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Governance of the Minnesota Health Insurance Exchange

Governance: A health insurance exchange could be established as a public entity (i.e., a new state agency or as part of an existing agency), a public-private entity, or a privately-owned entity.

• Placing the exchange inside of an existing state agency such as the Department of Employee Relations (which operates the state employee insurance program as well as a small purchasing pool for public employers) might have the advantage of lower startup costs and lower ongoing operating expenses (due to lower salaries for state employees compared to the private sector). The state would also directly control the policy and operational decisions made by the exchange. However, the necessary infrastructure to establish and operate an exchange does not currently exist in state government, and so the difference in start-up costs compared to another type of governance would not necessarily be large. In addition, given the recommendation above that participation in the exchange be voluntary (i.e., insurance can be purchased outside the exchange), the concerns of small employers about government involvement could limit participation in the exchange if it is viewed to be part of state government.
• Creating a public-private entity with public oversight - such as a nonprofit with a board that includes representatives from both the public and private sectors - to establish and operate the exchange would have the advantage of public accountability and the ability to run the exchange more like a business. It would likely be viewed more favorably by potential exchange participants, and would be responsive to both public and private concerns.
• A private entity that are its potential customers; however, such an entity would not be directly accountable to policymakers. This is a particular concern in relation to the exchange's proposed responsibility to determine eligibility for subsidies, since some degree of public oversight would be necessary if the exchange is expected to fulfill public goals as well as private ones.

Of these options, creating a public-private entity to run the exchange is the best choice, because the entity would be responsive to both public and private concerns, have the ability to run like a private business, and would likely be viewed more favorably by potential customers than a public agency.

The board of the exchange should include the commissioners of Health, Commerce, and Human Services, as well as other people with knowledge and experience in areas related to health insurance.