From health care transparency to a public option, lawmakers largely drilled into non-pandemic health care issues in 2021 session

When lawmakers kicked off their 120-day legislative session in February, the state was still recovering from a brutal winter surge of COVID-19, which saw a thousand new cases of the virus reported across the state each day.

Lawmakers early in the session came forward with some modest proposals to address the pandemic — including a bill to give workers paid time off to get vaccinated — but it was unclear at that point what COVID-19’s trajectory in the Silver State would be. With an influx of federal financial support boosting the state’s pandemic response, it wasn’t always easy to tell where lawmakers could be of most help. With sessions slated for only 120 days every other year, it also wasn’t clear they could craft policy responsive enough to the ever-changing needs created by the pandemic.

Instead, lawmakers generally focused on a host of other important, but perhaps less high-profile, health care proposals, from legislation to support the provision of telehealth services in the state, which became all the more popular during the pandemic, to a bill that would provide for Medicaid coverage of community health workers. They also honed in on data transparency, hearing bills that would make changes to the state’s drug pricing transparency program and establish an all-payer claims database in an effort to better understand the health care landscape in the state.

Lawmakers also took up a last-minute bill to establish a state-managed public health insurance option in Nevada, the second-ever to be approved in the nation. Despite reservations from Republican lawmakers — and even from some Democrats — the Legislature introduced and approved the bill in just a little more than a month with some strong-arming by Senate Majority Leader Nicole Cannizzaro (D-Las Vegas), who spearheaded the legislation. 

Behind the scenes, there were frustrations, though, among health care lobbyists. Industry lobbyists, for instance, were caught off guard that Cannizzaro hadn’t involved them in the process of developing the public option bill and dropped the proposal on them in the final weeks of the session.

“I can tell you that when there are very challenging things that occur within health care, when you lock us all in a room, we tend to find solutions,” Tom Clark, lobbyist for the Nevada Association of Health Plans, said during the bill’s first hearing.

Bobbette Bond, policy director for the Culinary Health Fund, also said it was difficult to craft good policy in a legislative environment so heavily shaped by the pandemic. For much of the session, the legislative building was closed to the public and committee meetings were only able to be attended virtually.

“It was hard to get revisions made. It was hard to have good conversations about what could be done. It was hard to build stakeholders,” Bond said. “It was hard to communicate, and I think the policy suffered for that.”

Bond also expressed dismay in the two-thirds requirement for passing tax increases, on the grounds that it has prevented lawmakers from tackling more ambitious health care legislation. Because there isn’t more funding to go around, including to support health care, she said lawmakers have turned to putting mandates on industry.

“The mandates … end up substituting for actual public health policy,” Bond said.

The Culinary Health Fund, which is the health insurance arm of the politically powerful and Democratic-aligned Culinary Union, did, however, continue to play a significant role in shaping health care policy this session with Democrats remaining in control of both chambers of the Legislature. Other industry representatives, who often work collaboratively with Democratic lawmakers but more often align with Republicans on business priorities, had less of an upper hand.

Mike Hillerby, a longtime lobbyist on health care issues in the state, said Nevada loses “a lot of subtlety in the public policy debate” when the discussion is “driven by the relationship between a couple of unions and a couple of hospital chains.”

“That drives so much of what we do, and it's so contentious. Look at balance billing from 2019. Look at some of the stuff this time, and everything's driven by that. That's not indicative of the market and the rest of Nevada. That's not indicative of what's happening with providers and patients and payers in rural Nevada, in the Reno area, and yet so much of it is driven by that and that financial reality, that bargaining relationship, those contractual relationships,” Hillerby said. “We just lose a lot of the subtlety and the ability to make better decisions.”

Here’s a look at some of the health policies that passed this session and others that didn’t.

Gov. Steve Sisolak signed several pieces of public health-related legislation into law in Las Vegas on Wednesday, June 9, 2021. (Jeff Scheid/The Nevada Independent)

Public option

The highest-profile piece of health care legislation to pass this year, SB420 — Nevada’s public option bill — was introduced with just a little more than a month left in the legislative session by Cannizzaro, the Senate majority leader. Proponents were quiet about the legislation for the first couple of months of the session until Cannizzaro was asked by a reporter in mid-April about the proposal and health care lobbyists started receiving briefings from consultants on the concept.

The bill, which builds upon previous public option proposals introduced in Nevada in 2017 and 2019, aims to leverage the state’s purchasing power with Medicaid managed care organizations — private insurance companies that contract with the state to provide coverage to the state’s low-income population — to get insurers to also offer public option plans. The plans will resemble existing qualified health plans on the state’s health insurance exchange, though they will be required to be offered at a 5 percent markdown with the goal of reducing the plans’ premium costs by 15 percent over four years. The plans won’t be offered for sale on the exchange until 2026.

The proposal cleared both the Senate and Assembly on party line votes and was signed into law in early June by Gov. Steve Sisolak, making Nevada the second state in the nation after Washington to enact a state-based public health insurance option into law. Colorado became the third state to establish such a policy in mid-June.

Though the legislation was heavily opposed by the health insurance industry — with some groups running ads and sending mailers opposing the proposal — Cannizzaro muscled the bill through the Legislature as the clock counted down to the end of the 120-day session. The bill easily cleared the Senate — where Cannizzaro, as majority leader, controls which bills come to the floor — and Democratic leaders in the Assembly threw their support behind the bill shortly thereafter, setting aside concerns about whether the bill can accomplish its goals of improving health care access and affordability.

“It's not a secret I have been skeptical of this bill from the very beginning, but I've seen the amendments, and I have talked to a number of the different proponents of the bill and opponents of the bill on it,” Assembly Ways and Means Chair Maggie Carlton (D-Las Vegas) said in late May, shortly before allowing the bill to be voted out of her committee. “I feel much more comfortable knowing that, in the future, the people that are in this building now that do come back are well aware of what's going on, and I trust them to make the best decisions they can to protect the constituents of this state.”

In her remarks, Carlton was referring to the long runway the bill establishes before the public option actually goes into effect, leaving time for the state to conduct an actuarial study to figure out whether the bill actually accomplishes the goals it sets out to and two legislative session in 2023 and 2025 for lawmakers to make any tweaks to the policy as necessary.

Heather Korbulic, who as head of the state’s health insurance exchange will have a key role in shaping the policy’s implementation, has said she plans to bring stakeholders together to “outline the actuarial study and conduct a meaningful analysis of the public option as it relates to every aspect of health care throughout the state.” 

Richard Whitley, director of the Department of Health and Human Services, said in an interview earlier this month that the public option isn’t “a single solution” but “does definitely enhance the opportunity for individuals to gain access to health care.”

“I think of this as an option for coverage,” Whitley said. “It definitely enhances that overall framework of health care coverage.”

Nuclear medicine technologist Vanessa Martinez, views scans at Lou Ruvo Center of Brain Health, on Tuesday, June 11, 2019. (Jeff Scheid/The Nevada Independent)

Transparency and data efforts

For the last two legislative sessions, lawmakers have focused on prescription drug cost transparency, passing a first-in-the-nation diabetes drug transparency law in 2017 and expanding that law to include asthma drugs in 2019. This year, lawmakers built upon those transparency efforts by passing legislation requiring transparency from more portions of the health care industry.

This year, lawmakers approved a bill, SB40, to establish what’s known as an all-payer claims database — a state database of claims of medical, dental and pharmacy services provided in the state. The law requires all public and private insurers regulated under state law to submit their claims to the database and authorizes insurers governed by federal law — such as the Culinary Health Fund — to submit their claims to the database. A similar bill proposed during the 2019 legislative session failed to move forward in the final minutes of that session, though the concept was revived by the Patient Protection Commission, which brought SB40 forward this session.

The bill, however, required extensive work when it got to the Legislature, with state Sen. Julia Ratti (D-Sparks) taking the bill under her wing as chair of the Senate Health and Human Services Committee and working with industry advocates — including the Nevada Association of Health Plans, the Nevada State Medical Association and the Nevada Hospital Association — to finalize the legislation.

“We knew the bill was going to pass, at some level ... so we wanted to make sure that the information that was going to be collected was accurate, was consistent with what was required in other states that had all-payer claims databases and also to learn from what those other states had done so we wouldn’t make the same mistakes,” Clark, the Nevada Association of Health Plans lobbyist, said. “Fortunately, Senator Ratti and others were good to work with and we’re comfortable with the way the bill passed.”

The legislation additionally makes data contained in the all-payer claims database confidential, meaning that it is not a public record or subject to subpoena, and specifies how the information contained in it can be disclosed. It can be shared in de-aggregated form to state or federal government entities, including the Nevada System of Higher Education, and any entity that submits data to the database. Anyone else looking to obtain the data can only receive it in aggregated form by submitting a request to the Department of Health and Human Services.

Lawmakers also built upon the diabetes and asthma drug transparency bills passed in 2017 and 2019, respectively, by expanding the universe of drugs the state imposes transparency requirements on. SB380, which was proposed by an interim committee created during the 2019 session to study prescription drug costs, requires the state to compile a list of prescription drugs with a list price that is more than $40 for a course of therapy that has undergone a 10 percent price increase in the preceding year or a 20 percent increase in the two prior years.

The legislation requires drug manufacturers to submit a report to the state explaining the reason for the price increase and explaining the factors that contributed to the price increase. Meanwhile, pharmacy benefit managers, or PBMs, the middlemen in the drug pricing process, are required to submit their own reports with certain data about the drugs, including rebates negotiated with manufacturers and the amount of the rebates retained by the PBM.

The state’s drug transparency program will also, for the first time, have funding behind it, utilizing dollars that have been collected in the form of fines paid by companies for not complying with the state’s drug transparency law. The Department of Health and Human Services put a $780,000 fiscal note on the bill to allow state health officials to transfer the existing drug transparency database to the state’s Enterprise Information Technology Services Division and hire a pharmacist and management analyst to manage the drug transparency program.

SB380 was, however, only one of two bills put forward by the interim prescription drug committee to pass this session. The other was SB396, which allows the state to establish intra- and interstate drug purchasing coalitions with private entities. 

The three bills that did not pass were:

  • SB201, which would have licensed pharmaceutical sales representatives
  • SB378, which would have required at least half of the health plans offered in the state by private insurers to provide prescription drug coverage with no deductible and a fixed copayment and limit the total amount of copayments insured individuals are required to pay in a year 
  • SB392, which would have licensed PBMs and created additional rules for how PBMs can operate.

Nick McGee, senior director of public affairs for PhRMA, the drug industry advocacy organization, in an email expressed disappointment that lawmakers pursued SB380 this session while not advancing the other proposals out of the interim committee. PhRMA did, however, in the end testify in neutral on SB380.

“We are disappointed that the legislature overlooked this opportunity to address patients’ concerns related to their ability to afford and access the medicines they need,” McGee said. “Instead, lawmakers pursued onerous reporting and unnecessary registration requirements that won’t do anything to help patients afford their medicines and fail to provide transparency into why insurers are shifting more and more costs on to patients.”

Bond, the policy director for the Culinary Health Fund, which played a key role in bringing the 2017 bill to fruition, described SB380 as a “step forward,” though she said the bill didn’t end up “as strong as we would have liked.”

“It’s incremental, and it’s progress,” she said.

