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Fixing Delaware’s Healthcare: Why Free-Market Solutions Matter

By: Jane Brady, Chair, A Better Delaware 

Delaware has long struggled with providing easy access to superior health care at a reasonable cost. A number of factors have affected the failure to meet those goals, but public policy is a significant part of the picture.

Delaware spends more than$12,000 annually per person in the state, at the top (fourth highest) of spending among all the states. Yet the outcomes are bottom rate – we have the highest per capita overdose death in the country, we have the worst shortage of primary care physicians – meeting only 16% of our need, and Delaware hospitals have the second worst (longest) wait times in the emergency rooms in the country.

Why? We have a heavy-handed bureaucracy and policy mandates that makes care more costly, reduces incentives to innovate and discourages competition.

We at A Better Delaware have long encouraged lawmakers to get rid of the Certificate of Need, now called the Certificate of Public Review, which puts a group of individuals, some associated with providers already operating in the State, in charge of deciding if a new provider can enter the market, or any provider can offer new technology, additional bed space or expand services. This requires providers to grant others permission to compete with them. What could go wrong? Nearly every state that ever had a certificate of need requirement has revoked them, and Delaware should too. Studies consistently find the certificate of need decreases access, increases costs and negatively affects quality of care.

Recent legislation has only tightened the strain bureaucracy puts on health care providers. In the name of containing costs, the legislature has placed a politically appointed panel in charge of reviewing hospital budgets to oversee how much and for what health care providers are proposing to spend. Again, what could go wrong? We are only the second state to enact such a bill, and the first found it to be a failure by most accounts.

Reimbursement rates for primary care physicians is lower than for most other categories of providers, yet, because they know their patients, they can provide better diagnoses and assessments, make a better determination of what additional care is needed, and save the high cost of a visit to the hospital for patient and insurer.  They need fair reimbursement rates, but recent legislation would again impose mandates on insurers and providers that is driven solely by cost and not focused on the objectives of improved access and quality care.

And, we have to question how well informed any decision about the cost of health care can be under the current practices and the consistent failure of providers to comply with price transparency laws.  Delaware has laws that require providers to make costs clear to patients, for example, the cost of a CT scan, knee replacement or the birth of a child. Knowing that information would allow patients to choose where to undergo testing or procedures.  There is little to no compliance with those laws, and so, whether patient or legislator, it is hard to know how one can competently identify any problems, let alone solve them.

Delaware’s policies that put politicians in charge of health care expansion or operation, restrict competition and hinder excellence and competition are a large part of the problem with providing quality and accessible care in our state. Enforce the laws requiring transparency and create more competition which will encourage more providers to locate here.  Let’s create a health care community in which providers can give their patients the care they know our community deserves.

Jane Brady serves as Chair of A Better Delaware. She previously served as Attorney General of Delaware and as a Judge of the Delaware Superior Court.

 

 

 

 

Delaware’s Budget Reality: Seven Fiscal Headwinds and the Choices Ahead

By George Rotsch, Guest Contributor

When moderate voters in both parties understand the State Budget and the trade-offs that will shape Delaware’s future, they will vote differently.

Budgets have a way of clarifying reality.

Unlike campaign speeches or policy proposals, a budget cannot hide behind rhetoric. It must add up. Every dollar spent must come from somewhere, and every new program competes with existing priorities. In the end, a budget forces organizations — whether families, businesses, or governments — to make real choices.

Those choices always carry consequences.

Delaware is now entering a period where those consequences will become more visible. For many years the state benefited from relatively strong revenues and manageable fiscal pressures. That stability allowed policymakers to expand programs, increase services, and invest in new priorities without confronting difficult trade-offs.

That era may be coming to an end.

The fiscal pressures facing Delaware are growing. Slower revenue growth, rising healthcare costs, demographic changes, and other structural forces are beginning to collide with long-standing spending commitments. None of these forces are unique to Delaware, but for a small state with limited revenue sources, they can quickly create difficult decisions.

This is precisely why a deeper public understanding of the state budget matters.

A well-informed electorate — particularly the moderate and independent voters who increasingly determine election outcomes — should understand not only what policies promise, but what they cost and what trade-offs they require.

That kind of civic understanding is healthy for democracy. And frankly, it is good for both parties.

For candidates in both parties, it presents an opportunity to speak clearly about fiscal discipline, sustainability, and long-term planning. But those arguments are far more persuasive when voters themselves understand the financial realities behind them.

To have that conversation honestly, we must begin with the structural challenges shaping Delaware’s budget.

Seven Fiscal Headwinds Facing Delaware

These pressures are not ideological arguments. They are fiscal realities that will shape policy debates for years to come.

