In his 2021 State of the State address, Gov. Steve Sisolak made a pledge: the state would increase its share of federal grants by $100 million over the next two years and by $500 million by 2026.
But that promise implicitly raises a problem that elected officials in both major political parties have been trying to solve for a decade — how to move Nevada up from its current bottom-of-the-list ranking of states that receive the largest share of the federal grant pie.
A new report by the Guinn Center for Policy Priorities released Wednesday highlights Nevada’s paltry ranking — the state ranked a lowly 45th in the nation in federal grants per capita in the 2020 fiscal year. Nevada also ranks 42nd on formula grants per capita (grants prescribed by law or administrative regulation, such as Medicaid) and 43rd in federal project grants per capita (which are competitively awarded).
Not all of the news is grim, Guinn Center Director of Economic Policy and report author Meredith Levine said in an interview. The state’s adoption of Medicaid expansion in 2014 under the Affordable Care Act has brought billions of federal dollars into the state, and total grant spending in the state has increased dramatically — a 304 percent increase in total federal grant money between 2008 and 2020 and a 227 percent increase in per-capita federal grant dollars over that same time period.
Even though Sisolak’s goals for expanding the state’s share of federal grants might seem ambitious, Levine (who worked on a similar report in 2018) said it’s a goal within the realm of possibility — the return on investment from competitive or matching federal grants can easily ramp up.
But Levine said that competitive grants always come with a degree of uncertainty and that Nevada’s best bet for increased federal grant funding would come from modifying federal formulas governing the large-scale “formula” grants such as Medicaid or Title I education programs.
“Ultimately, we're really going to be needing to look at the formula piece to have complete and sustainable revenue from the federal government,” she said.
The report isn’t a collection of direct policy recommendations, but rather more of a point-in-time evaluation of the federal grant landscape in Nevada and other states through multiple indicators. It breaks federal grants into two categories — formula grants, which are allocated to all states through law or regulation and are based on factors such as population, income, or poverty rate, and project grants, which are competitively awarded.
Formula grants make up the bulk of Nevada’s federal share of grants. In the 2020 fiscal year, Nevada received $5.8 billion in formula grants from the federal government, and $1.1 billion in project grants.
The large percentage of formula grants largely comes from Medicaid, which in 2020 accounted for about 51.2 percent of federal grant money awarded to the state. Take away the share of Medicaid dollars, and Nevada would drop from 45th to 50th in state federal grant recipient rankings, with the federal grant per capita amount dropping by 69 percent.
Nevada was ranked 42nd in formula grants per capita in 2020 — something that surprised Levine, given that the median state (Iowa) has a comparable population to Nevada, but received 21 percent more federal formula grants per capita.
The report doesn’t dwell much on issues with formula grant allocations, but mentions varying matching Medicaid rates and “small-state” minimums in Medicaid funding leading states to “receive disproportionate amounts of money as a result of these provisions, disadvantaging other states in relative terms.”
“I think that that means that we should reconsider how those formulas are written or how they're decided at the federal level, Levine said. “And there might be an opportunity for the stakeholders in the federal government to reconsider what those look like and see which states are coming out on which side of those formulas.”
But much of the attention on the Nevada side has focused on the other category: project grants. Lawmakers in 2019 approved a $10 million pilot program for a matching grants program, and lawmakers this session plan to introduce a bill creating a state Cabinet-level position focused on procuring federal grant opportunities.
In the 2020 fiscal year, Nevada ranked 43rd nationally in project grants per capita. But the report found evidence of recent improvement in the state’s share of project grants, rising from $153 per capita in the 2016 fiscal year (half the national average) to $342 per capita in the 2020 fiscal year, or about 70 percent of the national average.
The report cites seven recommendations made by the Nevada Advisory Council on Federal Assistance (composed of private and governmental officials focused on increasing the state share of federal grants) aimed at helping the state get over the “perennial barriers” that Nevada faces in obtaining federal grants.
One of those recommendations is implementation of a statewide grant management system. That’s not a new idea; lawmakers approved $200,000 a year in funding for the project in the 2017 Legislature, but was derailed by litigation and never got off the ground. The state’s grants office told lawmakers last month that it wasn’t requesting funding for a grant management system in the next budget cycle.
Levine said such a system could help the state better get a handle on what’s working and not working in terms of state efforts to get more federal grants.
“The one question that I get asked a lot about this is, ‘Why doesn’t Nevada get those competitive grants the way other states do?’” she said. “And the answer is, we don't know, because we don't know if folks are applying here at the rates that they are in other states, or if we're applying and not getting them.”
The report describes states as “somewhat circumscribed in their ability to increase federal formula grants receipts,” meaning states increasingly look to project or competitive grants to increase their share of federal dollars.
While the report groups Nevada with a collection of fellow states that lack an income tax, (Alaska, Florida, South Dakota, Texas, Washington, and Wyoming) to see if there were any similarities in grant disbursements, the report found “no discernible pattern in rankings” among the states (save Nevada, Texas and Florida continually at the bottom of the list).
“Only some states that do not collect individual income taxes consistently have performed well on (the) amount of project grants per capita,” the report states. “Over time, though, all comparison states – even those states at the bottom, like Nevada – have improved their performance, perhaps in recognition of the value that federal dollars provide to states.”
Personal care aides for older Nevadans and people with disabilities are in higher demand because of the COVID-19 pandemic, but a new report warns of a possible “care gap” if wages below the cost of living and limited benefits prevent the workforce from expanding to meet the need.
The report, released earlier this month by the Guinn Center for Policy Priorities, a nonprofit, nonpartisan research center in Nevada, indicated that by 2040, Nevada would require an additional 10,000 aides — an increase of more than 80 percent. SEIU Local 1107, the Nevada union which represents these workers, called attention to the report and the “dire crisis” for Nevadans if pay and protections remain unchanged and trigger a “dangerous shortage.”
“The demand for home care is skyrocketing, but the current system is not meeting the needs of seniors or workers,” Rozetta Love, a home care provider working in Las Vegas, said in an SEIU press release last week. “They are struggling to find reliable, quality care, and we can’t even care for our own families because wages are too low and we get no benefits, sick leave or even basic protections like PPE.”
A personal care aide (PCA) is an individual who provides daily, in-home assistance for older people and people with disabilities. The position differs from a certified nursing assistant or home health aide in that PCAs provide non-medical support. Instead, they are primarily caregivers, performing daily tasks including grooming, mobility assistance, housekeeping and grocery shopping.
According to the report, there are 13,000 PCAs working in Nevada, and that number is expected to rise as the state’s population aged 65 and older increases. From 2010 to 2018, the number of PCAs working in Nevada nearly tripled, and by 2026, the state is projected to need another 5,300 PCAs in the workforce.
More and more older Americans have been opting to hire in-home care rather than transition into nursing homes because of a desire to “age in place,” and states have found that providing in-home care is more cost-effective than operating long-term care institutions.
“Personal care aides are frontline, essential workers who provide the necessary supports that allow seniors and individuals with disabilities to avoid long-term care settings,” Guinn Center Director of Economic Policy Meredith Levine said in a press release. “As long-term care facilities have been devastated by COVID-19, the pandemic has underscored the value of personal care aides and the crucial role they play in helping vulnerable people remain in the comfort and privacy of their homes.”
By 2040, Nevada will have to increase the number of PCAs by 82 percent, but with 50 percent of the current PCA workforce between the ages of 45 and 64, the next 20 years will also see that portion exit the labor force and age into the demographic most in need of care.
Medicaid reimbursements and low wages
As need increases, workforce growth is projected to remain flat — and low salaries and a lack of benefits mean neither the think tank nor Nevada’s union expect that to change without legislative action.
The median salary of a PCA in the state is $23,020, which is an hourly wage of $11.07. The Guinn Center estimates that the average cost of living for a single aide with no children in the Las Vegas area is $32,410 per year, more than $9,000 more than the median salary.
In order to fill that gap, a PCA would have to work 56 hours a week or have hourly wages increased to more than $15 per hour. Nevada is ranked 31st in the country for median PCA salary, with the Nevada rate being $1,000 below the national median.
A major determinant of wages for PCAs is the Medicaid reimbursement rate for personal care services. Medicaid was the largest payer for personal care services in the state as of 2018.
The system reimburses agencies for services rendered to covered patients, and the hourly reimbursement rate sets the ceiling for what individual aides will be paid; part of that rate goes towards overhead for the agency employing the workers before the remainder is distributed to individual aides. In August 2020, that rate was the lowest it has been since 2003.
“Low-paying jobs that are depressed by a Medicaid reimbursement rate that has not kept up with inflation are contributing to a shrinking pool of available workers who can find more lucrative positions in leisure/hospitality or distribution/fulfillment centers,” says the Guinn Center’s report.
Reimbursement rates are set by states, and in 2003, Nevada set the rate at $17 per hour. In January 2020, the rate increased slightly, but budget cuts made during a special legislative session this summer and prompted by the COVID-19 pandemic have reduced the rate to $16.52 per hour. If reimbursements had kept up with inflation since 2003, the rate would have been $23.81 in July 2020.
