"In its first year of operations, MNsure's failures outweighed its achievements," the Minnesota Office of Legislative Audit's months-long review of Minnesota's health insurance exchange concluded.
That's a verdict that MNsure's leaders disputed, but it's likely to resonate politically as lawmakers debate changes to MNsure's organization.
Many of the MNsure faults identified in Tuesday's audit had been previously reported, but the audit gathered everything in one place and added new information.
"It mostly summarizes what has been intuitively obvious to the most casual observer," Sen. Michelle Benson, R-Ham Lake, said.
Gov. Mark Dayton took a similar position, but like other Democratic-Farmer-Labor Party members emphasized how many of those issues had been fixed. The audit only covered MNsure's first year, and not the 2015 open enrollment period, which concluded on Sunday.
"It's gotten a lot better, and the report stops before those improvements can be identified," Dayton said.
MNsure's website launched in October 2013 to widely reported technological glitches, and the audit found those reports weren't blown out of proportion.
At least three-quarters of MNsure enrollees surveyed by the auditor reported encountering "significant technical problems" while signing up for their health care -- and that doesn't count people who tried to buy insurance on MNsure but gave up in frustration.
A majority of respondents said they spent at least four hours on the enrollment process. Consumers were told to switch web browsers, encountered errors or had their applications get lost or stuck in the system.
"The entire website was a disaster top to bottom," one unidentified respondent who successfully bought MNsure insurance told the auditors. "Disjointed navigation, basic website features found everywhere online were missing or broken, slow, error prone, different user experience across sections of the website--incredible that such a bad product could come from such a huge expenditure."
Phone support wasn't necessarily any better. MNsure's goal was for no more than 5 percent of support line calls to give up in frustration, but the actual level of abandoned calls reached as high as 60 percent some months.
POOR OVERSIGHT
These problems weren't accidents, the audit found.MNsure "did not adequately test the site, and it made insufficient use of state government technology experts," the audit concluded.
The law enacting MNsure separated its information technology functions from the Office of MN.IT Services, which handles IT issues for most of the rest of state government. In the months leading up to MNsure's debut, MN.IT's then-director tried to "involve her office in planning for the exchange's software components," but this was "resisted by exchange staff."
Auditor James Nobles attributed that to "a very silly, unnecessary ... turf battle," with the then-director of MNsure April Todd-Malmlov "wanting everyone else to stay out of her business."
A few weeks before the website went live, testing found it couldn't handle more than 1,000 simultaneous users -- far less than the goal of 10,000 simultaneous users. Another review found 270 unresolved defects, including 97 "major" defects with "no workarounds."
These problems were exacerbated by the federal government, which imposed an ambitious deadline and changed rules late in the game.
But top decisionmakers say MNsure staff didn't share these warnings.
BAD COMMUNICATION
Staff in Gov. Mark Dayton's office and even members of the MNsure's own board told auditors they weren't told of those warnings, such as an independent review that found most aspects of MNsure were either "marginal" or "unsatisfactory."One unidentified MNsure board member "said that staff responses to 'deep questions' posed by the board tended to be brief."
At public meetings, MNsure's then-executive director April Todd-Malmlov downplayed concerns.
"We feel that we've mitigated all of the areas that we've been tracking, and that we will be ready to go," Todd-Malmlov told the chair of the MNsure board.
Several board members told the auditor they "felt misled by MNsure staff leadership."
REFUSED TO COOPERATE
Todd-Malmlov, MNsure's first executive director, abruptly resigned at the end of 2013 while she was under fire for taking a Costa Rican vacation while the exchange was in trouble. Before her vacation, MNsure's rollout was in critical shape, with consumers unable to get answers from staff, phone lines overwhelmed with calls and a website that failed to allow sign ups.Todd-Malmlov refused, through her attorney, to talk to auditors unless they paid any attorney's fees she accrued while participating.
"I thought that would have been inappropriate," Nobles said.
Nobles sent Todd-Malmlov a subpoena compelling her to testify, which she refused through her attorney. He chose not to enforce the subpoena with a court order because Todd-Malmlov now lives outside Minnesota and he was "not interested" in a "protracted legal battle."