Understanding them helps voters recognize why the next generation of budget decisions will likely involve difficult choices.

  1. Slowing and Uncertain Revenue Growth

Delaware’s budget depends heavily on a relatively small number of major revenue streams, including personal income taxes, corporate franchise taxes, and business formation revenues.

For years, these sources have performed well, particularly the corporate franchise tax system that has made Delaware the legal home for many of America’s corporations. But these revenues are also sensitive to economic cycles, financial markets, and policy changes outside the state’s control.

Recent projections suggest that revenue growth may slow significantly in the coming years, in part because of federal tax changes and economic uncertainty. When growth slows, the state cannot continue expanding spending at the same pace without eventually running into fiscal constraints.

That is the nature of a balanced budget system.

Delaware cannot simply spend money it does not have.

  1. Rapidly Rising Healthcare and Medicaid Costs

Healthcare spending represents one of the largest and fastest growing portions of Delaware’s operating budget.

Medicaid alone serves tens of thousands of residents, including low-income families, seniors in long-term care, and individuals with disabilities. As healthcare costs rise nationally, those increases are reflected in the state’s budget as well.

In addition, medical advances, demographic changes, and expanded eligibility for services have increased demand for healthcare spending.

These programs are vital to many Delawareans, but they also create long-term fiscal pressure. If healthcare spending grows faster than state revenue, policymakers will eventually be forced to shift funding away from other priorities or pursue reforms.

  1. Demographic Changes and an Aging Population

Delaware is growing, but the composition of that growth matters.

The state has become an attractive destination for retirees, thanks in part to its tax policies and quality of life. While this brings many benefits — including economic activity and community stability — it also affects the fiscal structure of the state.

Older populations tend to require more healthcare services and public support programs while contributing less in income tax revenue compared to younger working populations.

Over time, this demographic shift can increase demand for government services while placing pressure on the revenue base that funds them.

  1. Education Spending and the Demand for Better Outcomes

Education is one of Delaware’s largest and most important investments. Improving student outcomes, particularly in areas such as literacy and workforce readiness, is essential to the state’s long-term economic future.

However, education funding continues to rise as schools address classroom staffing, special education services, building maintenance, and program improvements.

Many advocates argue that additional funding is necessary to achieve meaningful educational progress. Others emphasize the need for stronger accountability and better outcomes from existing investments.

Both perspectives highlight an important reality: improving education often requires significant financial commitments, and those commitments must fit within the broader fiscal structure of the state budget.

  1. Growing Competition Between States

In the near term, one of the most important factors supporting Delaware’s fiscal stability is its unique role as the nation’s corporate capital.

More than two-thirds of Fortune 500 companies are incorporated in Delaware, and the state’s Court of Chancery and well-developed corporate law system have made Delaware the preferred jurisdiction for businesses seeking legal certainty and efficient dispute resolution.

This advantage is not just a point of pride — it is a critical pillar of the state budget.

Corporate franchise taxes and incorporation fees generate hundreds of millions of dollars in annual revenue, helping fund schools, healthcare, public safety, and other core services. For a state with no general sales tax, this revenue stream is especially important.

However, Delaware’s position cannot be taken for granted.

Other states continue to look for ways to compete for corporate registrations, and national policy discussions about corporate taxation and regulatory structures could influence where companies choose to incorporate. In addition, legal changes that weaken Delaware’s reputation for predictable and balanced corporate governance could gradually erode the state’s competitive advantage.

In the short term, protecting Delaware’s reputation as the most reliable and stable place to incorporate is one of the most important steps policymakers can take to preserve fiscal stability.

If that reputation were ever significantly weakened, the consequences for the state budget could be immediate and substantial.

Maintaining Delaware’s leadership in corporate law is therefore not simply a legal issue — it is a fundamental component of responsible fiscal management.

  1. Infrastructure and Capital Investment Pressures

Infrastructure is one of the least visible but most essential responsibilities of state government.

Roads, bridges, public buildings, schools, water systems, and environmental protection projects all require long-term investment. These projects are typically funded through the state’s capital budget, which must be managed carefully to balance infrastructure needs with responsible debt levels.

Delaying necessary infrastructure investments can lead to higher costs in the future, but accelerating projects also requires financial resources today.

Finding the right balance between investment and fiscal restraint is an ongoing challenge.

  1. The Challenge of Long-Term Fiscal Sustainability

Ultimately, the central question facing Delaware’s budget is simple:

Can spending commitments grow at a pace that the state’s revenue system can sustain?

Over time, programs expand, new priorities emerge, and political pressure builds to fund additional initiatives. While many of these efforts serve worthy goals, the cumulative effect can place strain on the budget if revenue growth does not keep pace.