One major provider, Addus Homecare, announced in late August that it will be leaving the state on account of the lowered rates. The exit could cost 300 Nevadans their jobs. A representative of the company told SEIU 1107 that Nevada’s new rate structure no longer allows for workers to make a “living wage.”
While the center had difficulty comparing Nevada’s current rates to those of other states, the 2018 rate of $17 per hour was 20 cents per hour less than the national median. However, it is also difficult to compare rates because of how reimbursements are allocated.
In Nevada, they are allocated to agencies that then determine salaries and how much to distribute to individual aides. However, in other states such as Massachusetts, PCA services are entirely self-directed, meaning an aide is hired directly by the patient and directly reimbursed through Medicaid.
Limited benefits and opportunities
The Guinn Center report also shows that approximately 20 percent of PCAs do not have health insurance, which is higher than the overall 12 percent uninsurance rate in Nevada. About one-third of insured PCAs receive that insurance through Medicaid.
The pressure of this low paid work with few benefits falls on a workforce that is predominantly female. In Nevada, 84 percent of PCAs are women. The workforce is also disproportionately made up of women of color, who make up only 17 percent of Nevada’s population but 35 percent of PCAs.
The center’s report also looked into training and education for PCAs in the state. A high school diploma isn’t required for the position, but the report shows that one-third of PCAs in Nevada have at least a high school diploma and 30 percent have some college education.
In terms of training, PCAs complete a minimum of eight hours of training before employment and then another eight hours every year while actively working. However, the report indicates that Nevada’s training “lags behind” other states in terms of both “comprehensiveness and rigor.”
Training is important for aides both to ensure higher quality care for patients and as it can be used to provide a foundation for a career pathway into other positions in the direct care workforce, according to the report. Seven states in the country require PCAs to go through certified nurse training, essentially making an aide position the “first rung” on the direct care career ladder.
However, the center does note that increased training requirements may be difficult to implement because of the cost it requires of agencies and the time it takes individual aides to complete the requirements.
Although the Guinn Center’s report did not point to a specific policy measure to remedy the impending care gap, it urged state policymakers to “consider policies that strengthen the personal care aide workforce in Nevada and ensure that the care gap is not realized.”
It also emphasized that the need for solutions is immediate. PCAs, it indicated, are well suited to preempting infection for Nevada’s vulnerable populations during an outbreak such as the COVID-19 pandemic, but a lack of proper training and lack of proper supplies have vastly limited that ability and will lead to an increased strain on hospitals and medical facilities.
“Personal care aides provide some of the most essential services in Nevada,” the report reads. “The career, while rewarding to so many personal care aides, can be physically taxing and emotionally exhausting. Moreover, home care continues to offer poor-quality, low-paying jobs that lead to high turnover and widespread vacancies.”
For a normal meal distribution event prior to the lockdown, the Food Bank of Northern Nevada served 150-200 families. On April 17, the organization served 980 families.
Before the pandemic 12.9 percent of Nevadans were identified as food insecure, meaning they lacked consistent access to nutritional food. The U.S. Department of Agriculture (USDA) hasn’t yet released an update to that number, but food banks statewide say they are observing drastic increases in the number of people in need of services.
“We have had to basically just recreate our distribution model,” said Larry Scott, the chief operations officer at Three Square Food Bank, which serves Southern Nevada. “Prior to the lockdown, the virus starting, we were distributing about a million pounds [of food] a week. Currently, we’re delivering and distributing about 1.3 million pounds.”
In Southern Nevada, food insecurity rates were 12 percent before lockdown, and Scott estimates that this number could increase to 13 or 14 percent. An increase of 1 or 2 percent means an additional 50,000 to 75,000 people in Southern Nevada alone could face uncertainty about where their next meals will come from.
The 30 percent increase, from 1 to 1.3 million pounds of food served, is the equivalent of 250,000 extra meals distributed every week.
Three Square operates 43 emergency distribution sites as a part of a disaster response plan implemented on March 11. Since then, these drive thru sites have served over 6.5 million meals.
Just since the opening of the sites in March, the organization has seen a 67 percent increase in meals served. Food Bank of Northern Nevada has seen a similar trend throughout the past months of lockdown.
“We saw increases right away,” said Jocelyn Lantrip, a spokeswoman for Food Bank of Northern Nevada. “They’re just getting larger and larger.”
Addressing greater needs
Nevada’s Aging and Disability Services Division has allocated $2.5 million in emergency funding to 19 partnering organizations from the Families First Coronavirus Response Act that is going toward feeding 9,500 seniors who weren’t previously receiving services.
Entirely new programs have been developed to try and get food to at-risk populations, such as Delivering with Dignity, which expanded its efforts to the Reno and Sparks area and has delivered 26,500 meals during its first five weeks of operation.
At a federal level, Supplemental Nutrition Assistance Program (SNAP) benefits have been expanded. As of March 23rd in Nevada, 15,047 people were being evaluated for SNAP benefits, compared to 7,638 on that date in 2019, and two thirds of those individuals had applied within that week.
As these numbers have increased, applying for benefits has also become more complicated as in-person operations cease and application and approval processes have moved online.
The state is now able to provide individuals with emergency supplemental benefits for up to two months. Additionally, paperwork and reapplication requirements have been waived and deadlines for processing case reviews have been extended.
“Collectively, these provisions have not only expanded benefits but allowed administrative processes to be streamlined to help ensure that demand is met, particularly as new applications are submitted,” Meredith Levine, director of economic policy at the Nevada-based Guinn Center for Policy Priorities, said in an email.
The Families First Coronavirus Response Act also suspended limits on benefits for unemployed individuals, and the USDA approved online purchasing of food for households receiving SNAP benefits through Walmart and Amazon.
However, rural communities and low-income individuals are still left out as a result of the “digital divide.” According to The Guinn Center, approximately 8.8 percent of Nevada households do not have access to a computing device and 18.3 percent have no internet subscription.
“This is the ‘double digital divide.’ Data shows that rural areas in the state have insufficient broadband, and spotty cellular service,” Levine said. “In-person applications and interviews have shifted online. This has reduced some barriers, such as the submission of paperwork for continued benefits, but created other impediments, as some people may not have the necessary tools … to apply for benefits.”
In order to fully cover those in need, The Guinn Center recommends further action be taken.
“At a federal level, policymakers should consider increasing SNAP benefits,” Levine said. “A 15 percent increase was proposed — but not enacted — under the CARES Act.”
Levine also pointed to Pandemic EBT benefits as an option the state should seek out from the federal government. These are extra food benefits for children who are eligible for free or reduced-priced meals at school, and states such as California, Arizona, and New Mexico have already applied.
“Aside from policy changes,” Levine said, “it is important for community groups, non-profits, and small businesses, to the extent possible, reach out to vulnerable households to aid any individuals who may need SNAP but be unaware of eligibility changes or lack Internet access to secure those benefits.”
The supply chain
Some food producers are reaching out directly to residents in their communities.
Last week, Isidro Alves, the owner of Sand Hill Dairy in Fallon, posted on social media that his dairy would pass out gallons of milk to anyone who needed it. In an interview, Alves said the response was “overwhelming.” Residents came not only from Fallon but also from Carson City and Reno, both about an hour away. He estimated that about 600 cars came to pick up milk.
“They were thankful,” he said. “I got some private emails, and it was a big help for their families.”
Alves said that, as with other businesses, it was important to give back to those who have been hit hardest by the pandemic. With concerns about food shortages, he said people are worried.
“You open up social media,” he said. “We've got restaurants that are struggling to stay open and they're making meals for first responders. We've got distilleries [that are making hand sanitizer]."
“We're farmers,” he added. “We make milk. What can we do with our milk? We decided to give it back to our community. And we knew there were so many people struggling in our community.”
Across the country, the pandemic has created economic disruptions and health challenges for food producers, one that has rippled through the agriculture industry. Unlike many dairy producers, Alves has not had to dump milk because of decreased demand. He processes his product on-site. Still, prices have dropped as restaurants and schools have shut their doors.
Doug Busselman, executive vice president for the Nevada Farm Bureau, said one dairy in Southern Nevada has had to deal with dumping milk. Before the pandemic, they had been sending the milk to Las Vegas for processing en route to being distributed at schools. But he said the practice has not been as widespread in Nevada, compared to other states.
“We're probably not as bad off as other segments of the agriculture industry around the country, but we may also be looking at having our day of reckoning ahead of us," Busselman said.
That’s because the state produces different commodities. But he could foresee some issues down the line as farmers look to sell hay to dairy farmers and ranchers market their livestock.
Still, the supply chain is a concern for food banks. For instance, Food Bank of Northern Nevada has been seeing delays in receiving shipments of food.
“We still are receiving food donations from suppliers and manufacturers. That’s still happening probably on a smaller scale,” Lantrip said. “We’re having to purchase a lot of food for these emergency boxes. It’s taking longer than usual to get it.”
