This is the fourth in a series of articles about Rhode Island's implementation of its health insurance exchange. Read the introductory post here.

Earlier this month, Christine Ferguson began overseeing the state's implementation of one of the key elements of the Affordable Care Act (ACA) as director of the Rhode Island Health Benefits Exchange. She was formally hired shortly before the Supreme Court ruled to largely uphold the health-care reform law, so it was all-systems-go when she walked into her Providence office for her first day on the job July 15.

As Governing has documented, Rhode Island has done arguably more legwork in preparing its online insurance marketplace than any other state. It was the first state last September to receive multi-year Level II funding from the White House, which is reserved for states that are farther along in developing an exchange, and sent out a request-for-proposals for the online exchange's technical infrastructure in May.

Now, Ferguson is tasked with guiding the ship home. The U.S. Department of Health and Human Services (HHS) has set a Nov. 16 deadline for states to demonstrate they'll be able to operate their own exchange. Under the ACA, the marketplaces will open for enrollment on Oct. 1, 2013, and begin selling insurance plans on Jan. 1, 2014.

Governing spoke with Ferguson about her history with health-care reform and her plans for Rhode Island over the next year and a half. Her answers have been edited and condensed for clarity.

Dylan Scott: Tell me about your history with health care and health-care reform.

Christine Ferguson: I started working in Washington, D.C., for a U.S. senator named John Chafee for 15 years. This was in the 1990’s, and I was the lead staff person for the Republican and then later bipartisan health-care reform bills. I actually wrote some of the individual mandate legislation during the first go-round. Then I was appointed to run the Department of Health and Human Services in Rhode Island from 1995 to 2001. So I have a background with Medicaid as well.

Then I was the commissioner of public health for Mitt Romney in Massachusetts. I helped with the original thinking of health-care reform bills there. Since then, I have been at George Washington University, running a couple of programs. I teach state health policy and health policy generally, and I’ve also done a lot of work related to health-care reform.

DS: What was your interest in running an exchange and the Rhode Island exchange specifically?

CF: Gov. Lincoln Chafee was very convincing about the need to move forward regardless of what happened with the federal legislation and the Supreme Court. The governor’s leadership and Lt. Gov. Elizabeth Roberts really put together a fantastic team, and their commitment was quite clear. Health Insurance Commissioner Chris Koller and Health and Human Services Secretary Steve Costantino were committed and very involved and wanted to be working collaboratively and in tandem with the exchange.

I felt that of all the places in the country that had the best chance of success -- not only enrolling those who would be newly eligible for the subsidy, but also starting to attack some of the issues around affordability as well as quality -- Rhode Island was probably the most likely to succeed at that. I felt like I could add some value to a team that was already very, very strong.

DS: As you well know, parallels are often drawn between the ACA and the Massachusetts health-care reform law. Given your involvement with the latter, what kind of lessons do you think can be drawn from Massachusetts’ experience as the rest of the country implements the federal law?

CF: It’s a wonderful full circle for me. I think that the lessons that are being learned across the country right now and also from the Massachusetts experience are that access is a critically important piece of this legislation, but affordability is also an important piece. And the exchange subsidies are absolutely essential to that. States won’t be able to do it without subsidies and the Medicaid expansion.

Read about Massachusetts' latest health-care reform.

But in addition to all of those things, we really need to be paying attention to what’s happening and what will happen to the cost of insurance with the evolution of the health-care delivery system. I think that’s what Massachusetts is struggling with now, and I think that we have an opportunity to look at how that gets built into the design and approach of where we go. But that’s a very big question, at the same time that you have the same you’re trying to design and establish an exchange that will be ready to enroll individuals and small businesses by 2014.

DS: Rhode Island has set up a layered governance structure for the exchange, with the exchange board, a set of workgroups and now you as the exchange director. Describe what your role will be in the planning and day-to-day operations of the exchange.

CF: Gov. Chafee has placed the exchange in his office. He is absolutely adamant that this entity and the work that this entity is doing is of the utmost priority to him. So, the board is an advisory role. The members of the cabinet who have a relationship with the health-care system are part of that board and meet on a regular basis around the issue that cross all of the departments.

My role is to continue to move the important issues for the governor and for the exchange in those environments forward. Rhode Island has done an excellent job of having an extensive stakeholder process, so that we can make sure we’re getting input and feedback as we move forward.

DS: What has to happen before November for Rhode Island to be able to present its exchange to HHS?

CF: There’s an extensive checklist that we need to meet. The key thing is to demonstrate that we have a technology solution and that we’ve been able to engage somebody for that. We’ve made some progress; we’ve put out a request-for-proposals for that. We have to show that we’ve made some decisions around qualified health plans, the regulatory environment and the exchange criteria and how they all interact. All of the components around the technology, especially regarding eligibility, have to be in working order.

And in Rhode Island, we have decided to go out for bid on a system that will incorporate not only the newly eligible exchange folks, but also the Medicaid program into the eligibility system and eventually other social programs. It’s a very large platform. So those are some of the key decisions.

DS: What might be some of the biggest challenges to meeting the November deadline?

CF: It’s a huge list. We’ve got to get a lot of agreements. The approach that the state has taken has been to be very inclusive and also to use this opportunity to really think through some very significant technology issues as well as policy issues. That makes the list a very big one. I think that’s one of the concerns that many have.

I think that anybody that’s ever brought up a large, new information system or eligibility system or any kind of data system understands the sheer magnitude and challenges of those things, particularly in an environment where we don’t have federal guidance on everything. I think that the technology is the biggest challenge here, as it will be everywhere in the country. There will be a lot of eyes on the folks who are trying to provide those technologies, as well as the states.

DS: Lastly, before the Supreme Court ruled on the ACA at the end of June, Lt. Gov. Roberts told me that Rhode Island would push forward with an exchange regardless of the decision. But after the Court upheld the law, she did express some relief that they wouldn’t be doing it alone. How does the finality from the Supreme Court influence or otherwise affect Rhode Island’s exchange planning and establishment?

CF: I was kind of relieved. It means that efforts to move full-speed ahead are even easier. Having said that, there’s always going to be a little bit of anxiety around whether there’s a possibility that people would consider repealing aspects from a legislative perspective or possibly reducing or eliminating the subsidies. So I think everybody’s watching that debate closely.

But I think that for us, the Supreme Court decision was a huge relief and a little bit of vindication that it was okay to move forward. Being out in front, having invested on the governor’s part so much energy and time to get this right, I think that was a tremendous vindication and return-on-investment that they made because we will be one of the first -- if not the first -- to really have a fully functioning exchange.