Lawmakers did not advance SB171, sponsored by state Sen. Joe Hardy (R-Boulder City), which would have barred most insurance companies from implementing copayment accumulator programs for any drug for which there is not a less expensive alternative or generic drug. Such programs prevent drug manufacturer coupons from applying toward patients’ deductibles and maximum out-of-pocket costs.

The Legislature additionally made a budgetary change to boost transparency, approving a request from the Department of Health and Human Services to centralize its data analysis efforts within the office of Data Analytics within the Director’s Office, while the Patient Protection Commission, which is focusing on health care spending and costs, was transferred from the governor’s office to Director’s Office as well.

Whitley, the department’s director, framed the reshuffling as an effort to bring together disparate health data collection and analysis efforts, adding that the pandemic showed the kind of real-time data the department could provide, as in the case of its COVID-19 dashboard, among other dashboards it now maintains.

“Usually people go, ‘We need more money.” Well, in government sometimes what you need is organizational structure,” Whitley said. “Putting data analytics all in one unit in my office … was really because of seeing all of the benefits that were coming out of monitoring the pandemic. That really served to inform what we could be doing.”

The Legislature also made a significant change to the Patient Protection Commission this session, transforming it from a largely industry-focused body to one instead made up largely of non-profit health industry representatives and patient advocates. AB348, sponsored by Carlton, requires the commission be made up of:

  • two patient advocates
  • one for-profit health care provider
  • one registered nurse who practices as a nonprofit hospital
  • one physician or registered nurse who practices at a federally qualified health center 
  • one pharmacist not affiliated with any retail chain pharmacy, or a patient advocate
  • one public nonprofit hospital representative
  • one private nonprofit health insurer representative
  • one member with expertise advocating for the uninsured
  • one member with expertise advocating for people with special health care needs
  • one member who has expertise in health information technology and works with the Department of Health and Human Services
  • one representative of the general public.

The bill also makes the Patient Protection Commission the sole state agency responsible for administering and coordinating the state’s involvement in the Peterson-Milbank Program for Sustainable Health Care Costs, a program that provides technical assistance to states developing targets for statewide health care spending trends. 

Health care industry representatives have, however, chafed at the reduction — or in the case of the drug industry, removal — of their representation on the commission. McGee, from PhRMA, said the change “[undermines] the ability of the commission to provide a comprehensive perspective.”

But Bond, a commission member whose ability to serve will be unaffected by the policy shift, said the change would give patients and consumers more of a voice.

“I understand the concerns about losing representation from the industry, but I also believe that industry has other places where they get represented,” Bond said. “They have the Nevada Hospital Association, the pharmaceutical industry has PhRMA. They get well represented in their core arena. Patients really don't have a core arena they can go to.”

The Patient Protection Commission’s other bill this session, SB5, also was approved by lawmakers, making a number of changes to telehealth in the state. That bill also contains a data transparency component, requiring the Department of Health and Human Services, to the extent money is available, to establish a data dashboard allowing for the analysis of data relating to telehealth access.

Another big bill that tried to tackle health care costs this session, AB347, sponsored by Assemblyman David Orentlicher (D-Las Vegas), died without receiving a vote. The ambitious bill, among other provisions, proposed establishing a rate-setting commission “to cover reasonable costs of providing health care services” while ensuring providers “earn a fair and reasonable profit.” The bill also would have raised Medicaid payments to Medicare levels via a provider tax.

Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko
Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko on Tuesday, April 3, 2018. (Jeff Scheid/The Nevada Independent)

Antitrust in health care

Lawmakers approved two antitrust in health care bills this session. The first one, AB47, requires parties to certain reportable health care or health carrier transactions to submit a notification to the attorney general with information about the transaction at least 30 days before it is finalized. Reportable transactions include material changes to the business or corporate structure of a group practice or health carrier that results in a group practice or health carrier providing 50 percent or more of services within a geographic market.

The bill, which was presented by the attorney general’s office, also prohibits employers from bringing court actions to restrict former employees from providing services to former customers or clients under certain circumstances and bars noncompete agreements from applying to employees that are paid on an hourly wage basis.

The bill attracted opposition from the Nevada Hospital Association and the Nevada State Medical Association. During a May hearing on the bill, Jesse Wadhams, a hospital association lobbyist, thanked the attorney general’s office for working with them on the bill but said the association still could not support the legislation.

“We believe the policy itself comes from a faulty premise,” Wadhams said. “We believe policies should promote more physicians, more access to care and more investment in the health care community.”

Another bill, SB329, requires hospitals to notify the Department of Health and Human Services of any merger, acquisition or similar transaction. It also requires physician group practices to report similar transactions if the practice represents at least 20 percent of the physicians in that specialty in a service area and if the practice represents the largest number of physicians of any practice in the transaction. The legislation, sponsored by state Sen. Roberta Lange (D-Las Vegas) and pushed for by the Culinary Health Fund, requires the department to publish that information online and write an annual report on that information.

Another section of the bill allows the attorney general or other individuals to bring a civil action against a health care provider that “willfully” enters into or solicits a contract that bars insurance companies from steering insured individuals to certain health care providers, putting health care providers in tiers or otherwise restricting insurers. It also makes such an action, known as “anti-tiering” or “anti-steering,” a misdemeanor. (A final amendment to the bill reduced the penalty from a felony to a misdemeanor.)

“I think this is one of the early steps in what will probably be a national trend,” Bond, of the Culinary Health Fund, said in an interview. “I think contract provisions are going to become more and more antitrust looking.”

The bill was opposed by the Nevada Hospital Association and individual Nevada hospital systems and hospitals.

“The technical elements of this and eliminating antitrust provisions by themselves are not the problem we have with this bill — it is making sure that it doesn’t impede the open contracting that occurs otherwise in this highly competitive environment,” Jim Wadhams, a lobbyist for the hospital association, said during a May hearing on the bill.

Tristian McArthur cares for an infant inside the Neonatal Intensive Care Unit at Sunrise Hospital on Tuesday, Dec. 4, 2018. (Daniel Clark/The Nevada Independent)

Medicaid

In perhaps the most substantial victory for health care providers this session, lawmakers rolled back a 6 percent Medicaid rate decrease approved by the Legislature during a budget-slashing special session last summer.

Legislative fiscal analysts projected the move would restore about $300 million in Medicaid funding both in the current fiscal year and in the upcoming biennium, including about $110 million in general fund spending.

“Nevada faced an unprecedented state budget crisis,” Bill Welch, CEO of the Nevada Hospital Association, and Jaron Hildebrand, executive director of the Nevada State Medical Association, wrote in a letter to the governor in May. “The work you did alongside the Nevada Legislature to restore funding to hospitals and providers will be instrumental in safeguarding the health care available to many Nevadans.”

Lawmakers made a number of other changes to Medicaid services as well, providing for coverage of doula services in AB256 and community health workers in AB191. The public option bill, SB420, also contained several Medicaid provisions, including one section providing that pregnant women are considered presumptively eligible for Medicaid without submitting an application for enrollment and another prohibiting pregnant women who are otherwise eligible for Medicaid to be barred from coverage for not having resided in the United States long enough to qualify.

On the mental health front, SB154 requires the state to apply for a waiver to receive federal funding to cover substance use disorder and mental health treatment inside what are known as institutions of mental disease — or psychiatric hospitals or residential treatment facilities with more than 16 beds. Medicaid has long been barred from paying for care in such facilities, but states were recently given the ability to apply to the federal government to cover these services through Medicaid via a federal waiver.

Lawmakers also approved AB358, sponsored by Assembly Speaker Jason Frierson (D-Las Vegas), which will allow for a more seamless transition of incarcerated people to Medicaid upon release from prison. The bill requires a person’s Medicaid eligibility to only be suspended, rather than terminated, when they are incarcerated and specifies that individuals who were not previously on Medicaid should be allowed to apply for enrollment in the program up to six months before their scheduled release date. The bill also requires eligibility for and coverage under Medicaid to be reinstated as soon as possible upon an individual’s release.

In a major victory for families of children with autism, lawmakers passed SB96, which boosts reimbursement rates for autism services.

A member of the Nevada National Guard places a swab in a container after performing a COVID-19 test at the Orleans on Wednesday, May 13, 2020. (Jeff Scheid/The Nevada Independent)

Public health

Lawmakers, by and large, did not spend much time tackling the COVID-19 pandemic head on during their legislative session, likely a byproduct of how rapidly the situation has evolved over the last six months.

Legislators did, however, approve SB209, sponsored by state Sen. Fabian Doñate (D-Las Vegas), which requires employers to provide paid leave to employees to receive the COVID-19 vaccine and requires the Legislative Committee on Health Care to conduct a study during the 2021-2022 interim about the state’s response to the COVID-19 pandemic and make recommendations to the governor and lawmakers for the next legislative session in 2023.

They also passed SB318, also sponsored by Doñate, requiring public health information provided by the state and local health districts to “take reasonable measures” to ensure that people with limited English proficiency have “meaningful and timely access to services to restrain the spread of COVID-19.” 

Beyond COVID, the Legislature passed a number of other public-health related measures this session, including, notably, establishing a public health resource office within the governor’s office through SB424, with the goal of taking a holistic, multidisciplinary approach to public health in the state. 

Lawmakers also approved SB461, which requires the state to disburse $20.9 million of American Rescue Plan dollars to specifically to address needs spotlighted by the public health emergency including “mental health treatment, substance use disorder treatment and other  behavioral health services, construction costs and other capital improvements in public facilities to meet COVID-19-related operational needs and expenses relating to establishing and enhancing public health data systems.”

The Legislature additionally passed a few tobacco-related pieces of legislation including AB59, sponsored by the attorney general’s office, officially raising the tobacco purchase age in the state to 21 — the federal Tobacco 21 law went into effect in December 2019 — and AB360, sponsored by Assemblyman Greg Hafen (R-Pahrump), which prohibits people from selling, distributing or offering to sell cigarettes or other tobacco products to a person under 40 without first conducting age verification. Additionally, SB460, the budget appropriations bill, allocates $5 million for vaping prevention activities.

Lawmakers also approved SB233, sponsored by state Sen. Joe Hardy (R-Boulder City), which appropriates $500,000 to the Nevada Health Services Corps, a state loan repayment program for physicians and other health practitioners aimed at encouraging providers to practice in underserved areas of the state. The Legislature also approved SB379, a health workforce data collection bill that proponents say is critical for the state’s health professional shortage area designation. 

“It’s kind of nerdy, wonky data stuff, but those designations are really critical for Nevada, for loan repayment, for health service corps, for [federally qualified health center] and community health center designation and reimbursement and all sorts of stuff,” said John Packham, co-director of the Nevada Health Workforce Research Center at the University of Nevada, Reno. “We just need better data, period, on the workforce.”

Vitality Unlimited provides substance abuse treatment in Elko
Vitality Unlimited provides substance abuse treatment in Elko. (Jeff Scheid/The Nevada Independent)

Mental health

While mental health advocates have become accustomed to making slim gains each legislative session, Robin Reedy, executive director of NAMI Nevada, believes 2021 was a good session for mental health.

“For once, it’s a long list. It’s just so amazing,” Reedy said of the mental health bills that passed this session. “Everything has just been an uphill climb constantly … but this year, oh my God.”

