Governing magazine: State and local government news for America's leaders

36 Hours Behind the Scenes of Rhode Island's Health Exchange

The pressure mounts as 18 states work to build Obamacare's online insurance marketplaces before the deadline -- a task that some health care veterans say is the most challenging they've ever faced.
by | May 22, 2013

The Rhode Island health insurance exchange lives behind an unassuming and unmarked door in the basement of the state department of administration building in Providence. That’s where the operation’s brains are: the staff of twentysomething charged with implementing one of the least understood but most important parts of the Affordable Care Act. At its most basic level, the exchange is intended to be an insurance marketplace, a website where people can shop for health coverage and access federal tax subsidies to help them buy it. The staff in Providence want it to be much more than that, but first, they have to get it ready for launch.

Their corner of the basement, lined with makeshift blue cubicles, used to be the building’s gym. Once in a while, a sweat-soaked state worker will shuffle through to the locker rooms along the back wall. There are no windows, just walls; the staff colloquially calls it “the dungeon.” There is nothing glamorous about this job. A recent survey found that nearly 80 percent of Rhode Islanders don’t even know that these people are doing any work at all, much less that they’re sometimes staying to midnight to get that work done by the Oct. 1, 2013 deadline set by the Affordable Care Act when it was signed by President Obama in March 2010. Gov. Lincoln Chafee created the exchange on Sept. 19, 2011, via executive order, and it’s been a race to meet what was always an aggressive timetable.

Moreover, this isn’t like other government programs. Everybody around here, most of whom have spent some time in the private sector, emphasizes how creating the exchange, which centers on launching a complex yet functional and usable website, is more like working at a commercial start-up. This isn’t some entitlement program with automatic eligibility and a strict set of benefits. Dharma Yechuri, a private consultant who came from Blue Cross/Blue Shield in North Carolina, explains that the whole enterprise boils down to getting a segment of state government to think like “a product-centered business.”

Ian Lang, the exchange’s director for marketing and communications, puts it another way: “We’re asking people to change their buying habits. We’re asking them to buy this product.” In many ways, that’s a totally new role for government.

To help do this, Rhode Island has $60 million in federal dollars—think of it as venture capital—and less than five months to finish the job. But they still must deal with the bureaucratic processes and inflexibility built into state government, including cumbersome purchasing and contracting rules. A private website could push back its launch if things weren’t ready when they were supposed to be. The Oct. 1 opening for the exchanges, by contrast, is written into federal statute. “10-1” is the mantra throughout every meeting.

With so little time left, nerves are clearly wearing thin, though the staff tries to put on a brave face because these are people who genuinely believe in what they’re doing. Everyone looks a little frazzled as the data and evaluation team gathers on a May afternoon. No time to spare: it starts at noon sharp and the mismatched fold-up tables that serve as a conference room are littered with plastic tubs and half-eaten salads. As one person tries to remember if they actually sent someone that thing they were going to send them, others are visibly frustrated. Throughout Governing’s 36 hours at the exchange, staff members would vent a little frustration, then hastily add that the previous comment was off the record.

At one point, a data analyst pulled migraine medication out of her purse and popped a dose before handing the bottle to the colleague on her right.

“We have to self-medicate,” she said wryly. She was kidding, of course. Mostly.

That’s the tone as the clock ticks toward the first of October. But despite the general feeling that everybody’s a little on edge, they’re also consistent in their confidence that they’ll be ready. To be frank, they better be. Rhode Island is one of 17 states that volunteered to set up an exchange themselves, rather than let the federal government do it. Some are already speculating that the implementation of the ACA’s final major reforms next year, and its relative smoothness, will be a major factor in the 2014 midterm elections. The exchanges are the big, shiny new object of the group, new entities created specifically by Obamacare with which the general public will interact. It will be the first conscious contact with the law’s reforms for many people, up to 20 million nationwide and more than 850,000 Rhode Islanders.

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So the Rhode Island exchange’s staff keeps pushing onward, testing daily whether government can function like a business. Exchange Director Christine Ferguson, a former Commissioner of Public Health in Massachusetts and U.S. Senate staffer, says this is the most challenging thing she’s ever attempted after more than 30 years in government.