According to Scott, Three Square is facing a similar issue — fewer donations and longer wait times for purchases.
“It strictly comes down to freight availability and costs,” he said. “When there’s higher demand, the costs can grow rapidly.”
Three Square is also a lower priority for freight shipments than grocery stores, which are also experiencing shortages and are ordering more food as a result. It can take longer for food banks to receive freight when grocery stores are getting deliveries first.
Previously, the organization had rescued meals from resorts, redistributing untouched, flash-frozen meals when event organizers found themselves with more food than patrons. But with hotels closed and no longer ordering food, that source has been cut off. While banquet meals only made up 500,000 of the 55 million pounds of food served annually by the organization, what Scott says was really lost was the quality of food those meals provided clients with.
“What we miss from being able to rescue the food from there is the quality of the food,” Scott said. “In particular we were able to rescue a lot of meat proteins, and those are very hard otherwise for us to be able to source.”
Grocery store rescue, however, has remained a continuous source of supply for Three Square.
“In spite of the circumstances, shoppers will still pass over the blemished apple,” Scott said. “So, fortunately, that becomes available to us.”
Additionally, the organization has been able to make up for lost donations and delays with federal help through the Commodity Supplemental Food Program through the USDA, which distributes food and funding to organizations improving the health of low-income seniors. At the moment, Three Square obtains 1.4 million pounds of food a month through the program. By the end of the summer, Scott expects that number to reach 2 million pounds.
For Three Square, the most immediate concern for the future, even as the state enters the first phase of re-opening, is the rising heat in Southern Nevada. As summer approaches, and temperatures skyrocket, keeping perishable foods fresh at distribution sites will become difficult.
Hours have already been adjusted at many emergency sites to allow food to be distributed earlier in the day, and operations at these sites are becoming increasingly efficient.
“I think we have a routine established right now that we can maintain through much of the summer,” Scott said. “Heat will always be an issue for us.”
The organization is also concerned about how they will continue to operate in August if schools re-open normally. Prior to lockdown, the organization provided 18,000 meals per day to schools in Clark County.
When schools closed, that meal preparation stopped and Three Square suspended volunteering at the facility where they were prepared to comply with social distancing.
“Our challenge is to be able to box thousands and thousands of meals every single day in our kitchen and accomplish social distancing in a safe environment,” Scott said.
Even if the state is fully reopened by August, food banks still expect the increased need for their services to continue.
“We don’t know how long it’s going to go,” Lantrip said. “But, truth be told, if people are out of work for a certain amount of time, even when we open back up, we’re anticipating that the people will still need our help.”
On the first day of the third week of the 2019 legislative session, the lawmakers on the Assembly Health and Human Services Committee were finally ready to get to work.
After sitting through two weeks of presentations, the first bill to come before the committee was a short, six-page proposal, one of the simpler pieces of policy the committee would hear during the session. Its title, too, was succinct: “Revises provisions relating to certain expenditures of money for public health.”
The primary purpose of the bill, which was sponsored by the committee, was to establish a public health improvement account in the state’s general fund and appropriate $15 million to it. Those funds were to be divided by population and distributed to local health districts or, where applicable, the state, which serves as the public health authority for 14 of Nevada’s 17 counties. Each entity was to evaluate the public health needs of the residents it serves, prioritize those needs and then spend the money accordingly. The goal: Give health districts more dollars and greater capacity to respond to emerging public health threats.
It wasn’t an unusual ask. Many entities come before the Legislature each session asking for a slice of the state’s financial pie. But it was the last anyone would hear of the bill.
The legislation, AB97, stood to have a significant impact on public health agencies in Nevada, where discretionary funds are few and far between, while program-specific, limited-duration grant dollars with lots of strings attached are plentiful. The legislation could have allowed the public health community in Nevada to be proactive to respond to health needs as they develop and not — as they often lament they’re forced to be — reactive.
“This investment in public health is very important to improve the health of our population,” Washoe County District Health Officer Kevin Dick told the committee during the February 2019 hearing. “It allows us to support data-driven community health assessment approaches to address priority health needs in our communities and, ultimately, the flexibility in this funding allows health authorities to address the root causes and social determinants of health.”
According to a recent report from the Commonwealth Fund, Nevada ranks 50th in the nation in public health spending per capita, with $8 spent on public health per Nevadan. (Missouri is last, spending $7 per person, New Mexico is first, at $137 per person, and the national average is $37.) With about 3 million residents in Nevada, the $15 million appropriation suggested by AB97 would have meant an extra $5 in spending per person on public health in the state.
Dick, during the hearing, called the sum the “gorilla in the room,” noting that the Department of Health and Human Services had requested the funding as part of its budget but did not receive it. He said he was hopeful during the session lawmakers might find an extra $15 million to allocate.
The dollars would have helped public health agencies build capacity to provide their usual suite of services, like family planning care and restaurant inspections, as well as address social determinants of health where the state is weak, such as violent crime and low immunization rates. But Dick also asked that at least some of the funding be reserved in the account in the event of a public health emergency — a sort of rainy day fund for public health.
“Now when the interim committee discussed this ... there was concern that if the funds all remained in the account, we might end up with a situation where the state faced other needs and yet this money was unavailable because it was in the account for public health improvement,” Dick said. “But I think we need to consider trying to at least allocate part of any remaining unspent funds to remain in the account, up to a certain limit so that we do have funds for public health emergencies.”
The most pressing threat at the time was measles, with 1,282 cases reported by the Centers for Disease Control and Prevention in 2019. Dick noted that a measles outbreak in Minnesota — of just 22 cases — was estimated by the CDC to have cost that state between $920,000 and $1.6 million.
During the session, lawmakers did find money for two public health initiatives: $6 million for family planning services, and $5 million to control and prevent the use of tobacco. But AB97 never received a second hearing. Multiple sources who followed the legislation attributed the bill’s death to the mid-session resignation of Assemblyman Mike Sprinkle. The Sparks Democrat had been shepherding the bill as chair of the Assembly Health and Human Services committee before he stepped down amid allegations of sexual harassment.
Now, a year later, the state’s underfunded health agencies are grappling with a public health emergency far bigger than measles. The novel coronavirus has infected more than 700 people and claimed the lives of 14 across the state, most of them in Clark County.
Even the most well-funded health departments across the country are struggling to provide necessary services related to the COVID-19 outbreak — things like case monitoring and contact tracing. This means Nevada's local health agencies would still face an uphill battle even had they received AB97's $15 million appropriation. But experts say the coronavirus pandemic is underscoring the historic lack of investment in public health agencies, which, in the time of coronavirus, have pivoted almost all of their limited resources to deal with the pandemic.
“It’s a nationwide problem. A lot of health departments across the country are struggling with cuts,” said John Packham, associate dean for the Office of Statewide Initiatives at UNR’s School of Medicine and chair of the Nevada Public Health Association’s advocacy and policy committee. “The irony is that those cuts were taking place during economic good times, and that’s kind of the disturbing part.
“If you pay for public housing or public education, you can at least see a tangible result, a new school or a teacher hired or somebody getting a place to live. But with public health, it’s tracking COVID-19,” he continued. “How do you see or measure that until it’s blown up on you? That’s kind of what we’re paying for.”
The situation in Southern Nevada
The first confirmed case of the novel coronavirus in Nevada was reported in Southern Nevada on March 5. The patient was a man in his 50s who had recently traveled to Washington state; at the time, the state was the center of the coronavirus outbreak in the U.S. The next day, Nevada saw another case; by the next week, there were 11 statewide.
Now, a little more than three weeks later, the Southern Nevada Health District is struggling to keep up. More than 500 people are confirmed to be infected with the virus in Clark County, and likely many more cases are going undiagnosed as testing remains limited across the U.S.
Initially, only two labs in the state tested for COVID-19. The Southern Nevada Public Health Laboratory was responsible for tests in Clark County, while the Nevada State Public Health Laboratory in Reno ran tests for everywhere else. But only a week and a half after the first confirmed case, and the Southern Nevada lab was already running out of supplies and sending samples to Reno for testing. The lab is now only providing testing for health district contact investigations and other priority investigations, while the bulk of testing for the general public falls on commercial labs.
Additionally, the health district has pulled in much of its staff — as of December, about 550 full-time equivalent employees — to assist with its response to COVID-19. The health district is continuing to offer clinical services to the community, but additional services have been either suspended or moved online.
“The main function of our health district is to respond to this outbreak,” Dr. Fermin Leguen, the district’s chief health officer, said in an interview this week. “We have deployed employees who are working in areas not related to surveillance. For example, we assigned them to support surveillance or to support clinic areas or other things that are related.”
The Southern Nevada Health District has the biggest annual budget of Nevada's local health agencies, about $72 million. The largest chunk is funded by property taxes, a revenue stream that local governments across the state have long complained has not kept up with growth and recovery in the wake of the Great Recession, and which the Legislature took no steps to address during the last session.
