Nevada became the second state in the nation to enact a state-managed public health insurance option on Wednesday, with Gov. Steve Sisolak’s signature transforming a bill that hadn’t even been made public until six weeks ago into law.
Though Sisolak voiced his intent to sign the bill last week, his signature formally ends a more than four-year-long quest to establish a public option in Nevada, though, in many ways, work on the public option is just beginning. Under the new law, Nevada’s public option plan won’t be available for purchase until 2026, giving state officials time to conduct an actuarial study of the proposal to determine whether it will accomplish proponents’ goals of increasing health care access and affordability and at what cost. It also provides time for state officials to transform the still relatively broad-strokes concept into a workable policy and return to the Legislature in 2023 with any changes that may need to be made to the law.
“I'm always looking for ways to expand health care opportunities in Nevada for Nevadans, and that's what this legislation does,” Sisolak said during a bill-signing ceremony in Las Vegas. “By leveraging the state's existing health care infrastructure and reducing costs, it is my hope that Nevadans will have improved access to comprehensive insurance.”
Senate Majority Leader Nicole Cannizzaro, who’s expecting her first child this summer and sponsored SB420, nodded to the effect it could have on the state’s youngest residents.
"This bill will help to open up some more doors in critical investments in prenatal and maternal care and Medicaid for Nevada moms and babies right here in our Silver State,” she said Wednesday.
Heather Korbulic, who as head of the state’s health insurance exchange will have a key role in the development of the public option, said in a statement that she plans to “bring all stakeholders together to outline the actuarial study and conduct a meaningful analysis of the public option as it relates to every aspect of health care throughout the state.”
“In the meantime I'm going to continue to focus on getting Nevadans connected to Nevada Health Link where we have an open enrollment period that runs through August 15th and — thanks to the Biden administration — almost everyone eligible is getting financial assistance,” she said, in a nod to the American Rescue Plan’s expansion of exchange subsidies.
Richard Whitley, director of the Department of Health and Human Services, in an interview last week said the public option isn’t “a single solution” but “does definitely enhance the opportunity for individuals to gain access to health care.”
“I think that as an option for coverage, it definitely enhances that overall framework,” Whitley said.
Under the new law, insurers that bid to provide coverage to the state’s Medicaid population will also be required to bid to offer a public option plan, with ultimate decision-making authority left to the state to decide how many plans to approve. The plans would resemble existing qualified health plans certified by the state’s health insurance exchange, though the legislation would require the public option plan or plans to be offered at a 5 percent markdown, with the goal of reducing average premium costs of the plans by 15 percent over four years.
The public option concept first surfaced during the 2017 legislative session, when former Assemblyman Mike Sprinkle (D-Sparks), introduced a bill to allow Nevadans to buy into the state’s Medicaid program, nicknamed Medicaid-for-all. While an amended version of that proposal, instead establishing a Medicaid-like plan, cleared the Legislature, former Gov. Brian Sandoval ultimately vetoed it.
Sandoval, a health care advocate who earned plaudits from Democrats for being the first Republican governor in the nation to opt into Medicaid expansion under the Affordable Care Act and fought to protect the federal health care law in 2017, said at the time of his veto that the public option proposal was “moving too soon, without factual foundation or adequate understanding of the possible consequences.”
Sprinkle proposed a narrower version of his vetoed bill during the 2019 legislative session, nicknamed Medicaid-for-some, that failed to advance after he resigned from the Legislature facing allegations of sexual harassment. Cannizzaro revived the proposal in the waning days of that session in the form of an interim study of yet another public option proposal — this time to allow Nevadans to buy into the state Public Employees’ Benefits Program rather than Medicaid.
That study, which was carried out by the health policy firm Manatt Health, was released with little fanfare in January as lawmakers geared up for the legislative session during some of the pandemic’s darkest days.
The study — which looked at both a PEBP buy-in proposal and a state-sponsored qualified health plan proposal — found that a 10 percent reduction in insurance plan premiums would translate to between zero and 1,500 uninsured individuals gaining coverage in the first year of the plan’s existence, while a 20 percent reduction would reduce the state’s uninsured population between 300 and 4,800 people. There are about 350,000 uninsured Nevadans.
“These enrollment figures highlight that a 10 percent or 20 percent reduction in premiums may not be enough to substantially encourage the currently uninsured to enroll in coverage for the first time,” the study concluded.
For the next couple of months, the public option remained in the background as lawmakers tackled other health care policies. But the public option resurfaced in mid-April when Cannizzaro confirmed she was working on legislation behind the scenes and started meeting with health care industry representatives to present the concept.
In late April, the proposal was introduced as SB420, this time with the goal of leveraging the state’s purchasing power with Medicaid managed care contracts with insurers to compel insurance companies to provide affordable public option plans, too. Unlike some previous iterations of the proposal, the plan would not be offered by a public insurer — such as Medicaid or PEBP — but by private insurers.
Proponents, including progressive groups like Battle Born Progress, the Progressive Leadership Alliance of Nevada and Planned Parenthood Votes Nevada, threw their weight behind the bill, arguing that the proposal would make health care more affordable and accessible. Opponents, including the Nevada Hospital Association, the Nevada State Medical Association and the Nevada Association of Health Plans, countered that it would do just the opposite, going so far as to destabilize Nevada’s already-fragile health care system.
Specifically, health care providers argued that a provision in the bill setting the floor for rates for the public option plans at Medicare rates — which providers say are better than Medicaid rates but not as good as those paid by private insurance plans — would act as an effective cap. They also pushed back on a section of the bill requiring doctors who contract with Medicaid, the Public Employees Benefits Program and workers’ compensation to participate in at least one public option plan.
Instead, opponents of the bill argued that the state should focus on targeting people who are uninsured but either eligible for Medicaid or for subsidies through the state’s health insurance exchange. Together, those two groups represent more than half of uninsured Nevadans. To that end, they proposed an amendment in the final days of the session to scale back the bill to just an actuarial study of the public concept proposal and to look further into how to get Nevadans already eligible for Medicaid or exchange plans insured. But that amendment that was never seriously entertained by Cannizzaro.
While many of the groups that testified in support of and against SB420 were Nevada-based organizations, the bill also attracted significant national attention, including support from the Committee to Protect Health Care, the Center for Health & Democracy and United States of Care and opposition from the Partnership for America’s Health Care Future, a coalition of some of the health care industry’s biggest names — including the American Hospital Association, America’s Health Insurance Plans, and the Pharmaceutical Research and Manufacturers of America — as well as the Koch-backed Americans for Prosperity and LIBRE Initiative. Many of those organizations devoted dollars toward their efforts, sending mailers and runningads in support of or against the proposal.
Sisolak’s signature on the public option bill comes as interest in establishing a national public option, as President Joe Biden promised on the campaign trail, appears to be dwindling. Individual states, however, have continued to pursue their own public option proposals. Washington, the first state in the nation to enact public option legislation, has started to offer plans for sale this year and a bill creating the “Colorado Option” passed out of the Colorado legislature on Monday.
Nevada lawmakers are poised to once again debate creating a state public health insurance option.
Legislation expected to be introduced Wednesday would require insurers that bid to provide coverage to the state’s Medicaid population to also apply to offer a public option plan.
The plans would resemble existing qualified health plans certified by the state health insurance exchange in many ways — for instance, covering a suite of essential health benefits — and would be available for purchase both on and off the exchange. The legislation would, however, require those plans to be offered, essentially, at a 5 percent markdown with the overall target of reducing average premium costs in the state by 15 percent over five years.
The bill also aims to align provider networks between Medicaid and public option plans in order to make access to care more seamless for people who, because of their income level, fluctuate between being covered by Medicaid and securing subsidized insurance on the state exchange.
The proposal, which is being spearheaded by Senate Majority Leader Nicole Cannizzaro, represents both an outgrowth of and a departure from other public option ideas lawmakers have considered in previous legislative sessions, including a 2017 bill that would have allowed Nevadans to buy into the state’s Medicaid program, which the Legislature approved but was vetoed by Gov. Brian Sandoval, and a 2019 study lawmakers approved to look into the possibility of allowing Nevadans to buy into the state’s Public Employee Benefits Program (PEBP) health plan.
The Medicaid buy-in proposal fell by the wayside during the 2019 session after its sponsor, Assemblyman Mike Sprinkle, resigned following accusations of sexual harassment. But Cannizzaro revived the public option conversation as a PEBP buy-in proposal in the final days of that session in the form of a resolution to study the concept.
“One of the top things that you will hear if you go and talk to people at the doors is the cost of health care here in the state,” Cannizzaro said. “When this idea of a public option came about, I immediately jumped on it because I think it is absolutely what folks are looking for and I think it’s a real solution to tackle this, ‘How do you make health care more accessible and more affordable?’”
Unlike the Medicaid and PEBP buy-in proposals, the public option that the new measure aims to establish would be overseen by the state but coverage would be directly provided by private health insurance companies, saving the state the overhead costs of administering a public health insurance program.
While the bill’s introduction will come a little less than five weeks before the end of the session, Cannizzaro said it took time after the release of the PEBP buy-in study in January to consult with state health officials on the legislation and work with the Legislative Counsel Bureau to draft it. The national nonprofit group United States of Care has also been involved with crafting the bill.
The legislation aims to leverage the state’s purchasing power with Medicaid managed care contracts with insurers — which were worth about $1.8 billion a year in fiscal year 2020, according to a memo from the bill’s proponents — to compel insurance companies to provide affordable public option plans as well. Under the legislation, all companies that bid to be a Medicaid managed care organization would also be required to submit a bid to be a public option plan.
