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.

Senate committee advances bill to create ‘988’ mental health hotline, set plan for allocating opioid settlement funds

Pills spilling from bottle

A legislative committee unanimously passed a bill that would create a state fund to house proceeds from opioid settlements, such as those against prominent pharmaceutical companies accused of helping fuel the opioid crisis.

It also would establish a behavioral health crisis hotline using a federally mandated 988 phone number, rather than a longer and harder-to-remember 10-digit number for a suicide hotline.

“This one I have a particularly high level of enthusiasm for because I think both of the components in this bill had the opportunity to really move the needle in our behavioral health,” Sen. Julia Ratti (D-Sparks) said during a hearing of the bill, SB390, on Thursday evening.

Opioid litigation funds

The bill would establish the “Nevada Fund for Healthy Communities,” which would hold the proceeds of state litigation against opioid manufacturers, distributors, sellers and marketers — including the $45 million Nevada is set to receive from the settlement of a lawsuit against consulting firm McKinsey & Company, which provided services for opioid manufacturers.

Ratti, who presented the Senate Health and Human Services Committee measure, explained that the fund would be used by the Department of Health and Human Services to remediate the negative impacts of the opioid crisis on the state.

Ratti said the bill would also work in tandem with another piece of legislation from Assemblywoman Jill Tolles (R-Reno). Her bill, AB374, which passed an Assembly committee this week and faces a possible vote of the full Assembly, would establish a statewide “Substance Use Response Working Group” in the attorney general’s office that would set out to prevent or reduce substance through mitigation and treatment efforts, education and examining behavioral health data.

In distributing the money from the fund, the department would solicit grant applications from local agencies and non-profit organizations and award grants based on recommendations from the working group as well as a comprehensive needs assessment first conducted by the department. Ratti provided one example of what the relationship between the state and local agencies could look like.

“If the county had the resources from their lawsuit to build a transitional housing property, because they got some one shot from these settlements, the state could put some of these dollars into Medicaid to leverage the services to be provided in that facility,” she said. “You might see the two partners collaborating in that way… collaborating together to address the impact.”

The fund could potentially hold billions of dollars in the coming years, Attorney General Aaron Ford said during the hearing presentation. Ford said that his office is pursuing opioid litigation against more than 60 defendants, including pharmaceutical companies Johnson & Johnson, Noramco and Cephalon. He also noted that, similar to the settlement with McKinsey & Company, his office continues to pursue litigation specifically for the benefit of Nevada, rather than as a part of multi-state litigation.

“Nevada's total share would not be enough to address or remediate the harms caused by the opioid epidemic in Nevada,” Ford said. “We are one of the hardest hit states, as I've said. And so my office is continuing to monitor these discussions, but we're moving forward with our own litigation in Nevada.”

Proceeds for the fund might come over a multi-year span, though. Ford said that some litigation was delayed by the pandemic, and because of the differences in litigation being pursued against the more than 60 defendants, money won would likely come in at different times.

Ratti explained that the bill would establish a plan and help generate ideas for how to spend that money as it is received by the state. 

Behavioral health crisis hotline

The bill also would set up a hotline, referred to as 988, that is mandated by the National Suicide Hotline Designation Act of 2020.

The federal bill requires states to move from a 10-digit suicide hotline number to a three-digit number (988), and the rollout of the new behavioral health crisis number has to be complete by July of 2022.

Stephanie Woodard, the state’s senior advisor on behavioral health, said the new number would work as a transition from the existing National Suicide Prevention Lifeline that already has call center personnel in place to a new easier-to-reach number that would improve the state’s behavioral health care system.

“The ideal crisis system would match the right intervention to the right person at the right place in the right time,” Woodard said during the hearing. “Without such services, individuals may forego the care that they need, or unnecessarily use high cost services such as emergency rooms.”

And though the 988 line builds off of the existing suicide prevention line, Ratti noted that part of the work in setting up the line will include ensuring members of the public know they can call the 988 line in the event of a behavioral health emergency, rather than calling 911 as many people are likely accustomed to.

The 988 line received significant support from the public, including the Nevada branch of the National Alliance on Mental Illness.

“A call for help shouldn't result in trauma or tragedy,” said Robin Reedy, executive director for the alliance. “Building a 988 crisis system in our state will move us closer toward a shared goal: a respectful, dignified and effective response to everyone who experienced mental health, substance use or suicidal crisis.”

The measure next faces a possible vote on the Senate floor.

