When lawmakers kicked off their 120-day legislative session in February, the state was still recovering from a brutal winter surge of COVID-19, which saw a thousand new cases of the virus reported across the state each day.
Lawmakers early in the session came forward with some modest proposals to address the pandemic — including a bill to give workers paid time off to get vaccinated — but it was unclear at that point what COVID-19’s trajectory in the Silver State would be. With an influx of federal financial support boosting the state’s pandemic response, it wasn’t always easy to tell where lawmakers could be of most help. With sessions slated for only 120 days every other year, it also wasn’t clear they could craft policy responsive enough to the ever-changing needs created by the pandemic.
Instead, lawmakers generally focused on a host of other important, but perhaps less high-profile, health care proposals, from legislation to support the provision of telehealth services in the state, which became all the more popular during the pandemic, to a bill that would provide for Medicaid coverage of community health workers. They also honed in on data transparency, hearing bills that would make changes to the state’s drug pricing transparency program and establish an all-payer claims database in an effort to better understand the health care landscape in the state.
Lawmakers also took up a last-minute bill to establish a state-managed public health insurance option in Nevada, the second-ever to be approved in the nation. Despite reservations from Republican lawmakers — and even from some Democrats — the Legislature introduced and approved the bill in just a little more than a month with some strong-arming by Senate Majority Leader Nicole Cannizzaro (D-Las Vegas), who spearheaded the legislation.
Behind the scenes, there were frustrations, though, among health care lobbyists. Industry lobbyists, for instance, were caught off guard that Cannizzaro hadn’t involved them in the process of developing the public option bill and dropped the proposal on them in the final weeks of the session.
“I can tell you that when there are very challenging things that occur within health care, when you lock us all in a room, we tend to find solutions,” Tom Clark, lobbyist for the Nevada Association of Health Plans, said during the bill’s first hearing.
Bobbette Bond, policy director for the Culinary Health Fund, also said it was difficult to craft good policy in a legislative environment so heavily shaped by the pandemic. For much of the session, the legislative building was closed to the public and committee meetings were only able to be attended virtually.
“It was hard to get revisions made. It was hard to have good conversations about what could be done. It was hard to build stakeholders,” Bond said. “It was hard to communicate, and I think the policy suffered for that.”
Bond also expressed dismay in the two-thirds requirement for passing tax increases, on the grounds that it has prevented lawmakers from tackling more ambitious health care legislation. Because there isn’t more funding to go around, including to support health care, she said lawmakers have turned to putting mandates on industry.
“The mandates … end up substituting for actual public health policy,” Bond said.
The Culinary Health Fund, which is the health insurance arm of the politically powerful and Democratic-aligned Culinary Union, did, however, continue to play a significant role in shaping health care policy this session with Democrats remaining in control of both chambers of the Legislature. Other industry representatives, who often work collaboratively with Democratic lawmakers but more often align with Republicans on business priorities, had less of an upper hand.
Mike Hillerby, a longtime lobbyist on health care issues in the state, said Nevada loses “a lot of subtlety in the public policy debate” when the discussion is “driven by the relationship between a couple of unions and a couple of hospital chains.”
“That drives so much of what we do, and it's so contentious. Look at balance billing from 2019. Look at some of the stuff this time, and everything's driven by that. That's not indicative of the market and the rest of Nevada. That's not indicative of what's happening with providers and patients and payers in rural Nevada, in the Reno area, and yet so much of it is driven by that and that financial reality, that bargaining relationship, those contractual relationships,” Hillerby said. “We just lose a lot of the subtlety and the ability to make better decisions.”
Here’s a look at some of the health policies that passed this session and others that didn’t.
The highest-profile piece of health care legislation to pass this year, SB420 — Nevada’s public option bill — was introduced with just a little more than a month left in the legislative session by Cannizzaro, the Senate majority leader. Proponents were quiet about the legislation for the first couple of months of the session until Cannizzaro was asked by a reporter in mid-April about the proposal and health care lobbyists started receiving briefings from consultants on the concept.
The bill, which builds upon previous public option proposals introduced in Nevada in 2017 and 2019, aims to leverage the state’s purchasing power with Medicaid managed care organizations — private insurance companies that contract with the state to provide coverage to the state’s low-income population — to get insurers to also offer public option plans. The plans will resemble existing qualified health plans on the state’s health insurance exchange, though they will be required to be offered at a 5 percent markdown with the goal of reducing the plans’ premium costs by 15 percent over four years. The plans won’t be offered for sale on the exchange until 2026.
The proposal cleared both the Senate and Assembly on party line votes and was signed into law in early June by Gov. Steve Sisolak, making Nevada the second state in the nation after Washington to enact a state-based public health insurance option into law. Colorado became the third state to establish such a policy in mid-June.