Though all three of the state’s Medicaid managed care organizations offer plans on the exchange, the legislation would mandate that insurers that offer a public option plan do so in every county and both on and off the exchange — with the goal of providing additional coverage options to the state’s rural residents and preventing any future threat of bare counties, such as the one the state faced in 2017. Two of the Medicaid managed care organizations offer exchange plans in all 17 counties, while one offers plans in only three counties.
Insurers that don’t apply to be a Medicaid managed care organization would be able to bid to become a public option plan as well, and the legislation leaves to the state’s discretion how many public option plans it approves. Under the bill, development and implementation of the public option would ultimately fall to the director of the Department of Health and Human Services, in consultation with the head of the Silver State Health Insurance Exchange and the commissioner of the Division of Insurance, with the first coverage year slated for 2025.
Because the public option plans would be offered on the state’s health insurance exchange, people who are eligible for federal subsidies under the Affordable Care Act would be able to use those dollars to purchase a fully or partially subsidized public option plan. In addition to being offered both on and off exchange in the individual market, the plans would also be open to the state’s small group health insurance market.
All providers that contract with Medicaid, PEBP and workers’ compensation would be required to participate in at least one public option plan. The legislation would set the floor for contracted rates between providers and insurance companies for public option plans at Medicare rates, a move the bill’s proponents have framed as protecting providers from being negotiated down to Medicaid rates. Medicare generally pays more than Medicaid but is not as generous as private insurance.
“We want to make sure that providers can continue to negotiate,” Cannizzaro said. “We want to be able to reward providers and insurers when they can provide good value-based care that is actually improving the health care of Nevadans long term.”
It isn’t yet clear what kind of impact the legislation might have on reducing the number of uninsured people in Nevada, which, with about 350,000 uninsured residents, has one of the highest uninsured rates in the nation. A handful of states have explored establishing a public option — and only one, Washington, has been successful in implementing one — but none of them have an uninsured rate as high as Nevada’s.
An interim study into the feasibility of implementing a state-sponsored public option plan, commissioned by the Legislature and conducted by the health policy firm Manatt Health, estimated that a 10 percent reduction in premiums would translate to between zero and 1,500 uninsured individuals gaining coverage in the first year of the plan’s existence. A 20 percent reduction in premiums would reduce the state’s uninsured population between 300 and 4,800 people in the first year.
“These enrollment figures highlight that a 10 percent or 20 percent reduction in premiums may not be enough to substantially encourage the currently uninsured to enroll in coverage for the first time,” the study said.
By comparison, this bill requires at least a 5 percent reduction in premiums from a “reference premium” — defined as the second lowest cost silver plan offered on the exchange in any given ZIP code either in 2024, adjusted for inflation, or the previous year, whichever is lower — though the goal is to eventually achieve an overall 15 percent reduction in average premium costs over five years. To that end, the legislation gives the state the ability to approve premiums that exceed that 5 percent premium reduction threshold provided that the state is still on target to hit that five-year goal.
The legislation would also require the state to apply for a waiver to allow it to capture any federal dollars saved as a result of the public option program and then apply those dollars toward reducing premiums and out-of-pocket costs. Such waivers have been used under both the Obama and Trump administrations to help states implement reinsurance programs, a different kind of cost-reducing measure.
The bill also notes the state may apply for a waiver that would allow it to combine risk pools between Medicaid and the public option, if doing so would reduce the overall costs of Medicaid to the state and federal governments.
The legislation authorizes the state to contract with an actuary to assess the impact of a public option plan on the state’s health insurance markets in preparation for applying for any federal waivers. That, coupled with the long lead time until the public option goes into effect in 2025, Cannizzaro said, will give the state and lawmakers time to iron out any issues that may arise.
“We’re giving some additional time in the interim to continue with data analysis and an actuarial [study] to determine what the right points of this bill will be,” Cannizzaro said. “If this needs some tweaks along the way, we have the time and the ability to do that with giving flexibility to [the Department of Health and Human Services] and then also allowing for time, if the Legislature needs to make some adjustments before its actual implementation, we have some time to do that.”
Bill proponents hope the reductions in premiums and out-of-pocket costs will be attractive to the roughly 17 percent of uninsured Nevadans for whom insurance through the exchange is unaffordable and, potentially, some of the 27 percent of uninsured Nevadans who are undocumented and therefore aren’t eligible for exchange subsidies or Medicaid.
“If there are affordable health care plans, people are going to be incentivized and want to try to get health care coverage. So much of what plays into your decision to pay for health care coverage or not comes down to cost,” Cannizzaro said. “We have such a high and persistently high uninsured population that, again, doing nothing is not solving that problem.”
Cost, however, is only part of the battle in reducing Nevada’s uninsured rate. More than half of uninsured individuals in the state are already eligible for Medicaid or subsidized coverage through the exchange — programs that make health care affordable or even free to families — but still aren’t insured.
While affordability already shouldn’t be an issue for those uninsured individuals, the bill’s proponents hope that public awareness about a state public option plan might encourage Nevadans to seek out coverage, where they will find that low or no cost plans are already available to them.
The bill also proposes making changes to the state’s Medicaid program by increasing eligibility for coverage for pregnant women in Nevada up to 200 percent of the federal poverty level, expanding the definition of providers who can determine presumptive eligibility for pregnant women, covering lawfully present immigrants who are pregnant, adding coverage for doulas and community health workers and requiring payment parity between advanced nurse practitioners and physicians.
“I bring a new perspective to this and realize how important it is to have access to this kind of care, especially for moms who can’t otherwise afford it,” said Cannizzaro, who is expecting her first child this summer. “If there’s a way that we can start to increase that here in the state, that is going to have long-term benefits for the health of Nevada families overall.”
Cannizzaro acknowledged there will be a cost to those Medicaid enhancements and said she is curious to see what fiscal notes state health officials put on the bill so lawmakers can start to figure out how to pay for them or whether they need to build more flexibility into the bill. There may be a cost, too, on the public option side of the bill, though it is not yet clear what that might be.
While health industry lobbyists have been receiving presentations on the bill over the last few days, Cannizzaro acknowledged there will likely be concerns with the legislation that will need to be discussed in the coming days and weeks.
“I’m hopeful that we’re going to come up with something that makes sense and that folks can get on board and in support of,” Cannizzaro said. “Do I think everyone is going to love this proposal from the get-go? No, but our job, and the reason why we’ve been having stakeholder meetings, is to talk to everyone who is at the table in this state so that we can hear their questions and concerns.”
Cannizzaro said that bill proponents have also been talking with the governor’s office about the bill.
“Obviously there is still work that needs to be done on this bill, but I know that the governor supports making sure that health care is accessible and affordable for Nevadans, and so we’re working with his office to make sure that we are getting this right as well,” Cannizzaro said. “He knows just as much as the rest of us that this pandemic has truly, I think, reiterated the need for something like this in Nevada.”
As in sessions past, The Nevada Independent is publishing a series of profiles featuring all the new lawmakers in the state. This is the tenth installment of more than a dozen. Check back in the coming days for additional stories on new legislators' backgrounds, interests and policy positions.
Freshman Democrat who succeeds appointed Democratic Assemblyman Greg Smith
Represents District 30, which includes portions of Sparks straddling I-80 and east of I-580
District 30 leans Democratic (38.6 percent Democratic, 29 percent Republican and 24.7 percent nonpartisan in the 2020 election)
Anderson defeated Lea Moser by nearly 18 percentage points in the 2020 Democratic primary
She then defeated Republican Randy Hoff and Charlene Young of the Independent American Party in the 2020 general election, winning a little more than 54 percent of the vote.
She sits on the following committees: Government Affairs, Natural Resources and Revenue.
Natha Anderson’s first record as a child was “Pooh for President,” in which the rotund yellow bear promised a “honey pot in every house.”
It may have been an early sign that she was destined for a life in politics that has so far included walking neighborhoods to campaign for others, lobbying for teacher’s unions and now serving as a Democratic member of the Assembly.
“This time I decided, ‘you know what? If I keep on asking people to run, I’d better put my name in there, too,’” she said. “And what a year to do it.”
Anderson isn’t the first in her family to be a Nevada lawmaker. When she was a senior in high school, her father sat the family down to discuss a bid for office.
“I remember the discussion,” Anderson said. “At that time, and even now, it’s scary, because you do get per diem, but you're not getting a large amount of a paycheck. And so you kind of got to look at yourself and be like, ‘OK, how am I gonna pay my insurance? How am I gonna do this?’”
He ultimately filed. Bernie Anderson served in the Assembly from 1990 to 2010, earning a reputation as a skillful chairman of the Assembly Judiciary Committee and an education proponent who wore a tall red and white Dr. Seuss hat on the Assembly floor in honor of Read Across America day in March.
Natha Anderson followed her parents’ footsteps in another significant way — as a fourth generation educator. She initially resisted the career after seeing her parents spend weekends at their schools trying to get everything done, but it was a required college class in English education leadership that shifted her view.
“I had to volunteer in a classroom,” she said. “And I was hooked.”
In two decades as an educator, she’s taught high school English, AP English and leadership. She lights up when talking about the literature she gets to guide her students through — The Handmaid’s Tale, Fences, Hamlet, the poems ofLangston Hughes, Bless Me Ultima and The Crucible.
One of the bills she’s most excited about this session is a proposal to expand the range of history and literature in Nevada students’ curriculum, to encompass diverse perspectives of people of color and the LGBT experience.