“What we’re doing is we’re taking something that people have to buy and we’re trying to ensure that there’s a value proposition for people who need to buy. That is far more like a private sector enterprise than a public sector enterprise,” she says. “I’ve posed this to a number of people, and none of us can come up with anything that government has ever done in any sector where that’s the case. This is different than anything that’s ever been done before.”

The cornerstone of any successful business is a good product. The exchange’s product is an experience, the relatively simple and seamless experience of shopping for and purchasing health insurance. For the customer, it’s supposed to be as easy as entering some basic information (the size of your family, your income, etc.), sifting through the available plans (helpfully labeled by colors such as gold and bronze to signify their level of coverage), and then automatically accessing tax credits to help purchase the one they want.

But for that process to be effortless for the end user, the exchange has to perform a lot of work behind the scenes. That’s where Brian Keane, a principal at Deloitte Consulting, which is building the exchange’s website, and his team take over. They have to launch a website that’s analogous to Expedia or Travelocity—though much more complicated—in the next five months. It has to synthesize information from the four insurers offering a combined 28 plans on the exchange into something that the lay person can understand. It has to send and receive information from a federal data hub that will determine whether people are eligible for help in purchasing their insurance and how much help they’re allowed to receive. Between 2,000 and 5,000 federal rules must be coded into the exchange’s software infrastructure. All of this has to be condensed into an easy web experience that won’t discourage the average Rhode Islander so much that they give up; Keane describes the actual consumer interface as the tip of the exchange’s proverbial iceberg.

Sitting in a Providence hotel room that has become his second home, Keane appears put together. His voice, with a light Irish accent softened by a quarter-century in the States, exudes confidence. He habitually knocks the wooden table to retain good luck. But he admits that an hour earlier, his team of 14 had been squeezed into this tight space, scrambling to get a demo of the website ready for a presentation with state officials later that afternoon. They’re happy with their work, though not happy enough to let Governing observe the presentation.

Deloitte is building exchanges for four other states, and that’s a good thing, Keane says. The company began its work for Rhode Island in January, which would mean they had 10 months to get the website ready for launch. “That would have been insane,” Keane says. But because they’d already done some work for other states, they had a head start here. So despite a lot of speculation in the policy world that the exchanges might not be ready on time, he pledges Rhode Island’s will be.

“We will deliver. The solution will be delivered. We’re testing for problems as we go along,” Keane says. “We won’t let the system turn on if it’s not ready, but even with all the time in the world, there’s always a couple of bugs and things to be addressed.”

But the website is just a part of the overall exchange. The state is also constructing a call center, so those who feel more comfortable buying insurance while talking to someone on the phone will have an alternative. It has to be able to handle more than 64,000 calls per month. Then, like any other good business, the exchange needs a customer service arm to handle the inevitable inquiries of confused or annoyed customers. That will include the call center and an online help section, as well as dozens of independent contractors called ‘navigators’ who will be scattered throughout the state. Lastly, and certainly not least, it requires a big marketing component to make sure those 80 percent of Rhode Islanders who don’t know about the exchange yet will be well aware of it by the time it opens. Like any fresh start-up, the staff conducts thorough market research, surveying the public on details as minute as the exchange’s tagline (“Your health. Your way.” and “We’ve got you covered.” tested well.)

Overhanging everything is the federal Center for Consumer Information and Insurance Oversight, the federal agency tasked with supervising the implementation of the exchanges. They’re the omnipresent overseer, constantly holding calls to offer support and make sure the exchange is following the rules and regulations that CCIIO crafted from the ACA’s provisions. During the data and evaluation meeting, one staff member ticks through the materials that the federal agency wants submitted in the next few days before being stopped by a colleague.

“They never told us that before!” the colleague said.

With every step, the bureaucracy of government adds an extra hurdle to the exchange’s development that some upstart Silicon Valley outfit would never encounter. Lang explains it like this: if he was working at a private company and needed to hire a marketing firm to push its product, he could probably do it within a week. Find a good partner and sign a contract. But to do the same thing for the exchange, he has to go through the state’s purchasing procedure. Put out a request for proposal and leave it open for a set period of time. Collect the offers and post them for public comment. Then clear the contract with the attorney general’s office. The whole process can take a month or more, while the Oct. 1 deadline moves steadily closer.

