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.

Sisolak signs bill making Nevada the second state to adopt a public health insurance option

Nevada became the second state in the nation to enact a state-managed public health insurance option on Wednesday, with Gov. Steve Sisolak’s signature transforming a bill that hadn’t even been made public until six weeks ago into law.

Though Sisolak voiced his intent to sign the bill last week, his signature formally ends a more than four-year-long quest to establish a public option in Nevada, though, in many ways, work on the public option is just beginning. Under the new law, Nevada’s public option plan won’t be available for purchase until 2026, giving state officials time to conduct an actuarial study of the proposal to determine whether it will accomplish proponents’ goals of increasing health care access and affordability and at what cost. It also provides time for state officials to transform the still relatively broad-strokes concept into a workable policy and return to the Legislature in 2023 with any changes that may need to be made to the law.

“I'm always looking for ways to expand health care opportunities in Nevada for Nevadans, and that's what this legislation does,” Sisolak said during a bill-signing ceremony in Las Vegas. “By leveraging the state's existing health care infrastructure and reducing costs, it is my hope that Nevadans will have improved access to comprehensive insurance.”

Senate Majority Leader Nicole Cannizzaro, who’s expecting her first child this summer and sponsored SB420, nodded to the effect it could have on the state’s youngest residents.

"This bill will help to open up some more doors in critical investments in prenatal and maternal care and Medicaid for Nevada moms and babies right here in our Silver State,” she said Wednesday.

Senate Majority Leader Nicole Cannizzaro (D-Las Vegas) smiles after Gov. Steve Sisolak signed SB420 in Las Vegas on Wednesday, June 9, 2021. (Jeff Scheid/The Nevada Independent)

Heather Korbulic, who as head of the state’s health insurance exchange will have a key role in the development of the public option, said in a statement that she plans to “bring all 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.”

“In the meantime I'm going to continue to focus on getting Nevadans connected to Nevada Health Link where we have an open enrollment period that runs through August 15th and — thanks to the Biden administration — almost everyone eligible is getting financial assistance,” she said, in a nod to the American Rescue Plan’s expansion of exchange subsidies.

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

“I think that as an option for coverage, it definitely enhances that overall framework,” Whitley said. 

Under the new law, insurers that bid to provide coverage to the state’s Medicaid population will also be required to bid to offer a public option plan, with ultimate decision-making authority left to the state to decide how many plans to approve. The plans would resemble existing qualified health plans certified by the state’s health insurance exchange, though the legislation would require the public option plan or plans to be offered at a 5 percent markdown, with the goal of reducing average premium costs of the plans by 15 percent over four years.

The public option concept first surfaced during the 2017 legislative session, when former Assemblyman Mike Sprinkle (D-Sparks), introduced a bill to allow Nevadans to buy into the state’s Medicaid program, nicknamed Medicaid-for-all. While an amended version of that proposal, instead establishing a Medicaid-like plan, cleared the Legislature, former Gov. Brian Sandoval ultimately vetoed it. 

Sandoval, a health care advocate who earned plaudits from Democrats for being the first Republican governor in the nation to opt into Medicaid expansion under the Affordable Care Act and fought to protect the federal health care law in 2017, said at the time of his veto that the public option proposal was “moving too soon, without factual foundation or adequate understanding of the possible consequences.”

Sprinkle proposed a narrower version of his vetoed bill during the 2019 legislative session, nicknamed Medicaid-for-some, that failed to advance after he resigned from the Legislature facing allegations of sexual harassment. Cannizzaro revived the proposal in the waning days of that session in the form of an interim study of yet another public option proposal — this time to allow Nevadans to buy into the state Public Employees’ Benefits Program rather than Medicaid.

That study, which was carried out by the health policy firm Manatt Health, was released with little fanfare in January as lawmakers geared up for the legislative session during some of the pandemic’s darkest days. 

The study — which looked at both a PEBP buy-in proposal and a state-sponsored qualified health plan proposal — found that a 10 percent reduction in insurance plan premiums would translate to between zero and 1,500 uninsured individuals gaining coverage in the first year of the plan’s existence, while a 20 percent reduction would reduce the state’s uninsured population between 300 and 4,800 people. There are about 350,000 uninsured Nevadans.

“These enrollment figures highlight that a 10 percent or 20 percent reduction in premiums may not be enough to substantially encourage the currently uninsured to enroll in coverage for the first time,” the study concluded.

For the next couple of months, the public option remained in the background as lawmakers tackled other health care policies. But the public option resurfaced in mid-April when Cannizzaro confirmed she was working on legislation behind the scenes and started meeting with health care industry representatives to present the concept.

In late April, the proposal was introduced as SB420, this time with the goal of leveraging the state’s purchasing power with Medicaid managed care contracts with insurers to compel insurance companies to provide affordable public option plans, too. Unlike some previous iterations of the proposal, the plan would not be offered by a public insurer — such as Medicaid or PEBP — but by private insurers.

Proponents, including progressive groups like Battle Born Progress, the Progressive Leadership Alliance of Nevada and Planned Parenthood Votes Nevada, threw their weight behind the bill, arguing that the proposal would make health care more affordable and accessible. Opponents, including the Nevada Hospital Association, the Nevada State Medical Association and the Nevada Association of Health Plans, countered that it would do just the opposite, going so far as to destabilize Nevada’s already-fragile health care system.

Specifically, health care providers argued that a provision in the bill setting the floor for rates for the public option plans at Medicare rates — which providers say are better than Medicaid rates but not as good as those paid by private insurance plans — would act as an effective cap. They also pushed back on a section of the bill requiring doctors who contract with Medicaid, the Public Employees Benefits Program and workers’ compensation to participate in at least one public option plan.

