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With the withdrawal of Aetna from Delaware’s Obamacare exchange, some consumers will face a health insurance monopoly. The benchmark silver plan for a 40-year old nonsmoker in Wilmington is projected to cost 49% more in 2018 than 2017, and to be the highest cost such plan in the US at $631/month (Kaiser Family Foundation). While those who receive subsidies are protected from this increase (between 80-90% of Obamacare exchange enrollees), those making over 400% ($47,550 for an individual in 2017) of the federal poverty level are not.

Why can’t consumers buy health insurance policies from insurers in other states where premiums might be lower or coverage better? The federal McCarran-Ferguson Act (1945) granted states the right to regulate health insurance plans within their borders, which resulted in a patchwork of 50 sets of regulations and highly concentrated health insurance markets within each state.[1] Market share of the dominant insurer (by state) averages 57% (individual policies), 58% (small group policies), 59% (large group policies); in Delaware these shares are 92%, 75% and 71% (2016, Kaiser Family Foundation).

Are these premiums high because of market power? Can they be reduced by encouraging out-of-state insurers to sell policies in Delaware? As we discuss below, the short answer is maybe.

Can Delaware Allow Cross Border Sales of Insurance?

Since states are the regulators of health insurance inside their borders, Delaware could already unilaterally allow insurers in other states to sell plans in the state. Eighteen states considered laws to allow such practices prior to ACA passage. Of those, only 2 states signed the bill into law: Rhode Island (SB 2286, 2008) and Wyoming (HB 128, 2010). Post-ACA, 13 states have considered such laws, with only 3 states passing them: Georgia (HB 47, 2011), Kentucky (HB 265, 2012), and Maine (HB 979 2011).

Some have suggested that states, like Delaware, may be too small to support more than one or two insurers without combining with other states’ markets. For this reason Section 1333 of the ACA permits states to form health care choice interstate compacts to allow insurers to sell ACA-compliant policies in any participating state.[2] No ACA compacts have been formed nor does there appear to be much interest by any state in doing so. Since many insurers already have a multi-state presence, such as Delaware’s dominant insurer Highmark Blue Cross Blue Shield, this could be less of a problem than the designers of the ACA imagined.

A nine-state health care compact was formed outside of the purview of the ACA (KS, AL, SC, UT, GA, OK, MO, TX, IN). The objective is to obtain federal funds as block grants and to take over primary responsibility for regulating the health care system, rather than being governed by ACA, Medicaid and Medicare regulations. Interstate compacts can be formed without Congressional approval although their legal status is ambiguous.[3] In this case since federal funds are involved, it seems almost certain that formal Congressional approval is needed. However, efforts to get Congressional approval have languished, although this could change.[4]

Clearly there already exist several avenues for states to allow insurers to sell policies across state borders. But there has been little effort to do so. Why?

Experiences with Cross-Border Sales

In none of the six states that permit cross-border sales of policies has an out-of-state insurer entered the market. Insurers cite the difficulty and high cost of establishing a provider network as the major reason for this, far more important than a state’s regulatory climate or benefit mandates. In fact, one insurer described Maine’s provider network as ‘locked up’ and one in which ‘[we] can’t make a deal [on reimbursement]’.[5] Moreover, they claim that the main reason for interstate differences in premiums is interstate differences in provider prices. An Institute of Medicine study in 2013 indicated that 70% of the differential in commercial insurance costs was due to differentials in provider prices.

Thus, the market power of dominant insurers may not be the only reason for interstate premium differentials and may not even be the main reason.  Instead, it appears that two highly concentrated industries, health insurers and healthcare providers, negotiate with each other and divide the revenue stream from policyholders between them. Potentially they could collude to keep the revenue stream as high as possible. Less pejoratively, they could work less diligently to reduce costs, hence policy premiums.

What Should Delaware Do?

Competition should be improved simultaneously in both health insurance and healthcare. The reason is illustrated by Ho and Lee in a 2013 NBER study where they demonstrate that introducing more competition in the insurer market potentially increases the bargaining power of providers, which would offset the effect of competition on insurer premiums. Liberalizing one industry and not the other merely changes the bargaining power and the amount of the revenue stream directed to each, but does not reduce costs for consumers.