Though the legislation was heavily opposed by the health insurance industry — with some groups running ads and sending mailers opposing the proposal — Cannizzaro muscled the bill through the Legislature as the clock counted down to the end of the 120-day session. The bill easily cleared the Senate — where Cannizzaro, as majority leader, controls which bills come to the floor — and Democratic leaders in the Assembly threw their support behind the bill shortly thereafter, setting aside concerns about whether the bill can accomplish its goals of improving health care access and affordability.
“It's not a secret I have been skeptical of this bill from the very beginning, but I've seen the amendments, and I have talked to a number of the different proponents of the bill and opponents of the bill on it,” Assembly Ways and Means Chair Maggie Carlton (D-Las Vegas) said in late May, shortly before allowing the bill to be voted out of her committee. “I feel much more comfortable knowing that, in the future, the people that are in this building now that do come back are well aware of what's going on, and I trust them to make the best decisions they can to protect the constituents of this state.”
In her remarks, Carlton was referring to the long runway the bill establishes before the public option actually goes into effect, leaving time for the state to conduct an actuarial study to figure out whether the bill actually accomplishes the goals it sets out to and two legislative session in 2023 and 2025 for lawmakers to make any tweaks to the policy as necessary.
Heather Korbulic, who as head of the state’s health insurance exchange will have a key role in shaping the policy’s implementation, has said she plans to bring stakeholders together to “outline the actuarial study and conduct a meaningful analysis of the public option as it relates to every aspect of health care throughout the state.”
Richard Whitley, director of the Department of Health and Human Services, said in an interview earlier this month that the public option isn’t “a single solution” but “does definitely enhance the opportunity for individuals to gain access to health care.”
“I think of this as an option for coverage,” Whitley said. “It definitely enhances that overall framework of health care coverage.”
Transparency and data efforts
For the last two legislative sessions, lawmakers have focused on prescription drug cost transparency, passing a first-in-the-nation diabetes drug transparency law in 2017 and expanding that law to include asthma drugs in 2019. This year, lawmakers built upon those transparency efforts by passing legislation requiring transparency from more portions of the health care industry.
This year, lawmakers approved a bill, SB40, to establish what’s known as an all-payer claims database — a state database of claims of medical, dental and pharmacy services provided in the state. The law requires all public and private insurers regulated under state law to submit their claims to the database and authorizes insurers governed by federal law — such as the Culinary Health Fund — to submit their claims to the database. A similar bill proposed during the 2019 legislative session failed to move forward in the final minutes of that session, though the concept was revived by the Patient Protection Commission, which brought SB40 forward this session.
The bill, however, required extensive work when it got to the Legislature, with state Sen. Julia Ratti (D-Sparks) taking the bill under her wing as chair of the Senate Health and Human Services Committee and working with industry advocates — including the Nevada Association of Health Plans, the Nevada State Medical Association and the Nevada Hospital Association — to finalize the legislation.
“We knew the bill was going to pass, at some level ... so we wanted to make sure that the information that was going to be collected was accurate, was consistent with what was required in other states that had all-payer claims databases and also to learn from what those other states had done so we wouldn’t make the same mistakes,” Clark, the Nevada Association of Health Plans lobbyist, said. “Fortunately, Senator Ratti and others were good to work with and we’re comfortable with the way the bill passed.”
The legislation additionally makes data contained in the all-payer claims database confidential, meaning that it is not a public record or subject to subpoena, and specifies how the information contained in it can be disclosed. It can be shared in de-aggregated form to state or federal government entities, including the Nevada System of Higher Education, and any entity that submits data to the database. Anyone else looking to obtain the data can only receive it in aggregated form by submitting a request to the Department of Health and Human Services.
Lawmakers also built upon the diabetes and asthma drug transparency bills passed in 2017 and 2019, respectively, by expanding the universe of drugs the state imposes transparency requirements on. SB380, which was proposed by an interim committee created during the 2019 session to study prescription drug costs, requires the state to compile a list of prescription drugs with a list price that is more than $40 for a course of therapy that has undergone a 10 percent price increase in the preceding year or a 20 percent increase in the two prior years.
The legislation requires drug manufacturers to submit a report to the state explaining the reason for the price increase and explaining the factors that contributed to the price increase. Meanwhile, pharmacy benefit managers, or PBMs, the middlemen in the drug pricing process, are required to submit their own reports with certain data about the drugs, including rebates negotiated with manufacturers and the amount of the rebates retained by the PBM.
The state’s drug transparency program will also, for the first time, have funding behind it, utilizing dollars that have been collected in the form of fines paid by companies for not complying with the state’s drug transparency law. The Department of Health and Human Services put a $780,000 fiscal note on the bill to allow state health officials to transfer the existing drug transparency database to the state’s Enterprise Information Technology Services Division and hire a pharmacist and management analyst to manage the drug transparency program.
SB380 was, however, only one of two bills put forward by the interim prescription drug committee to pass this session. The other was SB396, which allows the state to establish intra- and interstate drug purchasing coalitions with private entities.
