There may be no bigger health wonk in Rhode Island politics than Lt. Gov. Elizabeth Roberts. Now in her second term, the Democrat was tasked by Governor Chafee shortly after he took office with overseeing the state implementation of the federal health care law, and she’s moved quickly to do so.

After this morning’s U.S. Supreme Court ruling upholding the health law, I sat down with the lieutenant governor in her State House office to discuss what comes next. The transcript has been lightly edited for length and clarity.

This decision just says, OK, Rhode Island, keep doing what you’re doing with implementing the health care law, right?

It says keep doing what we’re doing and with a sense of confidence that the federal government is going to be our partner in this going forward. We also have a lot of regional conversations going on, and there’ll be more consistency from state to state – we now know that as a country we are moving forward with this law. That will change a lot of the politics, and also a lot of the practical work that we’re doing.

Take me through – at 30,000 feet – the big benchmarks and milestones ahead in implementing the law for Rhode Island.

First I want to say, the [new health insurance] exchange is part of the health reform effort – it’s not the whole health reform effort. We’re focusing on the exchange right now because that will be the door that small business walks through, that businesses walk through that are looking for insurance, but also people who might have employer-based insurance and want to look at and understand their insurance better – they can use it as a resource.

We’re required by Oct. 1, 2013, to start enrolling people through the exchange. That’s 15 months from now when we need to have that working. And by Jan. 1, 2014, we need to be full speed ahead. So that is a lot of work inside government and because we have moved forward with creating an integrated system rather than a separate health insurance component, we really want to move our government interface forward and make it much more seamless, much more responsive, a lot more like you would expect from the private sector – not a typical government program. We’re creating a unified portal.

I’ve heard people call it an Amazon.com of health insurance. Is that the idea?

But it’s not just health insurance.

Oh – so we’re talking way beyond the Affordable Care Act?

We’re blending resources together. A lot of it’s going to be focused on health insurance, but it’s also – if you are a lower-income Rhode Islander who’s subsidy-eligible, you might also have a childcare subsidy you’re eligible for; if you’re an older or younger Rhode Islander, you might also be eligible for food stamps. An Amazon is probably a good analogy if you think about the fact that some people may think it’s just about books, but really, you can find everything on Amazon. We’re trying to create something similar.

So theoretically I’d go to log in and say, I’m Ted Nesi, here’s my date of birth, here’s my income, what am I eligible for?

Exactly right. And they may say to you, you know what, the only thing you’re eligible for here is subsidized health insurance, and here’s your pathway into that. Or they’ll also ask how many children do you have, things like that. We’re trying to make it the kind of program you would expect when you go on the Internet looking for information and resources. It’s a unified system, and we’re blending together resources that the Affordable Care Act gives to help us build the exchange – [the federal government] is paying for 100% of that exchange – but also on our public support side – our RIte Care, Medicaid, food stamps – we receive 90% from the federal government. We’re really going to take that whole system and improve it significantly.

Who’s actually going to build that Amazon-type website for Rhode Island? A contractor?

Absolutely. Right now, as you and I are talking, we have the [request for proposals] out on the street – in fact, I think the bids might just have come in. There will be a formal review and I think the goal is by the end of the summer that contract will be in place.

Last I looked we were first in total dollars sent to a state for Affordable Care Act implementation. Is that still the case?

We’re probably not still total dollars, since we’re a small state with a small insurance market. We were – and we will never lose our place as – the first state in the country that was ready to apply to the federal government for the implementation dollars. I think three other states have followed us. We’ve received just under $65 million – that’s just for the technology construction, building the exchange. We aren’t counting about $8.5 million that has come into the state for seniors for prescription drug costs; we’re not counting the 7,000 to 8,000 young people who are [still] on their parents’ coverage; and we’re not counting – because we don’t have a way to count it, since it’s through the IRS – what small businesses have received in tax credits already, because even before the exchange there’s an eligibility for tax credits if you’re providing health insurance to your employees as a small business.

When you were first lieutenant governor, before I was a reporter here, you proposed sweeping health reform legislation. Would that have looked like Massachusetts? How would that have worked? Does this look like it?

A lot of it was modeled on Massachusetts, as is our federal law which has just been upheld today. We broke it into multiple parts, and some parts of it passed.

One of the things – and you talked about having a wonky conversation! – one of the things that has now been put in place with the law passed as part of that package three years ago is a claims database, an all-payer claims database, that will take all of the health care that’s paid for in our state. We’ll take everybody’s name off it, but it will help us understand how we’re spending our health care dollars and what’s the most cost-effective approach. Because without that kind of data, we can’t improve our system and make health care more affordable. There are 10 states in the country that have it, and it’s going to be a very important tool as we work to improve our system. That will start sometime in the next several months; right now we’re working with how we’re going to make it work and make absolutely sure we’re protecting confidentiality of all that information.

You’ve been in government for a long time and you’ve been working in the weeds on health policy. You know what the honest conversations are behind closed doors. How confident are you this law is a structure for changing our health system that really will get us where you think we need to be in 10 years?