North Las Vegas City Councilman Scott Black, who chairs the Southern Nevada Health District’s board, said property taxes now look like an even more unstable funding source with an economy in turmoil.
“Property tax, that’s about a third of our income, our revenue,” Black said. “We have no idea what’s coming down, three, six, nine, 12 months down the road as we look at our budget. It’s a vast and foggy unknown, and it's scary.”
Another fifth of the health district’s budget is funded by intergovernmental grants, either from the state or federal governments. But that funding is also unreliable: the kinds of available grants along with how much they're worth change yearly, and many come with a significant number of conditions, influencing how health districts allocate resources.
Leguen noted the health district lost a $700,000 federal grant last year that supported a program for new mothers, their families and early childcare. When those grants dry up or disappear, the health district has to figure out how to re-shuffle its staff or, ultimately, let them go.
“That’s a challenge for any public health organization across the country because when you receive a federal grant typically it is limited to a certain number of years, and after that period expires there might be another grant following the initial cycle,” Leguen said. “In most grants, one of the areas that is discussed is sustainability. But when you talk about losing $500,000 or $1 million, it becomes difficult for a health department to somehow reincorporate that funding.”
The final two significant sources of health district revenue are charges for services, and licenses and permits. But Black noted the health district actually has to provide those services and carry out its oversight role in order to earn that funding — a more difficult prospect in the middle of a pandemic.
“Out of those four pipelines of revenue to serve our communities, we have not one stable source of revenue that we can count on year over year that we can use as the base of our operating expenditures,” Black said.
The health district has also, generally, struggled to recover in the wake of the recession. Brian Labus, an assistant professor of public health at UNLV and former senior epidemiologist for the Southern Nevada Health District, said SNHD went through a period of layoffs during the recession, but the bigger problem was the health district had a lot of positions that it couldn’t fill.
“We couldn’t put in place these programs we desperately needed,” said Labus, who worked at the health district from 2001 to 2015. “We faced the same challenges that everyone did nationwide in an economic downturn.”
The health district has grown its staff between 15 and 20 percent in the last three years, Leguen said, but it still struggles to recruit enough people to meet the demand for services. It’s a problem familiar to those who work in health care in Nevada — there simply aren’t enough health care providers in the state. It's exacerbated for SNHD because it can’t afford to pay salaries as competitive as those offered by private health care companies, and because of Clark County’s rapidly growing population.
“Here in Southern Nevada, we are competing for health professionals with our community partners. We’re talking about competing for the services of nurses, physicians, support staff, also information system engineers, all of those kinds of professions that also complement the services that we do,” Leguen said. “Here in Las Vegas, for us, the challenge is bigger because of the lack of enough professionals for most of those areas.”
But it’s not just the Southern Nevada Health District that is struggling under the weight of the current crisis. Many health districts across the country experienced cuts over the last decade that have made it more difficult for them to respond to the COVID-19 pandemic simply because of limited resources and staffing.
“I wish I could say any of these problems are unique to Nevada,” Labus said. “But if you talk to anybody at any health department in the country, even the better funded ones are underfunded.”
The public health funding landscape in Nevada
Not only does Nevada have the second-lowest spending on public health per capita, most of it comes from the federal government. A recent study by the Guinn Center found 98.2 percent of the $11.4 million in funding for Nevada’s public health preparedness program — responsible for planning for public health emergencies, primary care planning, provider recruitment and retention and EMS response — is federal dollars.
“What surprised me was the degree of reliance on federal funding. When I went into this, I was looking at the public health emergency program and then just the public health preparedness, and I was expecting to see a state general fund contribution,” said Meredith Levine, the Guinn Center’s director of economic policy. “As I started to poke through the revenue sources and saw it was 98.2 percent federal, for me, that was the surprise finding in all of this.”
It’s not just on the public health preparedness side of the equation either. Packham, the associate dean at UNR’s School of Medicine, noted many public health initiatives, including chronic disease funding, the HIV/AIDS program and immunization, are primarily funded by the federal government, whether through CDC funding or the federal Health Resources and Services Administration.
The state Division of Public and Behavioral Health has other funding sources too, such as state general fund dollars and fees generated through inspections. But the bottom line, Packham said, is that Nevada is “heavily reliant” on the federal government to fund core public health activities, not just supplemental ones. And those funding sources don’t often give the state or local health agencies much flexibility when it comes to identifying their own immediate public health needs and funding them.
“When you have a new threat particularly like these infectious disease outbreaks, there are dollars you can move around, but most of the dollars, they’re earmarked for certain things. If you get dollars for TB control, that's what you have to spend it on,” Packham said. “You don’t necessarily have discretionary dollars you can devote to a disease outbreak that’s new. You don’t necessarily have dollars to do investigations into the vaping issues that came out of nowhere in the last three to four years.”
Packham said AB97 would have given health districts greater financial flexibility to respond to public health needs as they are identified.
“When COVID-19 has gone away, something else will pop up,” he said. “It’s whack-a-mole.”
The primary criticism from public health experts is that the reactive funding approach often taken with public health is in direct contrast to the way that public health is supposed to work.
“After 9/11, a ton of money went into public health preparedness but over time that money started to shrink. When West Nile happened, we dumped a ton of money into vector borne disease. Then Zika showed up,” Labus said.
Heidi Parker, the executive director of the nonprofit immunization organization Immunize Nevada, said federal grants help fill gaps in the short term. When they lapse, though, whatever particular area of public health it was addressing goes back to being underfunded.
“That's what we’re going to see happen with COVID too,” Parker said. “We’re going to get this influx of funding and it’s going to help in the short term, but what’s going to happen in the long term?”
The state has, in recent years, invested additional dollars in public health efforts, such as the appropriations toward tobacco prevention and education and family planning services last session. Sen. Julia Ratti, who chairs the Senate Committee on Health and Human Services, referred to them as “public health wins.”
“They’re not necessarily general fund dollars that build capacity or emergency capacity,” Ratti said. “But they send a very clear message that we have not been ignoring public health. We’ve had a couple of really big victories.”
A recent report from Trust for America’s Health shows public health spending in Nevada increased by 40 percent between 2018 and 2019. Still, public health experts say there’s plenty of room to grow.
“That sounds really great until you realize you could have a 40 percent increase if you were starting out from a small place to begin with,” Packham said. “I don’t view that as the health division’s problem. That’s a political problem that has bipartisan roots. We’re just stingy when it comes to funding public health.”
Dick told lawmakers last year in his presentation on AB97 that where other states fund 21 percent of local health department budgets, the Southern Nevada Health District and Washoe County Health Districts only receive 1 percent of their funding from the state, while Carson City Health and Human Services gets about 4 percent.
Another complicating factor is that the state is in the unique position of applying for federal funds and sub-granting those to local health agencies and other organizations as the state of Nevada — while also serving as the direct provider of public health services to 14 rural Nevada counties. That has, historically, caused some tension over how those resources are doled out across the state.
“When there’s not enough money to go around, there’s going to be tension,” Labus said. “The state’s facing the same challenges that all of the local health departments are. They are the ones controlling the funding coming from the CDC. Of course that’s going to cause tension.”
(The Department of Health and Human Services did not make anyone available to answer questions on the state’s public health funding landscape for this article but did provide The Nevada Independent with a number of documents and other resources detailing the public health funding situation in Nevada.)
Even if the state were to invest additional dollars in public health moving forward — a decision that would be up to the Legislature and governor — there is no guarantee those dollars would remain a stable funding source moving forward. Packham noted that 10 percent of the Tobacco Master Settlement Agreement funds Nevada received used to flow into what was called a “Trust Fund for Public Health.”
“We started funding public health programs with just the interest. It was phenomenal. It was like an endowed chair at a university paid for by just the interest that was accumulating and that 10 percent we kept socking away,” Packham said. “But when the recession in 2008 and 2009 hit, that was all swept away into the general fund.”
Packham said even states with significantly better public health outcomes than Nevada still rely on the federal government for support. But they also have stable state funding revenues — like a state income tax or a better property tax structure — to allow them to support state investment in public health.
“The double whammy in Nevada is our budget. We not only don’t have a state income tax, we’re so reliant on gaming and tourism that like the Great Recession, you know what happens to our revenues. You get a little more Medicaid funding and some other stuff, but it doesn’t offset the ability to fund public health,” Packham said. “If there’s a story it’s that we don’t fund public health in economic boom times.”
The broader, philosophical question is this: Where should the burden of funding public health fall? The federal government? The state? Local governments?
For Labus, the answer is simple.
“Under the Constitution, public health becomes a state and local issue, and they’re responsible for putting the programs in place that they need to protect their citizens,” Labus said. “The federal government is there providing extra funding for all sorts of programs, including the problem we’re dealing with right now. But it’s not their responsibility to take care of every single health department in the country. It’s something that the local governments and state governments need to fund.”
But public health experts acknowledge it’s difficult to think about investing significant sums of money in public health, when the results could take decades to manifest. There's an immediate payoff in putting additional dollars into a classroom today and seeing effects tomorrow.