The three bills that did not pass were:
SB201, which would have licensed pharmaceutical sales representatives
SB378, which would have required at least half of the health plans offered in the state by private insurers to provide prescription drug coverage with no deductible and a fixed copayment and limit the total amount of copayments insured individuals are required to pay in a year
SB392, which would have licensed PBMs and created additional rules for how PBMs can operate.
Nick McGee, senior director of public affairs for PhRMA, the drug industry advocacy organization, in an email expressed disappointment that lawmakers pursued SB380 this session while not advancing the other proposals out of the interim committee. PhRMA did, however, in the end testify in neutral on SB380.
“We are disappointed that the legislature overlooked this opportunity to address patients’ concerns related to their ability to afford and access the medicines they need,” McGee said. “Instead, lawmakers pursued onerous reporting and unnecessary registration requirements that won’t do anything to help patients afford their medicines and fail to provide transparency into why insurers are shifting more and more costs on to patients.”
Bond, the policy director for the Culinary Health Fund, which played a key role in bringing the 2017 bill to fruition, described SB380 as a “step forward,” though she said the bill didn’t end up “as strong as we would have liked.”
“It’s incremental, and it’s progress,” she said.
Lawmakers did not advance SB171, sponsored by state Sen. Joe Hardy (R-Boulder City), which would have barred most insurance companies from implementing copayment accumulator programs for any drug for which there is not a less expensive alternative or generic drug. Such programs prevent drug manufacturer coupons from applying toward patients’ deductibles and maximum out-of-pocket costs.
The Legislature additionally made a budgetary change to boost transparency, approving a request from the Department of Health and Human Services to centralize its data analysis efforts within the office of Data Analytics within the Director’s Office, while the Patient Protection Commission, which is focusing on health care spending and costs, was transferred from the governor’s office to Director’s Office as well.
Whitley, the department’s director, framed the reshuffling as an effort to bring together disparate health data collection and analysis efforts, adding that the pandemic showed the kind of real-time data the department could provide, as in the case of its COVID-19 dashboard, among other dashboards it now maintains.
“Usually people go, ‘We need more money.” Well, in government sometimes what you need is organizational structure,” Whitley said. “Putting data analytics all in one unit in my office … was really because of seeing all of the benefits that were coming out of monitoring the pandemic. That really served to inform what we could be doing.”
The Legislature also made a significant change to the Patient Protection Commission this session, transforming it from a largely industry-focused body to one instead made up largely of non-profit health industry representatives and patient advocates. AB348, sponsored by Carlton, requires the commission be made up of:
two patient advocates
one for-profit health care provider
one registered nurse who practices as a nonprofit hospital
one physician or registered nurse who practices at a federally qualified health center
one pharmacist not affiliated with any retail chain pharmacy, or a patient advocate
one public nonprofit hospital representative
one private nonprofit health insurer representative
one member with expertise advocating for the uninsured
one member with expertise advocating for people with special health care needs
one member who has expertise in health information technology and works with the Department of Health and Human Services
one representative of the general public.
The bill also makes the Patient Protection Commission the sole state agency responsible for administering and coordinating the state’s involvement in the Peterson-Milbank Program for Sustainable Health Care Costs, a program that provides technical assistance to states developing targets for statewide health care spending trends.
Health care industry representatives have, however, chafed at the reduction — or in the case of the drug industry, removal — of their representation on the commission. McGee, from PhRMA, said the change “[undermines] the ability of the commission to provide a comprehensive perspective.”
But Bond, a commission member whose ability to serve will be unaffected by the policy shift, said the change would give patients and consumers more of a voice.
“I understand the concerns about losing representation from the industry, but I also believe that industry has other places where they get represented,” Bond said. “They have the Nevada Hospital Association, the pharmaceutical industry has PhRMA. They get well represented in their core arena. Patients really don't have a core arena they can go to.”
The Patient Protection Commission’s other bill this session, SB5, also was approved by lawmakers, making a number of changes to telehealth in the state. That bill also contains a data transparency component, requiring the Department of Health and Human Services, to the extent money is available, to establish a data dashboard allowing for the analysis of data relating to telehealth access.
Another big bill that tried to tackle health care costs this session, AB347, sponsored by Assemblyman David Orentlicher (D-Las Vegas), died without receiving a vote. The ambitious bill, among other provisions, proposed establishing a rate-setting commission “to cover reasonable costs of providing health care services” while ensuring providers “earn a fair and reasonable profit.” The bill also would have raised Medicaid payments to Medicare levels via a provider tax.
Antitrust in health care
Lawmakers approved two antitrust in health care bills this session. The first one, AB47, requires parties to certain reportable health care or health carrier transactions to submit a notification to the attorney general with information about the transaction at least 30 days before it is finalized. Reportable transactions include material changes to the business or corporate structure of a group practice or health carrier that results in a group practice or health carrier providing 50 percent or more of services within a geographic market.
The bill, which was presented by the attorney general’s office, also prohibits employers from bringing court actions to restrict former employees from providing services to former customers or clients under certain circumstances and bars noncompete agreements from applying to employees that are paid on an hourly wage basis.