Other states have implemented pro-competition measures for the provider industry, such as elimination of certificate-of-need laws and price transparency (see previous columns). Regrettably, the ACA created incentives for additional provider consolidation via ‘accountable care organizations’ (a type of HMO). These should not be allowed to violate anti-trust laws. The FTC has been stepping up enforcement, unfortunately states have not. Delaware’s state government can do more on these measures.

One of the few mechanisms that is reducing healthcare costs is the spread of health savings accounts/high deductible health plans, which cause both patients and providers to be more price/cost-sensitive.  HSA-compatible plans had been available in Obamacare exchanges through 2017, however a regulation passed in March 2016 may eliminate them in 2018.[6] Delaware should do whatever it can to make HSA plans accessible to those who want them.

Some states have reduced the ability of insurers and providers to collude and to shut out potential competitors, most commonly by banning the most-favored-nation (MFN) clause, also referred to as a “most favored customer clause,” “prudent buyer clause,” or “nondiscrimination clause”. These ensure that the insurer will receive the best price from the provider.[7] Healthcare providers then cannot offer a better price to another (out-of-state) insurer, thus denying a new insurer the incentive to enter the market. A 2012 DOJ study shows these clauses result in higher prices across the board.[8] The DOJ has prosecuted on this basis and 18 states have enacted the ban (AK, CT, GA, ID, IN, KY, MD, MA, ME, MI, MN, NC, NH, NJ, ND, OH, RI, VT, WV). At a minimum, Delaware could follow the lead of these states. Delaware could also ban anti-steering clauses. In these clauses, an insurer is restricted from steering consumers to competitively priced providers (e.g. out-of-state providers), thus reducing local providers’ incentives to be competitive. Insurer guarantees that a provider will not be excluded from the network create the same problem.

Conclusions

The goal of increasing competition in health insurance by allowing cross-border sales of policies is a good one, but is unlikely to reduce premium prices much unless there is also price competition in the provider network. Additionally, the difficulty and cost of building a local provider network for potential entrants must be reduced as much as possible. Several measures are outlined in this column. Delaware is suffering some of the highest insurance premiums in the country, yet is lagging in investigating and implementing these measures. This has a high cost for its citizens, not just monetarily, but in their health.

-by Stacie Beck, Associate Professor of Economics, University of Delaware

& CRI Advisory Council Member and John Libert, CRI Summer Research Intern.

[1] Large employers who self-insure are exempt from these state regulations.

[2] Compacts require the approval of the US Department of Health and Human Services. HHS has been slow to issue regulations for this, but there has not been any reason to hurry, given states’ disinterest.

[3] See Jackel and Green, The Atlantic, Feb 4, 2017

[4] http://www.ncsl.org/research/health/states-pursue-health-compacts.aspx

[5] Corlette, et al Selling Health Insurance across State Lines Georgetown University Health Policy Institute, 2012, p.11. See also a recent summary by Jenson and Riley “Selling Health Insurance across State Lines” National Academy for State Health Policy, February 2017.

[6] We were unable to discover this regulation’s current status.

[7] It has occurred to us that this might be an unstated reason for providers’ resistance to posting prices for direct pay patients but we are not familiar enough with these contracts to know.

[8] Sznol, Issue Brief: Most Favored Nation Clauses, Blog: The Source on Healthcare Price & Competition, UCSF/UC Hastings Consortium on Law, Science & Health Policy, accessed Aug 18, 2017.

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The House Ways and Means Committee 2008 timeline for Obamacare rollout pre-ordained a complete failure of the health insurance industry in 2017 and 2018. The mechanism of the economic failure known as the “Death Spiral” can be best described by adverse selection. Expensive sick patients are staying in and healthy customers are bailing out.

In December, Highmark offered my wife and me a plan in which our premiums for the year would be $19,000 with a combined deductible of $15,000. We bailed out to Medi-share for a vastly reduced amount of money. Highmark BCBS is now in full-fledged collapse mode, greatly exacerbated by eliminating their HMO option and forcing people into high deductible PPO plans. Their biggest block of patients, Delaware state workers, is at risk. Their biggest problem is Aetna which is making a move to consolidate complete control of the Delaware health insurance market, (they just displaced Geisinger as the health insurer for the state’s second largest employer, Christiana Care Health Systems). Aetna may actually survive the death spiral by sheer size and being the last man standing, thereby dictating rates.

