more people eligible and they don't want to spend the money," he says.
That impression is pretty much confirmed by DeAnn Friedholm, Texas's Medicaid director. Staying with that income cap, even though it's now at the federal maximum, says Friedholm, saved Texas money that would have gone to assist medically needy elderly people with their nursing-home expenses.
"Let me tell you, that program, this year, yeah it saves money," she says. "We are spending $1.2 billion for 68,000 people, for nursing-home care. If you wanted to compare that to our welfare program, our AFDC [Aid to Families with Dependent Children], it's $585 million for 800,000 people."
For both programs, 64 percent of the money is federal and 36 percent comes from the state. Because there is no alternative, Medicaid has become the only way that many middle-class people are able to afford nursing-home care.
Friedholm doesn't argue the point that states like New York and California use the medically needy provision and spend much more for Medicaid coverage of nursing-home care.
"Yes, I'm sure New York spends more than us. New York spends more than us on everything. Everything they do is a lot more expensive than what we do," Friedholm said.
Friedholm does stress that however Texas compares to other states, the requirements are more lenient now than years ago.
"Not only have we never had the medically needy (provision), it's only been in the last few years that we've reached the highest level we can. This makes a lot more people eligible for coverage with us by going to the maximum federal cap," Friedholm says.
Mayo doesn't understand the budget considerations, particularly since this exempt trust provision is part of a national budget reconciliation act that, on balance, cut back on Medicaid eligibility.
"This would only pertain to the income cap states. The impact overall to Medicaid might be negligible. I don't know. It wouldn't help people in New York or California, those people are already on Medicaid," Mayo says. "It would help people here."
That motivation seems clear.
"Everybody knew how horrible this was, but not only was it horrible for people in Texas, the elderly ladies I'm talking about, it just wasn't fair. It really depended on what state you lived in whether you ate dog food or not. It just wasn't fair and everybody knew it."
Mayo mentions dog food several times while discussing the ill effects of the income cap rule in Texas. He maintains he has known elderly people who are so broke from paying a spouse's nursing home bill, they eat dog food. Mayo obviously knows his elder law, but he becomes quickly nonspecific when asked for the names of people who actually ate dog food. Hyperbole or no, reasonable people would not doubt that many elderly people cut dietary corners and rely on programs such as Meals on Wheels to provide nutritional support when cash is scarce.