She went on to head the Washoe County Teachers Association union, a role that had her lobbying on education policy in recent years and from which she is currently on leave. It’s the same position her mother held.
“For the last four and a half years, I've been out of the classroom. I've missed it like you wouldn't believe,” she said.
When Democratic Assemblyman Mike Sprinkle resigned in 2019 amid allegations of sexual harassment, she threw her hat in the ring as a potential replacement. The Washoe County Commission ultimately went with Greg Smith, the widower of the late Sen. Debbie Smith, but she won the seat in the 2020 election when Smith declined to run.
While the staunch education advocate is not on the Assembly Education Committee, she said she plans to keep a close eye on those issues in the session, and may play a role in addressing school funding challenges as a member of the Revenue Committee. She said she’s not afraid to take on difficult policy matters as a member of the Assembly, and would rather take a risk than regret not trying to enact change.
“If I'm only a one-termer, then I'm only a one-termer. I’d rather ask the questions then say, ‘Oh, well, I was gonna fix that next session,” she said. “There's no assurance of a next session.”
ON THE ISSUES
Anderson is shepherding a mental health bill that was initially proposed by Connie Munk, a Democratic lawmaker from Las Vegas who lost re-election in 2020 to Republican Richard McArthur.
It’s a study on the adequacy of the mental health workforce and factors that affect recruitment and retention, including a look at whether colleges are offering the right classes, what insurance policies might discourage people from practicing and what restrictions volunteer counselors might face.
“I want us to start talking about how many people that we have going into that profession, and retaining them,” she said. “What are some ways that we can start making this profession one that is, people will stay in Nevada, not just come to Nevada to major in it.”
Nevada’s mental health system consistently ranks at or near the bottom among states.
“I think that we've got to be looking at everything,” she said. “It's going to be tough, because there's no money.”
Anderson is excited to be on the Assembly Revenue Committee and have conversations about where money is coming from and whether it’s being spent correctly.
“We've had some tax breaks that maybe should not have always happened,” she said.
She’s also eager to reevaluate the sticky question of Nevada’s property tax formula. Property taxes in Nevada are not based on the sale price of a home, which is a policy unique to Nevada.
“I'm sorry, the only state that does this? Seriously, let's start fixing that,” she said. “We’ve got to start thinking about … how are we really looking at how our houses are worth.”
Criminal justice reform
Anderson is eager to discuss the possibility of Nevada abolishing the death penalty. It’s a cause her father espoused during his time as a lawmaker.
“There are just so many questions as to … the process that is utilized,” she said. “Also it’s a money thing. We need to be realistic about that.”
At least two bill draft requests on the matter, although the proposals died in the Legislature in 2017 and were never brought up for discussion in 2019.
“I'm not going to shy away from it,” she said. “I realize it’s the wild west and there are some people that have other beliefs, but I'm OK with that.”
Anderson said she knows something needs to be done to address climate change, although she’s not sure exactly what it is.
“I do think we're going the right course when it comes to some of our emission standards that are happening. I mean, that's pretty exciting,” she said. “I think we also have to be smart about how we do it.”
One of her concerns is how a shift to electric cars could ultimately affect a tax base that is, in part, dependent on a tax of fossil fuels.
“How do we make sure to fix something without it putting an even larger hole in our budget?” she said.
Two years after Nevada made history as the first U.S. state to have women compose a majority of its state Legislature, lawmakers will return to Carson City in 2021 with nearly 60 percent of the seats filled by female legislators — by far the largest percentage of any statehouse in the country.
Though Democrats lost three seats in the Assembly and one in the state Senate after final vote totals were released over the weekend, one of the most notable changes heading into the 2021 Legislature will be the gender makeup; female lawmakers will now represent 38 seats in the 63-member body.
In total, the 42-seat state Assembly will have 27 female lawmakers and 15 male lawmakers, including 19 female Democrats and eight female Republicans. In the 21-member state Senate, men will hold 10 seats and females will hold 11 (two Republicans and nine Democrats). Women held 33 of the 63 seats in the 2019 Legislature, hitting the majority mark after two female Assembly members (Rochelle Nguyen and Bea Duran) were appointed to vacant positions by the Clark County Commission in December 2019.
The increase in female lawmakers can be attributed to a variety of factors, including several retiring or termed out male legislators being replaced by women and both parties running female candidates in several major races, including three close state Senate seats. That means substantial turnover — roughly a quarter of legislative seats will be filled by newcomers — will result in Nevada again having the nation’s highest percentage of female lawmakers.
Democratic Assemblywoman Maggie Carlton, first elected in 1999, said the gender balance was closer to 70-30 male dominated when she entered the Legislature, but that gradual cultural shifts over the next 20 years helped drive the shift to first gender parity and later a clear female majority in the statehouse.
“Women realize that we've got to be at the table,” she said. “We've worked very hard for that. We've educated folks. We've gotten them involved. And they've seen what's at stake, and they want to be part of the conversation. I think that's fantastic.”
Regardless of gender make-up, lawmakers entering the 2021 legislative session will have an immediate and pressing agenda: constitutionally-mandated redistricting; a response to the COVID-19 pandemic and likely additional major budget cuts to the state general fund; and a host of potential tax issues, including efforts by the Clark County Education Association to qualify a sales and gaming tax initiative, and proposals brought during the 2020 summer special session to hike the cap on mining taxes in the state constitution.
But Jill Tolles, a Republican Assemblywoman entering her third term, said that growing ranks of female lawmakers also have helped bring more legislation to the forefront on previously under-addressed issues, including measures aimed at preventing sexual assault or sex trafficking.
Tolles said it was special to be a part of history as part of the first female majority Legislature, but that it will be more important when reaching gender parity isn’t newsworthy.
“It's still exciting, and it's still wonderful to see, but I think that one of the things that we saw in 2019 was we very quickly after the celebrations, just rolled up our sleeves and got to work on policy,” she said. “And not just policy on some of those issues that we hadn't traditionally given as much light to or given as much time to in the past, but all policies that impact men and women equally.”
Nationwide in 2020, only about 29.3 percent of lawmakers in state legislatures are female, according to a tally by the Center for American Women and Politics.
Seven legislative districts are going from male to female representative, including:
Assembly District 2, where Republican Heidi Kasama will take over a seat held by termed-out Assemblyman John Hambrick
Assembly District 6, where Democrat Shondra Summers-Armstrong will take the seat held previously by William McCurdy (elected to the Clark County Commission in 2020)
Assembly District 18, where Democrat Venicia Considine will take the seat of former Assemblyman Richard Carrillo. Carrillo left the seat to mount an unsuccessful bid for state Senate
Assembly District 19, where Republican Annie Black defeated incumbent Chris Edwards in the June primary election. Black did not face a general election opponent
Assembly District 21, where Democrat Elaine Marzola will represent the seat formerly held by Democrat Ozzie Fumo (who ran and lost in a bid for state Supreme Court)
Assembly District 30, where Democrat Natha Anderson will represent a district previously held by Democrat Greg Smith. Smith was appointed to the seat after the resignation of former Assemblyman Mike Sprinkle amid accusations of sexual harassment
State Senate District 7, where Democrat Roberta Lange takes the seat of termed-out state Sen. David Parks. Lange won a narrow primary victory over incumbent Assembly members Ellen Spiegel and Richard Carrillo, but did not face a general election opponent
Three districts previously represented by female lawmakers will now have a male representative, including:
Assembly District 7, previously held by Democrat Dina Neal but that now will be represented by Democrat C.H. Miller
Assembly District 20, previously held by Democrat Ellen Spiegel but that now will be represented by Democrat David Orentlicher
Assembly District 37, where Republican Andy Matthews ousted Democratic incumbent Shea Backus
The tally of female lawmakers has increased since the start of the 2019 session, owing to vacancies (several resignations and a death) of seats held by men but filled by female appointees. Ahead of the 2020 election, the 63-member body was composed of 34 female lawmakers and 29 male lawmakers.
Carlton said she has enjoyed working with an increasingly diverse group of female lawmakers of both parties during the legislative session, saying that the legislative process is improved when more diverse viewpoints are brought to the table. While female lawmakers aren’t a monolith — she noted that many come from different career fields and range from retirees to those just starting their careers — Carlton said that their outlook and approach to the legislative process yield beneficial results.
“We have a tendency more to want to wrap our arms around something and try to solve all the pieces of the puzzle, while I think the guys sometimes want to dissect it and see what's wrong, and then put it together,” she said. “We come at things in a different viewpoint with all the different life experiences that we have.”
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.”
In early September last year, high-profile tech companies in the Tahoe Reno Industrial Center appeared before a legislative committee with a request — public financing to help defray the costs of a major pipeline project. Their goal was to obtain more water to help fuel growth at the Northern Nevada industrial park, one of the largest in the world and home to Tesla’s Gigafactory.
The lawmakers approved. Then the state financing fell apart.
Less than three weeks later, the industrial park’s largest landowner withdrew its support of the deal, notifying the companies in a letter obtained by The Nevada Independent that it did not want to be associated with a project that could be seen as providing “corporate welfare.”
An attorney for Blockchains, a little-known techno-utopia company that owns most of the park’s land, wrote in the letter that “the project has now transformed to focus primarily on the precise type of taxpayer-funded subsidiary that we were against when we first learned of the project.”
Blockchains’ letter and other documents obtained through two public records requests offer new insight into the relationship between business and government at an industrial park that lured companies with incentives and support from the state.