In addition to SB154, mentioned above, key mental health bills passed this session hone in on mental health parity (AB181), implement the 9-8-8 National Suicide Prevention Hotline (SB390), bolster crisis stabilization services in the state (SB156) and remove stigmatizing language from state law referring to people with mental illness (AB421).

Lawmakers also approved bills put forward by the regional behavioral health policy boards established during the 2017 legislative session, including SB44, which aims to smooth the licensure process to boost the number of behavioral health providers in the state, and SB70, which makes changes to the state’s mental health crisis hold procedures.

Reedy attributed the increased focus on mental health this session to a “perfect storm of things coming together.”

“I think it's incredibly sad that it took a pandemic for people to actually look more at mental health — when everyone was going through some form of anxiety or depression from being isolated, from not knowing what the future held, from it being just really untenable, and everyone has different levels of acceptance of those things, and living through those things, different levels of resilience,” Reedy said. “Suddenly it's like, ‘Mental health.’ We've been working on this forever. Finally.”

But Reedy said there’s still a long way to go. For instance, she wishes that SB390, which authorizes the state to impose a surcharge on certain mobile communication services, IP-enabled voice services and landline telephone services to fund the 9-8-8 line, would have capped that charge at 50 cents instead of 35 cents. She believes had the session been a regular session and had mental health advocates been able to pack the committee room with patients, they would have been able to get that fee cap increased.

“I just don't think 35 cents is going to be enough … We’re 51st in the nation [for mental health],” Reedy said. “I know telecommunications does not want to pay to fill the hole, but that means crisis lines are going to be busy.”

A medical staff member prepares a COVID -19 vaccine during the Amazon employees Covid-19 vaccination event at the Amazon Fulfillment Center in North Las Vegas on Wednesday, March 31, 2021. (Jeff Scheid/The Nevada Independent)

Other health care bills

In addition to reigning in drug pricing costs, lawmakers passed several bills making changes to how Nevadans can access certain kinds of prescription drugs. SB190, sponsored by Cannizzaro, will allow pharmacists to dispense certain kinds of hormonal birth control directly to patients. SB325, sponsored by Senate Minority Leader James Settelmeyer (R-Minden), similarly allowed pharmacists to dispense preventative HIV medication, including PrEP.

Other prescription-drug focused bills passed this session include AB178, a bill sponsored by Assemblywoman Melissa Hardy (R-Henderson) requiring insurers to waive restrictions on the time period in which a prescription can be refilled during a state of emergency or disaster declaration, and AB177, a bill from Assemblywoman Teresa Benitez-Thompson (D-Reno) aiming to expand access to prescription drugs in people’s preferred language.

Lawmakers also passed a number of other health care related bills including:

  • SB275, sponsored by state Sen. Dallas Harris (D-Las Vegas), modernizes state laws on HIV by treating the virus the same way as other communicable diseases
  • SB342, sponsored by the Senate Education Committee, puts the legislative stamp of approval on a major partnership between the UNR School of Medicine and Renown Health
  • SB290, sponsored by state Sen. Roberta Lange (D-Las Vegas), makes it easier for certain stage 3 and 4 cancer patients to receive prescription drug treatment by allowing them to apply for an exemption from step therapy, which requires patients to approve that certain drugs are ineffective before insurance will cover a higher-cost drug 
  • SB340, sponsored by state Sen. Dina Neal (D-Las Vegas), provides for the establishment of a home care employment standards board
  • SB251, sponsored by state Sen. Heidi Seevers Gansert (R-Reno), requires primary care providers to conduct or refer patients for screening, genetic counseling and genetic testing in accordance with federal recommendations around BRCA genes, which influence someone’s chance of developing breast cancer

Several health care bills also died with the end of the legislative session, including AB351, which would have allowed terminally ill patients to self-administer life-ending medication, and AB387, a midwife licensure bill.

Budget subcommittee votes to roll back Medicaid rate decreases approved during summer special session

Lawmakers on a budget subcommittee voted Wednesday to recommend rolling back a 6 percent Medicaid rate decrease, approved by the Legislature during a budget-slashing special session last summer, in a major victory for Nevada’s health care providers who had pilloried the reductions.

The subcommittee also voted to finally enact a 2.5 percent increase to the acute care hospital rate, which was approved by lawmakers in 2019 and then axed during the summer special session. While that rate increase won’t take effect retroactively, the goal will be for it to kick in on July 1.

While Gov. Steve Sisolak had proposed in his executive budget restoring the 6 percent Medicaid rate decrease starting Oct. 1, the Governor’s Finance Office submitted a budget amendment over the weekend to entirely undo the Medicaid budget reductions approved last summer.

The move will restore about $300 million in Medicaid funding both in the current fiscal year and in the upcoming biennium, including about $110 million in general fund spending.

The budget cut restorations come just a little more than a week after economic forecasters projected that Nevada’s general fund revenue is projected to be more than $910 million more than what they had predicted in December. That includes a $590 million revision in the upcoming biennium and $320 million in the current fiscal year.

“We had the conversation in the special session. We realized what we had to do at that moment in time. We also made the commitment that as soon as we could fix this we would, and we as a body are honoring that commitment today,” said Assembly Ways and Means Chair Maggie Carlton. “We could have gone through this and picked and chose who we wanted to, especially in the fiscal situation that we are in right now, but we made the commitment that we would move forward on this when it was possible, and thank goodness we're able to do it today.”

Sisolak, in a statement on Wednesday, said the legislatively approved Medicaid cuts “no longer appear necessary to deal with a severe budget shortfall.” Lawmakers cut nearly a billion dollars from the state’s budget last summer.

“Medical providers have been on the front lines of the pandemic for more than a year, enduring untold stress, both financial and emotional,” Sisolak said. “Restoring provider reimbursement rate cuts will help these small businesses and hospitals that have done so much to keep hard-working Nevadans healthy during this pandemic.”

Several health care lobbyists called in to thank lawmakers for restoring the cuts during the public comment portion at the end of the budget hearing, and the Nevada Hospital Association and the Nevada State Medical Association sent a joint letter to Sisolak thanking him as well.

“Nevada faced an unprecedented state budget crisis,” Bill Welch, the hospital association’s president, and Jaron Hildebrand, the medical association’s executive director, said in the letter. “The work you did alongside the Nevada Legislature to restore funding to hospitals and providers will be instrumental in safeguarding the health care available to many Nevadans.”

Because the federal Centers for Medicare and Medicaid Services, which oversees state Medicaid programs, had yet to approve most of the rate decreases, the state is expected to simply withdraw its request to reduce the rates — in the form of what’s known as a state plan amendment — leaving Medicaid almost as if the cuts never happened.

The state had, however, already started to reduce the amount it was paying managed care organizations to provide health insurance to Medicaid recipients starting Jan. 1 in anticipation of the rate cuts being approved. It plans to boost payments to insurance companies retroactively.

Of the state’s three managed care organizations, only one had started to pass the rate reductions along to health care providers, and lawmakers emphasized on Wednesday that they expect that company, which was not named during the hearing, to pass the boosted payments along to providers as well.

“What we'll be doing here is those who haven't taken cuts will not have to take cuts. Those who have taken cuts, we're going to make the managed care organization whole, and then hope that the managed care organization will make the providers whole,” state Sen. Julia Ratti said during the hearing.

The budget subcommittee also approved a number of other adjustments to Medicaid’s budget on Wednesday, including significant caseload adjustments that will cost the state roughly $320 million in general fund dollars. The governor’s recommended budget had counted on a caseload of about 770,000 in each year of the biennium, now expected to be about 830,000 in fiscal year 2022 and 820,000 in fiscal year 2023.

They have, however, managed to find some additional savings elsewhere, including by budgeting for an enhanced federal matching rate to exist through the end of the year, a move that is expected to save the state about $40 million in general fund dollars.

The subcommittee also voted to approve the 6 percent rate reduction restoration the governor had initially recommended starting Oct. 1, at a cost of about $130 million over the biennium.

Editor’s Note: This story appears in Behind the Bar, The Nevada Independent’s newsletter dedicated to comprehensive coverage of the 2021 Legislature. Sign up for the newsletter here.

Medicaid pushes ahead with 6 percent rate decrease proposed during budget-slashing special session

Nevada Medicaid is moving forward with a planned 6 percent across-the-board rate reduction approved by lawmakers during a special session last month to balance a billion dollar shortfall in the state’s budget.

Though lawmakers were able to restore many proposed cuts to Medicaid programs during the course of the session, Medicaid still bore $130 million in budget cuts, including the 6 percent rate reduction, expected to save the state about $53 million. Health care providers, who have long argued for increases in Medicaid rates, opposed the reductions.

Medicaid is moving forward with the cuts, which will be discussed during a public hearing on Thursday, even though it is expected to take in an additional $30 million through enhanced federal matching dollars that were extended last month through the end of the year.

Though there was much talk during the special session about restoring some of the proposed cuts should the $30 million come through, Medicaid Administrator Suzanne Bierman, in a statement Wednesday, said that it was too soon to start discussing that. She said that the division will continue to monitor several variables, including federal funding, utilization trends and caseload, which has increased 11 percent since February.

“These variables are volatile and it is too early in the current state fiscal year to determine whether the current budget will allow for restorations,” Bierman said.

Additionally, Bierman noted that the language of the budget cuts bill passed by the Legislature, AB3, specifically requires the rate reductions.

“The meeting on August 13, 2020 includes rate cuts mandated by Assembly Bill 3 and a statement will be given at the start of the agenda so that stakeholders are aware of the bill's requirements,” Bierman said.

Nevada Hospital Association CEO Bill Welch, during a public comment session on the bill last month, said the cuts would cost Nevada hospitals more than $100 million a year in payments, with hospitals spending another $500 million on uncompensated care.

During the session, Department of Health and Human Services Director Richard Whitley indicated that it would be difficult to decide where to spend the $30 million if it came through.

“Doing math on the page may be simple for budgetary people, but does turning something down really amount to turning it off? Does reducing the rate lose providers?” Whitley said. “The nuance of all of that would be considered and we’ll work day and night to provide if resources become available.”

Special session draws to a close as lawmakers pass COVID liability bill exempting hospitals, schools

Lawmakers ended the second special session of the summer shortly after midnight on Wednesday after passing a heavily lobbied bill that shields many businesses from COVID-19-related lawsuits but ultimately exempted school districts, hospitals and other health care facilities from receiving the additional protections.

Members of the Assembly, after a five-hour hearing Wednesday night, voted 31-10 to grant final approval to SB4, the last major piece of legislation to advance in the special session. It mandates certain health and safety protections for hospitality workers, in addition to granting broad liability protections to nearly all businesses, governmental bodies and nonprofit groups in the state so long as they follow required local, state and federal health protocols. 

Several lawmakers described the vote as one of the most difficult of their legislative career, saying it was born of backroom deals and seemed to arbitrarily cut out important segments of the workforce. But supporters said they ultimately settled on the bill out of recognition that gaming is the lifeblood of the Nevada economy.

"Ultimately it comes down to one thing: I don't want to be back here in a few months trying to figure out where to find money on the backs of the most vulnerable among us to fill another $1.3 billion budget hole,” said Democratic Assemblywoman Shannon Bilbray-Axelrod. “We talk all the time about how we need to diversify our economy but the fact remains we are still a one trick pony — gaming and tourism fuel our economy.”