“People are used to seeing immediate things, like coronavirus, but if we put in place an amazing cancer prevention program right now, we wouldn’t see the benefits of that for decades,” Labus said. “Public health is a very tough sell because if we do our jobs right, people don’t know that we did them because they never got sick. So how do you convince people to pay for something they don’t see the outcome of?”
Public health in rural Nevada
When Lyon County had its first confirmed case of coronavirus on Wednesday, the notification process worked exactly as it was supposed to, Dr. Robin Titus, the county’s health officer, said.
The man recently sailed on a cruise ship and visited San Francisco. He was then tested in Washoe County. When his results came back positive, Washoe County reached out to the Quad County Emergency Operations Center, which serves as the response hub for Douglas, Storey and Lyon Counties, as well as Carson City. The center immediately contacted Titus.
In non-pandemic times, Carson City Health and Human Services operates as its own local health agency, providing some services for Douglas County; the other three counties are served by the state. For purposes of emergency response, the four jurisdictions join forces as the Quad Counties.
Rural Nevada does not, in general, have the kind of public health infrastructure that urban Clark and Washoe counties do. But, all things considered, Titus said, the process in Lyon County has been working well so far.
“We don’t have enough to stand up our own huge areas, so we combine resources,” said Titus, who is also an assemblywoman and heads the Assembly Republican Caucus. “I feel our public health system has done a great job with this.”
It’s the kind of public health operation Lyon County would like to see all the time. Shayla Holmes, director of Lyon County Human Services, said the Quad Counties and nearby Churchill County have been trying to work together to identify funding to pay for a study on cross-jurisdictional health districts in Nevada. Right now, rural counties pay the state for the services the Division of Public and Behavioral Health provides them, like community health nurses who offer family planning and vaccination services to local residents.
“There is a contract in place. I’ve tried negotiating that. I don’t win, but I try,” Holmes said. “We pay an assessment for each of the community health nurses out here in Lyon County. I don’t get any say over what they do. I have to provide the office space for them. They break it down for me on how those monies are used, but I don’t have any oversight.”
But Holmes said even if the counties were able to pool the money they send to the state, it still wouldn’t be enough to fund a regional health district. If the health district existed, they could apply for grant funding to help sustain it. But, without additional funding, they can’t form the district to get the funding.
It is, in essence, a chicken and the egg problem.
“The individuals we work with at the state do want to see enhancements to the system. We don’t meet a lot of resistance with the state when it comes to trying to engage them with, ‘How do we become more localized?’” Holmes said. “The problem is the way that (state law) is set up with the funding streams, any funding that I get with regards to being able to increase public health outcomes I really only have one option, and that’s to go with the state.”
For the remaining rural counties, the coronavirus pandemic may prove an even bigger test, since they don’t have a Quad County-style operation to lean on. Joan Hall, president of Nevada Rural Hospital Partners, said some rural hospitals didn’t know until recently that the Division of Public and Behavioral Health serves as their public health authority.
“Some people are going, ‘Oh my gosh, who should get what information?’ It’s an issue. Thank goodness we haven’t had many positive cases in the rurals,” Hall said. “It just shows from a rural perspective our lack of awareness of the public health process, and it’s more than just the hospitals. We wish we could spend more time on public health, but that’s not really our directive.”
Hall said the relationship between the state, local hospitals, the county medical officer and the county’s board of health were not well defined.
“Hospitals get together with emergency management to talk about flooding and wildfires and blizzards and how we’re going to all work together on singular outbreaks of norovirus. It’s been a whole test of the whole system,” Hall said. “I don’t think there’s blame to be placed on anybody, but I don’t think this was ever envisioned.”
The other difficulty, Hall said, is that rural hospitals had planned to lean on each other in the event of an emergency. In the past, hospitals would send each other personal protective equipment, medicine, rapid flu tests, blood and even nurses, she said, but now resources are scarce all around.
“We never thought the person we would ask for help wouldn’t be able to help us either,” Hall said.
In the short term, public health agencies have received additional resources from the federal government to respond to the COVID-19 pandemic. The Southern Nevada Health District received $2.3 million from the CDC this week, while the Washoe County Health District received a little more than $900,000, out of $6.5 million the state received from the CDC.
Leguen, SNHD’s chief health officer, said the new funds could be used for a number of different purposes, including supporting local response, lab resources, surveillance, or personal protective equipment. But that money isn’t going to be able to grow the kind of long-term capacity, such as additional staff and more health districts in rural corners of the state, that could help the state better combat coronavirus.
As recently as December, public health advocates pushed lawmakers during a meeting of the Legislature’s Interim Health Care Committee to establish a public health improvement fund and invest in public health infrastructure in Nevada. It’s the first priority listed by the Nevada Public Health Association on its 2020 policy agenda.
Ratti, the Senate’s health care committee chair, framed it as a balancing act for lawmakers between meeting pressing, current needs and planning for the future.
“The trick is, how do you be a good steward of the finances that are available? We don’t want to be setting a bunch of money aside to meet the critical needs of vulnerable Nevadans or the health and human services needs of Nevadans and have it all squirreled away for an emergency,” Ratti said. “But you want to have the capacity to address emergencies when they come.”
Although the state does not have dedicated public health emergency funds stashed away, it does have $401 million in general rainy day funds the Legislature has socked away after years of neglecting the account. Money can only be taken from the account if tax revenues fall below projections or state leaders declare a fiscal emergency.
“Certainly having that rainy day fund gives the overall system the ability to have the flexibility to make smart decisions and not have to make very quick decisions that may have sharper, steeper longer term consequences. I’m proud of that,” Ratti said. “I think the thing that has been challenging over the last several weeks is there were things we thought we could rely on from the federal government that have been difficult to access and that is hurting us at the state and local levels.”
Two decades ago, a storm dumped billions of gallons of water on Las Vegas in just a couple of hours, killing two people and causing millions of dollars in damage. It was known as the 100-year flood.
Black, the chair of the Southern Nevada Health District board, said the coronavirus pandemic is now the 100-year public health emergency flood.
“And we’re not ready for it,” Black said. “AB97 was a good first attempt, but I think we need to revisit that and look at what that means for us moving forward. You look at the sunny skies and say, ‘Why are we spending all of this money?’ And then the rain comes down and the waters come in from the canyons.”
The difficulty is, if public health officials are doing their job, that flood will never come.
“Outbreaks like this certainly help public health come to the front of people’s minds. We start thinking about disease differently and what we need in place to respond but as soon as this emergency is done there will be another one,” Labus said. “This is kind of the constant fight for public health. If you’re doing a good job you’re preventing things, and no one will ever see it.”
Rising fears over the novel coronavirus (COVID-19) throughout the United States and Nevada have brought the concept of a federal mandate for paid sick time off back into the limelight.
With a growing number of large events being cancelled, congressional Democrats and others have begun pushing for adoption of a federal policy to require that employers offer paid sick time off to employees. Spread of the virus — now deemed a pandemic by the World Health Organization — has prompted a new push with congressional Democrats introducing a new bill last week requiring all employers to offer at least seven days of paid sick time off (and an additional 14 days when there is a public health emergency).
Even though state lawmakers in 2019 approved a mandatory paid leave bill — making Nevada just the 12th state to require paid time off for workers — adoption of a federal paid leave policy could still have a sizable effect on the state.
That’s because the paid leave policy adopted by Nevada contained broad exemptions allowing any business with 50 or fewer employees to avoid the new requirement in law. That carve-out meant the bill exempted roughly 95 percent of employers and more than 36 percent of workers in the state.
Although the new Nevada bill does not require in-depth reporting of how many businesses are now offering paid time off, state Labor Commissioner Shannon Chambers said her office — charged with implementing and enforcing the new law — hasn’t exactly been overwhelmed with questions or concerns about the new policy since it took effect on Jan. 1, even with the rapidly spreading concerns over the coronavirus.
“A lot of companies, just to compete for employees, were already doing this,” she said. “So that made my job a little bit easier, and our office's job a little bit easier.”
Nationally, about 73 percent of workers have access to some kind of paid sick leave, but the percentage drops based on industry — a 2019 federal Bureau of Labor Statistics survey found paid sick leave coverage was at 64 percent for salespeople and 58 percent for service workers. But even those policies are not uniform, and vary in the amount of sick time off that can be accrued or rolled over from year-to-year.
Already, some Nevada employee groups are pushing for expanded paid sick leave — the politically powerful Culinary Workers Local 226 proposed five paid sick days in emergency negotiations amid concerns of a likely economic slowdown from the virus.
Economists interviewed by The Nevada Independent said regardless of the scope, the state’s new paid sick policy was a promising start and could help alleviate public health concerns of the virus continuing to spread, by giving many workers the option not to go into work while sick.
“It moves us a little bit into the right direction, that is, giving people the ability to have some time off without having to sacrifice their financial lives, without having to risk not being able to pay their rent, without having to risk not being able to buy food for their family,” UNLV Economics Department Chair Jeffrey Waddoups said. “So to the extent that it moves us in that direction, I think it's a good thing.”