The letter comes amid new scrutiny of those practices. Last month, The Nevada Independent detailed how the industrial park’s public water district, which wants to use eminent domain to build the pipeline project, blurred the line between a government and private utility for decades.
The water district is operated by a developer-owned company, TRI Water and Sewer, with board members who all reside at a brothel that is owned by the main broker for the industrial park.
The state office that helped engineer the complicated public financing for the pipeline has also come under recent scrutiny. On Monday, Gov. Steve Sisolak criticized the Governor’s Office of Economic Development for the criteria it uses when deciding to approve tax incentives. Sisolak said he plans to move the office in a new direction. Major companies at the industrial park have benefited from state and local tax breaks in addition to Nevada’s already lenient tax structure.
In an email last week, a high-ranking Reno lawmaker criticized the proposed pipeline financing.
“This deal was rushed, lacked transparency and is the antithesis of public accountability,” said Assembly Majority Leader Teresa Benitez-Thompson, a Democrat who was on the Interim Finance Committee. “It begs the question of allowing such statutes to remain on the books.”
A request from the state
In 2015, the Legislature met for a special session to consider tax breaks for Faraday Future, an electric car company that planned to move to North Las Vegas. The cash-strapped car company abandoned its plans to build a factory, but the statutes from that session remained on the books.
Out of that special session, the economic development office gained bonding authority. By September 2018, the office was looking at using bonds to help finance the effluent pipeline.
The 16-mile pipeline will siphon treated effluent from a regional wastewater facility to the park. City officials consider it a win-win for the Reno area, helping ratepayers defer costly upgrades while bringing more water to an industrial park that has helped diversify the state’s economy.
The companies backing the effluent pipeline wanted to expand their existing operations or build on vacant land. One limiting factor for their growth plans was water. But the effluent project was expected to cost more than $100 million. To finance the off-site pipeline — stretching from the park to the regional wastewater facility along the Truckee River — they turned to the state.
The industrial park would be responsible for building the project.
Storey County would issue special assessment bonds up to $35 million.
The state would issue mirroring bonds to pay for the Storey County bonds.
The companies would reimburse the state by agreeing to pay periodic assessments.
Eventually, the companies could get paid for some of their costs too. The companies would be reimbursed through a Tax Increment Area (TIA), a special tax district where a portion of new tax revenue — tied to the area — is reimbursed to the companies that paid for the infrastructure.
The reimbursements would not dip into dedicated property taxes for schools but would tap into revenues for county fire services. It also taps into payroll tax and the modified business tax. The state justified the revenue loss by noting that the reimbursements would be a sliver of the $1.35 billion in tax revenue that it expected the area to generate with the new infrastructure. Officials also noted that the revenues would benefit infrastructure built outside of the industrial park.
On Sept. 5, the 23-member Interim Finance Committee approved of what came to be known as the SAD/TIA deal. The vote to approve the bonds was unanimous.
But six legislators voted against using the newly-generated tax revenue to reimburse the companies: Benitez-Thompson, Sen. Pete Goicoechea, Assemblywoman Daniele Monroe-Moreno, Assemblywoman Ellen Spiegel, Assembly Mike Sprinkle and Assemblywoman Heidi Swank.
Blockchains: ‘Corporate welfare’
Those bonds were never issued.
After months of negotiations, several companies decided to pre-pay about 75 percent of the periodic assessments, according to the letter Blockchains sent to project leaders on Sept. 24.
In the letter, Blockchains General Counsel Lee Weiss recounts learning the night before that several companies intended to pre-pay about $24 million of the project upfront, despite their request for bonds. It suggested that companies had the finances to pay for the project.
At the same time, the companies would still be reimbursed with the new revenue.
With the company’s official launch about one month away, he wrote Blockchains was “unwilling to assume the risk of being portrayed as an organization that promotes projects that provide corporate welfare to pay for improvements that we have already contractually agreed to fund.”
Blockchains announced that it was withdrawing from the public financing.
Bob Sader, a former legislator and an attorney for the industrial park’s developer, declined to comment on the letter.
Not everyone agreed with Blockchains’ view of the deal. Proponents argue that in addition to boosting the economy, the pipeline would help cities save on expensive facility upgrades.
“I was disappointed by [Blockchains’] characterization of the project,” Ben Kieckhefer said in an interview last week. “There were plenty of reasons to support it from a public perspective.”
By October, the companies had scrapped the financing deal. The park’s developer, Tahoe Reno Industrial Center LLC, will pay to construct the pipeline. It has entered into private agreements with companies to fund it. The companies could still be reimbursed with the new tax revenue that the project helps generate. The county could reimburse up to $28 million to the companies.
The companies are not reimbursed from existing revenue.
A new landowner
At the center of the pipeline project is the industrial park’s public water district. Once the project is constructed, the water district will operate the pipeline and oversee how the water is used.
But the water district is another place where government and business collide. Despite being a political subdivision with public powers, the water district is operated by the park’s developer.
It is operated by a developer-controlled company, TRI Water and Sewer, and its board members live at a brothel owned by Lance Gilman, responsible for marketing the industrial park. Gilman is also a Storey County commissioner and lists TRI Water and Sewer on his financial disclosure.
The board members also report income from at least one of Gilman’s companies.
Through a 2001 operating agreement, any board responsibilities that are not required by statute were delegated to an existing developer-owned private water company, TRI Water and Sewer.
For many years, the relationship, blessed by Storey County, reflected a financial arrangement. The master developer, Tahoe Reno Industrial Center LLC, paid for the infrastructure and gave it to the public water district free of charge. It acquired the water rights that the district controlled.
Until recently, the water district operated in the red. The master developer subsidized the water district for more than a decade to keep rates competitive for companies coming to the park.
But the relationship came with benefits too.
The unique structure, a combination of circumstances and loopholes in Nevada law, allowed the industrial center to effectively operate a private water utility while avoiding oversight from state regulators. Instead, its oversight came from a board that is closely tied to the park’s developer.
When the industrial park land was largely vacant, the arrangement flew under the radar.
Then in January, Blockchains scooped up about 67,000 acres of land at the 107,000 acre park. It comprised most of the remaining acreage at the park. At the time, a land play of that size by such a mysterious company raised eyebrows about how it planned to develop its land. Those questions have only amplified since the Trump administration made the area eligible for a new tax break that could boost Blockchains and others if they invest in the land or decide to sell it.
With the sale, what became clear was the need to change the water district’s structure, said Sader, the attorney for the park’s developer. Once the sale went through, the water district was still controlled by the park’s developer, but the developer no longer controlled most of the land.
In early 2018, Sader began discussing the issue with the park’s major customers.
Those involved in or advised of the talks included Google, Switch, Tesla and Blockchains, Sader said. All of the companies declined to comment or did not respond to multiple email requests.
‘Change of control'
By the time legislators reviewed the financing, the companies had not resolved the problem of the water district’s structure. But during that time, one possible solution was being discussed.
Some companies were looking into transferring the ownership of the water district’s operating company, TRI Water and Sewer, from the developer to the major companies at the park. That would have put major customers, such as Switch and Google, in control of the water district.
One email suggests that the structure of the water district had some bearing on the project. On Sept. 24, 2018, Sader emailed Switch that he needed a decision soon on whether the large companies would take over the water district’s operator, TRI Water and Sewer.
Sader writes “time has just about run out on effectuating the transfer...so as not to disrupt the [project] and on-site process water projects. If so, [the park] must plan for an alternative path.”
“If I do not hear from you with details on a proposed change of control this week, I will assume Switch has lost interest in the concept and proceed accordingly,” Sader writes in his email.
The companies opted against the takeover, and the park’s developer still controls the district.
Sader said that the water district turned to an alternative plan. Based on Nevada law, a county commission can serve as a public water district’s de facto board in certain circumstances.
In one email in October, the water district’s recently hired general manager wrote to a group of Storey County officials and consultants that at an upcoming meeting, they would consider “a method of protecting Storey County from liability associated with taking on the [the water district] as a component unit of Storey County in the event that the [commission] elects to do so.”
The commission has yet to vote on whether it wants to serve as the district’s trustees.
“That is only in discussion,” said Austin Osborne, the county manager.
He said the county was not interested in taking over the management of the water district.
In recent weeks, the public water district has rolled out reforms and is restructuring itself so that it can operate as an independent entity, separate from the master developer. The district plans to hire staff, and board members have started reading disclosure statements at meetings. TRI Water and Sewer plans to terminate its operating contract with the water district on June 30.
A power struggle
The documents also highlight a shifting power dynamic at the park. Blockchains now controls most of the park’s land — an amount larger than Reno — but it has little power over decisions.
“While we do not profess to be eminent domain experts, as attorneys, we are not convinced that the pipeline project constitutes a ‘public use,’ Weiss, the lawyer, wrote in an Oct. 24 letter.
“First, it is the Master Developer, a private entity, not the [water district], that has the obligation to construct the pipeline such that the [water district] may not have standing to pursue the action. Second, the beneficiaries of the pipeline... are all private companies,” he continued.
Weiss’ letter concluded that “even if the [water district] has standing, as the pipeline is being constructed by a private party for the benefit of private parties, we do not believe that there is any significant public purpose to justify an eminent domain action.”
Other companies have not commented publicly on how they view the water district’s use of eminent domain. The water district has said eminent domain is justified, noting that it was a last-resort move after it made numerous efforts to negotiate with the private property owner.