Amazon surpasses Walmart for most Nevada employees and dependents on Medicaid

A sign for an Amazon distribution center, including the company's logo

Amazon has surpassed Walmart to become the employer with the most employees and dependents on Medicaid in Nevada, according to a new report from the state. 

The number of Nevada Amazon employees and dependents on Medicaid nearly doubled year over year, increasing from 4,040 to 7,892, despite statements on the company’s website that they offer medical, prescription drug, dental, and vision coverage to all of their employees, regardless of their level or position. Amazon reports having more than 10,500 full and part time jobs in the state.

The massive jump in Amazon employees and dependents covered by Medicaid came alongside a significant jump for Integrity Staffing Solutions, a job placement company that has two of its three listed Nevada offices located at Amazon fulfillment centers.

Integrity Staffing Solutions was the fifth-largest Nevada employer of Medicaid-covered employees and dependents in the 2020 fiscal year, increasing from less than 500 in the previous year to 1,746.

Walmart, the leading employer of Nevada Medicaid recipients in the last three fiscal years, fell behind Amazon, but its number of Medicaid-covered employees and dependents also continued to rise, increasing about 11 percent from the previous year to 7,725 in the last fiscal year.

Of the nearly 8,000 Nevada Walmart employees and dependents on Medicaid, 3,429 were company employees. The company reports having 14,548 employees in the state. Amazon would not indicate how many people it employs in the state.

Quentin Savwoir, the political director of Make It Work Nevada, a progressive non-profit and advocacy group, sees a problem with these increasing numbers. 

“If these corporations like Walmart, like an Amazon, invested in things like paying families quality, affordable childcare, or even just paying their employees equal pay, that would go a long way to making the lives of the women and families we work alongside a little bit better,” said Savwoir. “They wouldn't have the need to rely on the social safety net.”

When asked for comment, Walmart’s communications department offered information about the pay and health care coverage provided to employees, including that the average total compensation and benefits for its hourly employees, both full- and part-time, is more than $18 an hour as of last January — and that eligible full- and part-time employees can receive medical coverage beginning at a cost of $30.50 per biweekly pay period. It also stated that the company’s goal is “moving people beyond entry-level jobs.”

An Amazon spokesperson said that the figures in the report are misleading because they include part-time workers and people who were only employed by Amazon for a short time, including seasonal employees.

"We have hundreds of full-time roles available, however, some prefer part-time for the flexibility or other personal reasons,” an Amazon spokesperson said.

In Nevada, households with annual incomes of up to 138 percent of the federal poverty level — $16,753 per year for an individual or $34,638 per year for a family of four — may qualify for Medicaid. A single adult with three children would have to earn almost $17 per hour while working 40 hours per week to no longer be eligible for Medicaid.

That means that even full-time employees working for companies like Amazon and Walmart could qualify. Amazon pays its employees a minimum wage of $15 per hour, and Walmart employees in Nevada earn an average wage of $14.84 per hour.

The report from the Department of Health and Human Services’ Office of Analytics, which was mandated by a bill the Legislature passed in 2017, comes on the heels of a nationwide report released last November by the Government Accountability Office (GAO) that showed some similar trends.

The GAO report found that across the 11 states studied, Walmart was consistently one of the top employers of Medicaid and SNAP recipients. The report also showed that Amazon was among the top employers of workers on Medicaid. 

Sen. Bernie Sanders of Vermont, who commissioned the GAO report, called the findings “morally obscene.”

“U.S. taxpayers should not be forced to subsidize some of the largest and most profitable corporations in America,” Sanders said in a press release.

The growth in Medicaid recipients from employers with 50 or more employees resulted in an increased cost to Nevada Medicaid of $2.8 million from the 2019 to 2020 fiscal year.

That increase was much less than the combined increase for Amazon and Walmart employees — which in 2020 was nearly $12 million more than the previous year. However, that was offset by the decrease in the number of employees and dependents covered by Nevada Medicaid at other companies, including Clark County School District, Smith’s Food and Drug and Wynn Resorts.

During the 2020 fiscal year, Amazon and Walmart employees and dependents’ cost to Nevada Medicaid was more than $43 million. In that same period, the cost to Nevada Medicaid from companies with 50 or more employees was approximately $737 million.
As of November, more than 761,000 Nevadans were enrolled in Medicaid, which was 120,000 more than the 2019 Legislature had predicted. To account for that growth, Nevada will spend an additional $153.5 million on Medicaid in fiscal year 2022, according to the latest state budget proposal.

This story was updated at 1:00 p.m. on January 22 to include comment from an Amazon spokesperson.