What the bill does
Sponsored by Democratic Sen. Joyce Woodhouse, SB312 passed out of both legislative chambers with bipartisan majorities and broad support from the state’s business interests after lawmakers adopted a variety of exemptions and carve-outs into the bill.
As signed into law, the bill requires all private employers in the state with 50 or more employees to provide 40 hours of paid leave per year, accrued at a rate of 0.01923 hours of paid leave per hour worked (which works out to 40 hours of paid leave based on a year of 40-hour work weeks). The bill allows for paid leave for any reason, not just for illness-related issues.
Employees are allowed to begin using the paid leave within 90 calendar days of employment, and can use paid leave without providing a reason. Workers are supposed to notify their employers “as soon as practicable” if they plan to take paid time off, and cannot be retaliated against or forced to find a replacement worker.
Employers can set limits on minimum increments of paid time off (not to exceed four hours at any one time), but are not directly required to compensate employees for any unused paid leave days if they leave employment.
There’s also no requirement that employers carry over paid leave days, with the law stating that employers may allow accrued leave days to carry over to a maximum of 40 hours per benefit year.
The bill does not apply to employers with a matching or better paid leave policy, or to employees under a collective bargaining agreement that allows for paid time off, or to any seasonal, temporary or on-call employees. Businesses within the first two years of operation are also exempted from the paid leave requirement.
Approval of the bill made Nevada the 12th state to require employers offer a form of paid sick time off, joining Arizona, California, the District of Columbia, Connecticut, Maryland, Massachusetts, Michigan, New Jersey, Oregon, Rhode Island, Vermont and Washington.
In addition to the paid time off legislation, lawmakers in 2019 also approved another bill, AB181, that prohibits employers from requiring sick or injured workers from reporting in person to a workplace if they cannot work.
But Nevada’s paid time off laws had more expansive exemptions than most of those other states.
While an initial version of the bill would have applied the paid leave requirement to businesses with 25 or more employees, that exemption was amended and expanded to only apply to businesses with 50 or more employees. According to a 2019 Guinn Center for Policy Priorities study, increasing that exemption from businesses with 25 to 50 employees resulted in about 150,000 workers losing potential rights for paid leave. The law now only affects about 7 percent of businesses in the state.
The 50-employee cutoff is used by only two other states (Connecticut and Michigan), while half of the states requiring paid time off for employees have no carve-outs based on employer size.
The 2019 Guinn Center analysis found that the large employer-size carve-out had a sizable effect on the number of workers covered under the new paid leave law. A carve-out of 15 workers or fewer would exempt about 17 percent of the state’s workforce and 80 percent of businesses in the state, while exempting businesses with fewer than 50 employees (the ultimate policy adopted) would exempt about 36 percent of workers — estimated at 476,000 people — and 93 percent of businesses in the state.
The bill as approved also exempts any business during its first two years of operation and doesn’t apply to any employer who provides a separate paid time off policy. It also exempted temporary, seasonal and on-call employees who don’t meet the hour requirements under the bill.
The state labor commissioner’s office was charged with implementing and enforcing aspects of the paid time off bill and can impose administrative penalties of up to $5,000 for each violation against businesses that don’t follow the new law.
Chambers said her office included information on new requirements for paid sick leave in about 30 to 40 meetings that her office hosted to inform businesses of new wage and employment requirements passed by the 2019 Legislature. Her office also developed a one-page notice outlining the new requirements of the law, and a lengthier advisory opinion on the law with implementation instructions, including how to count employees to the 50-worker threshold and defining seasonal or temporary employees.
But outside of a small uptick in questions near the January 2020 effective date, Chambers said implementing the new paid leave law hasn’t been difficult given that many large employers in the state were already offering a form of paid sick leave to their employees.
“So far there hasn't been a wave of fights or complaints,” she said. “I'm hoping to keep it that way.”
Chambers said her office isn’t required to and isn’t tracking data on how many businesses in the state have started implementing paid sick leave policies, just the number of complaints filed with the office (one in the three months since it took effect that was quickly resolved.) She said most employers that have reached out with questions were trying to make sure their existing paid leave policies were sufficient under the new state requirements, and that the coronavirus outbreak hasn’t led to any great rush of questions or concerns with her office.
“I can tell you that as of right now, we really haven't received a great deal of questions from employers relating to the virus so far,” she said. “I think, again, this is just my opinion, I think employers are kind of following the federal guidelines and giving employees time off if they need it, maybe make other arrangements like teleworking and different things like that. But so far there has not been a wave of questions.”
It’s difficult to measure the impact of the state’s new paid time off law, given that it has only been in effect since January and that there are no requirements for data collection or any other report on implementation.
But Waddoups said just about any policy that keeps sick workers at home and not at their place of employment is beneficial from a public health standpoint. He added that it was typical for there to be some employee-number cutoff in employment law, but that Nevada’s exemption was “fairly big.”
“It's just the start,” he said. “It doesn't cover as many workers as would be one would like, but at least there's something on the books now.”
Although federal studies indicate that service and retail workers are the least likely to have access to paid time off, Chambers said she had interacted with a “broad spectrum” of businesses affected by the new paid leave law, including restaurants, contractors and even some temp agencies.
Meredith Levine, the Guinn Center’s Economic Policy Director, said concerns with the coronavirus had helped recast the idea of paid sick leave from a worker protection policy to a public health policy.
“If the idea is harm reduction or mitigating spread, then we would want to investigate something that would be as robust as possible to ensure that that doesn't take place,” she said. “And certainly, not to diminish the idea or the aspect of wages themselves being important, but I think that there's kind of two dynamics going on, which is one is to ensure that workers are protected and then at the other time is to ensure that from a public health standpoint that those measures are in place.”
More than one in 10 Nevadans are living without health insurance despite overall coverage gains as a result of the Affordable Care Act and the state’s decision to expand its Medicaid program, according to a new report from the Guinn Center released on Wednesday.
The report found that Nevada had the sixth-highest uninsured rate in the nation in 2017 with 14 percent of Nevadans going without insurance coverage that year — a figure that is 3.5 percentage points higher than the national average. All of the states with higher uninsured rates than Nevada’s chose not to expand their state Medicaid programs and fill in historical eligibility gaps for low-income adults, with the exception of Alaska.
That overall uninsured rate represents a decline from 2013 — the year before the Affordable Care Act was implemented — when 21.7 percent of Nevadans lacked health care coverage. But the report notes that while state decisions to opt in to Medicaid expansion tend to loosely correlate with rates of higher insurance coverage, seven states that expanded Medicaid, including Nevada and Alaska, still have uninsured rates that exceed the national average, and 14 non-expansion states have lower uninsured rates than Nevada’s.
Of the uninsured here, more than half, or 55.8 percent, are eligible for the state’s Medicaid program or a tax credit to purchase a plan through the state’s health insurance exchange but are foregoing insurance. The rest, 44.2 percent, are not eligible for any of those options — possibly because they have chosen to decline an employer-sponsored health plan and are thus ineligible for tax credits or because they are undocumented and don’t qualify for government assistance.
“Why are we so high? Let me be careful — I’m not accusing legislators or agencies of anything — but we are high,” said Meredith Levine, director of economic policy at the Guinn Center. “We have a pretty immediate concern in the state. Whether the national solutions will work or whether they won’t are up for grabs, but right now I would say we have something that is undermining the economic health and actual health of Nevada’s residents.”
The report, which is based on the most recently available data from the American Community Survey between 2013 and 2017, sheds additional light on who exactly is living without health insurance in Nevada and what policy solutions might help them gain coverage.
For instance, the state’s uninsured population is commonly thought of as being largely undocumented and, indeed, the report found that while Latinos make up 35.9 percent of the state’s population, they represent 59.1 percent of its uninsured population.
But Levine noted that it isn’t just the issue of legal status that is responsible for high uninsured rates in the Latino community. Other factors, she said, include language barriers in accessing health insurance, socioeconomic status and the relative youth of Latinos.
Another mitigating factor, she said, is citizenship status regardless of legal status. The report found that one in three Nevadans who are uninsured, 32.4 percent, are noncitizens, noting that noncitizens face a five-year waiting period before they can qualify for Medicaid.
Based on national uninsured rates of the undocumented population, the report estimates that roughly 94,500 undocumented immigrants went without insurance coverage in Nevada in 2017, representing only about 23.7 percent of the state’s uninsured population.
“There are a significant number of Latinos that are undocumented, but the question is what is actually going on with the Latino population? I don’t think it has wholly to do with authorization. I think that’s part of it,” Levine said. “My guess is there’s a constellation of items and they coalesce.”
The report also found that the state’s uninsured population is largely concentrated in populous Clark County — which has an uninsured rate of 14.7 percent — though some rural counties do have higher uninsured rates. Those counties include Mineral (15.3 percent), Humboldt (16 percent), Pershing (16.5 percent) and Esmeralda (20.2 percent). Overall, though, the report determined that the uninsured rate in the state’s urban counties, which it counted as Clark, Washoe and Carson City, is 14.2 percent, while the rate of uninsured individuals in rural Nevada is only 12 percent.