Four Democrats — Selena Torres, Edgar Flores, Richard Carrillo, and Brittney Miller — and six Republicans — John Ellison, Greg Hafen, Alexis Hansen, Al Kramer, Robin Titus and Chris Edwards — opposed the bill, which was approved by the Senate on a 16-5 vote earlier in the day.

In effect, the bill means that most regular businesses will be relatively protected from lawsuits if a customer contracts COVID-19 on the premises, so long as the company is following local, state and federal health mandates, such as ensuring that patrons are wearing masks. Customers will still be able to sue, but they’ll have to meet a much higher threshold for a court to allow their case to move forward.

The legislation also establishes protections for casino industry workers and outlines enhanced cleaning policies that large casino companies must follow, provisions the politically powerful Culinary Union has been long pushing for. Adolfo Fernandez, a Caesars Palace utility porter and Culinary Union member, died after contracting the virus in June, and his daughter, Irma, tearfully testified that she was carrying on a mantle of worker protection at his direction.

The two proposals were married together as SB4 in order to ensure that businesses — including gaming companies — and casino workers alike received the protections they wanted. 

However, while that mechanism ensured buy-in from some of the most politically powerful interests in the state, others were excluded from the process of drafting the bill. Hospitals and other health care facilities bemoaned their exclusion from the bill, schools argued against a last-minute amendment excluding them from liability protections and local health districts questioned why they weren’t consulted over new provisions that give them an enhanced oversight role over hotels.

“I share, like many of my colleagues, sentiments that this bill picks winners and losers and gives preferences to some special interest groups,” said Assembly Minority Leader Robin Titus. “I am very disappointed and hope that future legislatures will be able to right the wrongs that are being done today.”

Hospitals protest exclusion

During a lengthy public comment period, hospitals and health care workers warned that excluding health care facilities from liability protections would lead to them having to exclude vendors and visitors to hospitals, as well as think twice about transferring patients to lower-level facilities and threaten their ability to keep beds open during a pandemic.

“If we are following clear rules from the government, and in our case CDC guidelines, we should not be excluded,” said Bill Welch, CEO of the Nevada Hospital Association. “By excluding medical facilities from this bill, access to patient care will be impacted.”

Representatives of Gov. Steve Sisolak’s office tried to point to an emergency directive from April extending additional immunities from liability to providers of medical care engaged in the state’s COVID-19 response as justification for why hospitals and other health care facilities were excluded from the bill’s liability protections. 

However, Legislative Counsel Bureau General Counsel Kevin Powers told lawmakers Wednesday night that whether those additional immunities extend to health care facilities — not just their workers — is an “open question.”

“We cannot say that [the directive] provides medical facilities with the same immunity that their workers enjoy under [state law],” Powers said.

It also remained unclear as of Wednesday night who was responsible for health care facilities being excluded from the bill’s liability protections. During a hearing on the bill in the Senate early Tuesday morning, Brin Gibson, Sisolak’s interim general counsel, said the legislation was a byproduct of “some of the most important members of Nevada’s economy,” a point that several Assembly members asked about during the hearing on the bill.

Pressed during Wednesday’s hearing on who those “important members” were, Gibson demurred.

“There were myriad interests that were involved in the negotiation of this bill, from the travel and tourism industry, primarily, but there were a number of different interests,” Gibson said. “I don’t have a list.”

Sisolak’s staff, on Wednesday, acknowledged that the move was a policy decision from the governor’s office but offered no explanation as to why exactly hospitals had been excluded, other than that they believed that the facilities have enough existing protections.

At another point, the governor’s office suggested that putting in place liability protections would have been too difficult.

“This bill is around health and safety for public accommodations and also for businesses,” said Francisco Morales, a governor’s office staffer who presented the bill alongside Gibson. "To try and tackle liability protections for hospitals and medical providers ... would’ve been extremely complex, and I just want to go back and say that there are already robust protections under (state law).”

School district exemption

An amendment introduced early Wednesday carved out K-12 school districts, including charter schools, from the enhanced liability protections in the bill — a concession celebrated by two of the state’s largest teacher unions, the Nevada State Education Association (NSEA) and Clark County Education Association. 

Democratic lawmakers initially pitched the amendment as a way to ensure school districts would be more cautious about sending teachers back to school without high health and safety standards in place. Democratic Sen. Julia Ratti said it would “put our schools in the position of having to think just a little bit harder about the safety standards that they're providing.”

Legislative legal staff told lawmakers that schools would still be able to use normal litigation immunity offered under existing law, but several school districts said the lack of enhanced liability standards would open them up to liability and that they should be treated the same as other governmental entities.

“If employees and students choose not to follow health and safety standards outside of school, the district shouldn’t be at fault for their actions,” Nevada Association of School Boards President Bridget Peterson said in written testimony. “The potential lawsuits will be costly and put school districts in a financial risk at a time where our budgets are being reduced and expenses are increasing.”

Churchill County School District Superintendent Summer Stephens said districts were working hard to ensure that they could address health and safety issues as they arose and that the enhanced liability protections would put them in a better position in spite of existing liability protections written into law.

“Adding schools back into the bill does not mean schools will not protect their staff members,” she said.

In the end, NSEA lobbyist Chris Daly testified against the bill, saying that it wanted to show solidarity with workers who did not benefit from the measure.

"An injury to one is an injury to all,” he said.

Health districts excluded from drafting

The heads of Nevada’s two urban health districts said on Wednesday that they were not consulted as the legislation was being drafted, despite the fact that it newly tasks them with regular inspections of hotels to ensure compliance with COVID-19-related protocols and establishes a new enforcement role.

“It’s just another burden being placed upon the health district while we’re already overextended in our response to COVID-19,” Washoe County District Health Officer Kevin Dick said.

The health districts have also raised concerns that, while the bill appropriates additional funding to them, it only makes that funding available through the end of the calendar year. SB4 appropriates $2 million to the Southern Nevada Health District and $500,000 to the Washoe County Health District.

Michelle White, chief of staff to Sisolak, said that the governor’s office understands the health districts’ concerns about the time frame of the funding but that they are “completely confident” that the health districts “understand the critical nature of this work to protect Nevada’s employees and our economy.” She added that health districts already have existing authority and expertise with public accommodations, such as hotels, and so they seemed like an “obvious choice” to take on the new role.

“We are incredibly sympathetic with the health districts that they can do this as an expansion,” White said. “We will be a very strong partner with those health districts as we have been and can’t be more appreciative of the work and partnership that they’ve had thus far with us.”

Senate approves COVID-19 liability protections legislation that excludes hospitals, schools

Senate chambers

The Senate voted 16-5 Wednesday morning to advance a bill to shield companies from COVID-19-related liability, with a last-minute amendment carving out K-12 school districts.

The bill, which is expected to be the last major piece of legislation to advance in the special session, gives broad liability protections to nearly all businesses, governmental bodies and nonprofit groups in the state so long as they follow required local, state and federal health protocols. Under the legislation, health care facilities and, now, K-12 schools are exempt from those enhanced protections.

Four Republican senators — Ira Hansen, Pete Goicoechea, Joe Hardy and James Settelmeyer — and Democratic Sen. Marcia Washington all voted against the bill. It now heads to the Assembly, where it’s expected to come up for a hearing and vote at some point Wednesday.

But ahead of any Assembly meetings, lawmakers are planning yet another amendment to clarify language explicitly excluding any non-profit hospitals or health care facilities from the liability protections. Democratic Sen. Yvanna Cancela said after the vote on Wednesday that the change was being made as the existing version of the bill had “competing” provisions” to ensure that non-profit hospitals or health care facilities were excluded from the bill.

“As a result of that competing interpretation, the bill will likely be amended to ensure there’s clarity that no hospitals, regardless of their non-profit or for-profit status, will be afforded liability protections,” she said.

Ahead of the vote, many Republican lawmakers voiced significant concerns about an amendment exempting schools from the liability protections, saying it would essentially lead to school districts declining to return to in-person instruction and that the exempted industries were chosen for political reasons.

“I want to know who the people are that actually want to have these kind of liabilities removed, because I think I know who it is,” Hansen said. “And I think you're going to see some beautiful class action lawsuits, and there's gonna be some incredibly wealthy people if some of the schools dare to go back.”

But Democratic lawmakers, who introduced the amendment early Wednesday to address concerns from teachers’ unions and trial attorneys, said the language would require schools to think more about health and safety standards before reopening for in-person instruction. Democratic Sen. Julia Ratti said health and safety concerns would drive the decisions on reopening schools — not liability protections.

“Schools are filled with children, and children deserve perhaps a higher level of protection,” she said. “And so where I'm going to land on this is without the liability protection, maybe that does put our schools in the position of having to think just a little bit harder about the safety standards that they're providing.”

The amendment itself passed 12-9, with Washington joining Republicans in opposition. But several Republicans opted to vote in favor of the legislation in spite of the exemptions, saying the liability protections would help with the state’s fragile economic recovery.

“While I could find a couple of easy ways to vote no, getting people back to work will put me to yes, every day of the week that ends with ‘y,’ and twice on Sunday,” Republican Sen. Ben Kieckhefer said.

The legislation also establishes protections for casino industry workers and outlines enhanced cleaning policies that large casino companies must follow, provisions the politically powerful Culinary Union has been long pushing for. Adolfo Fernandez, a Caesars Palace utility porter and Culinary Union member, died after contracting the virus in June.

Democratic Sen. Yvanna Cancela directly invoked Fernandez during a floor speech, saying it was incumbent upon lawmakers to ensure that hospitality employees are guaranteed high safety and protection standards that not only ensure their safety, but to also send a signal that the state’s tourism industry is following the highest standards.

“Do I love every provision of this bill? No,” she said. “But do I know that it is important to move our economy forward to ensure that we lead the nation and what it looks like to safely reopen our hospitality industry? Yes.”

Lawmakers also did not take up a formal request from the Nevada Workers Coalition — a conglomerate of more than two dozen labor and progressive groups — sent on Monday that requested several changes to the legislation to make it more palatable to them.

Members of the coalition wrote that they “shocked” that the Legislature would take up a business liability proposal while Democrats in Congress were uniformly against similar policies being pushed by Republican Senate Majority Leader Mitch McConnell.

“The members of the Coalition feel that moving forward in this manner would undermine our U.S. Congressional delegation in their efforts to fight back the attempts on the national level,” the letter stated. “They also felt that we put workers in other states at risk that are currently fighting this battle in their home states if we are the first state to implement these liability immunity efforts.”

Their request included a new bill creating a “rebuttable presumption” for employees diagnosed with COVID-19 to receive workers compensation, as well as prohibiting workers compensation rates from being raised due to the pandemic. 

They also included proposed changes to SB3, which dealt with the state’s unemployment insurance system, that would allow the state to deem a person to be “unemployed” and eligible for benefits if they are required to be quarantined or isolated due to a positive COVID-19 diagnosis or close contact with a someone who is positive.

They also suggested changes to “controlling health standards” that businesses are required to comply with to qualify for the enhanced legal protections. It would keep the current standard in place for casinos and hotels, while changing the definition back to one which was included in a draft version of the bill that would require them to comply with recommendations, not just mandates, on best COVID-19 mitigation practices.

The Wednesday amendment also included other technical changes to the legislation, ensuring that specific entities such as credit unions and private nonprofit groups are covered under the legislation’s liability protections, as well as the officers and employees of any covered business. Lawmakers raised concerns during a Monday night hearing on the bill that the legislation unintentionally exempted several groups from its protections.

