{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T06:16:40Z","timestamp":1788243400273,"version":"build-2803163510"},"reference-count":17,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T00:00:00Z","timestamp":1781308800000},"content-version":"vor","delay-in-days":12,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T00:00:00Z","timestamp":1780272000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Services Research"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To estimate the prevalence of Medicaid estate recovery in North Carolina.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Setting and Design<\/jats:title>\n                    <jats:p>We descriptively analyzed the number of estates, amount recovered, and hardship waiver applications using North Carolina public records data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources and Analytic Sample<\/jats:title>\n                    <jats:p>\n                      The data contained information on the number of estates and amount recovered through Medicaid estate recovery between 2017 and 2021 (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20092975). Additionally, we analyzed hardship waiver application data for residents who applied and had their application processed between 2018 and 2021 (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009301).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Principal Findings<\/jats:title>\n                    <jats:p>We found approximately $83 billion was recovered from beneficiaries between 2017 and 2021, or 0.6% of the total cost of North Carolina's annual Medicaid program and just 0.9% of the fee\u2010for\u2010service annual long\u2010term services and supports Medicaid budget. We found that Black homeowners were more likely to have lower value estates recovered, and overall, more money was recovered from white estates.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>While states hope Medicaid estate recovery may balance Medicaid spending through increased revenue, our findings demonstrate that these efforts may be insufficient. Policymakers should opt for strategies outside of the Medicaid program that can more precisely target high\u2010net\u2010worth individuals instead of policies like estate recovery that disproportionately impact low\u2010income families.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1475-6773.70141","type":"journal-article","created":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T08:09:32Z","timestamp":1781338172000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Understanding Medicaid Estate Recovery: The Experience of North Carolina and Policy Implications for Future Reforms"],"prefix":"10.1111","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7396-261X","authenticated-orcid":false,"given":"Amanda","family":"Spishak\u2010Thomas","sequence":"first","affiliation":[{"name":"Center for State Health Policy Rutgers University  New Brunswick New Jersey USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5422-8877","authenticated-orcid":false,"given":"Emma","family":"Sandoe","sequence":"additional","affiliation":[{"name":"Oregon Health Authority  Salem Oregon USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-9471-3245","authenticated-orcid":false,"given":"Heather","family":"Howard","sequence":"additional","affiliation":[{"name":"School of Public and International Affairs Princeton University  Princeton New Jersey USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,6,13]]},"reference":[{"key":"e_1_2_9_2_1","unstructured":"M. O.Sabo \u201cH.R. 2264\u2010Omnibus Budget Reconciliation Act \u201d 1993 accessed March 17 2021 https:\/\/www.congress.gov\/bill\/103rd\u2010congress\/house\u2010bill\/2264."},{"key":"e_1_2_9_3_1","unstructured":"K.Williams \u201cThe Future of Estate Recovery: An Analysis of Different State Approaches and Changes \u201d NAELA 2020 accessed February 1 2021 https:\/\/www.naela.org\/NewsJournalOnline\/Journal_Articles\/2020\/Spring_2020\/EstRecovery.aspx."},{"key":"e_1_2_9_4_1","first-page":"359","article-title":"The State Giveth and the State Taketh Away: In Pursuit of a Practical Approach to Medicaid Estate Recovery","volume":"5","author":"Zieger J. M.","year":"1997","journal-title":"Elder LJ"},{"key":"e_1_2_9_5_1","unstructured":"J. H.ChoiandL.Goodman \u201cBuy Young Earn More: Buying a House Before Age 35 Gives Homeowners More Bang for Their Buck \u201d Urban Wired November 8 2018 accessed August 1 2022 https:\/\/www.urban.org\/urban\u2010wire\/buy\u2010young\u2010earn\u2010more\u2010buying\u2010house\u2010age\u201035\u2010gives\u2010homeowners\u2010more\u2010bang\u2010their\u2010buck."},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12877\u2010018\u20100925\u2010x"},{"key":"e_1_2_9_7_1","article-title":"Lots of Pain for Little Gain: Three Decades of Medicaid Estate Recovery","volume":"2025","author":"Spishak\u2010Thomas A.","year":"2025","journal-title":"Journal of Health Politics, Policy and Law"},{"key":"e_1_2_9_8_1","unstructured":"Medicaid and CHIP Payment and Access Commission (MACPAC) \u201cReport to Congress on Medicaid and CHIP \u201d 2021 accessed March 15 2021 https:\/\/www.macpac.gov\/publication\/march\u20102021\u2010report\u2010to\u2010congress\u2010on\u2010medicaid\u2010and\u2010chip\/."},{"key":"e_1_2_9_9_1","doi-asserted-by":"publisher","DOI":"10.1177\/0164027517697116"},{"key":"e_1_2_9_10_1","doi-asserted-by":"publisher","DOI":"10.1093\/geront\/gnae074"},{"key":"e_1_2_9_11_1","first-page":"97","volume-title":"Medicaid Estate Recovery: A 2004 Survey of State Programs and Practices","author":"Karp N.","year":"2005"},{"key":"e_1_2_9_12_1","volume-title":"North Carolina Department of Health and Human Services Division of Health Benefits","author":"Richard D.","year":"2023"},{"key":"e_1_2_9_13_1","unstructured":"B.ButricaandS.Mudrazija \u201cHome Equity Patterns Among Older American Households \u201d Urban Institute 2016 https:\/\/www.urban.org\/sites\/default\/files\/publication\/85326\/home\u2010equity\u2010patterns\u2010among\u2010older\u2010american\u2010households.pdf."},{"key":"e_1_2_9_14_1","unstructured":"NC Medicaid Enrollment \u201cNC Department of Health and Human Services Division of Health Benefits \u201d 2026 https:\/\/medicaid.ncdhhs.gov\/reports\/dashboards\/enrollment\u2010dashboard."},{"key":"e_1_2_9_15_1","volume-title":"Racial Wealth Disparity in North Carolina","author":"Nichol G.","year":"2010"},{"key":"e_1_2_9_16_1","unstructured":"Justice in Aging \u201cMitigating the Harmful Effects of Medicaid Estate Recovery: Strategies for State Advocates \u201d 2025 accessed December 18 2025 https:\/\/justiceinaging.org\/mitigating\u2010the\u2010harmful\u2010effects\u2010of\u2010medicaid\u2010estate\u2010recovery\u2010strategies\/."},{"key":"e_1_2_9_17_1","unstructured":"U.S. Census Bureau \u201cComparisons of A State With Each Other State \u201d 2023 accessed December 17 2025 https:\/\/www.census.gov\/csrm\/comparisons\/sorted\u2010list.html."},{"key":"e_1_2_9_18_1","volume-title":"Annual Report for State Fiscal Year 2021","author":"North Carolina Medicaid and NC Health Choice","year":"2022"}],"updated-by":[{"DOI":"10.1111\/1475-6773.70163","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000}}],"container-title":["Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1475-6773.70141","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/1475-6773.70141","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1475-6773.70141","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T13:55:37Z","timestamp":1782309337000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/1475-6773.70141"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6]]},"references-count":17,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,6]]}},"alternative-id":["10.1111\/1475-6773.70141"],"URL":"https:\/\/doi.org\/10.1111\/1475-6773.70141","archive":["Portico"],"relation":{},"ISSN":["0017-9124","1475-6773"],"issn-type":[{"value":"0017-9124","type":"print"},{"value":"1475-6773","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6]]},"assertion":[{"value":"2025-08-01","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-05-27","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-06-13","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70141"}}