A leading Republican in the GOP-controlled House thinks the state should alter MinnesotaCare, drop MNsure and jump to the federal government's HealthCare.gov website.
Meanwhile, over in the DFL-controlled Senate, a proposal to eliminate the MNsure board is moving forward, with a top Democrat questioning a recent board decision to prioritize what he calls "bells and whistles" for the exchange website.
Not far from the Capitol, a MNsure board member has publicly called for a "divorce" between the commercial insurance portion of the state's health exchange and the computer system for public health insurance programs.
All the talk signifies that debate is heating up over how to fix MNsure — with no clear resolution in sight.
"I think what we're seeing is a pretty broad recognition and agreement that change needs to come to MNsure," said Larry Jacobs, a University of Minnesota political scientist who studies health policy. "But the problem is what to do, and how to move forward."
Minnesota launched the MNsure exchange in 2013 with ambitious goals for a website that would transform the private health insurance market for individuals who buy non-group coverage. The plan also included a related IT system that would modernize enrollment and eligibility for the state's public health insurance programs.
The political promise was clear during spring 2013 when lawmakers passed a health exchange bill: Nearly 1.3 million Minnesotans would get their coverage through MNsure by 2016.
Roughly two years later, the vision has been confounded by a combination of technical problems and Âmarket realities.
Last week, MNsure's board made yet another cut to projections for commercial enrollment through the exchange. Initial projections suggested that anywhere from about 200,000 to 450,000 people would buy private plans through MNsure by 2016, but the exchange now expects about 95,000 private sign-ups by the end of next year.
People use MNsure to find out if they qualify for MinnesotaCare or Medical Assistance, which is the state's name for Medicaid. But technical problems continue to frustrate county and state government workers who use the system to connect people with these programs.
Legislative auditor James Nobles put the continuing problems squarely in front of legislators through a series of hearings in February, in which he presented an audit that concluded failures during MNsure's first year outweighed its achievements.
Rep. Matt Dean, chairman of the Health and Human Services Finance Committee in the House, said the auditor's report prompted him to introduce his bill calling for a switch in 2017 from MNsure to HealthCare.gov.
The bill is scheduled for its first hearing in the coming week, along with another bill from the Dellwood Republican that would fundamentally change MinnesotaCare. Rather than maintain the government program for the state's working poor, Dean proposes consumers buy private insurance policies next year through MNsure — and possibly through HealthCare.gov down the road.
"The goal is to try to get low income Minnesotans to be able to afford private health insurance that they can choose, and have good plans that they can chose from," Dean said.
Dean is not the first to put forward the MinnesotaCare idea, which could help MNsure financially by expanding the number people buying on the exchange.
But Greta Bergstrom of TakeAction Minnesota said her group strongly opposes Dean's bill, because MinnesotaCare has worked well for decades. TakeAction Minnesota was influential with DFL lawmakers in pushing to create MNsure, but the group questions whether people with incomes low enough for MinnesotaCare would find quality coverage from private insurers that's affordable.
"It's a program … that's worked effectively for two decades, and really is a legacy program for the state of Minnesota," Bergstrom said. Of Dean's proposal, she said: "We don't think it would work."
Sen. Tony Lourey, DFL-Kerrick, also opposes the MinnesotaCare changes, as well as the idea of jumping to HealthCare.gov. The federal exchange isn't free, Lourey said, and doesn't address the ongoing need for fixes to the IT system for public health insurance programs.
Lourey argued that jumping to the federal exchange is a particularly bad idea right now, since the U.S. Supreme Court is considering a case that could block tax credits through the federal exchange. Dean said Friday he was considering an amendment to his bill that might address the Supreme Court issue.
Lourey carried legislation during 2013 to create MNsure, and his bill to eliminate the health exchange board of directors is moving forward in the Senate.
In February, the MNsure board reviewed a list of 18 priority fixes for IT systems at the exchange, and voted 4-3 to add one item to the list — plan comparison and shopping tools that would make it easier for Minnesotans to buy private coverage. During a recent interview, Lourey said he questioned the vote because the plan comparison tools were not highlighted by a group of experts that's otherwise steering IT fixes at MNsure.
"This great autonomy given to this board. … Nobody can call them to task for ignoring this advice," Lourey said. Of the idea for adding plan comparison tools, he said: "Bells and whistles — on top of core functionality that isn't even there yet — become a mockery of themselves."
But Tom Forsythe, the board member that pushed for the vote, said the tools he's looking for are essential for giving Minnesotans an exchange website that's useful. Without them, consumers can't easily compare attributes of plans, and how different deductible and coinsurance features could affect what people would pay out-of-pocket if they get sick.
"These things are absolutely fundamental to the functioning of the exchange," Forsythe said in an interview.
In an opinion article published this month in the Star Tribune, Forsythe also proposes a divorce between the part of MNsure that handles commercial enrollment, and the IT system for enrolling people in public health insurance programs.
"We've spent $140 million. We're about to spend $89 million more," Forsythe wrote. "To show for it, we have a mediocre MNsure website and an IT mess at the Department of Human Services. … It's time for a change."
Elizabeth Lukanen, a health policy expert at the University of Minnesota, said she wasn't sure how a divorce for the back ends of the MNsure IT system would actually work. Most states that launched their own health exchanges have tried to integrate those functions, Lukanen said, and the lack of integration for some has caused trouble.
But Caroline Pearson of Avalere Health, a health care consulting firm in Washington D.C., said better tools for MNsure website consumers are needed.
"There's no formulary information available on the website, which is a pretty significant gap relative to all the rest," Pearson said, referring the list of medications covered by different insurance plans. "And it looks like the website has planned for a provider search tool … but it doesn't work right now."
Christopher Snowbeck • 612-673-4744
Twitter: @chrissnowbeck