I think that’s up to us, to be honest. You can meet the letter of the law and not deal with issues of affordability and quality. To me, that would be a failure. We need to focus on affordability and quality. Those are hard. Those are longer-term. Building the exchange is a clearly defined project, and we’ll know when we switch it on whether it’s working -

And it gets all the attention.

And it gets all the attention. But really, what we need to look at is how do we have high-quality hospitals that are meeting the needs of their community, where our health insurers are actually providing payment for the kinds of care that we need that improve health in our community? Those are the really important issues that in 10 years I hope we’ll be able to say, we have an amazing system of primary care in our system which has improved health care for all and improved patient quality of care and satisfaction with care. We’re going to have support for that through the Affordable Care Act, but that’s our challenge, to meet some of these goals.

You mentioned in the press conference Governor Chafee’s strong support for implementing the law is key for why Rhode Island is moving quickly on this. He basically put you in charge of it. How important is the governor’s role?

I think it’s one reason we are where we are today. The last governor – this was not an issue he was interested in pursuing, and we did what we could before Governor Chafee came into office. But the fact that he didn’t hesitate, the fact that he said, “Look, you’ve got something moving – let me help you move it even more,” and made a commitment inside his administration, because so much of this is about creating new financial relationships among government programs as well as connecting our government programs and our commercial insurance providers. His leadership, public leadership, both within government and outside government, is absolutely vital for us moving forward.

How big a role does the General Assembly play going forward in implementing the law? We know the exchange bill died because of the abortion provision.

The legislature has some very important roles. Clearly, they fund Medicaid – they’re funding the exchange through appropriations; it’s federal dollars, but they supported that in appropriating that in the state budget. When we make some decisions about what health insurance should look like in Rhode Island, a great deal of that is up to [Health Insurance] Commissioner Koller, but a lot of our health insurance regulation is in law, and that’s a very important role for the Assembly. I think you’re going to see some of those issues before the Assembly next year.

I can see why conservatives do say, maybe part of the problem is how many benefits we have on health insurance in Rhode Island – maybe we should go in the opposite direction and strip down our health mandates. Why, apart from being a Democrat, have you wound up thinking we do need this technocratic approach that involves a lot of government?

That is a legislative decision, about what the mandates look like. Those are in law, through the legislature. I think initially you’re going to see what’s available in the exchange reflective of our current health insurance market. I am a big supporter of innovation. In Massachusetts, they actually put a benefit plan in place that doesn’t conform with its traditional mandates that is more affordable for young adults. I am a believer in looking at more innovative approaches, looking at insurance benefit designs that might be different than our traditional benefit designs.

So I think we will – and we should – have an important discussion about mandates and I am not somebody who has said that we absolutely have to have every plan incorporate every mandate. But that is a legislative role. We, through the exchange, do not have the authority – nor should we – to make that decision. That’s a legislative decision.

But if a lawmaker came to you and asked for your counsel, would you suggest to them as someone who knows the issue well, they should err on the side of more mandates? Should they be looking at keeping it simple?

I’m somebody who thinks we need to start looking at innovation, which may mean that not every health insurance policy has to cover all of the exact same things. You need to be careful that you don’t segment the market and – to get really wonky – have people choose products that disproportionately impact the risk and change the cost structure. But I think we need to start looking at benefit designs that cover different things for different ages, as they’ve done for Massachusetts already, and I would be supportive of that conversation. I’m not somebody who thinks that all of our benefit mandates, and some of them have been in place for a long time, are necessarily vital to good health insurance for Rhode Islanders. But once again, that’s a legislative conversation we need to have because those are in law, and I think we will have that conversation going forward.

I’m not somebody who thinks that the way to have affordable health insurance is to remove all mandates, though. Really what we need to think about is, how do we pay for the care that we need in the right place at the right time, and not create a system that is driven by high revenue but is driven by good outcomes? And that, I think, will help us deal with costs in the long term much more effectively than changing our mandate structure.

Last question. Health care seems like a really tough policy to deal with. It’s massively complicated, it’s easy to demagogue. What lesson have you taken from more than a decade of work on this issue?

It’s really complicated, but I think the encouraging thing in Rhode Island is this is an area where we’ve maintained our focus, we’ve had a real commitment and we’ve made real progress. The economy has made it tough – when the economy drops, because we have employer-based coverage, we’ve had a decline in health insurance coverage. But we’ve really made progress, and I think we will continue to do so.

There is an incredible balancing act. It’s one of the biggest parts of our economy, providing health care – but it’s also one of the biggest cost-drivers for businesses in our state. So we’re always having to balance. We have a number of new leaders in our health care environment who are thinking differently about how to pay for and deliver care, which is exciting.

What’s exciting to me, as this new law gets validated, is we have a landscape that’s more clear and we’ve got a lot of new leadership in this state – including the governor – with a real commitment to moving us forward. So it’s an exciting time and I think we’re ready for it. •

(photo: lieutenant governor’s office, via Flickr)