MONEY Health Care

Why a Trip to the ER Could Cost You More Than You Expect

If a holiday weekend mishap sends you to the emergency room, watch your wallet. You shouldn't owe more if the hospital is outside your insurance network. But that could change if you're admitted.

When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you. That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care. The law also prohibits plans from requiring pre-approval to visit an emergency department that is out of your provider network. (Plans that are grandfathered under the law don’t have to abide by these provisions.)

That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect.

Although the law protects patients from higher out-of-network cost sharing in the emergency room, if they’re admitted to the hospital, patients may owe out-of-network rates for the hospital stay, says Angela Gardner, an associate professor of emergency medicine at the University of Texas Southwestern in Dallas who is the former president of the American College of Emergency Physicians.

“Even if the admission is warranted, you are subject to those charges,” she says.

If you live in a state that permits balance billing by out-of-network providers, your financial exposure could be even greater. In a balance-billing situation, a hospital may try to collect from the patient the difference between what the hospital billed and what the health plan paid for care. Such practices aren’t generally allowed if a consumer visits an in-network provider.

Consumers shouldn’t expect that the hospital will inform them of potential out-of-network coverage issues, so they need to inquire, says Gardner.

“At least being informed and knowing what you’re getting into can set you up to handle it with your insurer,” she says.

And while you’re at it check into being transferred to an in-network facility if it’s feasible.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

How Some Insurers Still Avoid Covering Contraception

Locked up birth control pills
Nicholas Eveleigh—Getty Images

Under health reform, your birth control should be fully paid for by insurance. But even before the Supreme Court gave more employers an out, some insurers have been pushing back.

How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut?

Not much, as it turns out, but that hasn’t stopped some from trying.

Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to.

In one of those messages recently, a woman said her insurer denied free coverage for the NuvaRing. This small plastic device, which is inserted into the vagina, works for three weeks at a time by releasing hormones similar to those used by birth control pills. She said her insurer told her she would be responsible for her contraceptive expenses unless she chooses an oral generic birth control pill. The NuvaRing costs between $15 and $80 a month, according to Planned Parenthood.

Under the health law, health plans have to cover the full range of FDA-approved birth control methods without any cost sharing by women, unless the plan falls into a limited number of categories that are excluded, either because it’s grandfathered under the law or it’s for is a religious employer or house of worship. Following the recent Supreme Court decision in the Hobby Lobby case, some private employers that have religious objections to providing birth control coverage as a free preventive benefit will also be excused from the requirement.

In addition, the federal government has given plans some flexibility by allowing them to use “reasonable medical management techniques” to keep their costs under control. So if there is both a generic and a brand-name version of a birth-control pill available, for example, a plan could decide to cover only the generic version without cost to the patient.

As for the NuvaRing, even though they may use the same hormones, the pill and the ring are different methods of birth control. As an official from the federal Department of Health and Human Services said in an email, “The pill, the ring and the patch are different types of hormonal methods … It is not permissible to cover only the pill, but not the ring or the patch.”

Guidance from the federal government clearly states that the full range of FDA-approved methods of birth control must be covered as a preventive benefit without cost sharing. That includes birth control pills, the ring or patch, intrauterine devices and sterilization, among others.

But despite federal guidance, “we’ve seen this happen, plenty,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. “Clearly insurance companies think things are ambiguous enough that they can get away with it.”

If you are denied coverage, your defense is to appeal the decision, and get your state insurance department involved.

“The state has the right and responsibility to enforce this law,” says Sonfield.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

More on the Affordable Care Act and contraception coverage:

 

 

 

 

 

TIME 2014 Election

This Democratic Senator Is Running on Obamacare in a Surprising New Ad

Hell freezes over

+ READ ARTICLE

Senator Mark Pryor (D-Ark.) is running in one of the tightest reelection races in the country, facing freshman Rep. Tom Cotton (R-Ark.), a U.S. Army veteran. So it may come as some surprise that in Pryor’s new ad released Wednesday, he chose to hone in on his support of President Barack Obama’s unpopular healthcare law.