Instead, opponents of the bill argued that the state should focus on targeting people who are uninsured but either eligible for Medicaid or for subsidies through the state’s health insurance exchange. Together, those two groups represent more than half of uninsured Nevadans. To that end, they proposed an amendment in the final days of the session to scale back the bill to just an actuarial study of the public concept proposal and to look further into how to get Nevadans already eligible for Medicaid or exchange plans insured. But that amendment that was never seriously entertained by Cannizzaro.

While many of the groups that testified in support of and against SB420 were Nevada-based organizations, the bill also attracted significant national attention, including support from the Committee to Protect Health Care, the Center for Health & Democracy and United States of Care and opposition from the Partnership for America’s Health Care Future, a coalition of some of the health care industry’s biggest names — including the American Hospital Association, America’s Health Insurance Plans, and the Pharmaceutical Research and Manufacturers of America — as well as the Koch-backed Americans for Prosperity and LIBRE Initiative. Many of those organizations devoted dollars toward their efforts, sending mailers and running ads in support of or against the proposal. 

Sisolak’s signature on the public option bill comes as interest in establishing a national public option, as President Joe Biden promised on the campaign trail, appears to be dwindling. Individual states, however, have continued to pursue their own public option proposals. Washington, the first state in the nation to enact public option legislation, has started to offer plans for sale this year and a bill creating the “Colorado Option” passed out of the Colorado legislature on Monday.

Former DETR head opens up about the threats she received during hearing on anti-doxxing bill

Heather Korbulic helmed the state’s Department Employment, Training and Rehabilitation during some of the pandemic’s darkest days last spring.

Thousands of Nevadans, who were thrust essentially overnight onto the state’s overwhelmed unemployment system as Nevada shuttered its economy in the early days of the pandemic, called Korbulic directly, desperate for relief as they struggled to navigate the claims system. Those Nevadans, she said, shared “equally compelling stories of desperation and fear.”

A small percentage, however, targeted their frustrations directly at Korbulic, and an even smaller percentage of those decided to “harass or threaten” her “with, at the very least, intent to scare” her, Korbulic told members of the Senate Judiciary Committee on Monday during a hearing on AB296, a bill sponsored by Assemblywoman Rochelle Nguyen (D-Las Vegas) that would create civil penalties for people who post people’s personal identifying or sensitive information online with the intent that that information be used for an unlawful purpose, otherwise known as doxxing. 

It was the first time Korbulic — who left DETR in June — has spoken publicly about the personal toll of the threats she received.

“I'm here today doing something I didn't want to do because I really believe in what Assemblywoman Nguyen is putting forward in Assembly Bill 296,” Korbulic said. “No one under any circumstance should be made to feel the way that my family and I felt when people were using my personally identifiable information to threaten and harass me.”

The bill would hold people liable for sharing such information if it causes death, bodily injury, stalking or mental anguish of the person or a close relation of the person whose information was shared, or would cause a “reasonable person” to feel mental anguish or fear any those consequences.

After the first legitimate threat to Korbulic’s safety, a law enforcement officer spent the night parked in front of her house while her husband and children were out of town. When neighbors asked her what was happening, she told them about the threat and asked them to keep an eye out for any suspicious activity.

“I went inside and I called my husband and I sobbed and I told him I was done because I couldn’t live like this,” Korbulic testified through tears. “He told me that I was stronger than the people who were threatening me and that he would cut short his trip and come home and install a security system.”

When her family came home, the kids were banned from playing in the front yard unsupervised because Korbulic was afraid that someone would kidnap them. The fear, she said, confused her children, who were angry with her over the new rule.

A few weeks later, in the middle of a meeting with lawmakers, someone posted Korbulic’s personal cell phone number on Facebook. She said that within a matter of minutes, she had more than 100 calls, and her voicemail box filled up with “hateful messages.” The calls were coming in so quickly she couldn’t even get through to Verizon to change her number.

“I sat down and I wept at my desk and I decided that I could no longer tolerate putting my family in this position and that I could not and would not live in fear for simply trying to do my job,” Korbulic said.

In June, Korbulic stepped down from the position, over what was described at the time generally as “threats to her personal safety” and returned to her previous job as executive director of the Silver State Health Insurance Exchange. She is currently serving as a policy advisor to Gov. Steve Sisolak.

During the Monday hearing, there was some discussion over a section of the bill exempting the sharing of information “which depicts a law enforcement officer acting under the color of law or a public officer acting in an official capacity” from punishment. Sen. Keith Pickard (R-Henderson) voiced a concern that the language would mean the people who threatened Korbulic would not be subject to penalties under the bill, and that the legislation could even invite people to dox police officers.

Lobbyists for the Las Vegas Metropolitan Police Department and the Nevada Sheriffs’ and Chiefs’ Association testified against the bill for that very reason, arguing that it unnecessarily exempts officers from protection. (Metro lobbyist Chuck Callaway also suggested that criminal penalties for doxxing, which were included in an earlier draft of the bill but were amended out, be left in.)

Bill proponents and legislative counsel, however, clarified that the bill would apply to a public official or police officer who is at home, after hours and being harassed. Legal counsel added that existing law currently prohibits the sharing of law enforcement officers’ home addresses or personal information that is confidential by statute.

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

Under proposed bill, push to change community college governance will start as a study

Sign in front of the UNLV College of Engineering

Gov. Steve Sisolak surprised the state’s higher education world this January when he suggested during his State of the State address that Nevada’s four community colleges should be governed by a “new independent authority” — presumed to be outside the existing Nevada System of Higher Education. 

“We need to recognize that our community colleges will play an even bigger role in workforce training,” Sisolak said at the time. “That’s why I will be asking the Legislature to work with the Nevada System of Higher Education over the next two years to develop a framework to transition Nevada’s community colleges to a new independent authority that will focus on making Nevadans job ready. Community colleges, together with union apprenticeship programs, are critical elements in building Nevada’s workforce and economic future.”

Then, it was unclear exactly what such an undertaking would look like, and community college presidents all deferred judgment on the idea until a concrete proposal existed. 