The public records show a continued effort to negotiate with the Menezes family, which owns a trucking company, a hay cubing operation and owns land above the pipeline’s proposed route.
In an emailed response to Weiss on Nov. 1, Sader noted that “our eminent domain attorney is strongly of the opinion that the legal analysis in your letter on the public use issue is flawed.”
During a board meeting on Friday, that eminent domain lawyer, John Gezelin, recommended using condemnation because the Menezes family declined the most recent settlement offer.
In an initial challenge to eminent domain, the Menezes family raised questions about who was behind the project and who was paying for it. They cited a 2008 constitutional amendment “that the transfer of property from one private party to another private party is not considered a public use.” Whether or not a project is for “public use” is a key standard for justifying eminent domain.
Some legal experts are unsure how the courts would rule on the provision.
Because many eminent domain cases end with settlements, there are few precedents. Reno attorney Steven Silva, who teaches property law at Truckee Meadows Community College, said the courts have traditionally weighed a project’s purpose more heavily than who is paying for it.
“The form of the actor has been less important,” he said “It is traditionally the use.”
A court dismissed the water district’s first attempt to use eminent domain over noticing issues.
On Friday, the water district voted to approve a new eminent domain action.
The Assembly Democratic Caucus is announcing seven endorsements on Friday, ahead of a major legislative reshuffling in 2020 as lawmakers hit their term limits or seek higher office.
All of the endorsements are in districts that are either solidly Democratic or lean Democratic and which Democrats won handily in the 2018 election. The party currently holds a supermajority in the Assembly, and are just shy of two-thirds support in the Senate.
The caucus is endorsing Shondra Summers-Armstrong, a management analyst with the Regional Transportation Commission of Southern Nevada and chief steward with SEIU Local 1107, for Assembly District 6. Assemblyman Will McCurdy, the occupant of that seat, is running for Clark County Commission. Democrat Katie Duncan, founder of the Ward 5 Chamber of Commerce, is also running for the seat.
In Assembly District 7, the caucus is backing Cameron “CH” Miller, who was announced Friday as Nevada political director on Minnesota Sen. Amy Klobuchar’s presidential campaign. Assemblywoman Dina Neal, who has represented that district since 2010, is running for the state Senate.
Clara “Claire” Thomas is the caucus’s pick in Assembly District 17, which was represented by Assemblyman Tyrone Thompson until he suddenly passed away earlier this year. Thomas is a case manager with the Clark County District Attorney’s Office and, like Summers-Armstrong, a steward with SEIU Local 1107.
The caucus is supporting Venicia Considine, director of development and community relations at the Legal Aid Center of Southern Nevada, for Assembly District 18. That seat is currently represented by Assemblyman Richard Carrillo, who is running against Assemblyman Ellen Spiegel for the state Senate seat that Sen. David Parks is termed out of.
To that end, the caucus is endorsing David Orentlicher, a professor at UNLV’s Boyd School of Law and co-director of the UNLV Health Law Program, for Spiegel’s seat in Assembly District 20.
The caucus will also support Elaine Marzola, an attorney and owner at Marzola Injury Law, for Assemblyman Ozzie Fumo’s seat in Assembly District 21. Fumo is seeking a position on the Nevada Supreme Court. Natha Anderson, president of the Washoe Education Association, will receive the caucus’s endorsement in Assembly District 30. That seat has been held by Assemblyman Greg Smith since Mike Sprinkle resigned in the wake of sexual harassment allegations against him.
Two lawmakers who were appointed to fill unexpected vacancies during the 2019 session say they will not run for the seats in 2020.
Democratic Sen. Marcia Washington, whom county commissioners appointed in March to serve the remainder of former Senate Majority Leader Kelvin Atkinson’s term after he resigned, says she will not run for re-election.
Washington said at the time of her appointment and in an email to The Nevada Independent on Tuesday that she did not intend to keep the seat. Atkinson’s term would have ended in 2020.
Democratic Assemblyman Greg Smith also will not seek re-election, saying “life is short” and he did not want to have to spend every other year campaigning. Smith was appointed by the Washoe County Commission in March after former Assemblyman Mike Sprinkle resigned amid sexual harassment allegations.
Smith was married to former state lawmaker Debbie Smith, who passed away in 2016 after fighting brain cancer. He was appointed from a field of 15 Democratic contenders to represent Assembly District 30, which includes the Sparks area.
Meanwhile, Senate Democrats have endorsed Assemblywoman Dina Neal to take Washington’s seat after Neal’s Assembly term ends next year. Neal has expressed her intent to represent the heavily Democratic Senate District 4 ever since she applied for the post in March, when Atkinson resigned and announced he would plead guilty to a federal charge of misusing campaign funds.
“As a lifelong resident of Senate District 4, I fully intend to represent the people and the historic neighborhoods where I grew up,” Neal said in the press release from Nevada Senate Democratic Caucus announcing her bid and the endorsement.
In the March appointment vote, Neal received support from Chairwoman Marilyn Kirkpatrick and Commissioner Lawrence Weekly, but Commissioners Larry Brown, Justin Jones, Michael Naft and Tick Segerblom voted in opposition. The board voted unanimously to appoint Washington instead.
If Neal’s campaign for Senate District 4 is successful, she will preside over an area very similar to her current Assembly District 7, but with expansion southward including the Corridor of Hope.
The Corridor of Hope is an area with a high concentration of people experiencing homelessness and organizations that providing emergency shelters, food and other medical, housing and support systems.
Homelessness activists reprimanded Neal in the last legislative session for gutting a bill, AB73, that would have authorized municipalities to place place new taxes that would create dedicated streams of revenue for cities to expand homelessness services. In April, Neal added an amendment to the bill, which passed, that eliminated the tax provisions and called for more input from county commissioners.
If Neal wins the seat, she would follow in the footsteps of her father, former Sen. Joe Neal, who represented Senate District 4 from 1973 to 2001.
Gov. Steve Sisolak was similarly busy on May 21, but for different reasons. Amid a packed schedule that saw him attend a wildfire status briefing and the cannabis bill hearing, the governor was also busy on the second-to-last Tuesday before the end of the Legislature calling several high-profile business and gaming executives — Eldorado Resorts’ Gary Carano, Peppermill Resorts President Billy Paganetti and Ultimate Fighting Championship COO Ike Lawrence Epstein.
Described by his office as general check-ins, the scheduled calls were part of a slew of calls made by Sisolak as the legislative session drew to a close, indicating that the governor kept open lines of communication with top business leaders even as lawmakers approved bills raising the minimum wage and requiring large private employers to offer paid sick leave — panned as anti-business by Republicans.
Those meetings and others held between Sisolak with high-powered lobbyists, legislators with major pending bills, federal government officials and a slew of well-known business leaders were revealed in a public records request submitted by The Nevada Independent for the governor’s calendar through the legislative session.
Meetings scheduled in Sisolak’s calendar don’t necessarily confirm that they actually happened, and often provide few details as to the point or reason for them. But information on the scheduled meetings of the state’s first Democratic governor in two decades provides insight into the power structure and important relationships that define and influence what laws and policies are (or aren’t) adopted.
“The calendar provided to The Nevada Independent is the Governor's working calendar, maintained by staff,” Sisolak spokesman Ryan McInerney said in an email. “Some of the calendared appointments occurred as scheduled, others did not occur at all, or were managed entirely by staff. Moreover, travel schedules for the Governor, First Lady Kathy Sisolak, and the Governor's family were redacted to ensure the safety of the Governor and his family.”
Although he positioned himself as a natural successor to popular and moderate Republican Gov. Brian Sandoval on the campaign trail, meetings scheduled by Sisolak throughout the legislative session included comparatively more meetings with labor leaders and other constituencies of the Democratic Party. They also reveal details about which individual interests were able to secure time with the governor ahead of major decisions on bills affecting energy, collective bargaining for state workers and health care issues.
But like Sandoval, many of Sisolak’s scheduled meetings show the names of the same Carson City power brokers, lobbyists and business leaders who continue to wield the same influence and effect on the legislative process, regardless of the party in power.
Not all details of Sisolak’s calendar were made public — at least 67 events on the calendar provided to The Nevada Independent were redacted. Sisolak’s office said that in addition to travel, the office also redacted telephone numbers and personnel information such as start and end dates.
Here’s a look at the people, groups and constituencies Sisolak met with during the 2019 legislative session.
Sisolak made an effort to meet with all 63 members of the Legislature during the first few weeks of the legislative session — a hectic schedule reflected in the early February weeks of his calendar.
But meetings held with lawmakers outside of those initial meet and greets shine a light on Sisolak’s involvement in the legislative process beyond just signing bills.
The lawmaker who scheduled the most meetings with Sisolak was Democratic Sen. Chris Brooks, who previously served one term in the Assembly and is married to Sisolak’s chief of staff, Michelle White.
Brooks confirmed in an interview that the meetings were related to several bills related to energy that Sisolak had identified as priorities on both the campaign trail and in his State of the State address. He said early on that he and White had established a “firewall” and worked with other staff in the governor’s office to arrange meeting and discuss strategy.
“We were pretty adamant about making sure she wasn’t involved personally,” he said.
Other meetings held between Sisolak and individual lawmakers include:
A March 27 meeting with Republican Assembly Leader Jim Wheeler and Blockchains CEO Jeff Berns, described by the governor’s office as a meet and greet that veered into a discussion of issues with wild horses
An April 30 meeting with Democratic Assemblywoman Teresa Benitez Thompson, related to her bill AB400, which removed certain types of taxes from possible economic abatements. The bill was signed into law by Sisolak.