But the amendment did not, however, address concerns from hospitals and other health care facilities, which are excluded from the legislation’s liability protections. The Nevada Hospital Association on Tuesday released a video arguing that the legislation would leave hospitals “vulnerable to frivolous lawsuits” and “limit patient capacity.”

“Throughout this pandemic, we have worked closely with Governor Sisolak and his office to fully support his goals to flatten the curve and protect hospital capacity. As written, this bill puts that capacity at risk, and undermines our efforts to protect Nevadans’ health,” Bill Welch, CEO of the hospital association, said during the hearing on the legislation. “Nevada hospitals are the frontline of this pandemic. Hospital capacity is critical for providers to treat this fast-spreading virus.”

It is not exactly clear who pushed for health care facilities to be exempted from the bill’s liability protections, though Brin Gibson, Gov. Steve Sisolak’s general counsel, said during a hearing on the bill that it was the byproduct of conversations between “some of the most important members of Nevada’s economy.” Gibson also suggested that health care facilities are already held to a higher standard because of the type of business they run.

“They're able to manage illness in a way that other businesses are not because they're experts in these spaces,” Gibson said during the hearing. “Our role was to try to not overburden the bill, but at the same time to extend it into every possible business that we could, with limitations.”

The Washoe County Health District has also voiced concern about the legislation, with Health Officer Kevin Dick saying on a press call on Wednesday that the health district was not consulted on the legislation. He also said that the legislation contains an unfunded mandate for health districts to inspect and enforce health protocols at hotel-casinos since it only appropriates funding for that purpose through the end of the calendar year.

“I wish we would’ve been engaged and part of the discussion as the bill was developed,” Dick said. “I don’t think there’s going to be much opportunity for any modifications to the approach that was already put together.”

Contentious COVID business liability, worker protection bill advances in Senate in early morning vote

The Legislature on Sunday, Aug. 2, 2020 during the third day of the 32nd Special Session in Carson City.

Members of the Senate preliminarily approved a long-awaited proposal to protect businesses from liability in the event that a customer contracts COVID-19 after a four hour-long hearing Monday evening that stretched past midnight.

The bill, which is likely to be the last piece of legislation introduced during the special session, cleared the Senate Committee of the Whole early Tuesday morning, 18-3, with Republican Sens. Ira Hansen, Joe Hardy and Pete Goicoechea in opposition. The legislation, SB4, has dominated the behind-the-scenes conversations during the session and is the culmination of a deal between some of the state’s most powerful political interests, including casinos, business groups and the Culinary Union.

But the bill also attracted the ire of other powerful interests in the state, including trial attorneys and progressive groups, who generally bemoaned the bill’s liability protections; teacher unions, who wanted a set of worker protections in the bill afforded to hotel workers extended to educators; and hospitals, who felt they were unfairly excluded from the bill’s liability protections.

“My main concern is about all of the workers, and not just the Culinary,” said Sen. Marcia Washington. “What about the other essential workers and the school district and the hospitals, construction, etc.?”

In opening remarks, gubernatorial Chief of Staff Michelle White reiterated the dire economic situation facing the state amid decreased business demand among Nevada’s casino and tourism industry, saying the bill was a desire to strike a balance between protecting business from “those seeking to capitalize on our current situation” without granting total immunity from lawsuits related to spread of the disease.

“I want to be clear, the bill being presented tonight does not provide total immunity to all businesses, under all circumstances, far from it. These inevitable bad actors that have ignored and continue to ignore executive branch directives and published health and safety protocols will not be protected from liability for those failures,” White said. “Those bad actors will continue to face legal consequences.”

While there was general agreement among lawmakers on the general liability and worker protections, several senators raised concerns during a lengthy question and answer session about the decision to exclude hospitals and other health care facilities from the legislation. 

Brin Gibson, Gov. Steve Sisolak’s interim general counsel, said during the hearing that the legislation was the byproduct of conversations between “some of the most important members of Nevada’s economy” and suggested that the decision was theirs.

“They struck this language, and they decided that based on how the various weights and balances that are out there, that these elements should be included in here in this way, and what I would say is that based on that yield, this is where we ended up,” Gibson said. “There's potential that this deal falls apart if we start amending out certain provisions. They’re there for reasons that aren't— may not be obvious, some are messaging related, some are optical, some are substantive. There are various reasons why.”

But that answer didn’t satisfy all lawmakers. Hansen, one of the three “no” votes out of committee, suggested that health care facilities were being asked to be the “sacrificial lamb” so that “the other guys can get protection.”

“That is just unacceptable,” Hansen said. “We cannot have our entire medical community being subjected to lawsuits while we give exemptions.”

Cleaning standards and worker safety

The bill, which was released in full on Monday, covers three topics: creating an outline of enhanced cleaning policies for large casinos and hotels in Las Vegas and Reno; enhanced protections for workers at those casinos and hotels; and, most controversially, broad immunity from COVID-19 related litigation for businesses, government agencies including schools, and nonprofits, but not hospitals or health care facilities.

First, the legislation directs the director of the Department of Health and Human Services, Richard Whitley, to promulgate regulations on cleaning standards for casino resort or hotels, including regular cleaning of high-touch areas used by the public such as fixtures, door handles, countertops, keycards, elevator buttons and other objects.

The bill requires Whitley to adopt another set of regulations to limit transmission of COVID-19, including protocols on social distancing, access to hand cleaning, sinks and soap, hand sanitizer and personal protective equipment, such as gloves or masks, at no cost to the employee.

The bill mandates that local and state health officials regularly inspect resort hotels every two months and hotels with more than 200 rooms every three months for compliance with the health standards. It also authorizes them to administer fines of $500 for an initial violation and $1,000 for each subsequent violation.

It  also allocates $2 million to the Southern Nevada Health District and $500,000 to the Washoe County Health District to implement and enforce requirements in the bill.

The legislation also includes requirements that employees at casino hotels receive paid time off while awaiting COVID-19 test results if they are in close contact with a guest or other employee who tested positive for the virus. Any employee who tests positive will be allowed a minimum of 14 days off, including 10 paid days.

Those provisions were hard won by the politically powerful Culinary Union, which represents about 60,000 workers in Las Vegas and Reno. The union has been pushing for many of the same worker protections — including enhanced safety and cleaning standards, free COVID-19 testing and detailed processes for when a worker contracts the virus or is exposed to someone who has it — after Adolfo Fernandez, a Caesars Palace utility porter, died after contracting the virus in June.

In her testimony, Culinary Union Secretary-Treasurer Geoconda Arguello-Kline voiced the union’s support for the legislation.

“This Special Session is important for all workers and the hospitality industry,” she said in written testimony. “We hope today that we will ensure workers and their families are protected from the spread of COVID-19 in the workplace.”

Liability protections

But much of the attention on the bill has centered around the sections on liability protections for businesses, nonprofits and government agencies, with hospitals and other health care facilities excluded.

Essentially, the bill sets up a higher standard before a COVID-19-related personal injury or death lawsuit against a business or entity can be filed. It requires any claim to be pled with “particularly,” meaning the plaintiffs have to meet a higher standard of proof than normal before even filing the case.

The bill states that all entities covered under the bill — including businesses, certain nonprofits and government agencies — are immune from such litigation if they are in “substantial compliance with controlling health standards,” unless the plaintiffs can prove that the entity violated those standards with gross negligence, causing personal injury or death.

The legislation defines “controlling health standards” as any federal, state or local law or regulation, or any written order by a governmental body, that “prescribed the manner in which a business must operate at the time the person allegedly failed to comply.”

That includes existing mask-wearing mandates and limits on gatherings of more than 50 people, but would not encompass many of the technically nonbinding recommendations made by the governor’s office and health officials over the many months of the pandemic. 

That controlling health standard language was tightened from an original draft of the bill obtained by The Nevada Independent, which referred to any state, local or federal health policies, laws or ordinances that were “clearly and conspicuously related to COVID-19 and which were in effect at the time of the alleged exposure.”

But the other part of the liability equation is determining whether or not the business is in “substantial compliance” with those controlling health standards. 

That term (“substantial compliance”) is also defined in the bill — as “good faith efforts” to help control spread of COVID-19, including establishing policies to enforce and implement controlling health standards in a “reasonable matter.” It also excludes “isolated or unforeseen events of noncompliance,” meaning that one-off contracting of the virus would not meet that standard required to bring a lawsuit.

The legal liability sections of the bill are set to expire whenever the governor lifts his declaration of emergency related to the pandemic, or by July 2023.

Multiple business and casino companies testified in support of the bill, citing the liability protections in particular. Sasha Stephenson, a lobbyist with MGM Resorts, said the casino company believed the litigation protections were necessary to help with the state’s economic recovery. 

“Unfounded litigation has the potential to cripple Nevada's businesses, leading to more closures and greater economic difficulties,” she said. “The targeted liability protection itself will have the opposite effect. It will allow good actors to stay open as long as they remain vigilant in keeping employees and guests safe.”

But the bill met staunch opposition from left-leaning groups, teacher unions and the state’s trade association for trial attorneys. Both the Nevada State Education Association and Clark County Education Association opposed the bill, citing concerns that it would incentivize schools to cut corners and not take full safety measures thanks to the lifted threat of litigation.

“While it is encouraging that kids don’t get sick and die in the same numbers as adults from COVID-19, evidence is mounting that they can be significant vectors,” NSEA lobbyist Chris Daly said. “Now, as thousands of educators and families prepare to go back to school, we believe essential school supplies should mean pencils and paper or Chromebooks and wifi, not wills and trusts.”

Nevada Justice Association board member Matthew Sharp, a trial attorney, said that supporters had provided no “coherent explanation” for what “controlling health standards” would include, and that there had been few if any such COVID-19 related personal injury lawsuits filed in the state thus far. 

“This Legislature, convening literally at the dead of night, is considering giving essentially complete immunity to certain businesses,” he said. “This isn't what a special session is for. And what we are looking at is a solution looking for our problem.”

Hospital exclusions

The legislation also came under heavy fire during the hearing from hospitals and other health care facilities, which argued that they were being treated unequally by being excluded from the liability protections. Hospitals also argued that if they were not extended the liability protections, they would have to make significant changes to hospital operations, including restricting visitors, students and vendors.

Bill Welch, CEO of the Nevada Hospital Association, also said that the legislation would hinder the ability of hospitals to be able to discharge their patients to long-term care and hospice facilities, limiting bed space to treat COVID-19 patients.

“Throughout this pandemic, we have worked closely with Governor Sisolak and his office to fully support his goals to flatten the curve and protect hospital capacity. As written, this bill puts that capacity at risk, and undermines our efforts to protect Nevadans’ health,” Welch said. “Nevada hospitals are the frontline of this pandemic. Hospital capacity is critical for providers to treat this fast-spreading virus.”

Gibson, during the hearing, argued that hospitals are already afforded certain immunities and protections under an emergency directive exempting them from liability “except in cases of willful misconduct or gross negligence” because of their role in responding to the pandemic.

Later, he acknowledged that the decision to exclude health care facilities was a byproduct of conversations with stakeholders and suggested that the deal between casinos, the business community and the Culinary Union might fall apart if legislators were to propose an amendment.