Several months later and that concrete proposal has finally emerged as AB450, which received an initial hearing last Thursday in the Assembly Education Committee. 

Sponsored by the governor’s office and presented by Sisolak’s policy director, Heather Korbulic, AB450 stops short of implementing any immediate changes. Instead, it would create an interim committee that would study workforce development programs at the state’s community colleges, as well as the role a change in governance structure could have in the way such programs — and the colleges themselves — are funded. 

“To reiterate, the governor believes that the NSHE funding formulas are in need of review, and that's why he specifically called on this study committee to analyze existing funding structures,” Korbulic said.

Last overhauled in 2013, those formulas ironed out differences between institutions through the use of weighted student credit hours, weighting more expensive courses, such as labs or graduate courses, higher than comparatively low-cost courses. 

However, community colleges have complained that the formula is “one-size-fits-all,” and that it does not adequately account for the material differences between community colleges and their research university counterparts. 

The seven-member committee would be split between education officials and economic development representatives, including: one member from the Governor’s Office for Economic Development; three members from local chambers of commerce (two south and one north); State Superintendent Jhone Ebert; Nevada System of Higher Education Chancellor Melody Rose; and one of the state’s four community college presidents. 

Though Thursday’s hearing on the bill was brief, a handful of questions did emerge over the committee’s makeup. Committee Chair Shannon Bilbray-Axelrod (D-Las Vegas) asked Korbulic if the governor’s office had considered the addition of labor group representatives, and later, a spokesperson for the Nevada Faculty Alliance testified against the measure so long as it excluded faculty and student representatives.   

In responding to Bilbray-Axelrod, Korbulic said the primary driver behind the committee’s small size was keeping it “quick and nimble.”

“So what we thought that we were doing is creating a bill that would allow for a lot of flexibility with primary stakeholders at the table and then allowing for subcommittees to be formed from there, and then also having a public forum in order to include all of the voices that felt like they wanted to be heard,” Korbulic said.

The bill received testimony in support from the Vegas Chamber, as well as testimony in neutral from the Clark County Education Association, which supported the measure in spirit but declined full support without assurances from lawmakers on CCEA’s pupil-centered funding plan. 

Waived through legislative deadlines, AB450 must still receive approval from the Assembly Education Committee before heading to the full floor for a vote.

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

In Carson City visit, Biden’s health chief announces extension of Obamacare special enrollment period

Health and Human Services Secretary Xavier Becerra announced Tuesday that a special enrollment period for the health insurance exchange created through Obamacare will be extended to Aug. 15, beyond the current deadline of May 15.

Becerra made the announcement while visiting a health care center in Carson City. He followed it up with a roundtable that featured Gov. Steve Sisolak and Heather Korbulic, a staffer for the governor and director of the Silver State Health Insurance Exchange.

Shortly after taking office, President Joe Biden signed an executive order creating a three-month special enrollment period for the marketplace, running from mid-February until mid-May. The marketplace offers health insurance plans for people who don’t have it through an employer, and those plans are eligible for significant government subsidies through tax credits.

Monday marked the 11th anniversary since President Barack Obama signed the Affordable Care Act. The measure prohibits health insurers from denying coverage or charging higher costs to people with pre-existing conditions, imposing annual or lifetime coverage limits and requires insurers provide coverage for dependents on their parent’s health plans until they are 26. 

At the health clinic, Nevadans who are beneficiaries of the Affordable Care Act shared personal stories and experiences with Becerra about the ways the expanded medical coverage has affected their lives. 

Dan Hamer, a Douglas County resident, explained the importance of his family’s health coverage as his 10-year-old daughter, Elsie Hamer, lives with cystic fibrosis, a genetic disease that affects her ability to breathe. With her condition, Elsie Hamer takes 75 to 85 pills a week to aid her digestion in addition to 14 pills to treat the root cause of cystic fibrosis. 

Dan Hamer said his daughter has spent six months collectively throughout her life in a vest machine designed to help clear her airways. 

“Without the Affordable Care Act, Elsie would potentially be subject to not being able to get health care… and that would dramatically affect our ability to care for her,” Dan Hamer said. 

Elsie Hamer’s medications would cost her family upwards of $390,000 annually. And while Dan Hamer said he is grateful to have good employer-provided insurance, their coverage doesn’t include visits to the emergency room or to the doctor. He also said others who are not as fortunate as his family suffer from a greater lack of access to health care. 

“Hitting our deductible is pretty common,” he said. 

Health and Human Services Secretary Xavier Becerra greets Elsie Hamer, 10, at a press event on the 11th anniversary of the Affordable Care Act at Nevada Health Centers in Carson City on March 23, 2021. Photo by Jazmin Orozco Rodriguez.

Amber Falgout told the roundtable that expanded federal and state health care coverage allowed her to leave an abusive relationship after getting pregnant at a young age, which she said left her dependent on her daughter’s father in order to receive health care. 

“I was able to get on Medicaid, and I was able to eventually leave that relationship and ended up being able to go to college and get two bachelor’s degrees,” Falgout said. 

She said her experience led her to pursue advocacy work with Battle Born Progress, a progressive nonprofit organization. 

Becerra called the passage of the Affordable Care Act “lifesaving” for families across the country and said expanding it is a nonpartisan issue. 

“It shouldn’t make a difference if you’re Republican or Democrat, red or blue,” Becerra said. “This is about health care for Americans. Some of these diseases, certainly COVID, does not discriminate based on your party affiliation.” 

During a roundtable meeting with Gov. Steve Sisolak and other state and local officials, Becerra congratulated Nevada for creating a state-based health exchange, Nevada Health Link, and a relatively quick vaccine rollout, as the general population over 16 will be eligible in less than two weeks on April 5. 

“It is nice to see that Nevada continues that pioneer spirit,” Becerra said. 

