Dec. 23--When the Minnesota Legislature opens business next month, near the top of the agenda is likely to be legislation to set up a health insurance exchange, a pillar of President Barack Obama's health care act.
There's one point on which fans and foes of the controversial act agree: Getting Minnesota's exchange functioning in a matter of months, as is required, will be a Herculean task.
"This is an incredibly tight timeline," said John Pollard, a spokesman for Minnesota Management and Budget, the agency that's shepherding development of the exchange within Gov. Mark Dayton's administration.
The exchanges often are analogized as something like Travelocity or Expedia for health insurance. They're seen as a one-stop virtual shop for individuals, small-business owners and those on public health programs to shop for and secure coverage. Users would enter their information on the exchange website and receive a customized list of coverage options, potentially accompanied by information to guide their decisions.
In Minnesota, more than 1 million people are expected to receive coverage through the exchange, including low- and middle-income people slated to receive subsidies to buy coverage under the federal law.
Each state must have an exchange in place by October 2013. States are given the option to design and implement their own exchanges, partner with the federal government to do so or accept an exchange built entirely by the federal government.
Before the November elections, it wasn't a sure thing which route Minnesota would take.
The Dayton administration has called for Minnesota to build its own exchange and has been planning one for months, having been awarded $71 million in federal grants to do so. But Republican lawmakers resisted passing a bill to set up an exchange when they controlled the Legislature in 2011 and 2012, citing their objection to the law and uncertainty about its future.
Last month's election of DFL majorities in the state House and Senate changed the equation, giving Dayton presumably cooperative teammates with which to pass exchange legislation. And the re-election of a Democratic U.S. Senate and Obama, the health care law's proponent-in-chief, assures it will remain in place for the foreseeable future.
Minnesota passed a key hurdle last week when it got conditional federal approval to operate an exchange.
But in the next few months, lawmakers and Dayton must fill in the many blanks of the exchange, including how it will be governed, how its considerable operating cost will be covered and what coverage options and other tools it will offer.
Larry Jacobs is a professor at the University of Minnesota'sHumphrey School of Public Affairs who has closely tracked the health care reform debate.
Jacobs says the discussion in Minnesota thus far has centered on the binary question of whether the state should build an exchange. Now that it's clear the state will move ahead, it only gets more complicated, he says.
"Now there's going to be an even more heated debate about how to do the exchange," Jacobs says.
The time crunch will limit what the exchange can look like at the outset, Pollard said. The October deadline actually understates the urgency because some key elements of the exchange, such as its governing structure and financing mechanism, must be identified by the end of March.
Eileen Smith is a spokeswoman for the Minnesota Council of Health Plans, which represents the state's health insurers.
To meet deadlines, Smith says the exchange should start out as a no-frills model. What Smith calls "add-ons" -- items that could add value to the exchange but aren't required, such as putting provider quality ratings on the exchange website to help guide coverage decisions -- should be postponed until later, she says.
"I'm not saying don't do those things ever," Smith said. "I'm just saying, by October, have the essentials running smoothly."
Dave Borgert is spokesman for St. Cloud-based CentraCare, the region's largest health care provider. Borgert says he hopes a potential public-private board to govern the exchange, a model favored by Dayton and others, will include representatives for providers and for consumers.
Borgert also says determining how to pay the operating cost of the exchange will be crucial. It's expected to cost about $54 million to operate in 2015, according to Pollard.
Borgert and other providers hope the state's health care access fund, fed in part by a tax on health care providers, won't be tapped.
"It's a target," Borgert said of the fund, "and it shouldn't be."
'Rushing this ahead'
Under the federal law, states may choose to permit all plans that meet minimum standards to be on their exchange. Or they may take a more active role in negotiating coverage options with health plans.
Borgert says those governing the exchange should give consumers as many options as possible.
"The more choices consumers have, the better," Borgert said.
The possibility of a exchange that heavily regulates coverage is one of many concerns about the issue voiced by Rep. Steve Gottwalt, R-St. Cloud.
Gottwalt chaired the House committee on health care policy, a likely starting point for any potential exchange legislation, when Republicans controlled the House for the past two years. He will remain the lead Republican on that committee in 2013.
The exchange issue already has given Gottwalt no small amount of heartburn. He was blasted by conservative activists and by some in his own party for joining the Minnesota Chamber of Commerce and other business groups in proposing the state build an exchange in 2011, a stance on which he later backpedaled.
Gottwalt says there are examples of how an exchange can function without imposing what he considers too heavy a hand. He cites the state of Utah, which operated an exchange before the federal health care law was adopted.
But under the so-called Obamacare law, Gottwalt predicts the cost of running the exchanges will increase the cost of health coverage. Some could even establish what Gottwalt calls "government-run health care," he says.
"We have to start painting a picture for average Minnesotans of what this will mean for them," Gottwalt said. "We're rushing this ahead so fast with so many unanswered questions."
Pollard doesn't dispute that there are many exchange-related questions that lawmakers and Dayton must resolve in the coming months.
"A lot of this is up to the Legislature," Pollard said. "There are some unknowns.
"That debate needs to play out, and people need to engage."
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