Delaware has historically maintained important fiscal safeguards, including spending benchmarks and reserve funds. Preserving these guardrails will be essential as new pressures emerge.

The challenge is not simply balancing next year’s budget — it is ensuring the state remains financially stable over the long term.

Why Voters Must Understand the Trade-Offs

The most important lesson of budgeting is that choices are unavoidable.

A budget forces decision-makers to weigh priorities against limited resources. Funding one program may require slowing growth in another. Expanding services may require higher taxes or reduced spending elsewhere.

These are not ideological questions alone. They are practical questions about trade-offs.

A smarter electorate — particularly moderate voters within both political parties — should understand these trade-offs clearly.

Democratic proposals often emphasize expanded services and public investments. Republican proposals frequently stress fiscal discipline, economic growth, and spending restraint.

Both perspectives raise legitimate questions about how Delaware should allocate its resources.

But voters can only evaluate those proposals responsibly if they understand the fiscal realities behind them.

For Republicans, this represents an important opportunity.

Arguments about fiscal responsibility resonate most strongly when voters understand the structural pressures within the budget. When citizens recognize the limits of revenue growth and the rising cost of government commitments, they are more likely to appreciate the importance of sustainable spending.

Ultimately, this is not about winning a political argument.

It is about strengthening civic understanding.   Budgets force choices. Delaware will face those choices in the coming years. And the voters who take the time to understand the numbers, the pressures, and the trade-offs will be the ones best equipped to guide the state toward responsible solutions.

A more informed electorate is not just good for democracy.   It is essential for Delaware’s future.

George Rotsch is currently Editor and Publisher of Delaware LIVE News.

 

Long-term Care, Mental Health Staff Needed*

By: Marie Wenzel

As the number of older adults increases, so does the demand for behavioral health services, case management, peer support and skilled nursing. However, the workforce needed to meet that demand is not keeping up.

Delaware is in the midst of a workforce crisis that is putting our most vulnerable residents at risk. Older adults who want to age in place, people struggling with behavioral health challenges and families trying to care for loved ones are all facing a harsh reality: There simply are not enough trained professionals to meet their needs.

As the number of older adults increases, so does the demand for behavioral health services, case management, peer support and skilled nursing. However, the workforce needed to meet that demand is not keeping up.

Today, more than 289,000 Delawareans live in areas where mental health care professionals are in shortage, accounting for more than a quarter of our state’s population. At the same time, national workforce projections show significant shortfalls in key behavioral health and long-term care professions. By 2037, the U.S. will face shortages of more than 87,000 mental health counselors, 113,000 addiction counselors and tens of thousands more psychologists, therapists and support staff (bhw.hrsa.gov).

Behavioral health providers alone are not enough. We also need more skilled nursing employees — including home health aides, personal care aides, nursing assistants and psychiatric aides — to support individuals aging in place or living with serious mental health or long-term care needs. National data projects that the need for long-term services and support professionals will grow by 42% between 2021-36. Demand for direct care workers, such as personal care aides and psychiatric aides, is expected to grow by 38%-135% over that period (dhss.delaware.gov).

For Delaware, these trends are especially concerning. Our over-60 population is roughly 290,180 individuals and is expected to grow dramatically in the coming decades (dhss.delaware.gov). Without a concerted effort to expand our care workforce, many residents could face long waits, limited services or forced institutional care, simply because no one is available to assist them at home.

To effectively respond, we must adopt an intersectional, collaborative strategy. Agencies and stakeholders — including behavioral health providers, Medicaid, the Delaware Division of Substance Abuse and Mental Health, the Delaware Division of Services for Aging and Adults With Physical Disabilities, and the Delaware State Housing Authority — should come together to pool resources, align programs and expand access to services statewide.

Specifically, we must:

  • Immediately increase the reimbursement rates to community-based behavioral health providers.
  • Invest in training, certification and retention for behavioral health professionals and skilled nursing caregivers.
  • Provide incentives, including competitive pay and benefits, to attract providers to underserved areas and populations.
  • Expand access to community-based long-term care, peer support and integrated care models that combine behavioral health, medical needs and housing support.

Delaware has long stood as a state that cares for its people. To keep that promise for the future and guarantee that older adults, individuals with mental health needs and residents living with disabilities have the support they deserve, we must act now. Strengthening our workforce is not just about filling jobs; it is about preserving dignity, independence and hope for thousands of Delawareans and their families.

Marie Wenzel is the CEO of Delaware’s branch of the National Alliance on Mental Health.

*First published in the Delaware State News on December 12, 2025. Reposted here with permission from the Author.