While most officials thanked Becerra for his visit to the state’s capital, some raised a few questions and concerns regarding the expansion of the Affordable Care Act — such as dental care. 

“In the last round of negotiations of the Affordable Care Act… we left out an important part of the body and that is the mouth,” said State Sen. Julia Ratti (D-Sparks), who chairs the Senate Health and Human Services Committee. 

Ratti also brought up making the expanded coverage more affordable for “middle Americans” who don’t qualify for the health exchange, to which Becerra replied that the federal government is “all ears” on making the measure more affordable. 

Assemblywoman Rochelle Nguyen (D-Las Vegas), who chairs the Assembly Health and Human Services Committee, said she was excited to see expanded Medicaid coverage for postpartum women in the American Rescue Plan, a COVID relief package signed into law earlier this month, and said she hopes those efforts will continue. 

The American Rescue Plan expanded the Affordable Care Act by allowing greater access to subsidies to pay for insurance. 

Sisolak celebrated Nevada surpassing one million vaccines being administered as of last week and asked one thing of Becerra and the federal government. 

“Whatever you can do to keep those vaccines coming,” Sisolak said.

Updated at 4:29 p.m. on March 23, 2021 to add additional details of Becerra's visit.

State prosecutes man for ‘threatening’ Facebook comments about Sisolak pandemic policies

Take a look at any of Gov. Steve Sisolak’s posts on Facebook, Twitter or other social media networks, and it isn’t difficult to find sharply critical comments or personal insults over his decisions in handling the COVID-19 pandemic.

But for Steve Feeder, a 60-year-old Clark County resident, his comments on Sisolak’s Facebook page this spring calling the governor a “tyrant” and stating that “like Hong Kong protesters we need to arm ourselves and form a militia and fight back” have resulted in real-world consequences — criminal misdemeanor charges.

Feeder is now awaiting a trial date next year over a series of Facebook comments made in May 2020 that sharply criticized Sisolak’s initial handling of the COVID-19 pandemic, after a Las Vegas Township Judge ruled in October that the state had met a minimal evidentiary standard for the misdemeanor crime of “inciting breach of peace.”

Several of his comments made unspecified violent calls to action against the state’s Democratic governor. 

“In any WAR which we are now in sheep will be casualties but we must March on,” he wrote in one comment on a May 19 post regarding the number of COVID-19 tests in the state. “If you enjoy getting [f*cked] in the SPHINCTER each morning continue to write here and get no results. It's time to fight back. If not say hello to your new TYRANT leader.”

Other incendiary remarks posted on Facebook by Feeder and cited by state prosecutors include more than three dozen instances of leaving a comment telling people to “arm themselves, form a militia, and go to war with the government,” a photo of Sisolak superimposed as a Nazi, and a GIF moving image of a gun pointed at a man’s head with the caption “I thought I saw John Wilkes Booth in the house.”

Prosecutors with the state Attorney’s General office said during a court hearing they often decline to bring charges just on social media-related threats directed at the governor and other public officials owing to the broad free speech protections in the First Amendment, but that Feeder’s comments were specific enough to warrant criminal charges.

“If you count all the threats, there's 34 of the exact same threats pasted on Governor Sisolak's page, which is open to the public for any crazy person to read it and act on it regardless of whether the defendant intended for somebody to act on it,” Deputy Attorney General Michael Kovac said during a preliminary hearing on the case in October in Las Vegas Justice Court. “The fact that he's posting that to Governor Sisolak's page shows a subjective intent to terrorize the governor. There's no other reason for him to post it there.”

Feeder was offered a plea deal prior to his preliminary hearing in Las Vegas Justice Court, which would have entailed a guilty plea to a single misdemeanor, a promise to stay out of trouble for six months, a $1,000 fine and a 120-day suspended sentence.

But an attorney for Feeder, Jay Maynard (who didn’t respond to an emailed request for comment), said in court filings and transcripts that his rhetoric — while incendiary — did not rise to the level of criminal conduct and are afforded free speech protections under the First Amendment. Feeder has pleaded not guilty to all charges, and has a jury trial set for June 2021.

Feeder’s attorney noted during a preliminary hearing that state prosecutors presented no evidence that Feeder had purchased a gun, planned a trip to Carson City, attempted to directly contact Sisolak or done anything beyond posting comments on Facebook. They also said his speech was not a specific enough call for violent action to warrant criminal proceedings.

“He was upset. Absolutely. He used some very pointed language. Absolutely. But he was protesting the fact that we had been in a quarantine for — as he put it at the time — 60 days, and that is well within his First Amendment right,” Feeder’s attorney said during that same Justice Court hearing in October. “Indeed, to be able to complain to our government is the most essential of the First Amendment rights. Political speech is protected beyond any other form of speech. It is sacrosanct and it is absolutely essential to the proper functioning of our democracy.”

Similar to federal law, Nevada has several laws on the books that criminalize making specific threats against an elected official. Feeder was initially charged with three crimes, including: 

Las Vegas Township Judge Karen Bennett-Haron ruled during an October preliminary hearing that state prosecutors had only met an initial standard of “slight or marginal evidence” on the count of publishing matter inciting breach of peace (a law added in 1911 which hasn’t been updated since), with the other two counts not sufficient to meet that evidentiary burden. That evidentiary standard is set at a higher level (proof beyond a reasonable doubt) in a misdemeanor case during the actual court proceedings.

Colter Earl of the Nevada Department of Public Safety, assigned to the investigative division as a detective, testified that he began looking into the case after receiving a complaint from the state’s Dignitary Protection Detail regarding “threats” made against Sisolak by Feeder on his Facebook page.

Earl told the court that he conducted a “knock-and-talk” investigation in May 2020 at the home of Feeder, who admitted to posting the comments on Sisolak’s Facebook page.