CALLS FOR CHANGES
Auditors said MNsure's current structure, a quasi-governmental body led by a board appointed by the governor, contributed to its problem.At the least, the audit concludes, lawmakers should make MNsure's executive director appointed by the governor, not the board.
"In addition, the Legislature should consider whether to retain the MNsure Board as a governing body or to make it purely advisory," the audit continues.
Lawmakers should also change the law to "formally create a governance structure for MNsure's enrollment system" and to subject its information technology operations to oversight from the Office of MN.IT Services.
"In our view, an agency with MNsure's impact and visibility should be directly accountable to the governor," the audit concludes.
An existing bill from DFL Sen. Tony Lourey of Kerrick would implement some of those recommendations by transforming MNsure into a standard state agency with a commissioner appointed by the governor.
Republican Rep. Matt Dean, R-Dellwood, said he likes the general thrust of the audit.
"I think it correctly points out the MNsure cannot be a fiefdom unto itself, which is unregulated and has no oversight for their budget," Dean said.
But Dean said House Republicans aren't adopting the audit's recommendations yet.
"We're going to look at all the solutions people put on the table," he said.
AGENCY DEFENDED
MNsure leaders said they appreciate the audit and don't disagree with many of its points."It was a very good audit," said MNsure CEO Scott Leitz.
But they objected to the report's conclusion about MNsure's failures.
"I do take a little issue with some of the things we've seen in the report regarding the failures as it weighs against the achievements," said Brian Beutner, chair of the MNsure board. "I would also expect, if we're going to make a value judgement about failures vs. achievements that we should document some of those achievements."
SOME SUCCESSES
Though most of the report outlined problems with MNsure, auditors did find some things it did well.Many people who bought insurance from MNsure reported frustration with the process -- but also that their insurance saved them money. Almost twice as many people said MNsure lowered their insurance costs as those who said it raised their costs.
Overall, 67 percent said they would choose the same insurance product again, though the audit notes many of them didn't have that choice because the most popular plan on the exchange, PreferredOne, opted out for this year.
Customers also said they appreciated the way MNsure let them shop and compare a wide range of plans in one place.
MNsure also likely contributed to lowering Minnesota's uninsured rate, but the audit said the precise effect is difficult to determine. Of people who bought private health insurance on MNsure, 28 percent had been previously uninsured.
PARTY LINES
Lawmakers had a chance to question the auditors and MNsure leaders Tuesday in a pair of committee hearings. By and large, results fell on party lines: Republican lawmakers, who unanimously opposed MNsure two years ago, said the shortcomings vindicated concerns they had been raising for years. DFL lawmakers argued many of MNsure's problems had been addressed and focused on its achievements."We are a little sore, yes," said Rep. Joe McDonald, R-Delano. "We don't want to say 'We told you so' and point fingers... but we'd be foolish not to say something, because we were a little upset."
Rep. Tina Liebling, DFL-Rochester, said MNsure is getting better all the time.
"Although maybe we spent more than we should have on things that didn't work, we're moving forward, we're getting experience, and things are improving," Liebling said. "It looks like, whether it's in another year or two years... Minnesota's going to have a pretty darn functional system."
REMAINING PROBLEMS
Policymakers are continuing to watch MNsure's enrollment figures, which have fallen far short of initial projections.And Nobles said the biggest remaining problem isn't the much-publicized website where consumers can find health insurance. Instead, he said it's parts of MNsure aimed at helping county and state officials sign people up for Medical Assistance and MinnesotaCare and manage their caseloads.
Those functions are largely inoperable, forcing the state to rely on decades-old legacy systems. Department of Human Services Commissioner Lucinda Jesson said she's had to call staff out of retirement when something breaks.
"Today counties can't determine how many (Medical Assistance) cases they have on their caseloads," said Joel Alter, the Office of Legislative Audit staffer who led the report. "When it comes to doing something you would think is routine, like (adding a new family member), that now takes about 60 to 90 minutes. In the old, outdated system, it took about five minutes."
Leitz told lawmakers he couldn't give a date by which those problems would be fixed. He said that's now the priority for the rest of 2015. In 2014, Leitz said, those issues were put on the back-burner to focus on the consumer side.
©2015 the Pioneer Press (St. Paul, Minn.)
