Medicaid Planning Trade-Offs: The Ethical Challenges In Balancing Asset Preservation And Care Needs

One of the most challenging realities of retirement planning is the risk that long-term care needs in the final few years of life can consume a disproportionate amount of a household’s entire retirement savings. At best, this culminates in a fear that someone might not be able to afford their desired level of care in the later years. At worst, it is paired with the rapid depletion of existing assets, which can impair the subsequent standard of living of a surviving spouse, or ‘unexpectedly’ deplete assets that might have otherwise gone as an inheritance to family members. Yet the so-called “Medicaid planning” tools in the financial planner’s toolbox to navigate this situation can quickly pit competing interests against one another, as strategies that preserve assets for heirs can outright limit the availability of assets to provide for a desired level of care while the individual is still alive. Putting financial planners into the awkward position of crafting recommendations in ethically complex situations.

In this guest post, David Haughton, VP of Estate Planning at Carson Group, explores the ethical dynamics that financial planners must navigate when crafting Medicaid planning recommendations to clients.

The starting point is to recognize that to the extent Medicaid was designed as a needs-based government benefit (i.e., to provide for the care of lower-income individuals who could not provide for themselves), proactive “Medicaid planning” involves finding ways to reduce the assets of the individual who may otherwise need long-term care support, before those assets are otherwise spent outright on care itself. The tools are varied, including transferring assets into Medicaid trusts, or gifting outright to family members, or the use of Medicaid annuities to convert the institutionalized spouse’s assets into the non-institutionalized spouse’s income. But the common thread is that assets no longer held in the individual’s name are no longer required to be spent on care… for which the caveat is that often they literally cannot be spent on care.

The end result of this planning is that strategies to preserve assets for a non-institutionalized spouse, or future heirs, come at the ‘cost’ of reducing the assets available to spend on care if desired. In many cases, this may mean restricting the range of facilities available (to only those that accept Medicaid), or the tiers of additional care services that may be chosen (that aren’t available in a primarily-Medicaid facility). Which is especially concerning when often the planning process begins with an adult child, thrust into a decision-making situation after a parent’s health event, who must now make decisions for their parent’s care with a direct impact on their own future inheritance.

The added complication is that for many financial advisors, our own compensation systems can present an additional conflict of interest in the process. Some tools – such as Medicaid annuities or asset-based long-term care policies – compensate insurance-licensed advisors who can receive commissions, but not fee-only advisors. Other tools – such as Medicaid trusts – do the opposite, preserving assets that can be managed by advisors who are paid on assets under management. Which means at the least, advisors must be mindful of their own compensation conflicts of interest in navigating recommendations.

So what should advisors do? Ultimately, the key is to engage in proactive conversations with all stakeholders – ideally including parents and children (while still recognizing which, in particular, has hired the advisor as the client, to whom the advisor owes their primary fiduciary duty) – to ensure that all trade-offs and potential priorities are considered. And then ensuring that not only are recommendations documented, but all the strategies that were considered, and the trade-offs that were discussed.

Ultimately, the key is to recognize that Medicaid planning is, perhaps even more so than other types of financial planning, rife with trade-offs for which there are no clear answers. And because multiple family members are involved, the trade-offs aren’t even a matter of just one person evaluating a trade-off (e.g., “should I spend less now to be able to save more for a higher standard of living in retirement?”), instead the decisions have impact across multiple people (an individual in need of care, his/her spouse, and their children or other heirs), each of whom have their own competing interests. Which raises the bar for how thoroughly advisors must explore – and document – the range of strategies that were considered, and how the trade-off decisions were made when there is no single right answer.