“His response was that his wife called him an idiot and that when I had showed up at his house that I was there for his rant,” Earl said, according to a court transcript. “He described himself basically as very angry and upset regarding the State's action in the COVID-19 response.”

Earl said that his division did not have a “rule book” determining when it was appropriate to investigate or bring charges related to social media threats, but that his division takes complaints from either public officials or from the Dignitary Protection Detail before conducting an initial investigation.

Investigators with the state also pointed to a litany of other comments left by Feeder, including calls for “civil disobedience,” telling the governor that “your [sic] the CANCER and your slow painful passing will be the cure” and saying that a family friend had prayed for “death to the tyrant and his family.”

While acknowledging that Feeder hadn’t taken any direct action beyond the Facebook posts, state prosecutors wrote in a court filing that making the threats in a “popular, public online forum amplifies the fear that Defendant (Feeder) might find a receptive audience of like-minded individuals willing to carry out such threats.” 

They cited recent cases including the arrest of three alleged members of the “Boogaloo” extremist movement in Las Vegas and the resignation of the state’s former Department of Employment, Training and Rehabilitation Director Heather Korbulic over threats made to her safety after less than two months on the job.

“It is an environment on edge, filled with angry, impulsive, and dangerous nutcases, many of whom are armed and appear ready to take action,” prosecutors with the attorney general’s office said in a filing. “It takes only one of these nutcases to be moved by one of these exhortations and decide to cross the oftentimes fine line separating vitriol from violence.”

But Feeder’s attorney still holds that the state failed to meet the minimum standard needed to overcome First Amendment protections: an “immediate call to an audience that the speaker knows is receptive.”

“Crazy people aren't the standard,” Feeder’s attorney Maynard said during the June evidentiary hearing. “The speaker has to know that his audience is receptive to an immediate calling. We don't see that anywhere.”

Indy Q&A: Exchange director Heather Korbulic talks ACA lawsuit, open enrollment during a pandemic

An Ipad with showing the health link website

As open enrollment kicked off on Nevada’s health insurance exchange earlier this month, the U.S. Supreme Court heard oral arguments in a case challenging the constitutionality of the law on which the exchange was built, the Affordable Care Act.

Though the court likely won’t rule on the case, California v. Texas, for several months, a majority of justices during oral arguments indicated they may be leaning towards finding only one portion of the federal health care law — the mandate requiring individuals to purchase health insurance — unconstitutional while leaving the rest of the law intact. That group of five justices includes three liberal justices and two conservative ones.

Heather Korbulic, the executive director of Nevada’s health insurance exchange, said the hearing came as a “sigh of relief” for her and the heads of other state exchanges around the country, though she noted that it’s too early to know for certain which way the court will rule.

“I think it’s cautious optimism,” Korbulic said, “and it’s very unique to see Supreme Court justices show their cards in the manner in which they did during the hearing.”

In the meantime, enrollment continues on the health insurance exchange until Jan. 15, with five health insurance companies offering 50 plans for purchase, nearly double the number of plans available last year. Korbulic is urging people to take advantage of the open enrollment period to get covered amid the ongoing coronavirus pandemic.

“If you are taking a risk with your health in terms of going without insurance, you're also taking a really significant financial risk,” she said.

Korbulic spoke about all of this and more in an interview with The Nevada Independent last week. The following has been edited for clarity and length.

To start off, let’s talk a little bit about open enrollment. What plans are available to folks this year and what’s changed from last year?

This year we have two new carriers that have joined the exchange, and that is Friday Health Plans and SelectHealth. SelectHealth is only in the Vegas area and Friday Health Plans has joined every one of our rating areas, so they are statewide. They're joining Health Plan of Nevada, SilverSummit, and Anthem who are returning this plan year. So between all of them, we have five carriers, and we've almost doubled our plans from the previous year. We have 50 plans available this year and last year we had about 27.

The rate increases this year are about 4.2 percent, which is relatively stable, and most importantly, consumers who get subsidies, or who get financial assistance, don't see really any impact from those rate increases because their subsidy increases as the rate increases, too.

Numbers-wise, how is open enrollment going so far?

We haven't released any of our numbers yet, but from what I can see, we're looking to be doing equally as well, if not slightly better, than in previous years, which does sort of surprise me just in terms of the noise factor of the elections sucking all the air out of the room in terms of getting attention to the exchange in our open enrollment period. So that does bode well.

I think we know there are a lot of Nevadans who have lost their jobs and who have lost access to those health plans through their employer, and so we've been doing a lot of targeted outreach to those folks to make sure that they understand open enrollment exists, preparing them for when they fall off of their COBRA plans or when they're no longer paying for COBRA and then really working on through DETR [the Department of Employment, Training and Rehabilitation] and the Division of Welfare and Supportive Services to get the word out to people who may not be eligible for Medicaid much longer or who have lost their jobs about open enrollment and getting connected right now.

What has enrollment on the exchange during the pandemic looked like this year generally?

Before I say much more about just this last year, I think it's safe to put out there that there has never been a normal or stable year of enrollment on the exchange. Every year the Affordable Care Act has had some kind of drama or trauma, and this year is no different, really.

What we've seen throughout the last eight months of the pandemic is an increase in special enrollment periods. People are taking advantage of the fact that you can get enrolled within 60 days of a qualifying life event. In general, most of those qualifying life events have been losing their employer-sponsored coverage. We also saw an uptick of about 6,000 new enrollments, when we had an emergency special enrollment period just related to the pandemic.

We also are a fully autonomous state-based exchange this year, which means we have the ability to do that emergency special enrollment period and we also have the ability to do what our board has decided to do for this open enrollment, which is to extend our open enrollment period by an additional 30 days. So our enrollment period will run from November 1 through January 15, whereas HealthCare.gov is stopping their enrollment on December 15. 

