Rhode Island’s health insurance exchange, HealthSource R.I., has outperformed most other states’ systems in the year since it opened to the marketplace but faces challenges of balancing competing stakeholder interests, budget problems and collaboration with state agencies, said invited speakers of a Taubman Center for Public Policy and American Institutions panel discussion Wednesday afternoon.
Christine Ferguson, director of HealthSource R.I., and Christine Hunsinger MPA’08, CEO of political communications consulting firm BGP Strategies, spoke about the origins and future of the exchange, set up as part of the Affordable Care Act to help connect consumers with different health insurance options.
Hunsinger, a former spokesperson for Gov. Lincoln Chafee ’74 P’14 P’17 and HealthSource R.I., opened the discussion by providing background on the history of the health exchange, which came under Ferguson’s direction in June 2012 after the U.S. Supreme Court upheld the ACA, allowing the formation of HealthSource R.I. to progress.
The exchange opened for pre-enrollment last October and coverage became available Jan. 1.
Ferguson was charged with the unique task of building a government agency from the ground up, Hunsinger said, adding that Ferguson collaborated with the office of Lt. Gov. Elizabeth Roberts ’78 and other stakeholders on the project.
Since then, HealthSource R.I. has fared well compared with other states’ exchanges. Rhode Island ranked second nationally for its rate of health insurance enrollments, exceeding the federal enrollment threshold as of March.
“Rhode Island’s not often touted as a leader in anything. Every time we make the top of a list, it’s a bad list. And every time there’s a good list, we’re at the bottom. But this is different,” Hunsinger said, adding that it was notable the state excelled at an initiative at the top of the national agenda.
The Rhode Island Department of Health and Human Services, the lieutenant governor, the Department of Administration and the governor’s office were the government stakeholders involved in planning HealthSource R.I. and setting up the rules of the exchange.
“At the leadership table, there are four different agencies with four different competing sets of interests. So it makes it challenging and very collaborative and sometimes very loud,” Hunsinger said.
“The providers don’t really have a seat at the table right now,” Hunsinger said, attributing this setup to the state’s relatively small size and the power of health insurance companies.
Ferguson’s vision of the exchange is straightforward: Providing consumers with clear information about health insurance plans will do a better job of reforming health care than legislation. Consumers can use a tool like HealthSource R.I., which includes an online platform and customer service representatives, to make educated decisions about the best insurance plan for them.
Giving consumers, especially business owners, the information they need to make informed choices is key, Ferguson said. People who are confused by the process have never had to purchase insurance before but are now required to under the ACA, she added. This population segment includes small business owners, many of whom have not been involved because they were not previously mandated to buy insurance for their employees, Ferguson said. “No one’s made it possible for them to even understand what the hell they’re buying.”
“The health insurance carriers listen every year to people’s feet,” Ferguson said, adding that consumer behavior impacts companies’ pricing and coverage. Consumers now can call HealthSource R.I. if they are dissatisfied with their plan, which enables the exchange to track problems and inform consumers, she said. “You fundamentally have to believe that competition drives innovation, price and quality.”
Ferguson said HealthSource R.I.’s structure and objectives differ from other states’ exchange platforms. “The differences of HealthSource R.I. make “people really uncomfortable because God forbid that we should do something different,” she said in a sarcastic tone.
Rhode Island did a lot of outreach to the community during the open enrollment period and expanded its Medicaid program for enrollees, The Herald previously reported. A November 2013 report from the Rhode Island Public Expenditure Council, a nonprofit and nonpartisan public policy group in Providence, found that HealthSource R.I. had the lowest premiums of the New England states’ exchanges, “proceeded with minimal technical obstacles” and offered a variety of available plans for small business owners. But RIPEC also concluded that Rhode Island lacked “sustainable funding mechanisms” for HealthSource R.I. and the state needed to find a place to maintain the program within the government.
“There has never ever been an opportunity like this in the 30 years that I’ve been working in this field,” Ferguson said, adding that there will not likely be a chance to implement similar health care reforms for the next half century.
If HealthSource R.I. were made a state agency, it would facilitate collaboration with other parts of Rhode Island’s government, but it would also create bureaucratic challenges, such as hiring or setting a budget, which “make it very difficult to respond quickly,” Ferguson said. “Doing things in the public sector means every decision you make and every experiment you try has to succeed,” she added.
Legislation that would make HealthSource R.I. “a quasi-independent agency” making it separate from the government and allowing it to “move at the speed of a business,” was introduced during Ferguson’s first year.
“The legislation was a political hot potato,” Hunsinger said.
The General Assembly ended its legislative period before passing the bill because of resistance from anti-abortion lawmakers since all the plans offered by the exchange covered abortions, Hunsinger said. As a result, the exchange remained under the purview of the governor’s office.
But when Chafee decided not to run for re-election, he also decided to let the next governor decide what to do with the state health exchange, she said.
Cranston Mayor and Republican candidate for governor Allan Fung would scale down the exchange, or possibly regionalize it by working with Massachusetts and Connecticut, Hunsinger said. General Treasurer and Democratic nominee Gina Raimondo would keep the exchange but reduce its budget. Moderate Party candidate Robert Healey wants to turn the exchange over to the federal government, she said.
The budget for the exchange under the new governor would be between $17 and $23 million, but health care represents 21 percent of the state economy, Hunsinger said.
“I think with a very good and thoughtful, creative leadership … we could test out new ways of working in government that might marry some of that,” Ferguson said. “But that really requires a lot of energy and thought, and I don’t know whether or not we have the bandwidth as a state in leadership roles right now to really fully be able to explore that, given all the other problems that we have.”
At Tuesday’s gubernatorial debate, the candidates started discussing the exchange, Hunsinger said. “But it’s a big deal because the governor will have to put in their budget how they’re going to fund it,” she added. “And that’s why it’s so surprising that the gubernatorial candidates have waited so long to take a position.”
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