A May 17 meeting with Assembly Judiciary Chair Steve Yeager on AB553, the bill creating the Cannabis Compliance Board. Yeager presented the bill in committee about a week later; it was later signed into law by Sisolak.
A May 22 meeting with Senator Julia Ratti on her dental therapy bill, SB366. The bill was amended twice after the meeting and eventually signed into law by Sisolak.
Sisolak’s meetings with lawmakers merely tap the surface of his involvement in the legislative process; the Democratic governor met with dozens of lobbyists or representatives for various interests groups throughout the entire 120-day session.
Notably, Sisolak recorded holding a short meeting with National Shooting Sports Foundation executive Larry Keane and the group’s state lobbyist, Patrick McNaught, on April 18.
The meeting came nearly a week before lawmakers approved major changes to a major gun safety bill by Democratic Assemblywoman Sandra Jauregui, AB291, that initially sought to allow local governments to pass more restrictive gun laws than those put in place by the state (a concept called pre-emption).
But the concerns of the NSSF, which holds the annual SHOT tradeshow in Las Vegas, helped almost sink the bill, and contributed to the removal of that language from the bill. Lawmakers instead added in provisions creating a “red flag” law process, which lets law enforcement and family members petition a court to temporarily seize a person’s firearms if they present a danger to themselves or others.
The NSSF itself issued several warnings about Sisolak in the run-up to the 2018 election, noting that he had promised to institute a long-stalled voter-approved gun background check initiative and to ban assault weapons. NSSF spokesman Mark Olivia said that the meeting was similar to ones the group had across the country and in Washington D.C. with other elected officials, and that the organization was grateful that Sisolak took the time to listen to their concerns.
“This is what any trade association is going to do to make sure their concerns are heard,” he said.
Other major lobbyists that Sisolak met with during the legislative session include:
Former Assembly Speaker turned lobbyist Richard Perkins and clients on February 19 in Las Vegas
Former state senator, current lobbyist Warren Hardy on February 19
A meet and greet with the Jewish Federation and former Rep. Shelley Berkley on March 5. Both supported a bill, AB257, that would have authorized creation of a Holocaust memorial museum in Nevada; the bill failed to pass
Griffin Company lobbyist Josh Griffin (and “group”) on May 20
Las Vegas Metro Chamber CEO Mary Beth Sewald on May 23, to discuss “legislation relating to Nevada employers,” a spokesperson for the Chamber said
Ferraro Group founder Greg Ferraro and former Fennemore Craig lobbyist Jim Wadhams on May 29, in a meeting regarding pending bills and the close of the legislative session. Wadhams also met with Sisolak on April 1.
Within hours after Democratic Assemblyman Mike Sprinkle announced he was resigning from the state Legislature over multiple claims of sexual harassment, Gov. Steve Sisolak was already meeting with his eventual successor — though the governor’s office claims it was just a coincidence.
While reporters scurried and stalked the legislative building in attempts to find Sprinkle or get comments from other lawmakers on his resignation, Sisolak had scheduled a meeting with Greg Smith — the husband of former Democratic state Sen. Debbie Smith. The meeting on March 14 came two weeks before his appointment to the Assembly and over a 15-person field of candidates who filed to replace Sprinkle.
But Sisolak’s office said the meeting was just a coincidence; Smith was brought in to advise the office on several pending bills related to apprenticeship programs (Smith is a retired union apprenticeship program administrator.) Smith did not return several calls seeking comment on the meeting.
On the campaign trail, few organizations were more helpful to Sisolak than the Clark County Education Association, which endorsed the future governor early in the campaign and spent more than a million dollars in third-party campaign ads ahead of the 2018 election.
Once in office, Sisolak’s door was open to the teacher’s union and its polarizing leader, John Vellardita. The governor and Vellardita met or called at least twice (once on March 14 and again on April 8), and held a meet and greet with CCEA educators on April. In contrast, the Nevada State Education Association (which endorsed Sisolak’s primary opponent) held a scheduled meeting with Sisolak just once, on March 19.
And in a legislative session defined by massive shifts to the state’s antiquated funding formula and calls for more funding, Sisolak also met with various school district and higher education leaders. He met with Clark County School District Superintendent Jesus Jara twice (once on March 4 and again on March 26), Washoe County School District lobbyist Lindsay Anderson on April 4, Nevada System of Higher Education Chancellor Thom Reilly on February 27, and UNLV President Marta Meana on April 24.
Sisolak also met with State Board of Education chair Elaine Wynn on May 21, the same day as the first legislative hearing on the revamped K-12 education formula.
Calls to major business and gambling company executives took up a sizable amount of Sisolak’s time, especially as the legislative session drew to a close.
Sisolak’s calendars show meetings with Anthony Marnell (CEO of Marnell Gaming, which operates the Sparks Nugget) on April 10, Golden Gaming CEO Blake Sartini on April 21 and Grand Sierra Resort and SLS Las Vegas owner Alex Muerelo on May 9. One of his last calls made before the legislative session ended on May 27 was to Virginia Valentine, the director of powerful casino trade group the Nevada Resorts Association. Valentine said the call was to relay the gaming industry’s support for AB533, the bill to create the Cannabis Compliance Board.
Other notable meetings or calls arranged between business executives and Sisolak include:
At least four of the Democratic presidential candidates met with or calling Sisolak during the legislative session, including billionaire philanthropist Tom Steyer, New Jersey Sen. Cory Booker and former Housing and Urban Development Secretary Julian Castro. Sisolak’s office also said he met with California Sen. Kamala Harris during her trip to Nevada, and that all candidate visits were accommodated based on the governor’s schedule and availability.
He also met with former New York City Mayor and billionaire Michael Bloomberg — who considered but ultimately decided against a presidential run — on February 26, after state lawmakers approved a bill implementing a long-stalled gun background check law. Bloomberg helped fund the group that backed the initial ballot question in the 2016 election.
Sisolak said during an AFSCME forum earlier this month that he wasn’t sure whether he would endorse any candidate before the state’s presidential caucus in February.
Sisolak arranged a call with former Acting Interior Secretary David Bernhardt on Feb. 5, and another call with former Labor Secretary Alex Acosta on March 28, the same day Nevada joined a group of states intervening in a lawsuit defending the constitutionality of the Affordable Care Act.
Sisolak also scheduled a call with Delaware Sen. Tom Carper on April 30, the same day he sent a publicized open letter to Carper and Wyoming Sen. John Barrasso to reiterate the state’s “strong opposition to the Yucca Mountain project” (Barrasso and Carper serve on the U.S. Senate Committee on Environment and Public Works).
Grants management lawsuit
Sisolak’s office also scheduled a meeting entitled “Streamlink Discussion” on April 15, a day after The Nevada Independentpublished a story detailing how litigation brought by Streamlink had gummed up a grants management software contract that state officials believed could help tap into millions of dollars worth of federal grants.
Although the state took no immediate action after the story was published, Carson City District Court Judge James Russell ruled against the state and in favor of Streamlink in May, leading the Department of Administration to announce it would drop future appeals and re-open bidding on the grants management software contract.
The contract was reopened in July, and the office expects to have the system fully functional by 2021.
Sisolak’s calendar also shows meetings with higher-profile individuals than the normal slew of Carson City insiders.
The governor scheduled a meet and greet meeting with actress Patricia Arquette on March 8, the same day the actress attended a press conference with Democratic lawmakers on several equal pay bills. Sisolak’s office said the meeting was indeed scheduled but never actually happened.
On May 15, he scheduled a meeting with former football star Boomer Esiason on the topic of cystic fibrosis, a genetic disease that Esiason has highlighted through creation of a foundation after his son was diagnosed with the disease.
Sisolak also met with legendary labor organizer Dolores Huerta on April 3, and presented her with a proclamation. Huerta came to Carson City to testify in favor of a bill that would allow for physician-assisted aid-in-dying. The bill, SB165, failed to advance out of the Legislature.
Lawmakers this session took patients out of the middle of negotiations between providers and insurance companies over out-of-network hospital bills in a landmark bill decades in the making and codified the Affordable Care Act’s protections for people with pre-existing conditions amid ongoing threats at the federal level.
But, by and large, the changes that the Legislature pursued this year to improve health care in the state weren’t big or flashy. Instead, lawmakers passed a number of incremental changes — such as establishing a maternal mortality review panel, allocating additional state dollars for family planning services and commissioning studies on prescription drugs and a state public option — that experts say will slowly begin to move the needle on health care.
“There were some little tweaks that were made that are going to have a big impact,” said Catherine O’Mara, executive director of the Nevada State Medical Association. “I think sometimes it doesn’t seem that exciting because there’s not these huge reform bills but, in the aggregate, there were a lot of little things that were done that are actually going to positively impact people.”
Part of that emphasis on smaller health policy items over the sweeping change that had seemed possible when a Medicaid buy-in proposal was the subject of conversations between the 2017 and 2019 legislative sessions was signaled early on by Gov. Steve Sisolak, who during his campaign promised the creation of a Patient Protection Commission charged with a top-to-bottom review of health care in the Silver State.
When Sisolak first proposed it last year, the commission was framed as a blue-ribbon panel that would bring together patients, doctors and other policymakers and, after convening for 100 days, recommend changes to be implemented by the Legislature.
In light of that, there was initially some speculation that the panel would operate similarly to an advisory panel that Sisolak established in January to map out sweeping regulatory changes to the marijuana industry. But Sisolak took a different tack with the Patient Protection Commission, proposing legislation, SB544, to create that body in mid-May and charging the body to return to the 2021 legislative session with its recommendations in the form of two bill draft requests.