Gibson then backtracked slightly, after he was pressed by Sen. Keith Pickard about who exactly was involved in drafting the legislation, with the governor’s counsel saying that he may have “oversimplified” his response. He suggested that health care facilities are already held to a higher standard because of the type of business they run.

“They're able to manage illness in a way that other businesses are not because they're experts in these spaces,” Gibson. “Our role was to try to not overburden the bill, but at the same time to extend it into every possible business that we could, with limitations.”

However, not all health care facilities will be treated equally under the bill. Legislative legal staff confirmed that University Medical Center, the county-run hospital in Clark County, would qualify for the liability protections since it is a government entity, and any county-run rural hospitals would be eligible as well.

After years of incremental health care reform, more than $200 million in budget cuts threaten to turn back time

State officials presented to the Senate on Wednesday $233 million in proposed cuts from the health care budget that will slash key programs for low-income Nevadans and significantly pare back mental health services to ease a budget crisis caused by the ongoing coronavirus pandemic.

Many of the proposed cuts will roll back initiatives spearheaded by lawmakers and  the Department of Health and Human Services over the last few legislative sessions in an effort to improve health care in the state, which ranks among the worst in the nation. Health officials also plan to sweep dollars from existing accounts, such as one fueled by tobacco settlement dollars, to help make up the budget shortfall.

The recommended reductions to the Department of Health and Human Services budget will, if approved, make up nearly 20 percent of the $1.2 billion shortfall projected by the governor’s office and more than 42 percent of the proposed $549 million in agency rate reductions. 

The K-12 general fund budget — which represents about 34.9 percent of total general fund spending, slightly more than the 33.5 percent that Health and Human Services comprises — faces proposed cuts of about $166 million.

The proposed health care cuts come as the Department of Health and Human Services continues to play an integral role in the state’s response to the ongoing COVID-19 pandemic. Richard Whitley, the department’s director, noted in his budget presentation the difficulty of cutting hundreds of millions of dollars in health services — most of which go toward supporting the most vulnerable Nevadans — in the middle of a global pandemic.

“What is being identified here is we’re delivering direct services in one hand in a crisis and we’re having to reduce down our spend with the other hand,” Whitley said. “I am doing the best I can at doing that with the least amount of harm possible, but there will be harm, and I’m not here to say that people’s lives won’t be impacted by these proposed reductions.”

Medicaid

The most significant cuts, $140.4 million, will come to the state’s Medicaid program, which has seen a 9 percent increase in its caseload since February as Nevadans lost their jobs and turned to the state for health insurance. No Nevadans will lose their Medicaid coverage as a result of the budget cuts — in part because of a mandate from the federal government that states not terminate anyone from the program in order to receive additional federal matching dollars — but the state is planning to limit or eliminate the services they can receive.

For instance, Medicaid plans to eliminate 12 services deemed “optional” by the federal government, to the tune of $18.7 million in savings. Those services include optometry, tenancy support, occupational therapy, basic skills training and psychosocial rehabilitation — benefits that both lawmakers and state health officials noted Medicaid enrollees rely on and aren’t going to be able to get elsewhere.

“The framework of mandatory versus optional is not, I mean it’s almost embarrassing to use those terms because they’re only relevant to a federal congressional act in terms of what governs Medicaid, not to the people who do need the health care service,” Whitley said.” So I do know that we will have impacts on people and their lives may be worsened by these services being eliminated. I can’t quantify that for you today. I just know I have limited spaces to go to make the reduction in our general fund spend.”

Medicaid has also proposed a 6 percent across the board rate decrease for all services, which will save the state $53 million, and eliminate hard-fought rate increases approved by the Legislature during the 2019 session for acute hospital services, neonatal and pediatric intensive care services and personal care services, a savings of about $12.4 million. Hospitals waged a long, public campaign for their increases and, along with doctors and other providers, have long argued that Medicaid rates overall in Nevada aren’t high enough as is.

Suzanne Bierman, Medicaid administrator, pointed to a Kaiser Family Foundation report that shows that Nevada has one of the highest Medicaid-to-Medicare ratios compared to other states,

Nevada Hospital Association CEO Bill Welch, during a public comment session Wednesday evening, said the cuts will cost Nevada hospitals more than $100 million a year in payments, with hospitals spending another $500 million on uncompensated care.

Medicaid additionally plans to eliminate adult dental and limit dental services for pregnant women and children, limit physical therapy for adults to 12 sessions and eliminate certain duplicative hospice services from being provided in the home, for a total savings of $30.2 million. Remaining savings will come from delaying risk mitigation payments to managed care organizations, the private insurers paid by the state to provide Medicaid services.

Medicaid could see an additional $30 million in savings should the federal government extend the enhanced federal matching rate through the end of the year, a decision that doesn’t have to be made until July 25. Officials are hoping to delay implementation of the Medicaid changes to Oct. 1, at which point they would have more information about their funding situation.

Whitley, asked where Medicaid would put the extra $30 million, said that it was a difficult question to answer.

“Doing math on the page may be simple for budgetary people, but does turning something down really amount to turning it off? Does reducing the rate lose providers?” Whitley said. “The nuance of all of that would be considered and we’ll work day and night to provide if resources become available.”

Public and behavioral health

Another $19.1 million in cuts have been proposed to public and behavioral health care programs in the state, with the majority coming from the Southern and Northern Nevada Adult Mental Health Services agencies. 

Some of the savings will be achieved by freezing hiring vacant positions within both mental health agencies. But Southern Nevada Adult Mental Health Services also plans to stop providing residential services to 270 people, referring them instead to other organizations, such as Catholic Charities and Share Village, unless they receive additional funding through the federal CARES Act.

The state has shifted the way it provides mental health services over the past several years, putting the emphasis on enrolling people in Medicaid and directing them to private providers, instead of having the state directly provide services. But Sen. Julia Ratti noted during the hearing that stripping back direct mental health dollars, coupled with the cuts to Medicaid, could essentially mean the state will only be providing mental health services to its prison population.

“With the cuts that we’re talking about here, and then you pair those with the cuts to substance use treatment and mental health that we talked about in the Medicaid budget, and then you overlay housing, and the tenancy support … I feel like maybe we’re reverting back to a place where if you really need behavioral health services, you almost have to be part of the criminal justice to access them,” Ratti said. “It feels like we're heading towards a perfect storm.”

Lisa Sherych, administrator of the Division of Public and Behavioral Health, agreed.

“These are extremely difficult decisions to make,” Sherych said, choking up. “I was very hopeful that this next session was going to be a great one based on last session. So, yes, our focus is primarily going to be the justice-involved population.”

Other cuts to public and behavioral health will come in the form of $1.6 million in cuts to rural clinics, in the form of deferred start dates for staff, $1.5 million in tobacco prevention dollars approved last session, $1.6 million in problem gambling dollars and $2.3 million in sweeps from other funds.

Aging and disability services

State officials plan to find another $30.2 million by freezing caseloads for some of its Aging and Disability Services programs, including, notably, its Autism Treatment and Assistance Program, to the tune of about $5.7 million in savings. 

The Legislature appropriated $17.4 million toward the program last session, including funds to reduce a roughly 800-child backlog in a program that was only serving about 200 children. Now, the program has 892 children enrolled in it, with 191 on the waitlist — but those levels would be frozen under a proposed budget cut, though children will still be moved into the program at its current capacity as children age out or move.

Three other programs will also have their caseloads capped, including supported living arrangement services, which provide residential support to people so they can live in a community-based setting. The division has also proposed deferring a provide rate increase for SLAs, reducing payments for other programs, freezing vacant positions, eliminating travel and training and deferring maintenance on facilities.

Other cuts

Another $18.4 million in savings will come from Director Whitley’s office, including $1.5 million of the $6 million in family planning dollars lawmakers appropriated in the 2019 session. The remainder will come from funds swept from the Healthy Nevada Fund, which was set up with tobacco settlement dollars to fund certain health grants.

The Division of Welfare and Supportive Services plans to contribute another $15.7 million in budget reductions, primarily through funding the salary cost for eligibility workers through December through the federal CARES Act, about $14 million in general fund savings. The rest is proposed to come from a reduced general fund match in child support and other administrative changes.

The Division of Child and Family Services will be responsible for the rest of the budget reductions, about $9.4 million. The majority of that, $5.1 million, will come from changes to child welfare, including a reduction in funds to incentivize Clark and Washoe counties to innovate their child welfare funding streams. Another $3.7 million will come from freezing 53 vacant juvenile correction positions and reducing the number of beds at juvenile correction facilities from 224 to 160.

Even with the reduction, Ross Armstrong, the division’s administrator, said that there should be enough beds to meet the needs, with an average daily census for calendar year 2019 of 157.

“Across the country now for about the last decade, there's been a big push in reducing the number of young people we have locked up in correctional air, and that has occurred in Nevada as well,” Armstrong said. “We made sure we didn't cut the funding to the counties that work on the prevention work, we didn't cut parole, who does the aftercare to prevent them from going back into the facility, and we also maintained all of our children's mental health beds.”

Nevada’s already slim physician workforce may grow slimmer with patients slow to return to doctor’s offices

A patient checks in at an urgent care

A majority of Nevada doctors believe they can only keep their doors open for another two to six months unless the volume of patients trickling back into their offices significantly increases, according to a new survey from the American Medical Association.

Ten percent of physicians in Nevada reported layoffs, 15 percent reported pay cuts, 20 percent reported temporary furloughs and 30 percent reported a reduction in staff hours, while 55 percent reported none of those changes, according to preliminary results from the survey, which Dr. Ron Swanger, president of the Nevada State Medical Association, presented to the Patient Protection Commission on Monday.

According to the survey, one in five medical practices has seen a decline in revenue of between 26 to 50 percent, while another third have seen a decline of 51 to 75 percent. A third of physicians say they aren’t sure how long they can keep their doors open at their current patient volume.

The Nevada data is a small subset of a larger survey conducted by the American Medical Association (AMA) of 10 states last month. Nevada State Medical Association Executive Director Jaron Hildebrand said in an email that the data from the Nevada portion of the survey, which included responses from 33 providers in the state, should be thought of as three to four focus groups worth of data and not necessarily representative of all the association’s members.

However, Swanger told the commission that the data tracks with trends that are being seen nationally, and they also hew closely to the results of a larger Nevada State Medical Association survey of 131 members taken in April.

According to the AMA survey, 70 percent of physicians reported being very concerned or extremely concerned about obtaining adequate revenue from their practices, even though many have been able to obtain assistance through the federal Paycheck Protection Program. Seventy-four percent said they have applied for federal assistance, and, of those, 89 percent reported having received it.

“I had received several letters from my colleagues saying that they were eliminating half of their staff,” Swanger said. “Luckily the PPP came through for them, and they're still open today, but I know that their volumes are just like ours, down about 30 or 40 percent. It's hard to cover your overhead and turn any profit at all. I know we're not turning profit right now. We're just trying to keep the doors open and our employees working.”

Though the numbers would be stark in any state, they’re of particular concern in Nevada, which has one of the lowest rates of doctors per capita of any state. The Silver State ranked 48th in the nation for total active patient care physicians and active primary care physicians in 2019, according to a workforce profile compiled by the American Association of Medical Colleges.

“There is always already a shortage of primary care providers in the state as a whole, and if even 5 percent or 10 percent drop out from providing that primary care, we would end up in a crisis,” said Dr. Ikram Khan, one of the commission’s members. “It's bad enough to begin with.”