The bill attracted opposition from the Nevada Hospital Association and the Nevada State Medical Association. During a May hearing on the bill, Jesse Wadhams, a hospital association lobbyist, thanked the attorney general’s office for working with them on the bill but said the association still could not support the legislation.
“We believe the policy itself comes from a faulty premise,” Wadhams said. “We believe policies should promote more physicians, more access to care and more investment in the health care community.”
Another bill, SB329, requires hospitals to notify the Department of Health and Human Services of any merger, acquisition or similar transaction. It also requires physician group practices to report similar transactions if the practice represents at least 20 percent of the physicians in that specialty in a service area and if the practice represents the largest number of physicians of any practice in the transaction. The legislation, sponsored by state Sen. Roberta Lange (D-Las Vegas) and pushed for by the Culinary Health Fund, requires the department to publish that information online and write an annual report on that information.
Another section of the bill allows the attorney general or other individuals to bring a civil action against a health care provider that “willfully” enters into or solicits a contract that bars insurance companies from steering insured individuals to certain health care providers, putting health care providers in tiers or otherwise restricting insurers. It also makes such an action, known as “anti-tiering” or “anti-steering,” a misdemeanor. (A final amendment to the bill reduced the penalty from a felony to a misdemeanor.)
“I think this is one of the early steps in what will probably be a national trend,” Bond, of the Culinary Health Fund, said in an interview. “I think contract provisions are going to become more and more antitrust looking.”
The bill was opposed by the Nevada Hospital Association and individual Nevada hospital systems and hospitals.
“The technical elements of this and eliminating antitrust provisions by themselves are not the problem we have with this bill — it is making sure that it doesn’t impede the open contracting that occurs otherwise in this highly competitive environment,” Jim Wadhams, a lobbyist for the hospital association, said during a May hearing on the bill.
In perhaps the most substantial victory for health care providers this session, lawmakers rolled back a 6 percent Medicaid rate decrease approved by the Legislature during a budget-slashing special session last summer.
Legislative fiscal analysts projected the move would restore about $300 million in Medicaid funding both in the current fiscal year and in the upcoming biennium, including about $110 million in general fund spending.
“Nevada faced an unprecedented state budget crisis,” Bill Welch, CEO of the Nevada Hospital Association, and Jaron Hildebrand, executive director of the Nevada State Medical Association, wrote in a letter to the governor in May. “The work you did alongside the Nevada Legislature to restore funding to hospitals and providers will be instrumental in safeguarding the health care available to many Nevadans.”
Lawmakers made a number of other changes to Medicaid services as well, providing for coverage of doula services in AB256 and community health workers in AB191. The public option bill, SB420, also contained several Medicaid provisions, including one section providing that pregnant women are considered presumptively eligible for Medicaid without submitting an application for enrollment and another prohibiting pregnant women who are otherwise eligible for Medicaid to be barred from coverage for not having resided in the United States long enough to qualify.
On the mental health front, SB154 requires the state to apply for a waiver to receive federal funding to cover substance use disorder and mental health treatment inside what are known as institutions of mental disease — or psychiatric hospitals or residential treatment facilities with more than 16 beds. Medicaid has long been barred from paying for care in such facilities, but states were recently given the ability to apply to the federal government to cover these services through Medicaid via a federal waiver.
Lawmakers also approved AB358, sponsored by Assembly Speaker Jason Frierson (D-Las Vegas), which will allow for a more seamless transition of incarcerated people to Medicaid upon release from prison. The bill requires a person’s Medicaid eligibility to only be suspended, rather than terminated, when they are incarcerated and specifies that individuals who were not previously on Medicaid should be allowed to apply for enrollment in the program up to six months before their scheduled release date. The bill also requires eligibility for and coverage under Medicaid to be reinstated as soon as possible upon an individual’s release.
In a major victory for families of children with autism, lawmakers passed SB96, which boosts reimbursement rates for autism services.
Lawmakers, by and large, did not spend much time tackling the COVID-19 pandemic head on during their legislative session, likely a byproduct of how rapidly the situation has evolved over the last six months.
Legislators did, however, approve SB209, sponsored by state Sen. Fabian Doñate (D-Las Vegas), which requires employers to provide paid leave to employees to receive the COVID-19 vaccine and requires the Legislative Committee on Health Care to conduct a study during the 2021-2022 interim about the state’s response to the COVID-19 pandemic and make recommendations to the governor and lawmakers for the next legislative session in 2023.
They also passed SB318, also sponsored by Doñate, requiring public health information provided by the state and local health districts to “take reasonable measures” to ensure that people with limited English proficiency have “meaningful and timely access to services to restrain the spread of COVID-19.”
Beyond COVID, the Legislature passed a number of other public-health related measures this session, including, notably, establishing a public health resource office within the governor’s office through SB424, with the goal of taking a holistic, multidisciplinary approach to public health in the state.