“What we found is as Clark goes so Nevada goes,” Levine said. “What we did find is that not only is there no urban-rural divide, but rurals are a little bit lower.”
Employed Nevadans also make up a disproportionate share, 62.9 percent, of the state’s uninsured population. The report notes that those employees may work for companies with 50 or fewer full-time employees — which aren’t required to provide coverage — or work less than 30 hours a week. They also may choose to forego employer coverage if the employee contribution is too pricey.
Of the uninsured, 37.3 percent worked full-time, year round, 35.8 percent worked less than full-time, year round and 26.8 percent did not work.
“The stereotype is if you have employer-sponsored insurance that you’re going to have insurance, but you see there’s a high percentage of unemployed workers,” Levine said. “I think that is notable that in the state we have working folks that are uninsured.”
The report also found that young adults are overrepresented in the state’s uninsured population, making up one-fifth of the state’s uninsured population but only 12.8 percent of the total population. Another group that was overrepresented were those without a high school diploma — who make up 14.1 percent of Nevada’s total population but 29.4 percent of its uninsured — and those in households with an income between $25,000 and $49,999, a category that 22.7 percent of Nevadans fall in but makes up 31.6 percent of the state’s uninsured.
For more than two years, a six-figure contract to operate a statewide grant management system has been on ice amid a lawsuit charging that the administrator juiced the contract for a preferred vendor.
Although state lawmakers in 2017 approved $200,000 a year in new funding for a grant management software program — a system backers said could result in up to tens of millions of dollars in untapped federal funds — a lawsuit filed by a company that sought but didn’t receive the contract has stalled implementation of the system for the foreseeable future.
That company, Streamlink, prevailed in its lawsuit in September, with an administrative law judge finding that the head of the state’s grant management office based the contract on a proposal submitted by a preferred vendor that promised her professional opportunities and other benefits, while she submitted artificially low scores for competitors applying for the contract under the state’s competitive bid process.
The state has appealed and disputed the claims; oral arguments in District Court have been scheduled for next month. The litigation has meant a waste of not only the $400,000 in unused state dollars but also a possible loss of millions of dollars not tapped by the state over the last two years.
Grant management isn’t a typically hot-button issue, but concentrated efforts to secure federal grants and dollars by state governments can have potentially major effects on budgets. Federal dollars make up roughly 33 percent of Nevada’s yearly budget (roughly $9 billion), providing for services and programs without raising taxes or expending state revenues. Some estimates project Nevada is losing out on as much as $500 million a year in federal grant revenue, in large part because of the state government’s lack of programs and resources dedicated to obtaining federal grant dollars.
“We are so far behind other similar states, that we just have to get this stuff in place as fast as possible,” said John Ritter, chairman of the statewide grants advisory council. “Not having this grants management system in place is just delaying Nevada getting hundreds of millions of dollars a year in additional federal funding.”
Lawmakers, who for the most part were unaware of the lawsuit or declined to comment on it, nonetheless say they’re frustrated the money put up by the state has so far not resulted in a tangible result.
“It is disappointing,” said Democratic Sen. David Parks, who carried the 2011 bill to create the state’s grants management office. “My personal interest is that I would like to see a more extensive program operated by the state to acquire even greater amounts of money. When you compare us to states like New Mexico, they probably get three to four times as much federal funding as Nevada gets.”
Nevada and grants
The concept of federal grants typically evokes imagery of Medicaid, Medicare and other large federal government grant programs automatically dished out to states through a formula based on population.
But federal grants are much broader, and often crucial to cash-strapped state governments, local agencies, nonprofits and businesses while accounting for roughly a third of all state government revenues according to Census Bureau data. In total, the share of federal funding as a source of revenue for state governments has been climbing for years — in large part because of the expansion of Medicaid under the Affordable Care Act.
And though a 2018 report from the nonpartisan Guinn Center found federal money accounted for more than 34 percent of Nevada revenues for the 2017-2019 biennium, the state’s grant revenue per capita has consistently lagged behind other western states, often ranking among the lowest in the country. As of 2017, Nevada received an average of $1,475.78 in federal government grant dollars per capita — the 44th lowest of any state.
“I think who’s actually being hurt the most are Nevadans, because they are ultimately the recipients of programs and services that are beneficiaries of the grants,” said Meredith Levine, Director of Economic Policy at the nonpartisan Guinn Center. “The purpose of grants are to serve populations. To the extent that grants aren’t coming through, then we are not addressing the unmet needs of people who live in this state among certain populations and in certain communities.”
That doesn’t necessarily mean that Nevada is worse at grant management than states such as New Mexico, which took in $2,954.49 per capita in federal grants in 2017. Levine said that because many large federal programs are based on a formula that uses poverty levels and population, substantive differences in federal funding are largely the result of demographic trends.
But expanded Medicaid — which former Gov. Brian Sandoval agreed to implement in 2014 — inflates those numbers; with those dollars excluded, Nevada’s funds per capita for federal grants drops to $485.26, 49th lowest of all states. To Levine and others, that’s evidence that the state isn’t getting as much in federal grants as it theoretically could.
“To the extent that folks in the state would be resistant to any sort of tax increases, this is a way to get money,” she said. “It’s not free money, there’s no such thing as free, but this is a situation where we could be bringing in more money to the state to help support something where the general fund has to do a lot of the work.”
Lawmakers have been aware of the problem since at least 2011, when a bill by Parks creating a statewide grants management office was approved unanimously in the Senate and Assembly and signed into law by Sandoval. The office, which has five employees, acts as a statewide advisory clearinghouse for federal grants, either reviewing applications submitted by other agencies or entities or reaching out to them if it discovers a possible grant opportunity.
In 2015, legislators passed a bill creating the Nevada Advisory Council on Federal Assistance — an entity composed of lawmakers, head of the grants office and other appointees charged with studying and determining ways by which to obtain and maximize federal assistance, including grants.
Between legislative sessions, that advisory council listed as one of its top recommendations the creation of statewide grant management software. Such a system would replace the “ad hoc and complex” web of Excel spreadsheets currently in use, according to a description in the eventual request for proposal (RFP) for a grants management system.
Ritter, who chairs the advisory council, said the recommendation came out of the realization that neighboring states with higher reported federal grant revenue all used some sort of centralized tracking software.
“Every single one of the states that does significantly better than us has some sort of system with which grant officials, whether its in state agencies or municipalities or philanthropic agencies, they all have a way of seeing simply what’s going on in the grants world within their state; grant opportunities grant partnerships, active grants,” he said. “Often, states like ours need to collaborate on grants, and right now there’s just no way of knowing who’s working on what, what assets are available, what collaboration or coordination is possible.”
Such a system would be a boon to the state, Levine said, as the lack of any sort of centralized tracking system means there’s no way to quantify how much money the state could be losing out on through not applying for grants.
“There’s absolutely no way to know,” she said. “We just know that there are grants out there that we’re not going for or we're not getting for whatever reason. If we don't have tools to assess that, then we can’t even begin to know.”
At a budget committee hearing in the 2017 session, grants management office Director Connie Lucido told lawmakers that the office believed it could acquire a sufficient software program for $200,000 a year, which would help the state manage and track existing grants while having access to a centralized clearinghouse of grants that people, organizations and agencies in the state might be eligible to apply for but were not aware of.
“I would imagine we’re missing a lot of them,” she said at the time. “So this system would bring in those identified opportunities for agencies as well as our office to be able to look out.”
Lawmakers were enamored, especially by Lucido’s claim that a similar system in Arizona had identified more than $1 billion in potential lost revenue after it brought grant management software online. With little fuss, lawmakers approved the $200,000 per year for the office, giving it the go-ahead to contract with an outside firm and obtain the software for the state.
But for more than two years, litigation has delayed implementation of any such software — two additional years of money left on the table.
Unbeknownst to lawmakers and only revealed through records requests and court documents, Lucido had determined as early as 2016 that her preferred choice for a grant management software would come from a company called eCivis, which provides software for Arizona and other states.
In November and December of 2016, Lucido sent several emails seeking possible contracts with eCivis and another vendor, Streamlink, before the grants office began to pursue a formal competitive bidding process.
But Lucido’s opinion of Streamlink quickly soured; she later testified that the company was “deceitful” and had hired a lobbyist — Carrara Nevada’s Rocky Finseth — to “throw rocks at my budget.” Upon cross examination, she said she had “closed the book” on the company by April 2017. Finseth and other Carrara lobbyists did not speak during public budget hearings on the request in 2017, but had conversations with lawmakers about her description of the scope of the project compared to what Lucido had told them prior to the session.
In a later email to the CEO of eCivis on Aug. 22, 2017, she said in reference to Streamlink “no one in their right mind would ever do business with (your) competitor.”
During the pre-bid process and the actual preparation of the RFP, Lucido communicated frequently with key eCivis staff through text messages and over the phone, including conversations with eCivis Executive Vice President and COO Merril Oliver and Director of Government Solutions Tom Grimes.