“For a first-session governor to create a Patient Protection Commission I think is really prudent,” O’Mara said. “The administration didn’t just jump in and say, ‘We’re going to change health care.’ He said, ‘We’re going to jump in and hear from everybody and figure out where all the pain points are and go from there.’”
Some in the industry see a model for the commission in the success of the landmark surprise emergency room billing legislation that passed this session, which was a byproduct of extensive conversations between insurers, hospitals and doctors between sessions and a mandate from Assembly Speaker Jason Frierson that they reach a compromise. Industry representatives who were a part of those conversations said they weren’t completely happy with the end result, but it was something that they were willing to live with.
“The surprise billing issue has been around and hasn’t come to any level of resolution for years, and a giant step was taken in that bill passed,” said Tom Clark, a lobbyist for the Nevada Association of Health Plans. “Kudos to Assemblyman Frierson, the speaker, for taking that bull by the horns and really making sure that all of the stakeholders got together and figured that out.”
Similarly, Sisolak has made it clear that the commission, an 11-member panel made up of industry and patient representatives, will be a working body. He warned at an industry briefing before the legislation was introduced that the overall goal is compromise, and anyone not working toward that could those their seat at the table.
“I think the way it’s being structured is going to give all sides of the issue a chance to be at the table and facilitate the development of good regulation and good legislation, whichever the case may be,” said Bill Welch, president and CEO of the Nevada Hospital Association.
Questions still remain about how the body will work with the interim health committee, a panel of lawmakers that studies issues between sessions to develop policy to bring forward when the Legislature meets again and with two health-care studies that have been commissioned. But industry representatives — from doctors and hospitals to insurers and pharmaceutical companies — are optimistic about the commission’s potential.
“For our part, we want to come to the table with proposed solutions and ideas and an openness to address the challenges Nevada’s health-care system is facing,” said Priscilla VanderVeer, a spokeswoman for the national drug lobbying association Pharmaceutical Research and Manufacturers of America, in an email. “We believe this is a real opportunity to work together across the broader health-care system and the political spectrum to enact real change and we look forward to being a part of it.”
Part of that optimism comes from the hope that the commission will look at the root cause of some of the state’s health-care ills with an eye toward prevention and mitigation early on to prevent poor health-care outcomes down the line. For instance, lawmakers approved rate bumps for hospitals providing intensive care to some of the state’s sickest babies, but the broader question of how to expand access to prenatal care so those babies are born healthy remains.
“When I hear from hospitals or skilled nursing facilities or certain provider types, their messaging is very good, but we need to be looking at the whole landscape of health care and where we need to move the dial and where the opportunity is,” said Richard Whitley, director of the Department of Health and Human Services. “If it can be prevented, if we can intervene early, we ought to intervene.”
Here’s a look at some of the other health policies that passed this session, and others that didn’t:
Studying (again) a state public option
A last-minute bill, SCR10, introduced by Senate Majority Leader Nicole Cannizzaro is tasking the Legislative Commission with studying the feasibility of allowing Nevadans to buy into the Public Employee Benefits Plan, or PEBP, which provides health insurance to state workers.
Cheryl Bruce, executive director of the Nevada Senate Democratic Caucus, framed the legislation as a way for the Legislature to continue to explore the idea of a public option. Conversations on the topic waned following the resignation of Democratic Assemblyman Mike Sprinkle, who had led the interim conversations on a Medicaid buy-in proposal.
“We think this is a good first step to get more information before moving forward with any future legislation,” Bruce said in a text message.
Some in the industry have raised concerns that the legislation is too narrow because it specifically targets the interim study to the feasibility of a PEBP buy-in and that it focuses on access to insurance without also targeting access to care.
“I did talk with the sponsor of the bill, and they assured me that some of the things I wanted to amend into the bill and include the bill are generically incorporated in the bill already,” Welch, the hospital association CEO, said. “I want to make sure they are focusing on the full picture.”
The overarching question that the study will have to address is who a public option plan aims to help. Conversations about increasing access to health insurance in Nevada have generally centered around increasing access to rural residents who only have one plan available to them for purchase on the exchange, improving access to residents across the state who are increasingly priced out of exchange plans or targeting the state’s undocumented population, which faces severe barriers to accessing insurance and care.
Before Sprinkle’s resignation, some of the conversations around Medicaid buy-in focused on how the proposal could help the state’s rural residents and possibly other populations on a limited basis.
“At the end of the day I will be shocked if this study shows much more than that again. I only say that because if you bring all of this uninsured population to the state’s health benefit plan it will change your actuarial mix of who are insured,” Welch said. “You’re going to be bringing in individuals potentially who have chronic medical conditions that will change how you actually set your premiums.”
Codification and stabilization of the Affordable Care Act
The most sweeping bill related to the Affordable Care Act that passed this session was AB170, which codified the federal health-care law’s protections for people with pre-existing conditions into state law. A similar measure last session was vetoed by former Gov. Brian Sandoval, who said at the time that it would have locked into law “requirements that may be unnecessary, imprudent, or simply unaffordable in the years to come.”
Approval of the legislation comes amid an ongoing legal challenge to the Affordable Care Act on the federal level that could strike down the law entirely, including its popular pre-existing condition protections.
“Who knows if the federal administration is ever going to actually overturn the Affordable Care Act, but they certainly are chipping away pieces of it,” said Elisa Cafferata, lobbyist for Planned Parenthood. “It’s good to have those protections in place because what everybody really liked about the Affordable Health Care was the preventative health care and pre-existing conditions.”
The compromise pre-existing condition language was first crafted a different bill spearheaded by Democratic Sen. Julia Ratti who, as chair of the Senate Health and Human Services Committee, worked to ensure the legislation would codify the protections in the Affordable Care Act as they stand now — no more and no less. The work on that bill, SB235, was then folded into Democratic Assemblywoman Ellen Spiegel’s AB170.
The legislation also requires health insurance plans to provide to the Governor’s Office for Consumer Health Assistance the phone number of a navigator or case manager who can help patients make an appointment with a doctor in a timely fashion. The bill had initially proposed requiring insurance companies to cover out-of-network doctor’s visits at no additional cost to patients if no in-network physician was readily accessible, but was amended down in a compromise with insurance companies.
Though it’s a small change, those in the health-care industry say it stands to improve access to care for patients.
“Our take is that AB170 is a very simple little bill that will actually have a practical impact in helping patients,” O’Mara said. “It’s one of those bills that isn’t flashy but will make a difference.”
The Legislature also passed two Affordable Care Act stabilization bills — SB481 and SB482 — that place additional restrictions on two types of health insurance plans with potentially skimpier coverage than that required under the federal health-care law and direct the state to apply for a federal innovation waiver to allow the state to explore other options to stabilize the individual health insurance market.
Heather Korbulic, executive director of the Silver State Health Insurance Exchange, said that together the bills “could have a dramatic impact on getting people connected to plans that are right for their needs.”
Lawmakers additionally approved the exchange’s budget, which included the funding necessary to become an entirely state-based exchange instead of the hybrid model that the exchange has been operating under now. Exchange officials have said that a Nevada-run platform will both save the state money and allow them to know who is actually purchasing individual plans through the exchange and better target their outreach.
“That itself lends a lot of autonomy and control,” Korbulic said. “Lawmakers were cognizant of that potential flexibility.”
Changes for hospitals
Lawmakers passed two bills this session that strike at the core of what it means to be a hospital and what services those facilities should and ought to provide.
One of them, Democratic Assemblywoman Maggie Carlton’s AB317, shifts the responsibility of determining whether to establish any additional trauma centers from the local level to the state. It comes amid renewed discussions over Southern Nevada’s trauma need and whether to approve additional trauma centers. Welch said that the change “might potentially create some additional time to make those determinations going forward” but that “overall the approach is a balanced approach.”
The legislation also requires every off campus facility that a hospital operates — such as a microhospital or freestanding emergency department — to have a unique national provider identifier number. The goal is to help the state better track and understand how those facilities are utilized compared to traditional hospitals.
Another bill advocated for by the hospital association, Democratic Assemblywoman Rochelle Nguyen’s AB232, requires all hospitals in the state to be certified by the federal Centers for Medicare and Medicaid Services (CMS). The legislation specifically targets a tourist-focused microhospital near the Strip, Elite Medical Center, which doesn’t bill Medicaid or Medicare.
In hearings on the bill, Elite argued that its business model isn’t based around providing care to Medicaid and Medicare patients and that it would rather write off the cost of uncompensated care it provides to those individuals than go through the onerous process to become Medicaid and Medicare participating. But lawmakers sided with the hospital association, which argued that hospitals should have the responsibility of taking care of all patients.
“We’re not opposed to microhospitals,” Welch said. “We’re supportive of microhospitals, but we’re supportive of them coming in and being a part of the integrated health-care delivery system.”
The legislation gives Elite until July 1, 2021 to be certified by CMS.
The Legislature also took steps to address the financial needs of the state’s hospitals, which have long argued that they are increasingly strained by the number of Medicaid patients they treat. Lawmakers approved a 25 percent bump in the per diem Medicaid rate to care for babies in the neonatal intensive care unit (NICU) and a 15 percent bump in pediatric intensive care unit (PICU) rates to ensure that hospitals are able to maintain the current level of services that they are providing to the community.
Welch said the hospitals are “ecstatic” about the increases.
