Ex-MNsure board member Tom Forsythe on past mistakes and future of exchange

During MNsure's troubled rollout, Tom Forsythe was one of the first board members to voice regrets that he hadn't raised concerns earlier. During a February 2014 meeting on MNsure's beleaguered call center, Forsythe confessed: "I am struggling with how to be a good board member here." MNsure's still got issues. But when he ended his three-year term this spring, Forsythe could cite both technology improvements and growing enrollment that helped push the state's uninsured rate to historic lows. MNsure was launched under the federal Affordable Care Act as a government-run marketplace for individuals to buy private health coverage. About 6 percent of state residents buy coverage in the individual market, which has undergone sweeping changes by way of MNsure and other health law initiatives.

Q: The individual market in the past year has seen significant disruption. UnitedHealthcare will retreat next year from exchanges in about 30 states. Blue Cross and Blue Shield of Minnesota says it will significantly narrow its product offerings in the state. Why is this market struggling so much?

A: The principal reason the market is struggling in Minnesota is because it's not big enough. The sheer number of lives that they have in the pool is relatively small. There's a good-news side to that, and that is: Employment has been strong in Minnesota, and employer-provided benefits are still strong. … But that makes our individual market small.

Q: What does the future hold?

A: It's not yet stable. So, premiums are still seeking the right level that provides coverage to people — that keeps them buying — but also keeps insurance companies willing to offer the products. That pool, the individual market, hasn't stabilized. That's why we've seen changing premiums, and that's why we may soon see people falling out of the health care pool because of rising premiums.

Q: Blue Cross is dropping many products but will continue to sell HMO plans with narrow networks of hospitals and doctors. Is there a risk that some insurers might drop the market entirely?

A: I think there is a risk. … It certainly isn't a good thing if health insurers chose not to participate in the individual market. On the other hand, you can see why they might based on the losses they've experienced despite the premiums they have charged. This is not a good scenario, because I fear what might come next from a public policy perspective.

A: I'm certain there will be some who will want to ensure that there are offerings available to people in every region, and every county. If those offerings aren't voluntary in the marketplace, then I'm sure there would be some who would want to seek a legislative solution. I am a market advocate, and have always supported market-based solutions, so I don't think we might like where that conversation might take us.

Q: President Obama wrote recently in a medical journal that a "public option" health plan might be needed in counties where there isn't enough competition among private insurers. Is that the sort of thing that worries you?

A: Yes, that's one thing. … The public option will lose money, because they'll want to set premiums that don't cover costs. And so the public option is going to be subsidized by the taxpayers. That's a bad scenario because it might be cheaper to move to county A, and out of county B, so you can get the public option that's subsidized by the taxpayers. Seriously. This is not a good scenario on a county-by-county basis.

Q: The Blue Cross announcement clearly suggests that narrow network plans are on the rise. Does MNsure need an online tool that lets people shop on the basis of which health plan includes their doctor?

A: I view it as an imperative.

A: We had a terrible start. On the other hand, the number of people we've insured is actually quite impressive. On the whole, we have successfully brought down the uninsured rate and extended coverage to a great many Minnesotans, so that brings up our grade. But the way in which we've accomplished it has certainly been checkered.

Q: Why was the rollout so troubled?

A: The notion that we would have four different vendors come together with essentially off-the-shelf IT modules that would be combined into something that would work seamlessly was a flawed strategy from the outset. But I would roll it back one step, and that is: The Legislature linked the health care insurance exchange with the Department of Human Services IT needs from the very beginning. …

If you can be proud of anything as a board member, from those initial days, it's that we pivoted and grabbed the organization by the lapels and pulled the organization out of the ditch and eventually made the thing operate. But it has still been burdened by that original flawed vision, and certainly we started out with tremendous missteps based on that initial flawed IT strategy.

Q: In one of your last meetings on the MNsure board, you seemed very interested in comments from a vendor who pitched a new IT approach. Why?

Q: You didn't collect your salary as a board member during the first year of the exchange. Did that continue?