This story was updated at 2:00 p.m. on January 22 to include information about the number of jobs Amazon has in Nevada.

Medicaid drives Nevada's share of federal funds

United States Capitol building

By Michelle Rindels and Megan Messerly

After years of being a “donor state” that gives more to the federal government than it gets back, Nevada’s become a “recipient state” that gets more than it gives — mainly due to an influx of new federal money from the state’s move to expand Medicaid beyond the poorest of the poor.

Nevada now receives $1.14 in federal money for each $1 it pays to the federal government in taxes, compared with 2005, when it got back $0.65 for every dollar it put in, according to the nonprofit Federal Funds Information for States.

But in spite of the improvement, critics say Nevada is still leaving hundreds of millions of federal dollars on the table each year for other states to grab, giving its citizens short shrift on potentially life-altering programs like Head Start, special education and welfare.

Researchers at UNLV’s Lincy Institute concluded in a 2014 report that Nevada is shortchanged by $529 million each year compared to fellow states in the Intermountain West when Medicaid isn’t counted. Nevada’s procedures for getting a grant approved are too cumbersome, they found, and the state isn’t forking out enough state matching funds or hiring enough people to help it apply for grants.

“Nevada has always been stingy with the size of its government. ‘Why are we going to pay someone not to do a job but to get us money?’” said UNLV political science professor David Damore. “These people could be rainmakers, but there’s been a short of short-term thinking.”

Sandoval was the first Republican governor to commit to expanding Medicaid under the ACA in December 2012. More than 630,000 Nevadans were covered under Medicaid in November 2016, a number that’s projected to increase to 680,000 by mid-2019, and the costs for those newly eligible enrollees is almost entirely covered by the federal government.  

Nevada now receives $1,437 from the federal government per resident — an increase of $540 from 2010 — and Medicaid funding accounts for $873 of those dollars. Another $563 comes from non-Medicaid funding sources.

The Silver State saw the biggest percentage point change (14.2 percent) in Medicaid matching rates from 2010 to 2015. That jump is responsible for putting Nevada behind only Oregon in states that have seen the highest change in per-capita spending from the federal government since 2010.

At the same time, non-Medicaid funding in Nevada has actually decreased, dropping from $587 per capita in 2010. The state also ranks 51 out of 52 in the nation in terms of education funding, receiving only $96 in federal funds per capita.

The Lincy Institute pointed to a number of systemic barriers that keep Nevada from getting in the game when it comes to federal grants. While 59 percent of federal money flowing to Nevada comes in the form of direct payments like Social Security or veterans' benefits, and 22 percent goes to federal employees and contracts including defense spending, 19 percent is grants that Nevada must work for.

Researchers said state officials they interviewed pointed to the lack of state matching funds as the main reason they don’t seek federal funding, and those officials indicated they don’t even see a state contribution as a viable option. One interviewee said “If a grant comes across the desk that has a match — it goes in the trash,” according to the report.

Where other states have been strategic about siphoning money into programs that allow them to receive federal matching dollars, Nevada hasn’t, said Damore.

“The federal government will say, ‘You put in a quarter and we’ll put in a dollar,’” Damore said of federal grants that require a match. “But we don’t put in a quarter.”

The Lincy Institute also said there aren’t enough qualified, experienced grant writers and grant administrators to design and implement projects that would win grants.

State lawmakers have been working to shore up Nevada’s poor performance in the grants race. In 2011, the Legislature unanimously created the Nevada Grants Office to help state agencies seize grant opportunities, and an Advisory Council on Federal Assistance has been working on the issue since the end of the 2015 session.

The council recommended setting up a statewide grants management system so it’s easy to see which agency applied for grants and to identify opportunities, according to former Assemblyman Derek Armstrong, its vice chair.

Another proposal that’s expected to come before the Legislature this spring would make changes to the grants office, including adding an additional staff member.

One council idea that didn’t make it into the governor’s budget was setting up a “match fund” that grant applicants could tap into if a federal grant required some state matching funds.

But in spite of Nevada’s stepped-up efforts to claim grants, questions linger about what federal funding available to states will look like going forward with a new administration in the White House.

“I’d like to be optimistic, but I think there’s so much uncertainty about what’s going to happen in D.C., is the old model going to go up?” Damore said. “I think there’s just so much uncertainty about not only the president but how Congress is going to interact with the president on all of that.”

(See the list of all federal awards Nevada received in fiscal year 2016.)

Photo courtesy of John Williams under Creative Commons.


Federal Grants Report - Federal Funds Information for States by Michelle Rindels on Scribd