In the personal new ad, Pryor’s father, David, a former senator himself, talks about his son’s battle with sarcoma, a rare form of cancer, in 1996. “When Mark was diagnosed with cancer, we thought we might lose him,” David Pryor says in a voiceover. “But you know what? Mark’s insurance company didn’t want to pay for the treatment that ultimately saved his life.”

By opening up about the struggle for his own life, Pryor aims to connect with his constituents. “No one should be fighting an insurance company when you’re fighting for your life,” he says in the ad. “That’s why I helped pass a law that prevents insurance companies from canceling your policy if you’re sick or deny coverage from preexisting conditions.”

Pryor’s ad does at least three things right. First, he hones in on the most popular aspect of the Affordable Care Act: coverage for those with preexisting conditions, which has support across the aisle. “We all agree that nobody should be denied coverage due to a pre-existing condition,” David Ray, a Cotton campaign spokesman, told TIME in an emailed statement.

Second, Pryor’s ad doesn’t use the term “Obamacare,” the Affordable Care Act’s nickname first coined by its critics. A Kaiser Health Tracking poll released August 1 found that a little over half of the public—53%—have an unfavorable view of Obamacare. But when referred to by a different name, the law’s negative ratings can decrease, polls show. One Kentucky poll in May found that while 57% of registered voters disliked “Obamacare,” only 22 percent had unfavorable views of Kynect, the state exchange created as a result of the Affordable Care Act’s passage in 2010.

Third, the ad includes his father, a former Congressman, Senator and Governor who is still a popular advocate despite being out of office for the better part of two decades.

And as Pryor runs on Obamacare, Senate Republican candidates and their supporters across the country have backed off on their attacks against the law. In April, anti-Obamacare advertising accounted for 54 percent of the issue ads in North Carolina, and almost all ads in Louisiana were focused on the health care law, according to Kantar Media’s Campaign Media Analysis Group, as reported by Bloomberg. But by July, that number dropped to 27% in North Carolina and 41% in Louisiana.

This shift could be for a variety of reasons, including a renewed focus on the economy and jobs in this election cycle. But Republicans might also be reacting to a law that beat expectations, with higher enrollment figures and fewer than expected cancelled plans (1.9 million versus the purported 4.8 million, according to Health Affairs.) In Arkansas, the law reduced the percentage of uninsured from 22.5% to 12.4% over last year, according to Gallup. That 10.1% decline is the largest of any state in the nation.

Of course, Republicans stated goal on Obamacare remains “repeal and replace,” and ads could reemerge this fall even if premiums don’t increase. David Ray, a campaign spokesman for Pyror’s opponent, Cotton, told TIME in an emailed statement that the aforementioned pre-existing condition provision makes sense, but overall the law should be overturned as it raises health care costs and taxes and lowers wages.

“We thank God that Senator Pryor survived cancer, and we admire his courage in that fight,” wrote Ray. “However, we didn’t need Obamacare to change insurance regulations. We all agree that nobody should be denied coverage due to a pre-existing condition. Obamacare raises taxes on the middle class, has caused millions of Americans to lose insurance plans they were promised they could keep, has doubled or even tripled premiums on families who can’t afford it, has caused lost wages and hours at work, and is preventing many small businesses from growing and hiring more people. Further, Senator Pryor has supported a taxpayer-funded bailout of big insurance companies that lose money as a result of Obamacare. We need to start over with reform that makes healthcare more affordable and keeps healthcare decisions between patients and doctors.”

MONEY Ask the Expert

When Parents Can Say No to Picking Up the Tab for Insurance

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Q. My ex-husband has been responsible for providing health insurance for our kids until the age of majority. My sons are now 21 and almost 18. My ex has family coverage for himself and his new wife, but he wants me to put the kids on my insurance now that they have reached the age of majority. Covering the kids doesn’t cost him anything extra, but for me to switch from a single plan to a family plan is an extra $175 a month and I can’t afford it. Since the age of majority for health insurance is now 26, is it possible he still is required to keep them on his insurance?