Lawmakers also approved SB461, which requires the state to disburse $20.9 million of American Rescue Plan dollars to specifically to address needs spotlighted by the public health emergency including “mental health treatment, substance use disorder treatment and other behavioral health services, construction costs and other capital improvements in public facilities to meet COVID-19-related operational needs and expenses relating to establishing and enhancing public health data systems.”
The Legislature additionally passed a few tobacco-related pieces of legislation including AB59, sponsored by the attorney general’s office, officially raising the tobacco purchase age in the state to 21 — the federal Tobacco 21 law went into effect in December 2019 — and AB360, sponsored by Assemblyman Greg Hafen (R-Pahrump), which prohibits people from selling, distributing or offering to sell cigarettes or other tobacco products to a person under 40 without first conducting age verification. Additionally, SB460, the budget appropriations bill, allocates $5 million for vaping prevention activities.
Lawmakers also approved SB233, sponsored by state Sen. Joe Hardy (R-Boulder City), which appropriates $500,000 to the Nevada Health Services Corps, a state loan repayment program for physicians and other health practitioners aimed at encouraging providers to practice in underserved areas of the state. The Legislature also approved SB379, a health workforce data collection bill that proponents say is critical for the state’s health professional shortage area designation.
“It’s kind of nerdy, wonky data stuff, but those designations are really critical for Nevada, for loan repayment, for health service corps, for [federally qualified health center] and community health center designation and reimbursement and all sorts of stuff,” said John Packham, co-director of the Nevada Health Workforce Research Center at the University of Nevada, Reno. “We just need better data, period, on the workforce.”
While mental health advocates have become accustomed to making slim gains each legislative session, Robin Reedy, executive director of NAMI Nevada, believes 2021 was a good session for mental health.
“For once, it’s a long list. It’s just so amazing,” Reedy said of the mental health bills that passed this session. “Everything has just been an uphill climb constantly … but this year, oh my God.”
In addition to SB154, mentioned above, key mental health bills passed this session hone in on mental health parity (AB181), implement the 9-8-8 National Suicide Prevention Hotline (SB390), bolster crisis stabilization services in the state (SB156) and remove stigmatizing language from state law referring to people with mental illness (AB421).
Lawmakers also approved bills put forward by the regional behavioral health policy boards established during the 2017 legislative session, including SB44, which aims to smooth the licensure process to boost the number of behavioral health providers in the state, and SB70, which makes changes to the state’s mental health crisis hold procedures.
Reedy attributed the increased focus on mental health this session to a “perfect storm of things coming together.”
“I think it's incredibly sad that it took a pandemic for people to actually look more at mental health — when everyone was going through some form of anxiety or depression from being isolated, from not knowing what the future held, from it being just really untenable, and everyone has different levels of acceptance of those things, and living through those things, different levels of resilience,” Reedy said. “Suddenly it's like, ‘Mental health.’ We've been working on this forever. Finally.”
But Reedy said there’s still a long way to go. For instance, she wishes that SB390, which authorizes the state to impose a surcharge on certain mobile communication services, IP-enabled voice services and landline telephone services to fund the 9-8-8 line, would have capped that charge at 50 cents instead of 35 cents. She believes had the session been a regular session and had mental health advocates been able to pack the committee room with patients, they would have been able to get that fee cap increased.
“I just don't think 35 cents is going to be enough … We’re 51st in the nation [for mental health],” Reedy said. “I know telecommunications does not want to pay to fill the hole, but that means crisis lines are going to be busy.”
Other health care bills
In addition to reigning in drug pricing costs, lawmakers passed several bills making changes to how Nevadans can access certain kinds of prescription drugs. SB190, sponsored by Cannizzaro, will allow pharmacists to dispense certain kinds of hormonal birth control directly to patients. SB325, sponsored by Senate Minority Leader James Settelmeyer (R-Minden), similarly allowed pharmacists to dispense preventative HIV medication, including PrEP.
Other prescription-drug focused bills passed this session include AB178, a bill sponsored by Assemblywoman Melissa Hardy (R-Henderson) requiring insurers to waive restrictions on the time period in which a prescription can be refilled during a state of emergency or disaster declaration, and AB177, a bill from Assemblywoman Teresa Benitez-Thompson (D-Reno) aiming to expand access to prescription drugs in people’s preferred language.
Lawmakers also passed a number of other health care related bills including:
SB275, sponsored by state Sen. Dallas Harris (D-Las Vegas), modernizes state laws on HIV by treating the virus the same way as other communicable diseases
SB342, sponsored by the Senate Education Committee, puts the legislative stamp of approval on a major partnership between the UNR School of Medicine and Renown Health
SB290, sponsored by state Sen. Roberta Lange (D-Las Vegas), makes it easier for certain stage 3 and 4 cancer patients to receive prescription drug treatment by allowing them to apply for an exemption from step therapy, which requires patients to approve that certain drugs are ineffective before insurance will cover a higher-cost drug
SB340, sponsored by state Sen. Dina Neal (D-Las Vegas), provides for the establishment of a home care employment standards board
SB251, sponsored by state Sen. Heidi Seevers Gansert (R-Reno), requires primary care providers to conduct or refer patients for screening, genetic counseling and genetic testing in accordance with federal recommendations around BRCA genes, which influence someone’s chance of developing breast cancer
Several health care bills also died with the end of the legislative session, including AB351, which would have allowed terminally ill patients to self-administer life-ending medication, and AB387, a midwife licensure bill.