All of that and the competition that we've added to the marketplace this year really does contribute to a very opportune moment for Nevada consumers to get connected to plans that have subsidies that make them affordable, and the qualifications of being under an ACA plan makes those plans very comprehensive. 

Turning to the Supreme Court case, you’ve been emphasizing the point that, whatever happens, people should still feel comfortable enrolling in plans because you’re not expecting a decision in that case to have any impact on this upcoming plan year. Is that right?

It's an interesting dynamic because, on the one hand, absolutely, the impact of having a repeal of the Affordable Care Act is and could be equivalent to chaos in our health care systems at the state level and at a national level, and there are a lot of significant consequences should the ACA be overturned, and then when you put that in the context of the fact that we have a national public health crisis and a national economic crisis happening, the compounding factor of chaos just gets worse. 

At the same time, my job is to also make sure that Nevadans understand and that plan year 2021 is happening and there are better deals for them, there are more carriers, there are more opportunities, and that pandemics are a very bad time to be uninsured. You absolutely should be getting coverage from comprehensive health insurance that will cover the diagnostics and the treatment of COVID and not be duped or fooled into purchasing a plan that isn't as comprehensive and could potentially leave you on the hook for a lot of medical bills.

During oral arguments in the Supreme Court case last week, it seemed like justices, both some of those that would be considered liberal and more conservative justices were leaning against throwing out the entire Affordable Care Act. What is the chatter in the world of state exchanges? 

I think, in general, there is a bit of a sigh of relief, but if 2020 has taught us anything it’s to not really put all your eggs in one basket, and so I think it's cautious optimism, and it is very unique to see Supreme Court justices show their cards in the manner in which they did during that hearing, with some of the more conservative justices being very focused on the matter of severability, and the conversation about Congress's intent was extremely interesting. In terms of how I feel and how my colleagues feel across the country, it is to feel very optimistic.

Back in 2017, when Congress made the decision to zero out the individual mandate penalty, there was a lot of concern that doing that would lead many people to not want to get covered. But it seems like over the last couple of years, that hasn’t played out in the way many expected it to. Is that a fair assessment? 

I think that's absolutely fair. I was one of those people banging the pot and pan saying I think this is going to be a real problem if we don't have a penalty, and I'm happy to say that I was proven wrong. I think what happened over the first several years of the Affordable Care Act is that we started building momentum with folks realizing how important it is to have that comprehensive coverage and really there was no there is no going back for those folks. They're not being motivated by a penalty as much as they are by the benefits that are provided under their plans.

If the Supreme Court makes the decision to just strike down the individual mandate penalty and leave the rest of the Affordable Care Act standing, would there be any measurable change to the exchange in Nevada?

No, none that I could anticipate. I don't see there being any changes in the approach that we have, nor do I see there being any changes in state statute or really manifesting any consequences at the federal level, either, to be honest.

If the Supreme Court rules in a broader fashion and strikes down the entire Affordable Care Act as unconstitutional, do you have any sense of what that would mean for Nevada?

That's a question that I have asked every single person who pays attention in this space, because, of course, that is something I am desperate to know. But I think in terms of when they'll make a decision, it'll be sometime in the middle of 2021, June or July, of next year, and in general, the Supreme Court may decide on the ruling of law, but they don't decide on the mechanisms on which to unwind. So it is likely that the court would potentially decide to repeal, or whatever the word is that we want to use here, the Affordable Care Act and then kick it to lower courts for a determination on how to implement those changes and working through the timeline. I do think that would take quite a bit of time, and that's why I feel confident saying I don't think there are any consequences that can be expected even if the worst case scenario plays out for plan year 2021.

Tying things up, we’re in the middle of a global pandemic and there is a risk to not having health insurance and falling ill, whether it’s with COVID or any other health issue that might normally come up. Why is it extra important that folks get insured this year?

If COVID has taught us anything as a state it is that health is wealth. I think at least every Nevada now must know somebody who got sick with the coronavirus and got very, very ill if not knowing someone who has passed away. If you are taking a risk with your health in terms of going without insurance, you're also taking a really significant financial risk, because having to go to the doctor alone can be very expensive when you're sick, but going to the doctor or going to the hospital and having extended stay is, I mean, bankruptcy-level expensive. 

Most importantly, we need to encourage our loved ones and our family members who are uninsured or underinsured in these plans that are not as comprehensive to get connected with a plan on Nevada Health Link because there are consequences to all of our public safety. When you don't have insurance you are less likely to be willing to go to the doctor and to get treatment, which means if we have people who are sick with the coronavirus in the community who are uninsured and unwilling to get treatment as a result of that they could be much more likely to be spreading that throughout the community, and that is deeply concerning to me.

As Supreme Court set to hear Affordable Care Act case, open enrollment begins on Nevada’s health insurance exchange

An Ipad with showing the health link website

Though the U.S. Supreme Court is set to hear oral arguments in a case challenging the constitutionality of the Affordable Care Act next week, Nevada’s health insurance exchange isn’t anticipating any impact on next year’s policies.

Instead, exchange officials are urging people to get enrolled during a 75-day open enrollment period that started on Sunday, cautioning against going without insurance coverage in the time of the coronavirus pandemic. This year’s open enrollment period runs through Jan. 15, with people who enroll before 11:59 p.m. on Dec. 31 slated to have their coverage begin on Jan. 1, while coverage for those who enroll later will start on Feb. 1.

“All of our plans are Affordable Care Act compliant, they cover 10 essential health benefits such as mental health, pregnancy, childbirth, prescription drugs, and emergency services, including the coverage of all pre-existing conditions,” Heather Korbulic, the exchange’s executive director, said during a press conference on Monday. “And importantly, they cover a COVID-19 diagnosis and treatment. There is no need to purchase any additional plan.”

This year, Nevadans will be able to choose between 50 plans, nearly double the number of options available in past years, across five health insurance companies: Health Plan of Nevada, Silver Summit, Anthem, Friday Health Plans and Select Health. Though health plan rates have increased about 4.2 percent this year, exchange officials have noted that those who qualify for assistance in purchasing their plans will also see increases to their subsidies.