A. No, he’s not obligated to keep them on his health plan. Under the health law, insurers must offer to cover young adults up to age 26, but parents aren’t obligated to provide it, says Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Further, the requirement to offer coverage isn’t related to the age of majority, which is defined by individual states and is generally between 18 and 21, says Randy Kessler, an Atlanta divorce lawyer and past chair of the American Bar Association’s family law section.

The health insurance coverage arrangement that you describe is pretty typical, says Kessler. You could go back to court and try to get your child-support payments increased to cover the cost of providing health insurance for the kids, but “it would be unusual for the courts to be helpful,” says Kessler. Absent some significant change in your or your ex-husband’s finances, or unforeseen and costly medical expenses for your children, in general “you can’t have another bite at the apple.”

With no legal requirement to compel either of you to cover your kids, it’s something the two of you will just have to work out, says Kessler. In addition to covering your children on your own or your ex’s plan, it’s also worth exploring whether they might qualify for subsidized coverage on the state marketplaces or for Medicaid, if your state has expanded coverage to childless adults. If they’re in college, student health coverage is worth investigating as well.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY

Why You Probably Have More Mental Health Care Options Than You Think

Rorschach test with dollar signs
Sarina Finkelstein (photo illustration)—William Andrew/spxChrome/Getty Images

The suicide of comedian Robin Williams shows how tough it can be to overcome mental illness. The good news is that mental health care coverage is now more widely available, thanks to recent insurance rule changes.

The apparent suicide of comedian Robin Williams, who had reportedly suffered from depression, shows how tough it can be to overcome mental illness. His struggles are shared by millions of Americans—some one in four adults in a given year.

The good news is that mental health care coverage is now more widely available and at least somewhat more affordable, thanks to recent changes in federal law. And there’s reason to believe these rules can have an impact on suicide rates: Ken Duckworth, medical director of the National Alliance on Mental Illness, told USA Today that about 90% of people who commit suicide suffer from an untreated or under treated mental illness.

Here’s what you need to know:

1. If your health insurance covers mental illness, your benefits must be comparable to medical coverage.

If you’re covered under an employer health plan that offers mental health benefits—and some 85% of company plans do, according to the Society for Human Resource Management—you’re now entitled to coverage that is on par with coverage for physical illnesses. That’s the result of the Mental Health Parity and Addiction Equity Act of 2008—the final provisions of which just went into effect. (The parity act mainly addresses larger company plans.) Yet according to a study earlier this year by the American Psychological Association, more than 90% of Americans are unfamiliar with their rights under this law.

The mandate is even stronger for individuals buying coverage through the health insurance exchanges created under Obamacare. The Affordable Care Act included mental health care as one of 10 essential benefits that must be covered, expanding the parity rules to plans bought in the state exchanges.

“The parity act is a landmark law that creates a level playing field in insurance,” says Ron Honberg, national policy director for the National Alliance on Mental Illness.

2. Mental health care must have the same coverage limits as other medical care.

Before to the new rules kicked in, you would typically have had to get prior authorization for mental health or substance abuse treatment. And you would also have to cope with yearly limits and lifetime limits on treatments that were lower than for medical benefits.

“Now mental health care treatment rules have to be on par with medical care,” says Debbie Plotnick, senior director of state policy for Mental Health America.

That means you cannot be denied coverage for therapy visits or a stay in a treatment center, unless your plan also restricts coverage for comparable medical conditions. And you cannot be charged higher co-pays or co-insurance than you are for most medical and surgical services.

That doesn’t guarantee you’ll find treatment affordable. The sticking point for many people seeking counseling is that their provider may not be in their health plan’s network—far fewer mental health providers are part of an insurance network than other types of healthcare providers. If you’re in a plan that covers out-of-network treatment, you’ll still be reimbursed, albeit at lower rates than for in-network treatment. Note, though, that the entire bill may not be eligible since many providers charge more than insurers deem “reasonable and customary.”

3. Your insurance plan needs to disclose the medical criteria for denial of mental health care.

If you are denied reimbursement or coverage for mental health treatment, you will be entitled to the same appeal procedures as for medical care. The plan cannot simply refuse coverage without providing a detailed explanation that shows why the treatment is not deemed necessary, says Plotnick.