Khan said he knows physicians in private practice whose costs significantly increased as they secured additional personal protective equipment, even as their patient volume significantly decreased. Other doctors, employed by larger companies, have been laid off, he said.

“These physicians can’t go and open shop next door because it’s fiscally not possible to do so either,” Khan said.

The medical community has been trying to get the word out to patients that it is safe to return for appointments and surgeries, particularly those needed to keep chronic medical conditions under control. But Swanger said that patients have been slow to return.

“We're seeing somewhat of a patient comeback, but it's not strong enough and I'm not sure what else we can do to be honest with you,” Swanger said. “I think the messaging is out there and we continue to push the message that you need to seek care, particularly for chronic health.”

Bill Welch, CEO of the Nevada Hospital Association, told the commission that utilization of Nevada hospitals dropped more than 30 percent. It wasn’t that people stopped needing care, he said, but that they were uncomfortable coming to hospitals for fear of being exposed to COVID-19.

“Whether it's for cardiology, oncology, gynecology, etc., we are starting to see an uptick in patients coming back to the hospital for that,” Welch said. “But again, still not back to the normal volume that we've seen in the past.”

At the same time, the hospitals are preparing for another spike in COVID-19 cases. Welch said that if the spike comes as flu season is starting, it will be a challenge for hospitals to ensure they have enough staff and personal protective equipment to treat them.

“We feel reasonable that we should have beds, if we get hit both with the flu and the COVID-19 continues on,” Welch said. “Will it be a challenge for us? Without question.”

Christopher Lake, executive director of community resilience for the hospital association, added that testing continues to be a challenge for hospitals.

“Testing availability and result turnaround time, again, is a huge concern,” Lake said. “We really, as we enter the flu season, need to shoot for having that COVID-19 test back to the hospitals within 24 hours. We're not there yet, but we really need to strive to get there.”

This story and all others about the Patient Protection Commission are edited by Managing Editor Elizabeth Thompson and/or Assistant Editor Michelle Rindels. Sara Cholhagian, the commission’s executive director, is in a relationship with Editor Jon Ralston.

‘A lot of little things’: Incremental health policy changes favored over sweeping reform in 2019 legislative session

Lawmakers this session took patients out of the middle of negotiations between providers and insurance companies over out-of-network hospital bills in a landmark bill decades in the making and codified the Affordable Care Act’s protections for people with pre-existing conditions amid ongoing threats at the federal level.

But, by and large, the changes that the Legislature pursued this year to improve health care in the state weren’t big or flashy. Instead, lawmakers passed a number of incremental changes — such as establishing a maternal mortality review panel, allocating additional state dollars for family planning services and commissioning studies on prescription drugs and a state public option — that experts say will slowly begin to move the needle on health care.

“There were some little tweaks that were made that are going to have a big impact,” said Catherine O’Mara, executive director of the Nevada State Medical Association. “I think sometimes it doesn’t seem that exciting because there’s not these huge reform bills but, in the aggregate, there were a lot of little things that were done that are actually going to positively impact people.”

Part of that emphasis on smaller health policy items over the sweeping change that had seemed possible when a Medicaid buy-in proposal was the subject of conversations between the 2017 and 2019 legislative sessions was signaled early on by Gov. Steve Sisolak, who during his campaign promised the creation of a Patient Protection Commission charged with a top-to-bottom review of health care in the Silver State.

When Sisolak first proposed it last year, the commission was framed as a blue-ribbon panel that would bring together patients, doctors and other policymakers and, after convening for 100 days, recommend changes to be implemented by the Legislature.

In light of that, there was initially some speculation that the panel would operate similarly to an advisory panel that Sisolak established in January to map out sweeping regulatory changes to the marijuana industry. But Sisolak took a different tack with the Patient Protection Commission, proposing legislation, SB544, to create that body in mid-May and charging the body to return to the 2021 legislative session with its recommendations in the form of two bill draft requests.

“For a first-session governor to create a Patient Protection Commission I think is really prudent,” O’Mara said. “The administration didn’t just jump in and say, ‘We’re going to change health care.’ He said, ‘We’re going to jump in and hear from everybody and figure out where all the pain points are and go from there.’”

Some in the industry see a model for the commission in the success of the landmark surprise emergency room billing legislation that passed this session, which was a byproduct of extensive conversations between insurers, hospitals and doctors between sessions and a mandate from Assembly Speaker Jason Frierson that they reach a compromise. Industry representatives who were a part of those conversations said they weren’t completely happy with the end result, but it was something that they were willing to live with.

“The surprise billing issue has been around and hasn’t come to any level of resolution for years, and a giant step was taken in that bill passed,” said Tom Clark, a lobbyist for the Nevada Association of Health Plans. “Kudos to Assemblyman Frierson, the speaker, for taking that bull by the horns and really making sure that all of the stakeholders got together and figured that out.”

Similarly, Sisolak has made it clear that the commission, an 11-member panel made up of industry and patient representatives, will be a working body. He warned at an industry briefing before the legislation was introduced that the overall goal is compromise, and anyone not working toward that could those their seat at the table.

“I think the way it’s being structured is going to give all sides of the issue a chance to be at the table and facilitate the development of good regulation and good legislation, whichever the case may be,” said Bill Welch, president and CEO of the Nevada Hospital Association.

Questions still remain about how the body will work with the interim health committee, a panel of lawmakers that studies issues between sessions to develop policy to bring forward when the Legislature meets again and with two health-care studies that have been commissioned. But industry representatives — from doctors and hospitals to insurers and pharmaceutical companies — are optimistic about the commission’s potential.

“For our part, we want to come to the table with proposed solutions and ideas and an openness to address the challenges Nevada’s health-care system is facing,” said Priscilla VanderVeer, a spokeswoman for the national drug lobbying association Pharmaceutical Research and Manufacturers of America, in an email. “We believe this is a real opportunity to work together across the broader health-care system and the political spectrum to enact real change and we look forward to being a part of it.”

Part of that optimism comes from the hope that the commission will look at the root cause of some of the state’s health-care ills with an eye toward prevention and mitigation early on to prevent poor health-care outcomes down the line. For instance, lawmakers approved rate bumps for hospitals providing intensive care to some of the state’s sickest babies, but the broader question of how to expand access to prenatal care so those babies are born healthy remains.

“When I hear from hospitals or skilled nursing facilities or certain provider types, their messaging is very good, but we need to be looking at the whole landscape of health care and where we need to move the dial and where the opportunity is,” said Richard Whitley, director of the Department of Health and Human Services. “If it can be prevented, if we can intervene early, we ought to intervene.”

Here’s a look at some of the other health policies that passed this session, and others that didn’t:

Studying (again) a state public option

A last-minute bill, SCR10, introduced by Senate Majority Leader Nicole Cannizzaro is tasking the Legislative Commission with studying the feasibility of allowing Nevadans to buy into the Public Employee Benefits Plan, or PEBP, which provides health insurance to state workers.

Cheryl Bruce, executive director of the Nevada Senate Democratic Caucus, framed the legislation as a way for the Legislature to continue to explore the idea of a public option. Conversations on the topic waned following the resignation of Democratic Assemblyman Mike Sprinkle, who had led the interim conversations on a Medicaid buy-in proposal.

“We think this is a good first step to get more information before moving forward with any future legislation,” Bruce said in a text message.

Some in the industry have raised concerns that the legislation is too narrow because it specifically targets the interim study to the feasibility of a PEBP buy-in and that it focuses on access to insurance without also targeting access to care.

“I did talk with the sponsor of the bill, and they assured me that some of the things I wanted to amend into the bill and include the bill are generically incorporated in the bill already,” Welch, the hospital association CEO, said. “I want to make sure they are focusing on the full picture.”

The overarching question that the study will have to address is who a public option plan aims to help. Conversations about increasing access to health insurance in Nevada have generally centered around increasing access to rural residents who only have one plan available to them for purchase on the exchange, improving access to residents across the state who are increasingly priced out of exchange plans or targeting the state’s undocumented population, which faces severe barriers to accessing insurance and care.

Before Sprinkle’s resignation, some of the conversations around Medicaid buy-in focused on how the proposal could help the state’s rural residents and possibly other populations on a limited basis.

“At the end of the day I will be shocked if this study shows much more than that again. I only say that because if you bring all of this uninsured population to the state’s health benefit plan it will change your actuarial mix of who are insured,” Welch said. “You’re going to be bringing in individuals potentially who have chronic medical conditions that will change how you actually set your premiums.”

Codification and stabilization of the Affordable Care Act

The most sweeping bill related to the Affordable Care Act that passed this session was AB170, which codified the federal health-care law’s protections for people with pre-existing conditions into state law. A similar measure last session was vetoed by former Gov. Brian Sandoval, who said at the time that it would have locked into law “requirements that may be unnecessary, imprudent, or simply unaffordable in the years to come.”

Approval of the legislation comes amid an ongoing legal challenge to the Affordable Care Act on the federal level that could strike down the law entirely, including its popular pre-existing condition protections.

“Who knows if the federal administration is ever going to actually overturn the Affordable Care Act, but they certainly are chipping away pieces of it,” said Elisa Cafferata, lobbyist for Planned Parenthood. “It’s good to have those protections in place because what everybody really liked about the Affordable Health Care was the preventative health care and pre-existing conditions.”

The compromise pre-existing condition language was first crafted a different bill spearheaded by Democratic Sen. Julia Ratti who, as chair of the Senate Health and Human Services Committee, worked to ensure the legislation would codify the protections in the Affordable Care Act as they stand now — no more and no less. The work on that bill, SB235, was then folded into Democratic Assemblywoman Ellen Spiegel’s AB170.

The legislation also requires health insurance plans to provide to the Governor’s Office for Consumer Health Assistance the phone number of a navigator or case manager who can help patients make an appointment with a doctor in a timely fashion. The bill had initially proposed requiring insurance companies to cover out-of-network doctor’s visits at no additional cost to patients if no in-network physician was readily accessible, but was amended down in a compromise with insurance companies.

Though it’s a small change, those in the health-care industry say it stands to improve access to care for patients.

“Our take is that AB170 is a very simple little bill that will actually have a practical impact in helping patients,” O’Mara said. “It’s one of those bills that isn’t flashy but will make a difference.”

The Legislature also passed two Affordable Care Act stabilization bills — SB481 and SB482 — that place additional restrictions on two types of health insurance plans with potentially skimpier coverage than that required under the federal health-care law and direct the state to apply for a federal innovation waiver to allow the state to explore other options to stabilize the individual health insurance market.

Heather Korbulic, executive director of the Silver State Health Insurance Exchange, said that together the bills “could have a dramatic impact on getting people connected to plans that are right for their needs.”

Lawmakers additionally approved the exchange’s budget, which included the funding necessary to become an entirely state-based exchange instead of the hybrid model that the exchange has been operating under now. Exchange officials have said that a Nevada-run platform will both save the state money and allow them to know who is actually purchasing individual plans through the exchange and better target their outreach.

“That itself lends a lot of autonomy and control,” Korbulic said. “Lawmakers were cognizant of that potential flexibility.”

Changes for hospitals

Lawmakers passed two bills this session that strike at the core of what it means to be a hospital and what services those facilities should and ought to provide.

