NORTHAMPTON — As the health care debate in Washington descended into absurdity last month — with senators not knowing the content of bills they were preparing to amend and supporting unwritten bills they hoped wouldn’t become law — there were at least two categories of people waiting out the results.

The first were Americans with their eyes glazed over, unaware of the fact that proposed caps on the Medicaid program could make an enormous difference in their lives if they run out of money in retirement. Already, Medicaid pays at least some of the nursing home tab for 62 percent of those who live in them, according to the Kaiser Family Foundation. It is, for older adults at least, a poverty program that serves many people who were middle class not long ago.

Then there are the people who sweat the details of the Medicaid program each day: the relatives, social workers, medical professionals and others who watch over the 7.4 million older people Medicaid covers. They live in fear of large cuts to a program that already seems strained.

In that second category we find Estelle Stasz, 67, who works full time as a Medicaid specialist for Michael Hooker, an elder-law attorney here in this small western Massachusetts city. She helps clients understand the rules, shepherds their applications, assists service providers who want to be paid and will appeal to Medicaid gatekeepers who can be tough about the regulations.

She’s not crazy about her title, noting that theirs is the kind of office where everyone could sub in for anyone else on any given day. Hooker refers to her as a “guru,” a term she’s too modest to embrace.

But the mere fact that a job like hers needs to exist — that Medicaid touches so many lives and is so complex that an elder-law attorney would want full-time help to serve clients who use the program — ought to tell us plenty about Medicaid’s importance and how poorly most of us understand its reach and complexity.

Stasz said that people often arrive at the law firm’s office with a will, power of attorney and a health care proxy, and believe that their planning for old age is done. But they have only just begun.

“People think mostly in terms of death,” Hooker said. “But what about when you’re not dead? People aren’t thinking about disability, when they are alive and old and need care.”

And a growing number of those people can get it only when Medicaid pays for it once they run low on money or don’t have long-term care insurance, given that Medicare usually doesn’t pay for long-term care in your home or in a nursing home.

Hooker, 59, spent many years as a lawyer for the mentally ill and then began serving as a legal guardian in some instances as well. He encountered Stasz working in the business office of a local nursing home as he began to represent older people. “She was an amazing resource, full of knowledge,” he said.

It’s not the kind of thing you can pick up in college. Stasz, a high school graduate, was a single mother working in a convenience store when a friend helped her get a job at a nursing home in 1987. She started out making $8.25 an hour handling billing.

Given that Medicaid was paying a lot of the residents’ bills, she began teaching herself how the system worked. Qualifying generally involves proving that you are impoverished or close to it, though there are countless quirks and exceptions around assets, real estate, spouses, trusts and annuities.

“I have to know why I’m doing something, which has always been a driving force for me,” she said. “Medicaid is an ever-changing system that will absolutely make you crazy. You need to keep on top of it.”

Eleven years ago, having long admired Stasz’s encyclopedic knowledge of the system, Hooker hired her away from the nursing home industry. This was right around the time that a Medicaid caseworker would not allow a client into the program until he could properly document the origins of a $2 monthly pension payment from Uniroyal.

Today, Stasz does much of that legwork. Clients are a mix of former factory workers and farmers, plus an occasional academic, given the five colleges nearby. Many are couples, with one person fretting over the quality of care for a sick spouse while that spouse may be desperate to avoid impoverishing the other one, who could live decades longer.

Working as many as 15 cases at a time and consulting regulatory language that she keeps handy in her computer, Stasz tries to move things along at a relatively rapid clip.

“Eleven years ago, I got a client approved for Medicaid in seven days, which was a record,” she said. “That will never happen now. It can take up to six months.”

Nursing homes and other service providers often cross their fingers and wait to be reimbursed retroactively, once their clients do qualify. Some bring particularly hard cases to the firm, lest they have to write off the bills for care altogether.

No two cases are alike, and some are more complicated than others. One involved a person who couldn’t get Medicaid to cover her care after a relative listed on her bank account withdrew $80,000 from casino ATMs. The question of whether the money was a gift to him or outright theft is a legitimate one, given that taxpayers would be picking up the bills for her dementia care now that the money was gone.

The office hopes to have better luck with a potential client whose property holdings include a swamp that the local authorities assess at $11,000. Hooker, who grew up on Long Island and still talks like it, chuckled at the fact that he has landed in a part of the world where he sometimes has to help figure out how to sell such a thing.

Then there was the matter of Robert Wilce, a World War II veteran. His situation was complicated by the fact that the Medicaid program did not recognize his service-connected disability when his wife, Joanne Parker, needed to enter a nursing home for dementia care and sought Medicaid coverage.

Wilce fends for himself quite well at 92. On Thursday, he had instant recall of the name of a Republican senator who had cast key swing votes on health care and would do so again early the next morning — Lisa Murkowski of Alaska — while nursing a 16-ounce mojito just before noon during lunch. But his first lawyer didn’t know how to solve his Medicaid problem. Hooker and Stasz found a solution, though not until they were finished producing a 4-inch stack of documents to file on his wife’s behalf.

“I think about Winston Churchill’s famous line when I think about Estelle,” Wilce said. “Never give in. Never, never, never, never.”

Stasz has no intention of doing so, at least for another year or two. Her deal with Hooker allows her to work from home one town away, which helps take the edge off the sometimes frustrating tasks.

When it comes to the Senate follies, the pair say they aren’t much for predicting the future. They point to a Waterford crystal sphere that they keep in their conference room, a piece that once belonged to Hooker’s mother. “That’s our crystal ball,” Stasz said. “We tell people that it doesn’t always work.”

Still, she points to the demographics in her town, where in five years, one-third of the population will be over 60. Hooker already worries about relying on the United States to continue to pick up the tab for ever-larger numbers of older people who will live longer and run out of money.

And if our elected representatives do find a way to put caps on Medicaid, even though their latest effort at health care reform failed again, how much harder will their jobs become, to say nothing of the lives of their clients?

“I’m not a political person,” Stasz said. “But in an ideal world, we take care of our elderly. Why wouldn’t we? These are the people that made our world what it is today. And yet we don’t seem to think that we have the means to take care of them sufficiently.”

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Navigating Medicaid rules? It’s not for amateurs – GazetteNET