Over the past couple of years, many employer plans have already improved coverage of mental health. And there are early indications that more people are benefiting, particularly young adults who have remained on their parents’ health plans. (Adolescence and young adulthood is often when severe mental illness is diagnosed.) A recent study published in Health Affairs found that among people ages 19 to 25 receiving mental health treatment, uninsured visits declined by 12.4 percentage points, and visits paid by private insurance increased by 12.9 percentage points.

The new rules don’t cover everyone. Small plans may not be governed by these rules (depending on state laws). If you don’t have a large employer plan or one purchased on the exchanges, and if you don’t qualify for Medicaid, you may have to scramble. In many regions, and for many specialities, it may also be difficult to find a psychiatrist or therapist who takes your insurance. And if you go out of network, you will only be reimbursed for “reasonable and customary” costs that don’t cover your actual bills.

Still, for those suffering from mental illness, these new rules are major step forward. One more reason to, as late night talk show Jimmy Kimmel noted at the end of his Twitter tribute to Robin Williams: “If you’re sad, tell someone.”

MONEY Health Care

How to Find Health Coverage To Fill a Gap

Short-term insurance plans have major shortcomings, but having one will at least protect your from catastrophic costs.

Consumers who missed open enrollment on the state health insurance marketplaces this spring or who are waiting for employer coverage to start don’t have to “go bare.” Short-term policies that last from 30 days up to a year can help bridge the gap and offer some protection from unexpected medical expenses. But these plans provide far from comprehensive coverage, and buyers need to understand their limitations.

In contrast to regular health plans, applicants for short-term coverage may be rejected because they have pre-existing medical conditions.

Even if they’re accepted by the plan, the drugs and medical care necessary to manage their diabetes, for example, generally wouldn’t be covered, says Carrie McLean, director of customer care at online health insurance vendor ehealth.com.

Nor do short-term plans typically cover preventive care or pregnancy and maternity services.

“It’s not going to function like a regular health plan,” says McLean.

Lifetime coverage maximums are typical as are high deductibles. Between April and June, the average deductible for short-term individual plans sold by ehealth.com was $3,391, while families faced an average deductible of $8,252. Premiums averaged $107 for individuals and $249 for families.

Plans with similar limitations and restrictions used to be commonplace on the individual market. But the health law changed that. Today, regular insurance plans sold on the individual and small group markets must all cover a comprehensive set of 10 “essential health benefits,” and they can no longer turn people away because they have pre-existing medical conditions.

The 2014 enrollment for these plans ended in March, but some people who have specific changes in their life, such as losing job-based coverage or having a baby, can still get a special enrollment period to sign up for regular insurance plans.

Because short-term plans don’t meet the standards of the health law for “minimum essential coverage,” they also expose consumers to the health law penalty for not having health insurance of $95 or 1% of income, whichever is greater.

So why would someone buy a short-term plan, anyway? Basically, it provides some protection against catastrophic hit-by-a-bus expenses. Some consumers are looking for just that.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Read more about the impact of health reform:

MONEY Health Care

Why the Good News for Retiree Health Care May Not Last

With overall health-care costs in check, Medicare didn't hike the premiums seniors pay again this year. But once economic growth picks up, rising prices could come back too.

Medicare turned 49 years old last week, and the program celebrated with some good financial news for seniors: Premiums will not rise in 2015 for the third consecutive year.

The question now: How long can the good news persist? Worries about Medicare’s long-range financial health persist, but for now persistent low healthcare cost inflation will translate into a monthly premium of $104.90 next year for Part B (outpatient services), according to the Medicare trustees. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) says the average premium for a basic Part D prescription drug plan will rise by about $1, to $32 per month.

The Part B premium has been $104.90 since 2012—except for 2011, when it actually dropped by about $15, to $99.90. The moderation is good news for seniors, since premiums are deducted from Social Security checks. Beneficiaries will keep all of next year’s Social Security cost-of-living adjustment, which likely will be about 1.7%.

