Vermont did not properly allocate millions of dollars in federal grants when establishing its marketplace created under the Affordable Care Act, a report released Tuesday by the Department of Health and Human Services Office of Inspector General said.

Vermont’s Agency of Human Services did not always follow federal requirements for allocating costs to establishment grants to establish its marketplace or for drawing down establishment grant funds, the report says.

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Two issue briefs published today by The Commonwealth Fund and authored by several RAND Corporation economists (led by Christine Eibner) will be noted by casual readers for their presumably “scientific” conclusions that (1) a set of Clinton proposals will increase the number of insured Americans by over 9 million and decrease average spending by up to 33% for those with moderately low incomes; and (2) a sketchy set of Trump policy stances would increase the number of uninsured individuals by 16 million to 25 million relative to the current-law ACA baseline and disproportionately affect low-income individuals and those in poor health.

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The bitter, long-running fight over ObamaCare’s individual and employer mandates is all over but the shouting.

The problems plaguing the ObamaCare exchanges as enrollment lags, premiums spike and insurers from Aetna to UnitedHealth head for the exits have reached a critical stage, even as the penalties are about to spike for far too many millions of people who get a bad deal from the law. This year, 8 million people paid the individual mandate penalty — not too far from the 10.6 million who had coverage via the exchanges at the end of June. The status quo won’t survive the inevitable political backlash, nor should it. ObamaCare is like a car with a bad muffler: It can keep traveling down the road, even as everyone it passes begs the driver to pull over and get it serviced.

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While health care has not been central to the 2016 Presidential campaign, the election’s outcome will be a major determining factor in the country’s future health care policy. A number of issues have garnered media attention, including the future of the Affordable Care Act (ACA), rising prescription drug costs, and the opioid epidemic.

Hillary Clinton and Donald Trump have laid out different approaches to addressing these and other health care issues. Central among these is their position on the future of the ACA. Hillary Clinton would maintain the ACA, and many of her policy proposals would build on provisions already in place. Donald Trump, in contrast, would fully repeal the ACA, and although his policy proposals and positions do not offer a full replacement plan, they do reflect an approach based on free market principles.

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About 27,000 Hoosiers will lose their Obamacare plans next year after Indiana University Health Plans announced it is withdrawing from the Indiana marketplace, citing big losses from the new enrollees. It had covered 15% of marketplace enrollees last year. Indiana Sen. Dan Coats, a Republican, said the announcement from IU Health Plans is evidence the healthcare law is “collapsing before our eyes.”  “Because of the broken Obamacare system, Hoosiers continue to face rising premiums and limited choices rather than reliable, affordable healthcare,” Coats said.

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Obamacare’s fourth open enrollment period will begin November 1. For the Internal Revenue Service, it will be open season on uninsured taxpayers. In an effort to maximize enrollment, the IRS is mining the personal tax information of people who have chosen not to buy Obamacare policies or claimed an exemption. CMS proclaims Obamacare policies are “a product consumers want and need” and plans an outreach campaign. The agency can’t understand why millions of people—many of them young and healthy—still don’t realize what they want and need it.

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Several RAND Corporation health economists have offered very rough estimates of the coverage and cost effects of the hazy health policy proposals by the two major presidential candidates, Hillary Clinton and Donald Trump. In choosing to fill Trump’s policy vacuum with their own void of limited health policy modeling, the RAND researchers conclude that Trump’s proposals would increase the number of uninsured individuals within a range of 16 to 25 million individuals (relative to current-law ACA arrangements), with disproportionate losses suffered by those with low incomes or in poor health. However, Trump doesn’t spend much more taxpayer money to achieve these results, and his plans in health policy would increase the federal deficit by somewhere between $0.5 billion to $41 billion.

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BlueCross BlueShield of Tennessee sent shock waves Monday across Tennessee with the company’s decision to exit the Obamacare exchange in Nashville, Memphis and Knoxville, a move that highlights persistent volatility in the young health insurance marketplace.

Three years into the Affordable Care Act exchange, the state’s largest insurer is grappling with hefty losses and ongoing uncertainty on the marketplace. BCBST is open to coming fully back into the market once uncertainties about policies and the membership wane.

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In yet another sign of instability in Obamacare’s health-insurance Exchanges, BlueCross BlueShield of Nebraska has announced it will leave that state’s Exchange entirely, while BlueCross BlueShield of Tennessee will exit the Exchange in all three of that state’s major metropolitan areas. The moves will leave 112,000 Tennesseans and tens of thousands of Nebraskans scrambling to find new coverage for 2017 from a dwindling number of carriers.

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Insurers have announced that they are sharply raising prices or pulling out of the Obamacare markets entirely. Many consumers will have fewer choices of insurance plans, and many insurance plans will include fewer doctors and hospitals. Many of the most important problems can be understood if you think of an Obamacare marketplace as a particular kind of restaurant: an all-you-can-eat buffet. It can be a solid business, but it’s hard to get the pricing right. For example, you can be in deep trouble if your buffet suddenly becomes the favorite hangout of the high school football team.  Unless you make major adjustments, you will quickly lose money. That may be what has happened to some of the companies selling health insurance.

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