Challenges ahead for health benefits exchange

PROVIDENCE, RI – Governor Chafee didn't have to do an intergalactic search to find the person best qualified to run the state's latest effort to extend health insurance to all citizens. For once, the person best suited for the job is a Rhode Islander, Christy Ferguson of Jamestown.

She has both the resume and the requisites. She was a top health care policy aide to the late Sen. John Chafee, the governor's father. Then she ran the Rhode Island state Human Services agency under Gov. Lincoln Almond. After that, she became Massachusetts Health Commissioner, where she helped Gov. Mitt Romney establish the nation's first state-run universal health insurance program.

The latest part of her career has been spent studying health care as a professor at Washington, D.C.'s George Washington University. What she brings to her new job is a combination of skills rare in government: She's a policy wonk who is cross-pollinated with practical experience running substantial government agencies.

Expectations are obviously high for Ferguson's new assignment. Yet, there are storm clouds on the horizon that could wash Rhode Island's universal health care attempt up on the rocks. And there isn't really much she can do about it.

First, of course, is a U.S. Supreme Court decision on the so-called individual mandate that is expected any day now. Then there are the November elections.

The individual mandate is the requirement that all citizens purchase health insurance. As Massachusetts has proven, this can be done easily. Most people get coverage from their employers. Others buy it directly from an insurer. Those who are unemployed, disabled or too poor to buy coverage receive government insurance subsidies. And the elderly have federal Medicare.

The mandate makes the health insurance market mirror mandatory auto insurance. If you want to drive, you have to have car insurance. No everyone who drives is likely to get into an accident. But almost everyone is going to need health care at some point in their lives. Who among us leaves this world alive?

The problems with the current system are many. One of the biggest is that those who have health insurance end up paying for those who don't. Let's say you don't have coverage, get seriously sick and end up in a hospital emergency room. Under federal law, the hospital has to treat you. If you can't pay, the hospital has to shift the cost of your care to others who are insured.

The individual mandate was once seen as a conservative, Republican idea that merged the virtue of individual responsibility with and end to the relentless cost-shifting that has plagued the health care system nationwide.

But with the rise of the Tea Party and Libertarian philosophy within the Republican Party, the individual mandate was cosigned to history's dustbin by the GOP. Now, Republicans don't believe the government ought to be allowed to make people buy health insurance.

The Supreme Court has heard a much-publicized lawsuit challenging the mandate and is expected to rule soon. If the mandate is tossed, it becomes much harder for government to move to universal care and control the cost of health insurance.

The other looming issue will probably be decided by the elections. Republicans, from presumptive presidential candidate Romney to aspirants for House and Senate, vow to cut the federal subsidies that are designed to allow the poor to purchase health insurance. Without those subsidies, as even Ferguson concedes, moving Rhode Island to universal care becomes virtually impossible.

The lack of a clear federal policy has pushed state governments to figure out health care on their own. Our New England neighbors are working on vastly different plans. Vermont is moving toward a single-payer system on the Canadian model. New Hampshire wants no part of the federal plan and is hoping for more competition among insurers to reduce costs. And Massachusetts is aggressively trying to control costs while keeping the individual mandate as a cornerstone of a plan that has made it the only state to reach universal coverage.

Just about 11 percent of Rhode Island adults and 6 percent of children lack health insurance. Ferguson and her team will probably figure out a way to extend coverage to all residents of the Ocean State while working to stabilize health care costs. If only the Supreme Court and the voters allow it.