Meanwhile, the average Part D premium has been $30 or $31 since 2011. That’s because of a dramatic shift to cheap generic drugs, and innovation by plan providers competing for customers.

“Seniors can expect to see more of what they’ve been getting over the last few years, which is increasing effort by Part D insurers to offer very-low-premium plans,” says Matthew Eyles, executive vice president of Avalere Health, a consulting firm specializing in healthcare.

As in recent years, Eyles says, the best deals will be found in plans that require enrollment in preferred pharmacy networks. Those plans offer lower premiums and co-pays. “We’ll also see plans limiting or eliminating deductibles, and encouraging the use of generics by offering them free or at nominal prices,” says Eyles.

But the average figures mask a more complicated story. Part D enrollees will find significant regional variations in premiums around the country. CMS data shows average premiums will be as low as $21.19 in New Mexico, and $25.83 in Florida—but as high as $39.74 in Idaho and Utah.

Eyles says it is not entirely clear why premiums will vary so extensively, although the prices tend to track the overall cost of healthcare, and are related to the overall healthiness of seniors by state.

“The plan providers have to submit bids for regions that take into account differences in the enrolled populations, including prescribing and utilization patterns,” he says. “It could be that one state tends to have more people using statins, or a diabetes medication.”

Another complication in Part D is the “doughnut hole,” the gap in coverage for Part D enrollees with high drug costs. Higher-cost plans are available to provide gap coverage, but the hole’s size is being shrunk under a provision of the Affordable Care Act (ACA), and the gap is set to disappear in 2020.

The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Next year the gap starts at $2,960 (up from $2,850 this year) and ends after you’ve spent $4,700 (up from $4,550 this year).

Seniors who enter the gap also get discounts on brand-name and generic drugs, and those breaks will be larger next year. Enrollees will pay 45% of the cost of brand-name drugs in 2015 (down from 47.5% this year) and 65% of the cost of generic drugs (down from 72% this year).

Can the recent good news on lower healthcare costs continue indefinitely? Medicare spending reflects our overall health economy, and the big picture is that the United States does not have effective controls on spending growth. Healthcare outlays have quadrupled since the 1950s as a percentage of gross domestic product, to 17.7% in 2011. What’s more, our spending is more than double any other major industrialized nation, according to the Organization for Economic Cooperation and Development.

Still, our per capita Medicare spending growth averaged 2% from 2009 to 2012, and it was nearly zero last year.

The Obama administration often points to the ACA, but outside experts are more skeptical. Research published this month by Health Affairs, a leading health policy and research and journal, credited 70% of the recent spending slowdown to the slack economy. Absent further changes in the structure of our healthcare system, the researchers expect higher healthcare inflation to resume as the economy improves.

“A significant amount of it is due to the economic slowdown,” says Eyles, “although we know that changes in the way providers deliver care, and how providers are being paid are also making a difference in the overall rate of growth.”

MONEY Health Care

Here’s One Thing That’s Cheaper in the City, and It Will Help You Live Longer

New York City Cityscape
Hint: It's not rent. Charles Taylor Crothers—GalleryStock

In some states, rural residents are paying far more for health insurance. Here's why—and why that might change next year.

By many measures, city living is a racket: skyrocketing rents, expensive food, and pricy entertainment options can make for a high cost of living. But a new study from the Robert Wood Johnson Foundation finds that city residents have the slight edge on one metric: this year they had access to cheaper individual health insurance plans on the state and federal exchanges that were created under Obamacare.

Nationally, rural residents pay only slightly more: A 50-year-old nonsmoker from a rural county is spending $387 a month on average for a mid-tier silver plan in 2014, while a city denizens pay $369 for the same kind of plan, the study found. But in some states the gap is much wider.

In Nevada, for example, residents of rural counties must spend an average of $554 a month for a silver plan—57% more than their urban peers. In eight other states, country consumers are charged at least $50 a month more for the same healthcare coverage.