“Most of our consumers will have very minimal, if any, premium cost increases,” Korbulic said.

She added that a ruling on the latest lawsuit challenging the constitutionality of the Affordable Care Act lawsuit, which has been winding its way through the federal court system since early 2018, isn’t anticipated until several months into 2021. In the lawsuit, a coalition of Republican state attorneys general have argued that the Tax Cuts and Jobs Act, which Congress passed in 2017, rendered the ACA unconstitutional by zeroing out the ACA’s tax penalty on individuals who don’t have health insurance.

“We do not anticipate any impacts on plan year 2021,” Korbulic said.

Last year, Nevada asked to join the coalition of states defending the Affordable Care Act in the lawsuit. Attorney General Aaron Ford, on Monday, said that seniors, women and low-income individuals, among others, would be hurt if the ACA is overturned.

“We are in fact, as I've indicated, dedicated to ensuring that your health is protected,” Ford said.

Sisolak announces ‘strike force’ led by former lawmaker to improve unemployment claims processing

Gov. Steve Sisolak has appointed former lawmaker and legal aid center leader Barbara Buckley to lead a “strike force” focused on improving the processing of Nevada’s backlogged unemployment claims.

At a press conference on Thursday in Carson City, he also named Elisa Cafferata — who was most recently a top administrator in the state’s welfare division — as the acting director of the Nevada Department of Employment, Training and Rehabilitation. The post has been vacant since Heather Korbulic resigned in June, citing threats to her safety.

“I want you to know, I hear you. I am listening, and I am taking action,” Sisolak said in prepared remarks. “One individual, one family going without benefits they deserve and need to pay the bills, put food on the table, is one too many.”

Sisolak said Buckley will work for the next 60-90 days with support from federal CARES Act dollars, and that she has already started consulting with experts to work on improving the business and technology processes at the agency. Hundreds of thousands of the more than one million initial claims for benefits filed during the pandemic have gone unpaid for a variety of reasons, including processing delays, duplication and ineligibility but also because many are flagged as fraudulent.

Through last Friday, there have been 991,641 initial claims for unemployment in Nevada since mid-March, including 606,146 for the standard program and 385,495 for the Pandemic Unemployment Assistance (PUA) program for gig workers and the self-employed. Of those, about 420,000 individuals have been paid. Nevada's total workforce is estimated at 1.5 million people.

“All options will be considered to bring more IT, personnel and policy resources to reduce this backlog in the short-term,” the governor said in prepared remarks, “and consider how our program needs to evolve for the long- term to ensure that we can serve Nevadans in the best way possible during this pandemic and beyond.”

In June, people who had applied, with varied success, to the PUA program in Nevada filed a class-action lawsuit seeking immediate payment. A Washoe County judge declined to issue the order and, instead, appointed a Reno lawyer as a special master to investigate the issue of delayed claims.

Jason Guinasso, the court-appointed special master, prepared a lengthy report detailing bottlenecks and possible solutions in paying PUA claims. Asked about how that report would dovetail with the newly created strike force, Sisolak declined to comment on the pending litigation other than to say, “We’ll just have to wait and see.”

“It’s going to resolve a lot of complaints and hopefully in a much quicker manner than was done in the past,” he said, referring to the strike force. 

Buckley, a former speaker of the Assembly and head of Legal Aid of Southern Nevada, said she already has enlisted the help and expertise of public and private sector leaders. The group has been brainstorming solutions such as a data verification plan that could overcome an identity verification issue that has been holding up one group of claimants. That fix, she said, could lead to those claims being approved in the next week.

They’re also eyeing the possibility of temporarily transferring welfare eligibility workers to assist with processing unemployment claims. And Buckley said the state would also be creating an online dashboard to provide updates to the public about the backlog and the progress working through it.

“All solutions are on the table, and the governor has made it clear that this is urgent and that all resources of state government will be engaged to help,” Buckley said. 

Sisolak also acknowledged the role fraud has played in slowing down processing of claims. This week, U.S. Attorney Nick Trutanich announced the arrest of a Las Vegas man found with at least 23 unemployment debit cards from Nevada and Arizona in other people’s names, and there have been widespread reports of DETR notifying employed people that someone has filed for benefits on their behalf.

DETR officials have said they can’t provide a precise number on fraudulent claims, and Sisolak after the press conference said he didn’t know when a precise number would be available. Agency officials have said that they believe upwards of 100,000 filings in the Pandemic Unemployment Assistance program are illegitimate, and Trutanich said the arrest “is likely just the proverbial ‘tip of the iceberg.’”

“We are going to prosecute to the fullest extent of the law as we uncover bad actors,” Sisolak said. “That’s a guarantee.”

At the press conference, Sisolak also signed SB3, a bill passed nearly unanimously in the Nevada Legislature’s just-concluded special session that gives the unemployment agency more flexibility and intends to speed processing of claims. It will also unlock an additional seven weeks of federally funded benefits for those who have exhausted other allotments.

Nearly 17,000 more PUA claimants received first payments in past week, but initial claims rolling in at nearly double that pace

More than 95,000 Nevadans who have filed claims with the Pandemic Unemployment Assistance (PUA) program have received payment so far, a jump of nearly 17,000 from the number who were receiving money as of a week ago — even as many claimants continue to air frustrations that their benefits haven’t come through.

Kimberly Gaa and David Schmidt, two top officials from the Nevada Department of Employment, Training and Rehabilitation (DETR), provided the update in a videoconference on Friday. It was the first time that the weekly briefing did not include Heather Korbulic, who announced last week that she was leaving the role as head of the inundated state agency because of threats against her personal safety.