The most recent instruction from President Trump to the IRS to not require tax filers to tell whether or not they purchased health insurance in 2016 accelerates the pace of the collapse by eliminating the risk of a penalty for healthy people not participating in the insurance pool. The pool of covered lives is therefore populated with sicker people. Mandated insurance coverage which eliminates denial for pre-existing conditions causes a situation where an uninsured person can develop an expensive disease and then immediately gain insurance coverage, of course at a substantial loss to the insurer.

All of this was obviously predictable, as I wrote in 2009, by simply looking at the timeline. 2017 and 2018 were baked in 8 years ago. Looking forward, the most optimistic chance for stabilization of the chaotic and insolvent market can only begin in 2019. By that time, the temporary federal Medicaid subsidy to Delaware will be gone and Delaware’s budget will not be able to be balanced. Between the loss of free market health insurance competition, the burgeoning cost of Medicaid, and the cost of providing health insurance to Delaware state workers and pensioners, the budget will be busted.

C.D Casscells, MD

Healthcare Policy

Caesar Rodney Institute

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Originally published at caesarrodney.org

The cost of healthcare in Delaware is again rising rapidly.  It is looming as a major budgetary issue for the State of Delaware current employees and pensioners. Delaware’s Medicaid budget is increasingly strained. There is a steady flow of articles in the News Journal about the rising cost of health insurance, the rising cost of pharmaceuticals, and the rapid rise in both co-pays and deductibles for patients. There are, however, a few elements in play that have been overlooked, and may have significant effects in the short-term on the overall costs of both insurance and actual healthcare delivery.
While it is abundantly obvious to everyone that utilizes healthcare services that both co-pays and deductibles have risen in an effort supposedly to keep the cost of the overall premium down, the complaint has been made that this discourages the use of health insurance for routine care because of the high out of pocket cost. This is only a part of the problem.
While it is true that discouraging the use of healthcare services saves money for the insurance carrier, there is another side to this disincentive. I am referring to a phenomenon that we see frequently in medicine. Patients, who are usually quite economically aware of the deductible are also very aware that once the deductible has been met, all further healthcare is essentially free for the rest of the year until their deductible resets.
As a consequence, those who have had some healthcare incident recently often then seek out other elective healthcare treatments, medications, and surgery they might otherwise postpone. “I might as well get it done now under this year’s deductible.” Whenever there is an uptick in elective medical services, there is also an uptick in the sheer number of expensive adverse outcomes, although the percentage still may be very small.
Thus costs to the insurer go up. We are seeing this more frequently in our office this year and it is very common toward the end of the year that our services for elective surgeries become highly demanded. In common terms, the patients want to get the elective surgery done before the end of the year when their deductible resets. This is a strong economic motivation.
Quite obviously this will cause a substantial increase in overall costs to Medicare, Medicaid, and the health insurance industry.  All three of these entities have responded to the increasing costs of expanded coverage of the population by increasing the scrutiny over authorized services and increasing the frequency of denials of authorization, in short, rationing services.
The former of these two phenomena, elective utilization of health services after meeting the deductible, tends to raise overall spending on healthcare. The latter, rationing, of course, does the opposite and tends to lower overall expenditure. The question of which will be the dominant effect will be answered by the insurance actuaries when the next year rates are published. Most anticipate substantial rate increases.
There is, however, another phenomenon that we are seeing increasingly. This is the absolute lack of access to physicians. Increasingly, fairly young physicians are retiring from practice for a host of reasons. Dr. Ezekial Emanuel, one of Obamacare’s chief architects, famously said last year on television when asked about this phenomenon that “They will have to work. We will make them”. It turns out not to be true. What turns out to be reality is that doctors will not work under those circumstances and it further turns out that many doctors, especially those who are older and more experienced, easily have the wherewithal to retire.
In addition to this there is the phenomenon of “Community Care Plans”. These are Medicaid plans offered through the Obamacare exchange. In our office we have been getting dozens of phone calls from people asking whether we participate in these plans and if we know anybody who does participate in these plans. The truth is there is a very thin panel of doctors. By my count, looking at the Delaware panel of doctors for United Healthcare “Community Care”, fully one third of the listed entities were either not doctors, were duplicate listings, or were the names of facilities. Most of the family practices on the list are closed to new patients.
In my specialty, Orthopaedics, there are six surgeons listed who are all based at Crozier Chester Hospital in Pennsylvania. In short, there is very limited access to contracted physicians and surgeons. The net result is that the patient’s have a heavily subsidized health insurance card which is not capable of giving them access to healthcare except under convoluted circumstances, usually the Emergency Room. This is of course a very effective mechanism for United Healthcare to control its costs and continue to receive subsidies from both the federal government and the State of Delaware who offers these plans. The State can then say it has expanded the pool of people with health insurance even though that insurance is unusable.
The actual number of previously uninsured people now receiving preventative care is surprisingly small. As the Oregon experiment demonstrated with over a decade of data, the addition of Medicaid insurance to the uninsured population does not change their pattern of choice of the emergency room for their care. In fact, the net result was quite the opposite, emergency room utilization increased. It is not yet clear if that is happening or will happen in Delaware but similar efforts in both Massachusetts and Vermont have had identical outcomes to Oregon.
The news is not bad for everyone. Large hospital systems are suddenly thriving because their previously uninsured patients are now covered by Medicaid. The insurance industry is consolidating and the large carriers are reaping windfall profits from subsidies. For the moment, Delaware continues to have its state Medicaid insurance program subsidized by the federal government.
Soon enough though, federal Medicaid subsidies to Delaware will cease and the full burden of cost will return to the Delaware budget. The insurance industries will be squeezed by the “Death Spiral” as healthy patients decline to purchase the ever more expensive policies and only the expensive chronically ill remain in the insurance pool. In 2018 penalties, fees, and taxes are set to essentially end the health insurance industry as we know it.  Medicare has not yet been reformed and its insolvency has been accelerated by almost a decade. Small hospital systems will consolidate into large systems but will become de facto accountable care organizations, responsible for all community health, but presumably with highly restricted budgets based upon an insolvent single payor. Hospital care is costly and limited access to care is inevitable.
The “Affordable Care Act”, clearly misnamed, appears to be yet another example of “The Uncannily Predictable Law of Unintended Consequences”. Acronym TUPLUC.
C.D. Casscells, MD
Director, Center for Healthcare Policy