A chief reason for higher premiums, researchers believe, is a lack of competition. Rural areas are home to fewer doctors, which makes it hard for insurers to score discounts for their policyholders. And rural residents have fewer health insurance options. This year, on average, urban health-care shoppers had their pick of five insurers on the exchanges, the study found; those who live in rural areas had only 3.8 options. Also, urban shoppers were able to choose from one of 17 plans on average, while rural consumers saw an average of 14.2 plan options.

Another problem is that insurance is sold on a state-by-state basis, says Janet Weiner, associate director for health policy at the Leonard Davis Institute of Health Economics. Take Nevada. In a few rural counties bordering Utah and California, there aren’t that many doctors and hospitals, and many of the closest ones are out-of-state. “The insurers do not sell multi-state plans, and so even if there are more providers close by, but across state lines, they cannot expand their provider networks,” Weiner says. “This limits the ability of insurers to drive discounts and keep costs down.”

The potential good news? Rural residents could see some relief in 2015 as more insurers join the exchanges (open enrollment starts on Nov. 15). While some states, including Florida and California, have already announced premium hikes for next year, new insurers could inject some much-needed competition into the marketplaces. For instance, both Cigna and Aetna have announced plans to expand into Georgia, a state where rural customers currently pay 24% more than urban customers do for the same kind of plan. UnitedHealthcare, the nations’ largest insurer, has announced that it will sell policies on far more state exchanges next year. “If insurers see a business opportunity, rural areas may be in luck,” Weiner says.

Read more about the impact of health reform:

 

MONEY Health Care

The Hidden Health Care Subsidy for the Rich

Waiter holding silver platter
AndyL—Getty Images

If a recent appeals court decision holds up, many middle-class families will lose federal subsidies to buy insurance. But high-income families can still get help.

A recent decision by a federal appeals court has put an essential feature of the Affordable Care Act, better known as Obamacare, in danger. That ruling may not stand up in the next round of appeal. But if the court’s decision survives, it will create a troubling—and, I would argue, outright perverse—inequality.

The quick backstory: Opponents of the new health care law argued in court that a strict reading of the law doesn’t allow the federal government to subsidize individual insurance premiums in states that have not set up their own “exchanges,” online marketplaces where people can go to buy coverage. The D.C. circuit court agreed, while another court the same day reached the opposite conclusion, setting up a likely showdown in the Supreme Court next year. If the ruling stands, millions of people in up to 36 states could lose federal tax credits that helped make insurance affordable.

What’s so perverse about this is that while many low-income and middle-income people would no longer get help from the federal government to buy insurance, loads of affluent people still will.

Here’s why: Even before Obamacare, the federal government played a big, but hidden, role in funding the private health insurance of most working-age people. When you get insurance at work, the money your employer pays for your premiums isn’t included in your taxable compensation. That’s a valuable tax benefit to you, but that lost revenue costs the government just as much as if was cutting a check.

This system has done a lot to encourage companies to offer health insurance, which is a good thing. But it also had a surprisingly backwards effect. Affluent people are more likely to have coverage (and costlier coverage, too). And because they face higher tax rates, they benefit more from tax breaks. As a result, you get more from this hidden subsidy the more you earn. The Tax Policy Center recently estimated that the average benefit of the health-insurance tax break is about $800 for a household in the middle 20% of earners. For people in the top 20%, it’s $3,400.

Prior to the Affordable Care Act, tax subsidies for health care you bought for yourself were much stingier. One of the points of the law was to address this gap. Families earning less than 400% of the poverty line—as high as about $95,000 for a family of four—currently get a tax credit when they buy coverage on a state exchange or the federal Healthcare.gov. Now that particular subsidy is under threat in some states. But the tax break for employer insurance will still be around for those fortunate enough to have an employer who pays up for premiums.

Of course, if this happens—and I should stress if—it wouldn’t exactly be new. This is how health insurance worked everywhere in the country before the ACA. But people on both sides of the political spectrum knew that was a crazy system. And now, the difference would be all the more glaring, since some Americans buying their own insurance would still get help, and others wouldn’t—all based on the technicality of whether their state set up a website.

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