“What it is going to do is ensure that those beds that we do have are not going to close, because there has been a lot of discussion over the last 18 months about whether certain hospitals were going to be able to continue providing services at that rate,” Welch said.
Hospitals also got a last-minute boost in the form of SB528, an appropriations bill passed in the final two hours of the legislative session that included a 2.5 percent increase to the state’s acute care per diem rate for Medicaid. Welch said that he had asked for a 20 percent increase at the beginning of the session but didn’t know whether hospitals would get any rate bump until those final minutes.
“Between those three things, that will help us immensely,” Welch said. “It won’t get us anywhere near cost, but at least it’s moving us in the right direction and hopefully will help us be able to sustain the services.”
After negotiation between proponents and the hospitals, lawmakers also passed SB364, Democratic Sen. David Parks’s bill requiring hospitals to identify patients by their preferred name and pronouns, representing a significant victory for the state’s transgender community.
Drilling down on drug costs
At the beginning of the session, there were several sweeping proposals to tackle the high cost of prescription drugs, including a mandate that the middlemen in the drug pricing process pass along rebates they negotiate with drug manufacturers to consumers and a Prescription Drug Affordability Board with the ability to examine high cost prescription drugs and limit what payers can spend on them.
Neither of those ambitious proposals moved forward this session, but lawmakers did vote to expand a diabetes drug transparency bill passed in 2017 to require manufacturers of asthma drugs and drug pricing middlemen, or pharmacy benefit managers (PBMs), disclose certain costs and profits to the state.
The bill, Democratic Sen. Yvanna Cancela’s SB262, requires manufacturers of asthma drugs whose prices have increased significantly in the past year or two to report specific data to the state for each drug including the cost of producing it, administrative expenditures such as marketing and advertising costs, profit earned, financial assistance provided to help patients, and coupons and rebates offered. PBMs are also required to report any rebates they negotiated and any profits they retained associated with asthma drugs that experienced significant price increases.
“The hundreds of thousands of Nevadans living with asthma deserve to know that the price they’re paying for their medication they need to breathe is fair, and this bill will help shed some light on factors affecting these drug prices,” Sisolak said at a bill signing last month.
But drug manufacturers, who sued over the diabetes drug transparency legislation two years ago, raised concerns during hearings on the bill that regulations adopted by the state in 2018 to keep confidential information companies deem to be trade-secret protected would only apply to diabetes drug reporting and not the new asthma drug reporting.
VanderVeer, the PhRMA spokeswoman, said that she couldn’t speculate on whether there will be litigation related to the new asthma drug transparency law.
“We will be closely monitoring and engaging in the regulatory process,” VanderVeer said.
Another bill, Republican Assemblywoman Melissa Hardy’s AB141, builds on some of the prohibitions on gag rules inserted by PBMs into contracts with pharmacists — preventing them from disclosing certain information to patients — passed in the 2017 session. The legislation prevents PBMs from stopping a pharmacist from providing information to patients about the availability of a less expensive drug and from penalizing a pharmacist for selling a less expensive generic drug to a person.
Lawmakers, in passing Cancela’s SB276, have also directed the Legislative Commission to appoint a committee to conduct an interim study concerning the issue of the costs of prescription drugs, including the impact the PBM rebates have on prices.
VanderVeer said that PhRMA was “glad to see a discussion about the broader pharmaceutical supply chain taking place in Nevada this year,” though the association still believes it was unfairly targeted in 2019.
“While we continued to see a one-sided political attack that took place in 2017, we are glad that there was some recognition of the broader pharmaceutical supply chain and the importance of protecting patients’ access to needed medicines and the future development of new treatments and cures,” VanderVeer said.
Access to care
Lawmakers tackled a number of broader access to care issues this session, too, including patients’ ability to access mental health, dental and family planning services.
One bill, which emerged from one of the regional behavioral health policy boards created by the Legislature in 2017, establishes a new endorsement for psychiatric hospitals to be deemed a crisis stabilization facility and mandates that those stabilization services be covered under Medicaid. The need for crisis mental health services in the state was brought into sharp focus in 2018 when WestCare abruptly closed its crisis triage center in Reno and Clark County had to shell out additional funding to keep the doors of the company’s Las Vegas crisis triage center open.
“These could be game changers from the impact they could have on reducing emergency room and jail holds on patients,” said Chuck Duarte, CEO of Community Health Alliance and chair of the Washoe Regional Behavioral Health Policy Board. “I’m hopeful we’ll see some of these facilities developing in Nevada. I think they’ll have a significant impact on unwanted institutionalization.”
The bill, AB66, also requires the state to adopt regulations to license and regulate providers of nonemergency secure behavioral health transportation services to transport people experiencing a mental health crisis. Right now, a significant portion of the burden of transporting individuals undergoing a mental health crisis falls on law enforcement, particularly in rural Nevada.
Another piece of legislation passed, Cannizzaro’s SB425, requires Medicaid to provide additional home and community-based services, including tenancy support services. Under federal law, states are allowed to implement tenancy support services for people who are elderly or disabled.
“It doesn’t solve the housing problem” Duarte said. “But this establishes the sustainable revenue stream.”
Other bills drilled down into the issue of access to dental care. One of them, Ratti’s SB366, establishes a new mid-level dental provider type, known as dental therapists, who will be allowed to perform a number of routine dental procedures currently performed only by dentists, including extracting loose teeth, filling cavities and applying sealants.
The dental therapists will only be allowed to practice in underserved areas, including federally qualified health centers, rural health clinics, tribal health clinics, and any other clinics that primarily serve Medicaid patients or other low-income, uninsured individuals.
Duarte said that it “makes a lot of sense” for federally qualified health centers, including Community Health Alliance, to be able to lean on dental therapists to provide services, particularly when non-emergency adult dental services are not covered by Medicaid in Nevada.
“Right now with Medicaid not covering adult dental services, it’s hard to provide comprehensive care to adults without insurance,” Duarte said.
Lawmakers also approved AB223, sponsored by Democratic Assemblywoman Dina Neal, requiring the Department of Health and Human Services to seek permission from the federal government to establish a pilot program to provide dental care to adults with diabetes.
Women’s reproductive rights were another key focus for lawmakers this session with the passage of SB179, a bill sponsored by Cancela that removes longstanding criminal penalties on abortion and removes requirements that doctors explain to women the emotional implications of undergoing the procedure, and SB94, which clarifies how state family planning dollars can be spent. Sisolak also allocated and lawmakers approved $6 million in state family planning funds this session.
“It’s going to significantly increase the access to family planning services around the state,” Cafferata, the Planned Parenthood lobbyist, said. “Especially for rural Nevada that bill is going to be significant.”
One family planning bill that did not advance last-minute was Cannizzaro’s SB361, which would have required the state’s chief medical officer to issue a standing order allowing for self-administered birth control, essentially allowing patients to skip a doctor’s visit and go straight to the pharmacy for their medication. Those involved with the legislation said there were some last-minute tweaks to the bill and that lawmakers ran out of time to get the bill finalized.
But Whitley, the director of the Department of Health and Human Services, said it may be possible for the state to take action on the issue in the interim, particularly to increase access to birth control in communities where it’s difficult to get in to see a doctor.
“The Board of Pharmacy has authority to explore their existing authority through regulation for that,” Whitley said. “I’d like to work with them to see if there is something we can do since we do know that much of our state is a health-care workforce shortage area.”
Public health solutions
Beyond the industry-specific changes they made, lawmakers also signaled their interest in focusing on public health issues, from maternal mortality to vaping.
AB169, sponsored by Democratic Assemblywoman Daniele Monroe-Moreno, established a maternal mortality review panel amid rising concerns nationally over the recent rise of maternal deaths and complications. To fund the board, Nevada is applying to the federal government for a slice of a $43.5 million grant from the Centers for Disease Control and Prevention dedicated to investigating the causes of pregnancy-related deaths and complications.
“It wasn’t controversial at all but the Maternal Mortality Review Board, which actually passed quite early, was a really an important step for the state to take,” Cafferata said. “It was one of those quieter bills, because it didn’t have a lot of controversy around it, but I think it will be a significant bill for all of us.”
Lawmakers also made changes to an opioid prescribing law passed in 2017 that was aimed at tamping down on the overprescription of opioids but that doctors said was unduly burdensome and harmful to patient care. The new bill, AB239, allows providers more discretion when writing prescriptions for controlled substances to treat acute pain.
Another bill, Ratti’s SB263, places a 30 percent tax on e-cigarettes and their accessories and directs a significant portion of the $8 million a year in revenue it is projected to generate back to vaping prevention activities. Whitley said the legislation puts Nevada ahead of the curve when it comes to prevention in this area.
“[It] is really a first in our state for taking a behavior and not waiting” for the FDA to take action, Whitley said. “If you look at the history of tobacco use or alcohol use or gambling or other behaviors that can in excess cause harm, really the response in vaping, we’re with the group of states that are ahead in starting to tackle this.”
A final public health-focused bill to establish an all-payer health insurance claims database, SB472, failed to move forward in the final minutes of the session. The bill would have required the state to compile a database of billing information from insurance companies to better understand health-care costs.
Whitley said that he believes it was another case where lawmakers ran out of time, but that he’s already exploring options for the department to pursue such a database on its own in the interim in conjunction with the UNLV School of Public Health.
“An all-payer database would allow us to actually see where services are occurring and where maybe we need to give focus,” Whitley said. “We’re going to continue to work with community partners and the university to see if we can do it as a voluntary database to build the system.”