“Government doesn’t turn on a dime, and it shouldn’t with the public’s money. But there’s a tension there,” Lang says. “Government isn’t usually an incubator for this kind of work. You have to get people to buy into the concept. It’s a leap.”

A lot of reputations ride on the exchange staff overcoming the aggressive timetable and onerous inconveniences that come with being a business within a government construct. That starts with the governor. Chafee issued his executive order because the state legislature wouldn’t agree to a bill to create the exchange. In a sense, he took ownership of its success or failure. Lt. Gov. Elizabeth Roberts has been the chairwoman of the state’s health care reform task force, overseeing all of the ACA implementation, but particularly the exchange. She has a health care background and plans on leaving office when her term expires in 2015. She knows her eight-year tenure will largely be viewed on whether she adequately prepared the state for Obamacare.

“This is what I really have a passion for. Health care is one of those issues that can be a political winner and a political loser,” Roberts says. “We are going to work as hard as possible to leave things moving in the right direction. I want to do as much as I can while I have the chance.”

Then there’s Ferguson. If the exchange is a corporation, then she is its CEO. She plays the role well; during a board meeting, she’s the one with all the answers, the person to whom participants direct their questions. She’s been around government a long time, heading state departments in Massachusetts and Rhode Island as well as serving as a top adviser to Chafee’s father John in the U.S. Senate in the 90’s. She rattles off a list of adjectives to describe her current state of mind—“clear”, “targeted”, “nervous”, “anxious”—before adding a superlative kicker: “Negotiating with Clinton was easier than this.”

She’s been the one responsible with transplanting the commercial start-up mentality into the Rhode Island State House. She’s added a lot of corporate-minded people to do it, people like Yechuri, Keane and Lang, who left a job at his own consulting firm to head the exchange’s outreach effort. The outcome largely rests on her shoulders. Win or lose, Ferguson is the face of the enterprise. She knows it, too: “I don’t sleep a lot,” she says with a laugh.

Despite all the tangible tension, the exchange staff is uniformly expecting a win. They’ve already scored a big one in their minds: the exchange will offer full employee choice for employees of small businesses next year. That means individuals will be able to pick their own plan, rather than relying on their employer. The federal government has already said it’s postponing employee choice until 2015—they’re stuck with one plan selected by their company—so the Rhode Island staff takes great pride in having it ready for the launch. It’s a significant change from the pre-ACA norm, Ferguson says, and it’s important in getting the public to buy into the exchange.

But they’re also preemptively managing expectations. Almost everybody acknowledges that there will be problems on Oct. 1. That recognition has ascended all the way up to U.S. Health and Human Services Secretary Kathleen Sebelius and even President Obama himself. But the goal is to keep those problems to a minimum and as invisible to the public as possible.

Five months from product launch, nobody can say for sure what the exchange’s opening will be like. But its leaders are already thinking ahead. They envision the exchange as more than an insurance marketplace. They have hopes of creating a base for improving Rhode Island’s overall health. They want to allow employers to track how many days their workers miss for preventable reasons. They want to help consumers find health care providers and then rate and review them. They want somebody to be able to come onto the exchange, apply for an insurance tax credit, and find out if they’re eligible for food stamps or other social programs while they're at it. That’s the grand vision that keeps these people working hard, the motivation that has Lang still juggling his Blackberry and iPhone at his son’s swim lesson, so much so that another parent has to tell him to pay attention.

But first, they have to get to the opening date. In the exchange’s official home, on the first floor of the Rhode Island State House across the street from the dungeon, there’s a white dry-erase board hanging in the corner with “158 Days” written in blue marker. That’s the countdown to Oct. 1. When told it’s a little out of date (there are less than 140 days left), one staff member says: “Some days, we don’t change it. It’s too depressing.”

But they keep going, focused on the mission. The next day, the outdated figure is erased and replaced. “138 days” to go.

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