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.
It comes as hugs with family, dinners with friends, work days that feel just a little safer and errands run without a second thought.
It comes as first doses, second doses and paper vaccination cards multiply. It comes as cases, hospitalizations and deaths fall.
It comes as the virus begins to slip into the background, as the numbers seem less important, as the deliberateness and thoughtfulness with which many have approached the last year fades away.
It comes as a gradual exhale, a slow sigh of relief.
Hospital workers, who for a year have had a front-row seat to the pandemic, were the first to start to feel it.
Jody Domineck, a pediatric nurse in Las Vegas, was so excited for her vaccine appointment that she accidentally arrived early. As she sat waiting in the parking lot, she was at the point of tears. The awfulness of the last year, the fears of bringing the virus home to her family and the relentless drumbeat of the pandemic seemed like they were finally coming to an end.
“We took pictures. Everybody was cheering,” Domineck said. “The history was almost palpable, that this is literally making history, this is saving lives, this is how we beat this. All the work we’ve done, all the stress, all of the fear: This is how we get out of it.”
Dr. Shadaba Asad, the medical director of infectious disease at University Medical Center, described receiving the vaccine as a blessing and a relief. Her husband, who is also a doctor, fell very ill with COVID during the pandemic.
“If you work in a hospital, you’re exposed to these patients day in and day out,” Asad said. “I think when the dust settles and this thing ends, we will realize that this was the turning point in the pandemic for us.”
Dr. Scott Scherr, an emergency medicine physician in Las Vegas, described a feeling of “pure happiness.”
“When the vaccines rolled out, that was the first time in nine months that we had a sigh of relief,” Scherr said. “Having that extra layer of security really takes a huge weight off all of our shoulders.”
It has now been 118 days since the first health care workers in Nevada received their jabs, a small price to pay for protection from COVID-19. Since then, more than a million Nevadans have been either partially or fully vaccinated, a number that officials hope will quickly climb in the coming weeks now that eligibility has opened up widely to the general population.
For many, the hope is palpable.
The denouement, though, is tentative.
Roughly two-thirds of the state’s population remain unvaccinated, with 49 percent of Nevadans eligible but unvaccinated and another 19 percent ineligible because they’re under the age of 16. Typically, somewhere between 50 and 90 percent of the population needs immunity against a virus to slow its spread for good, though scientists still don’t know what the magic number will be for COVID-19.
If the current pace of vaccination from the last week holds steady, it will take 35 more days for 50 percent of Nevadans to be at least partially vaccinated against the virus. Ninety percent will take 116 days.
And, in the near future, the pace of vaccination may shift from a sprint to a crawl when the state runs out of Nevadans eager to be vaccinated. At that point, the work of informing and persuading those who are open but less eager to get the shot will become even more key for public health officials, immunization advocates and community organizations.
Those involved in the vaccination effort in Nevada acknowledge that once the state reaches that phase, it could take significant effort to boost the total percentage of vaccinated Nevadans even slightly.
The denouement drags its heels.
One day, the World Health Organization will officially declare the pandemic over, the U.S. will end its state of emergency and, so, too, will Nevada. But there is no sense of when we can expect to hit those milestones in what continues to be an ever-evolving situation.
This past week, COVID-19 cases in Nevada ticked upward for the first time in three months. It’s a trend other states are seeing too as they lift pandemic health and safety restrictions and as more transmissible variants of the virus become more prevalent. Michigan, where the situation is worse than anywhere in the U.S. right now, has almost climbed back to its December peak.
Some public health experts have warned of a fourth wave of COVID-19 cases nationwide. Rochelle Walensky, director of the Centers for Disease Control and Prevention, recently described a sense of “impending doom.” Others, including Dr. Anthony Fauci, the Biden administration's chief medical advisor, believe a fourth wave is unlikely in light of the increasing number of vaccinations.
Where there is more consensus, though, is that we have once again reached a critical juncture in the pandemic as the vaccination effort races against the spread of the variants and our overwhelming desire for life to return to normal as quickly as possible.
We long for a catharsis that will purge the virus and its many varied consequences — financial, emotional or otherwise — from our lives.
That catharsis has been delayed.
It may, however, offer an opportunity:
An opportunity for state officials, public health experts and others involved in Nevada’s pandemic response to not put the events of the last year behind them but instead sit with them and think through what could have been done differently. An opportunity to assess where the state is today and prepare for a recovery that is only beginning. An opportunity to think about the future and how to better brace for the next pandemic, the next natural disaster and the next emergency.