“I want to express my thank you to all of the DETR team that continues to carry on each day, ever-focused with the mission-critical work throughout the duration of this pandemic,” Gaa said during an extended period of thank-yous before launching into the numbers. “Your successes are countless, and know you have the support to continue the critical work of connecting Nevadans to their benefits.”

The PUA program, which is federally funded and serves independent or self-employed workers that are ineligible for standard unemployment benefits, has seen heavy demand and faces sharp criticism from many claimants who have not yet been paid. Some have said they are desperate and fear losing their homes after months without income, although Thursday’s announcement that an eviction moratorium will last until September is expected to buy many of them more time. 

There have been 190,262 initial claims filed for PUA as of yesterday, and 141,783 of have filed weekly claims — something required before the state can make payments. Of those, 95,460 have received payment, or about two thirds of those that could possibly be paid.

That means there’s a gap of about 46,293 people who filed weekly claims that have not been paid. But Schmidt said Nevadans should not expect all of the claims to be paid; he said the number of applications filed appears to be outpacing the estimates of how many self-employed people there are in Nevada, which is thought to be anywhere from 85,000 to 200,000 people. 

“The important figure is not 100 percent payment of all initial claims but proper payment of all claims that are filed,” he said. “As with other states, Nevada is seeing an unusually high level of potential fraud in the PUA program compared with the UI program and significantly more claims within PUA will need to be held for fraud review as a result.”

He offered as an example the 34,000 PUA claimants who filed for benefits for one or more weeks in the month of February. Because the first case of COVID-19 was not announced until March 5, and business shutdown orders did not kick in until mid-March, Schmidt said, it was “highly unlikely” there would be a significant number of eligible claims in Nevada from February.

He said that while he can’t offer details on active investigations, "there are large and active efforts by coordinated groups and organizations and individuals to commit fraud. This is not unique to Nevada."

Among other eligibility requirements, PUA claimants must be unemployed, underemployed, unable to work or unavailable for work in a particular week because of COVID-19.

One major chokepoint in people landing their benefits has been questions about whether an applicant is eligible for PUA or for traditional unemployment benefits paid through the state’s trust fund. Federal regulations require states to determine whether someone qualifies for the state program before paying out PUA.

As of earlier this month, some 40,000 PUA claims were awaiting a decision from one of eight state employees qualified to make decisions on claims on which it’s not immediately apparent which program to pay from.

One of those unpaid claimants who is unclear on her status is Kiera Sanchez, who believes she should be drawing from the state program because she worked at the beauty supply store Ulta. But she’s filing claims through both programs while she’s furloughed because she has yet to receive payment and is not completely sure.

She also hit a snag because an unemployment account she used several years ago was under her previous last name and she was unable to create an account under her new name. She designates two days a week that she devotes to trying to get through the unemployment phone lines to resolve the issues.

Sanchez, who has three children and just learned she is expecting her fourth, said the ordeal has affected the self-confidence and savings that she had been building before the pandemic after entering recovery. 

“It's put me in kind of a dark place,” she said. “I remind myself that I didn't do this to myself.”

She’s getting by only after her fiance was released from a conservation camp last month and has been able to return to work. Still, having the money would mean the ability to leave the transitional housing she’s at now and find a more permanent living arrangement to accommodate her growing family.

“I don't feel for myself. I feel for the people who are about to be homeless and carless,” she said.

Claims adjudication

An amended lawsuit filed against DETR this week seeks a court order compelling the agency to pay PUA claimants who have been declared preliminarily eligible for the program, even if it’s unclear whether they should be drawing from PUA or standard unemployment. 

While the agency declined to comment directly on the pending litigation, a spokeswoman said DETR “is confident that all actions taken related to Pandemic Unemployment Assistance (PUA) are in line with federal law and guidance” and pointed to memos giving parameters to state agencies administering the programs.

"We are leveraging every waiver and every flexibility already that the DOL and the governor's office ... has given us,” Gaa said. “We also continue to add additional staff."

The agency did not offer specifics on how its staff count has changed. DETR officials told lawmakers in early June that they had requested an additional 133 positions from the pandemic period through the end of June, in addition to adding contract vendor Alorica, which was asked to staff a 100-person call center and a 35-person PUA claims adjudication team. 

"We are actively recruiting. We have hired a number of staff. I know that there's been many questions specific to the numbers, but it's changing every day and every week because we're adding staff all the time,” Gaa said.

Other statistics

Initial claims for standard unemployment benefits ticked down slightly to 10,347 in the week ending June 20, but there have still been 538,892 initial claims filed in the year 2020 to date. Some individuals may have filed more than one initial claim if, for example, they were on benefits, got a job and then were laid off again during the pandemic.

There were 29,440 initial claims for PUA benefits last week, which was up nearly 5,000 from the prior week.

Continued claims — which are those filed week after week for benefits — totaled 294,649 last week, a 5.6 percent drop from the week before.

“This is the first report since April where the total number of continued claims has fallen below 300,000, indicating a return to work for some claimants following the re-opening of businesses across the state,” the agency said in a press release.

Continued claims in the PUA program totaled 114,776 last week.

The insured unemployment rate, or ratio of continued claims in a week to the total number of jobs eligible for standard unemployment benefits, fell 1.2 percentage points to 21.4 percent.

That figure is different from the widely recognized unemployment rate, which was 25.3 percent in the month of May. Nevada’s rate is highest in the nation and nearly double the national rate of 13.3.

At the end of last week, the state’s unemployment trust fund stood at just over $1 billion, or enough to pay out nine weeks of benefits.

While the balance is about half of what it was before the pandemic, Schmidt emphasized that the state can borrow money from the federal government to cover benefits if the fund runs dry.

More than $3.7 billion in benefits have been paid to Nevada claimants so far this year, with the largest share coming from the Federal Pandemic Unemployment Compensation program that adds $600 payments to the base PUA or standard benefits a claimant receives each week. That program is set to expire at the end of July.