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CRI predicted years ago charity care would soon become a thing of the past. That’s because the Affordable Care Act, which just about everyone calls Obamacare, is set up to remove charity care from the equation.

Charity care is free healthcare many doctors provide as a service to the community. There is (or was) no financial incentive; a doctor did it because he or she believes in helping their fellow human beings. This was a way for very poor people and/or those who don’t have health insurance to receive healthcare they could not otherwise afford. Well, no more (in Delaware at least):

State to cut ‘charity care’ for near-poor

Delawareans pinching pennies near the federal poverty level – making from $16,100 for an individual to a maximum of $47,700 for a family of four – will lose health coverage through the state’s Community Healthcare Access Program (CHAP) starting Feb. 1, state officials said late Monday afternoon.

CHAP is a state-run program that offers discounted medical services for those not eligible for Delaware’s Medicaid program. The state earmarked $478,000 in tobacco settlement funds for the program this fiscal year.

CHAP recipients are ineligible for Medicaid either because they are undocumented immigrants or make more than 138 percent of the federal poverty level, Delaware’s cutoff for Medicaid assistance. The federal poverty level is $11,670 a year for an individual.

State officials said they will offer an alternative to CHAP on a case-by-case basis, only for those who can prove they are ineligible for other plans or are exempt from the federal insurance mandate.”

Now some of those who were on this program were individuals not legally authorized to be in the country. However, some were and will no longer receive help, and even for those here illegally, most medical professionals will tell you their desire is to help everyone who needs it, no matter what, because it is their calling.

“This is charity care and charity care more or less will be going away based on the mandate that everyone must have health insurance,” said Rita Langraf, secretary of Delaware’s Department of Health and Social Services, referencing the 2010 Affordable Care Act’s requirement that everyone should have health insurance.

The department is taking that mantra seriously. Landgraf said the state will continue to offer coverage for the undocumented population past Feb. 1, but CHAP recipients who make up to 200 percent of the federal poverty level will need to find new coverage.”

This is another problem. DHSS Secretary Landgraf is saying the state will ensure those not authorized to be here will receive benefits not extended to American citizens. Why? Because ACA mandates that all citizens must have health insurance- note the bolded words.