We want life to go back to normal. We want to move on. We want to forget.
The denouement, though, comes slowly.
It asks us to sit here among the still-smoldering ashes of a once-raging wildfire.
It asks us to nurse the wounds of the devastation the pandemic has brought down on our public health system, on our economy, on our schools, on our government entities and on us.
It asks us not to forget.
For the last year, hospital workers in Nevada and across the nation have found themselves on the frontlines of a war with what has often felt like little to no armor.
Even when they did have the appropriate personal protective equipment, they still worried about getting sick or, often worse, bringing the virus home to their families. Anxiety, for many, became a constant companion.
That all changed when the vaccines arrived.
“The bullets were flying by you for a year, and finally somebody handed you a bulletproof vest. That’s what it felt like to me. I’m like, ‘Wow, can I get a helmet with that?’ And they’re like, ‘Yeah, that’s the second shot. Here’s your helmet,’” said Dr. Bret Frey, an emergency medicine physician in Reno. “I’m like, ‘Wow, I got gear. I feel good.’”
UMC, the county-run hospital in Las Vegas, was the first to start administering vaccines in the state nearly four months ago. The hospital had set up its vaccination clinics — complete with computers, signs and social distancing markers — days before the first shipment of vaccines were expected to arrive and had been drilling its vaccine distribution process.
So, when the doses arrived early, on Dec. 14, the hospital saw no reason to wait.
“Our gut was telling us that we were going to get it on Monday. So the team got in early, we prepared, and then we got the call from the health district that said the shipment had arrived,” said Mason VanHouweling, UMC’s CEO. “Within an hour and a half we were putting a vaccine in our longstanding ICU nurse, who had been working day and night at the hospital and she volunteered to be our first vaccinated health care worker in the state of Nevada.”
It was an auspicious beginning to a vaccination effort that would prove, at times, rocky over the next several weeks as the state struggled early on to secure needed information from the federal government, battled infrastructure and technology issues and grappled with growing inequality in the vaccine distribution process. At one point in January, the state ranked third to last in the nation for doses administered per capita.
Candice McDaniel, who until recently helmed the state’s COVID-19 vaccination effort as a health bureau chief within the Division of Public and Behavioral Health, framed those difficulties as the growing pains of an unprecedented public health operation.
“It’s the scale,” said McDaniel, the new deputy administrator of the Division of Welfare and Supportive Services. “It’s the amount of individuals you’re really trying to reach.”
One of the biggest challenges the state faced early on was the lack of advance notice from the federal government about the state’s vaccine allocation. Because the federal government only told the state how much vaccine it could expect to receive a week in advance, it was difficult for state health officials to scale the vaccine operation up or down to match the number of doses being sent.
That communication, though, has significantly improved in recent weeks, state health officials say — and not just in the form of more advance warning from the federal government on vaccine allocation. McDaniel pointed to the rollout of the health center vaccination program and the expansion of the retail pharmacy vaccination program as two instances where the federal government has ensured the state has been in the loop even though those programs are administered at the federal level.
“I would never venture to say that there aren't challenges,” McDaniel said of the state’s relationship with the federal government on the vaccination effort. “But I feel like when we reach out for guidance or response, we are able to get that.”
It wasn’t just the federal government, though, that stymied the state’s early rollout of the COVID-19 vaccine. The state also faced significant internal challenges.
Despite months of preparations, the state’s vaccine infrastructure found itself quickly overwhelmed as the immunization effort opened up to seniors in January. Vaccination registration portals sometimes crashed because of the number of people trying to access them at the same time; seniors struggling to sign up for appointments overwhelmed vaccine help lines; and records of thousands of shots administered needing manual input into the state’s vaccine database piled up.
Immunize Nevada, the only statewide immunization-focused nonprofit, saw its call volume increase 550 percent in January, the organization’s executive director, Heidi Parker, said. To handle the increased workload, the organization brought on 19 interns for the spring semester instead of its usual four or five.
The state also pivoted, standing up a standardized statewide vaccine registration portal, which the Southern Nevada and Washoe County health districts now use, and a statewide call center. Federal Emergency Management Administration (FEMA) staff came in to help clear the data entry backlog, most of which was in Clark County, and FEMA and the National Guard continue to play a key role in operation of the county’s mass vaccination sites.
Dr. Fermin Leguen, health officer for the Southern Nevada Health District, said that Clark County, which is home to nearly three-quarters of the state’s population, was bound to experience some of the most significant challenges in the vaccine’s rollout owing to its size.
“The complexity of the dynamics of this metropolitan area are quite different from these other jurisdictions,” Leguen said. “The resources needed and everything is quite different and exponentially larger than what you could experience in any of those other jurisdictions.”
The state’s rural counties, by contrast, saw a comparatively smooth early rollout of the vaccine. While some rural counties have grappled with geographic challenges, particularly if they have multiple population centers, others saw a relatively easy rollout, which they attribute to their small population numbers and the close-knit nature of their communities.