In these conversations, an administrative judge determined Lucido was improperly offered professional perks or “things of value” that would stem from a contract with eCivis, including increased interactions with county governments and opportunities to sit on committees or a “more prominent presence” on federal issues in the state.
After the contract went out to bid in July 2017, both eCivis and Streamlink submitted bids. Like other competitive contracts put up for bid by the state, the request for proposal (RFP) process includes scoring certain aspects of each bid by a three-person committee. For this contract, the committee included Lucido, who recommended herself to serve on it given her experience with both companies.
During the week prior to the RFP being issued by the state, Lucido and Grimes exchanged multiple text messages. Both testified in court that they could not remember the content of text messages and had since deleted them, but the timing of the messages (revealed through a records request by Streamlink) raised concerns.
“Informal and not clearly identified communications during such a critical time in the preparation of a competitive bid are problematic,” the court wrote.
Purchasing Division head Jeff Haag testified during a 2018 administrative hearing that Lucido was “disappointed that we had to go to [request for proposal],” adding that “we’d been through a long process and you know, they felt pretty strongly that eCivis could, again, deliver on their technical requirements at a cost that they could accept, that met their budget limitations.”
Once the RFP was closed and bids were being evaluated, administrative court documents allege Lucido “minimized real concerns as to additional costs involving eCivis as to licensing yet continued to emphasize irrelevant pre-competition bid concerns as to Streamlink being able to comply with the budget set forth under [the RFP].”
Those assessments were then applied to Lucido’s scoring of each bid as an evaluator, where her scoring of StreamLink were found to be “inconsistent, arbitrary and capricious” by the administrative judge, who also said she was “willing to overlook key defects in eCivis’s response.”
Those defects include an alleged inability by eCivis to provide a system within the state’s $200,000 budget, largely because of the obfuscation of certain licensing fees related to an eCivis subcontractor, WizeHive. If those fees were added, the eCivis system would reportedly cost $360,000 for the number of individual licenses required by the state.
In 2017, Lucido told lawmakers that the initial projected cost for the software program was $2.5 million for a “top of the line” system, but that she determined that price tag “was not something we’d be able to pursue in our economic environment.”
Lucido told lawmakers that the much lower $200,000 price point would be enough to purchase “very robust systems,” with varying levels of the number of users who could access the software, functionality and other upgrades. It’s a point Ritter agreed with; saying that a lower price point would be an easier sell amid the fierce battle for state dollars that occurs every legislative session.
“I don’t remember a session where we had enough money,” he said. “So it’s necessary to get stuff done, at least in my experience, to try and find the best possible solution that is the most affordable, because otherwise it’s not just going to be funded.”
Additionally, the court found “problematic” aspects to the relationship between eCivis employees and Lucido. On the day the bid was opened, a high-ranking eCivis member— referred to as the “LeBron James of grant management” by a coworker — invited Lucido to speak on a grant-focused panel at a Nevada Association of Counties meeting later that year.
“The pursuit of such opportunities and networking as head of the Grants Office is well within Ms. Lucido’s job duties under regular circumstances,” the court wrote. “However, as the head of the using agency and a member of the Evaluation Committee, while a competitive bid was open and actively pending, is another matter.”
In September 2018, state appeals officer Rajinder Nielsen ultimately ruled in favor of Streamlink, arguing in a 45-page decision that not only had eCivis representatives “improperly involved themselves” in the bidding process, but that “no reasonable methodology” had been applied to Lucido’s bid scoring, “even when reviewing such applied methodology with the widest lens.”
These offenses were found to be violations of state law that govern the state’s purchasing contracts, and require the contract to be put out to bid again. But Nielsen’s decision also argued that this particular situation was unique to Lucido’s conduct as head of her department, and had no bearing on the conduct or procedures used by the Grants Office or Purchasing Division at large.
In a court filing submitted ahead of a District Court hearing this month, the state disputed these arguments nearly whole cloth, arguing — among other things — that Nielsen “acted in excess of authority, committed errors of law, and found against the Purchasing Division contrary to the evidence” in order to cancel a contract that was awarded according to the relevant state laws.
Key to the state’s argument is whether Nielsen had improperly relied on a formal discovery process — a process where both sides in a legal case have the opportunity to request evidence that would normally be unavailable to an administrative hearing without first being authorized.
It was this process that Nielsen used to show communication between Lucido and eCivis regarding “things of value,” a violation of NRS chapter 333. Such a violation would, crucially, require the perks offered to Lucido to be “things of value” and not, as the state argued, routine business.
The state also argued that Nielsen “glossed over” details of Streamlink’s application that would make the company unlikely to receive the contract. In its filing, it states that the company’s initial range of pricing for the software was closer to $2.5 million, and that the $200,000 contract would only result in a pilot program that covered a handful of state agencies, rather than the hundreds requested as part of the RFP. It also noted that the judge should have recused herself from the case, given that her ex-husband had a relationship with one of the attorneys for Streamlink.
For his part, StreamLink CEO Adam Roth told The Nevada Independent that from his perspective, the case has gone well — even with the state appeal.
“There doesn't appear to be any new arguments being presented in the appeal, it appears to just be a rehash of the old arguments that had already been determined at the hearing officer level,” he said. “And the facts of the case, with those arguments, I think bore out an accurate decision.”
eCivis did not respond to a request for comment. The case in District Court is proceeding, and an oral argument date has been set in May. Lucido left the grant office in 2019, and was hired by the Department of Health and Human Services in January as Social Services Chief under the department’s community partnership and grants division. She did not return multiple calls for comment, and a DHHS spokeswoman said she would not be able to provide information about the case “while this matter is pending.”
Republican Sen. Pete Goicoechea, who served on the Advisory Council on Federal Assistance when it made the recommendation that the state pursue grants management software, said he never questioned or thought twice about Lucido’s conduct as a member of the board, but said the result of the initial court proceeding spoke for itself.
“Clearly she overstepped it, or there wouldn’t be a lawsuit that did prevail,” he said.
What comes next
Two years later, there’s still no timeline for when a grants management system might be in place. Deonne Contine, the new head of the state’s Department of Administration said in an email to The Nevada Independent that any plans for a new RFP related to the contract are on hold until the ongoing litigation is sorted out.
In the meantime, state lawmakers appear likely to reauthorize the $400,000 in funding for the grants management software. A budget subcommittee that met last month voted to recommend continuation of the funding, with some contingency language in case the state loses its case in court and is required to put the contract back out to bid.
In the meantime, Contine said that state agencies “continue to report a lack of grant application capacity and the same barriers to increasing grant funding in Nevada, which include duplicative financial reporting and a lack of affordable grant training resources.”
However, the state statute in question does provide for the Purchasing Division to cancel an RFP, back out of an awarded contract and ultimately re-issue an RFP. It’s happened at least once before in the last year, when the state canceled an RFP and contract for a dental benefits administrator in 2018.
Regardless, several measures aimed at improving the grant process are pending before state lawmakers. SB205, which is sponsored by Democratic Sen. Marilyn Dondero Loop, would create a pilot program allocating $2.5 million to the grant office over the next two fiscal years for use as a source of matching funds for any federal grant that requires a match. It’s designed to combat what the Guinn Center calls a “vicious circle” where agencies and nonprofits with tight budgets are unable to apply for grants given the lack of state authorization for matching grant funds. The bill has been exempted from legislative deadlines.
Another bill affecting the grant management process is SB206, a measure sponsored by Democratic Sen. Joyce Woodhouse that would amend the state’s current law requiring the Interim Finance Committee to grant approval before an agency accepts a grant. The bill was passed out of committee on Friday, surviving the deadline for bills to pass out of their first committee.
If approved, it would allow the committee to grant “provisional” approval for grants prior to them being awarded, and lower the amount of time the committee has to approve a bill from 45 to 30 days before it is automatically deemed approved.
Lawmakers may also decide to take up another top suggestion of the Nevada Advisory Council on Federal Assistance, the state board charged with studying ways to obtain and improve the state’s grant process.
In its 2018 annual report, the council recommended the ideas taken up in the form of SB205 and SB206, but also recommended that lawmakers amend language in budget bills requiring any state agency’s state funding be decreased to the extent that it receives other revenue sources, such as federal grants, during the two-year budget period.
“In effect, this means that securing new grant funding has no positive net benefit for an agency’s budget, and actually costs the agency through expenditure of precious staff time,” the report stated. “And the harm to agencies does not stop there – when the grant funding runs out the agency must submit a budget enhancement request just to get back to its pre-grant funding level.”
Although those changes may help, Goicoechea said the state’s grant office could stand to even double in size, given the vast scope and potential federal dollars not tapped by the state.
“We’re not dedicating near enough resources to it,” he said. “If we truly want some benefits. We’re dealing with it like we do with a lot of these agencies, boards and councils, the advisory board will meet every two or three months, and give them a little direction, and we’re not following through. We really need to get down and get dedicated.”