The main reason charity care is disappearing is because the government will begin reimbursing doctors for care previously provided as charity. This means taxpayer dollars will flow into doctor’s pockets for services they were going to perform anyway. If you were going to do something you always did, say brush your teeth, and the government offered to pay you to do that, would you turn that offer down? Most people would not and thus the government is ensuring a larger budget deficit for a service they don’t need to pay for. The other thing this will do remove the “good samaritan” role of medicine, eliminating volunteerism in favor of “rent-seeking” from the government (seeking public money for private bank accounts).

The health insurance exchanges open on Saturday and we were now only hours away from knowing what the 2015 insurance rates will be. If you haven’t yet received a letter notifying you of your insurance status for 2015, you will get it very soon. On Thursday CRI will publish another article on healthcare breaking down the new rates, discussing what you can expect going forward, and discussing how you can Impact Delaware!

photo:myptsolutions.com

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From the Independent Institute:

“According to data compiled by the Kaiser Family Foundation, in fiscal year 2010 the average Medicaid payment per enrollee was $5,563. To be sure, there was a wide variance: For aged Medicaid enrollees the average payment was $12,958, and for disabled enrollees it was $16,240. The average for adults was $3,025, and for children it was $2,359.

Medicaid enrollees have terrible access to care, according to a number of studies discussed in John Goodman’s Priceless (chapter 15). New research published in JAMA Internal Medicine suggests that it would be better simply to give Medicaid patients this money and let them spend it directly on medical care.

Posing as patients, researchers made almost 13,000 calls to doctors’ offices in ten states, seeking appointments for a variety of ailments. Those posing as privately insured patients got appointments 85 percent of the time. Those posing as patients on Medicaid got appointments only 58 percent of the time. Researchers also posed as uninsured patients who were willing to pay in full at the time of the appointment.

The result? For appointments costing more than $75, 78 percent of the “uninsured” researchers got a medical appointment — a success rate 36 percent higher than for those posing as Medicaid patients and quite close to those posing as privately insured.

The policy implication? Taking Medicaid money away from Medicaid bureaucracies and giving it to low-income people to pay directly for health care would increase access significantly.”

 

The argument over Medicaid is not even whether or not we should have it and how much we should pay for it. The question is WHY the government and its elected and unelected officials continue to offer shoddy health insurance to poor/disabled nonseniors and treat Medicaid as though it was a program gifted by the Almighty, or whatever entity you believe in. Medicaid has structural flaws in its payment model (higher taxes on everyone, large bureaucracy) and delivery of services and it needs to be modified or else Delaware, like nearly every state in the union, will be dragged down with Medicaid as a budget-buster this decade. And this all came BEFORE Medicaid expansion under ACA.

source:

http://blog.independent.org/2014/04/14/uninsured-patients-are-36-percent-more-likely-to-get-medical-appointments-than-are-medicaid-patients/

http://blog.independent.org/2014/04/08/medicaid-patients-access-to-specialists-has-dropped-almost-one-fifth-in-five-years/

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From Dr. Scott Gottlieb, Forbes.com: For the individual insurance market (plans sold directly to consumers); among the ten states seeing some of the sharpest average increases are: Delaware at 100%, New Hampshire 90%, Indiana 54%, California 53%, Connecticut 45%, Michigan 36%, Florida 37%, Georgia 29%, Kentucky 29%, and Pennsylvania 28%.

 

You read that right. No state in America had a bigger increase in individual insurance market premiums than our Diamond State. Delaware currently has only 2 health insurance companies, and Blue Cross Blue Shield gets almost all of the individual market. Coventry’s market is much smaller. With the over-emphasis on sicker and older people purchasing health insurance on the ACA “Marketplace” exchanges this past cycle, what will the prices look like in November when the Health Exchanges reopen?

Delaware’s exchange enrollment rate is official about 11,000 (final tally to be given at  future date), but most of those people obtained subsidies to purchase insurance or were added to the Medicaid rolls. All subsidies and Medicaid are paid for by taxpayers (Meaning: you)and so far the vast majority of Delaware enrollees were not the young and healthy individuals the state exchange needs for November.

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The number of reported enrollees in Delaware’s health insurance exchange is only four thus far.