One of them, Democratic Assemblywoman Maggie Carlton’s AB317, shifts the responsibility of determining whether to establish any additional trauma centers from the local level to the state. It comes amid renewed discussions over Southern Nevada’s trauma need and whether to approve additional trauma centers. Welch said that the change “might potentially create some additional time to make those determinations going forward” but that “overall the approach is a balanced approach.”

The legislation also requires every off campus facility that a hospital operates — such as a microhospital or freestanding emergency department — to have a unique national provider identifier number. The goal is to help the state better track and understand how those facilities are utilized compared to traditional hospitals.

Another bill advocated for by the hospital association, Democratic Assemblywoman Rochelle Nguyen’s AB232, requires all hospitals in the state to be certified by the federal Centers for Medicare and Medicaid Services (CMS). The legislation specifically targets a tourist-focused microhospital near the Strip, Elite Medical Center, which doesn’t bill Medicaid or Medicare.

In hearings on the bill, Elite argued that its business model isn’t based around providing care to Medicaid and Medicare patients and that it would rather write off the cost of uncompensated care it provides to those individuals than go through the onerous process to become Medicaid and Medicare participating. But lawmakers sided with the hospital association, which argued that hospitals should have the responsibility of taking care of all patients.

“We’re not opposed to microhospitals,” Welch said. “We’re supportive of microhospitals, but we’re supportive of them coming in and being a part of the integrated health-care delivery system.”

The legislation gives Elite until July 1, 2021 to be certified by CMS.

The Legislature also took steps to address the financial needs of the state’s hospitals, which have long argued that they are increasingly strained by the number of Medicaid patients they treat. Lawmakers approved a 25 percent bump in the per diem Medicaid rate to care for babies in the neonatal intensive care unit (NICU) and a 15 percent bump in pediatric intensive care unit (PICU) rates to ensure that hospitals are able to maintain the current level of services that they are providing to the community.

Welch said the hospitals are “ecstatic” about the increases.

“What it is going to do is ensure that those beds that we do have are not going to close, because there has been a lot of discussion over the last 18 months about whether certain hospitals were going to be able to continue providing services at that rate,” Welch said.

Hospitals also got a last-minute boost in the form of SB528, an appropriations bill passed in the final two hours of the legislative session that included a 2.5 percent increase to the state’s acute care per diem rate for Medicaid. Welch said that he had asked for a 20 percent increase at the beginning of the session but didn’t know whether hospitals would get any rate bump until those final minutes.

“Between those three things, that will help us immensely,” Welch said. “It won’t get us anywhere near cost, but at least it’s moving us in the right direction and hopefully will help us be able to sustain the services.”

After negotiation between proponents and the hospitals, lawmakers also passed SB364, Democratic Sen. David Parks’s bill requiring hospitals to identify patients by their preferred name and pronouns, representing a significant victory for the state’s transgender community.

Drilling down on drug costs

At the beginning of the session, there were several sweeping proposals to tackle the high cost of prescription drugs, including a mandate that the middlemen in the drug pricing process pass along rebates they negotiate with drug manufacturers to consumers and a Prescription Drug Affordability Board with the ability to examine high cost prescription drugs and limit what payers can spend on them.

Neither of those ambitious proposals moved forward this session, but lawmakers did vote to expand a diabetes drug transparency bill passed in 2017 to require manufacturers of asthma drugs and drug pricing middlemen, or pharmacy benefit managers (PBMs), disclose certain costs and profits to the state.

The bill, Democratic Sen. Yvanna Cancela’s SB262, requires manufacturers of asthma drugs whose prices have increased significantly in the past year or two to report specific data to the state for each drug including the cost of producing it, administrative expenditures such as marketing and advertising costs, profit earned, financial assistance provided to help patients, and coupons and rebates offered. PBMs are also required to report any rebates they negotiated and any profits they retained associated with asthma drugs that experienced significant price increases.

“The hundreds of thousands of Nevadans living with asthma deserve to know that the price they’re paying for their medication they need to breathe is fair, and this bill will help shed some light on factors affecting these drug prices,” Sisolak said at a bill signing last month.

But drug manufacturers, who sued over the diabetes drug transparency legislation two years ago, raised concerns during hearings on the bill that regulations adopted by the state in 2018 to keep confidential information companies deem to be trade-secret protected would only apply to diabetes drug reporting and not the new asthma drug reporting.

VanderVeer, the PhRMA spokeswoman, said that she couldn’t speculate on whether there will be litigation related to the new asthma drug transparency law.

“We will be closely monitoring and engaging in the regulatory process,” VanderVeer said.

Another bill, Republican Assemblywoman Melissa Hardy’s AB141, builds on some of the prohibitions on gag rules inserted by PBMs into contracts with pharmacists — preventing them from disclosing certain information to patients — passed in the 2017 session. The legislation prevents PBMs from stopping a pharmacist from providing information to patients about the availability of a less expensive drug and from penalizing a pharmacist for selling a less expensive generic drug to a person.

Lawmakers, in passing Cancela’s SB276, have also directed the Legislative Commission to appoint a committee to conduct an interim study concerning the issue of the costs of prescription drugs, including the impact the PBM rebates have on prices.

VanderVeer said that PhRMA was “glad to see a discussion about the broader pharmaceutical supply chain taking place in Nevada this year,” though the association still believes it was unfairly targeted in 2019.

“While we continued to see a one-sided political attack that took place in 2017, we are glad that there was some recognition of the broader pharmaceutical supply chain and the importance of protecting patients’ access to needed medicines and the future development of new treatments and cures,” VanderVeer said.

Access to care

Lawmakers tackled a number of broader access to care issues this session, too, including patients’ ability to access mental health, dental and family planning services.

One bill, which emerged from one of the regional behavioral health policy boards created by the Legislature in 2017, establishes a new endorsement for psychiatric hospitals to be deemed a crisis stabilization facility and mandates that those stabilization services be covered under Medicaid. The need for crisis mental health services in the state was brought into sharp focus in 2018 when WestCare abruptly closed its crisis triage center in Reno and Clark County had to shell out additional funding to keep the doors of the company’s Las Vegas crisis triage center open.

“These could be game changers from the impact they could have on reducing emergency room and jail holds on patients,” said Chuck Duarte, CEO of Community Health Alliance and chair of the Washoe Regional Behavioral Health Policy Board. “I’m hopeful we’ll see some of these facilities developing in Nevada. I think they’ll have a significant impact on unwanted institutionalization.”

The bill, AB66, also requires the state to adopt regulations to license and regulate providers of nonemergency secure behavioral health transportation services to transport people experiencing a mental health crisis. Right now, a significant portion of the burden of transporting individuals undergoing a mental health crisis falls on law enforcement, particularly in rural Nevada.

Another piece of legislation passed, Cannizzaro’s SB425, requires Medicaid to provide additional home and community-based services, including tenancy support services. Under federal law, states are allowed to implement tenancy support services for people who are elderly or disabled.

“It doesn’t solve the housing problem” Duarte said. “But this establishes the sustainable revenue stream.”

Other bills drilled down into the issue of access to dental care. One of them, Ratti’s SB366, establishes a new mid-level dental provider type, known as dental therapists, who will be allowed to perform a number of routine dental procedures currently performed only by dentists, including extracting loose teeth, filling cavities and applying sealants.

The dental therapists will only be allowed to practice in underserved areas, including federally qualified health centers, rural health clinics, tribal health clinics, and any other clinics that primarily serve Medicaid patients or other low-income, uninsured individuals.

Duarte said that it “makes a lot of sense” for federally qualified health centers, including Community Health Alliance, to be able to lean on dental therapists to provide services, particularly when non-emergency adult dental services are not covered by Medicaid in Nevada.

“Right now with Medicaid not covering adult dental services, it’s hard to provide comprehensive care to adults without insurance,” Duarte said.

Lawmakers also approved AB223, sponsored by Democratic Assemblywoman Dina Neal, requiring the Department of Health and Human Services to seek permission from the federal government to establish a pilot program to provide dental care to adults with diabetes.

Women’s reproductive rights were another key focus for lawmakers this session with the passage of SB179, a bill sponsored by Cancela that removes longstanding criminal penalties on abortion and removes requirements that doctors explain to women the emotional implications of undergoing the procedure, and SB94, which clarifies how state family planning dollars can be spent. Sisolak also allocated and lawmakers approved $6 million in state family planning funds this session.

“It’s going to significantly increase the access to family planning services around the state,” Cafferata, the Planned Parenthood lobbyist, said. “Especially for rural Nevada that bill is going to be significant.”

One family planning bill that did not advance last-minute was Cannizzaro’s SB361, which would have required the state’s chief medical officer to issue a standing order allowing for self-administered birth control, essentially allowing patients to skip a doctor’s visit and go straight to the pharmacy for their medication. Those involved with the legislation said there were some last-minute tweaks to the bill and that lawmakers ran out of time to get the bill finalized.

But Whitley, the director of the Department of Health and Human Services, said it may be possible for the state to take action on the issue in the interim, particularly to increase access to birth control in communities where it’s difficult to get in to see a doctor.

“The Board of Pharmacy has authority to explore their existing authority through regulation for that,” Whitley said. “I’d like to work with them to see if there is something we can do since we do know that much of our state is a health-care workforce shortage area.”

Public health solutions

Beyond the industry-specific changes they made, lawmakers also signaled their interest in focusing on public health issues, from maternal mortality to vaping.

AB169, sponsored by Democratic Assemblywoman Daniele Monroe-Moreno, established a maternal mortality review panel amid rising concerns nationally over the recent rise of maternal deaths and complications. To fund the board, Nevada is applying to the federal government for a slice of a $43.5 million grant from the Centers for Disease Control and Prevention dedicated to investigating the causes of pregnancy-related deaths and complications.

“It wasn’t controversial at all but the Maternal Mortality Review Board, which actually passed quite early, was a really an important step for the state to take,” Cafferata said. “It was one of those quieter bills, because it didn’t have a lot of controversy around it, but I think it will be a significant bill for all of us.”

Lawmakers also made changes to an opioid prescribing law passed in 2017 that was aimed at tamping down on the overprescription of opioids but that doctors said was unduly burdensome and harmful to patient care. The new bill, AB239, allows providers more discretion when writing prescriptions for controlled substances to treat acute pain.

Another bill, Ratti’s SB263, places a 30 percent tax on e-cigarettes and their accessories and directs a significant portion of the $8 million a year in revenue it is projected to generate back to vaping prevention activities. Whitley said the legislation puts Nevada ahead of the curve when it comes to prevention in this area.

“[It] is really a first in our state for taking a behavior and not waiting” for the FDA to take action, Whitley said. “If you look at the history of tobacco use or alcohol use or gambling or other behaviors that can in excess cause harm, really the response in vaping, we’re with the group of states that are ahead in starting to tackle this.”

A final public health-focused bill to establish an all-payer health insurance claims database, SB472, failed to move forward in the final minutes of the session. The bill would have required the state to compile a database of billing information from insurance companies to better understand health-care costs.

Whitley said that he believes it was another case where lawmakers ran out of time, but that he’s already exploring options for the department to pursue such a database on its own in the interim in conjunction with the UNLV School of Public Health.

“An all-payer database would allow us to actually see where services are occurring and where maybe we need to give focus,” Whitley said. “We’re going to continue to work with community partners and the university to see if we can do it as a voluntary database to build the system.”