Let us do a point count, here at half time. 6 people signed up for Obamacare, day one, 148 by day three. 6,000,000 people were given insurance termination notices in October, by health insurance companies whose products have been decertified by the government ACA requirements. The ACA and GSA predict 11,000,000 will lose their chosen coverage and be forced into Obamacare by January 11,2014,. Actuaries put that number at 43,000,000 who will lose their coverage. 43 million! The stated goal was to insure 16 million uninsured, and 7/10ths of a million pre-existing condition “uninsurable”.

The problem is beyond the number of enrollees who sign up. If only those who consume more health care services have signed up on the exchanges by March 31, then the actuaries who set insurance prices for the 2015 year will have only a limited amount of data to work with. If that is the case expect to see “sticker shock” prices for that year. This is because insurance may not be purchased on the exchanges after March 31 for 2014; therefore, very few people if anyone will volunteer to enroll in the health exchanges between April 1 and October 15 when the enrollment period opens for 2015. In addition, if one does not purchase health insurance but gets sick or in an accident, the hospitals can enroll people on the exchanges on the spot. This is something to keep in mind for next year unless a lot of healthy people decide to sign up for this.

Sweeney: Should climate deniers be banned from writing?

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SO with only 12 days until the healthcare exchanges roll out nationwide and in Delaware, you are probably wondering what is going to happen in the Diamond State.

If you have signed up for the “Choose Health Delaware” e-mails, you probably have been getting many as the state gets more and more excited to bring us the “healthcare insurance exchange”. Of course, Delaware still hasn’t received approval for its pricing plans from the Federal government as of this writing (September 19), so if they don’t get it by October 1 then it is possible the state will begin rolling out coverage plans which have no price attached to them. Meaning, you will not be able to look through or choose any plan or compare any pricing because there won’t be any. Word is (from CRI’s secret sources) that today was the day Secretary Sebelius was supposed to announce the rates for the states with the federal exchanges, which clearly will not be ready by October 1.

A key component of the law is getting young people to enroll in the exchanges to offset the likihood of older people in the exchanges using more healthcare services. Here are some samples:

Malik’s story: I’m young and I need health insurance

Have you met Malik?

Malik is a 23 year old bartender and server who works in the restaurant industry.

He works on his feet all day and like millions of Americans, Malik does not have health insurance because he can’t afford it.

Can’t afford insurance. Can’t afford to miss work.

Malik shared his story with us:

“I hurt my foot pretty bad and I personally thought it was a fracture. I can’t afford to not go to work and not walk on it so I’ve just kind of struggled through it.

If I did have insurance, I would have gone to make sure that it wasn’t worse than I assumed it was.

Without insurance, a serious accident would pretty much turn my life upside down. It would probably set me back for life.

I feel like the Marketplace will help me achieve my goals. It’ll just be a load off my shoulders.”

Then there’s Alejandra:

Alejandra’s story: College students need coverage too!

http://1.usa.gov/18COX6t

How the Marketplace helps people like Alejandra

Clearly the $300 just “disappears” and becomes “free”. Maybe for her, but for the taxpayer, that means more money needs to come out of our pockets.

According to the Manhattan Institute, an associate of CRI, their map says if Alejandra lives in California, she will an extra $34 a month for an individual plan (most likely the silver plan). Which is an extra $408 a year-more than the $300 she paid with no insurance.

She doesn’t live there? Pricing is unfair? If she lives in Oregon, New York, Washington State, Washington DC, Virginia, Vermont, South Dakota, New Mexico, Connecticut, Or Maine, she will pay an increased rate. Even if she lives in New York, Ohio, Colorado, or Rhode Island where rates have decreased, she would still pay no less than $169 a month (Ohio) to get coverage. No Alejandra, who probably has little income, could attempt to enroll in Medicaid or qualify for lots of subsidies for health insurance-which then means her “free” checkup will be passed along to everyone else in the health exchange or the taxpayers.

Of course, the exchanges must be up and running by then to even give Malik and Alejandra a chance to succeed.

Expect glitches when the ACA rolls out Oct. 1

12 days is a long time. Stay tuned.

UPDATE****************************************

On Friday, September 20, the Delaware State News published the exchange rates for their Choose Health Delaware plan. Expect a future blog post/article from CRI with our response to the plans shortly.

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