“When it came time to do the frontline medical personnel, they had all the medical personnel done within a week or two,” said Ely Mayor Nathan Robertson. “It took larger areas in the state a month or more to even get to where we were.”
White Pine County, where Ely is located, continues to have one of the highest rates of vaccination in the state, with 5,500 doses administered for every 10,000 residents, compared to 4,800 in Clark County. White Pine also has a population of a little less than 10,000, compared to Clark, at about 2.3 million.
As the vaccination effort continued, frustrations arose as a result of changes to and confusion over the state’s vaccination playbook. In October, state officials released the first iteration of the playbook, which divided the population into four vaccination tiers. That initial vaccine plan prioritized almost all of the state’s essential workers before people with pre-existing conditions, who were in turn prioritized ahead of elderly Nevadans.
In January, the state announced a new version of the playbook that shifted the state to a new vaccination structure that would instead create two parallel vaccination “lanes” that would allow the state to work through vaccinating its essential workforce at the same time it began to vaccinate members of the general population.
While the change may have made sense on a practical level, it frustrated some county officials, who had been making preparations based on the earlier tiered structure, and confused some residents, who were unclear where they fell among the dozens of categories across the two lanes and which categories were even currently eligible for vaccination, particularly as counties proceeded through the lanes at different paces.
Counties also sometimes found themselves hamstrung by the state, wanting to proceed through the lanes more quickly as they struggled to fill open appointments. McDaniel said the state’s focus was on making sure counties had the data they needed to make decisions about whether it was the appropriate time to progress to the next group.
“Obviously with any very large data set, there’s going to be a possible delay in getting that information to them in the timeframe they need to make decisions,” McDaniel said. “That was definitely, obviously a challenge.”
Karissa Loper, McDaniel’s deputy, added that it wasn’t that the state was “stopping” counties from progressing through the lanes. Rather, she said, the state “wanted to use the data to do so thoughtfully.”
Four months from when the vaccine distribution effort began, those working on the immunization front in Nevada feel hopeful. Despite the fact that Nevada has continued to receive significantly fewer doses per capita than other states — as a result of the federal government using older population estimates to allocate doses — it continues to rank among the among the top half of states for vaccines administered as a percentage of vaccines delivered.
“Despite, I think, a lot of hiccups and some of the challenges that maybe were at the top of mind early on, we worked through those and everybody continued to innovate and adapt and do all these things to continue to get us moving forward,” Parker said.
The state’s vaccination effort, though, will face new tests in the weeks and months to come. With demand for the vaccine far outweighing supply over the last several months, public health officials have focused on getting shots into the arms of people who want them as quickly as possible.
It’s not that they haven’t already started to focus on the issue of vaccine hesitancy. But the conditions over the last few weeks — which have required people to scour state and pharmacy websites for appointments and wait in long lines at often busy mass vaccination sites — have made it a tough sell.
Moving forward, as supply starts to exceed demand, the core focus for public health officials and others involved in the vaccination effort at the state and local levels will be on education. They hope to answer questions from vaccine-hesitant people and remove barriers by making shots more widely available at pharmacies and doctor’s offices.
The state, in partnership with Immunize Nevada and the ad agency Estipona Group, is also launching a new campaign called “3 Million Reasons,” encouraging people to get vaccinated to protect their 3 million fellow Nevadans.
Michelle White, chief of staff to Gov. Steve Sisolak, whose background is in elections, compared it to a get-out-the-vote (GOTV) effort. In every election, there are voters who are going to cast their ballots no matter what. Others need to be persuaded about a candidate or may only vote if it’s convenient for them.
“They’re not going to be opposed to a vaccine, they’re not anti-vax, they’re likely to be on board, but we have to make the effort to make sure they actually show up,” White said. “That takes a ton of effort, that GOTV effort. There’s a reason why it’s the biggest push on a campaign, and it’s the same thing here. It is making sure we provide every opportunity to get those folks out.”
There is a concern, though, that the numbers of new people vaccinated each day may soon start to plateau. In the 2019-2020 flu season, only 44 percent of Nevadans got vaccinated, and the state had one of the lowest vaccination rates among both children and adults in the nation. As of today, 40 percent of those eligible have been vaccinated against COVID-19, or 33 percent of the overall population.
Vaccine hesitancy comes in many forms. For some, it might be questions about how safe the vaccine is or whether they need to be insured to receive it. It might be that they need those questions answered in their preferred language. It might be that they need to have a conversation with a trusted community leader, like a pastor, rather than a doctor or public health expert.
“We firmly believe that people who refuse it, it’s because many of them are scared,” Asad, the medical director for infectious disease at UMC, said. “They have questions and sometimes they’re just afraid to even ask that question.”
For others, it may be that they would rather get the vaccine at their local pharmacy or doctor’s office, somewhere that is more comfortable and convenient than a mass vaccination site. State officials said there is no specific timeline to stand down the state’s mass vaccination sites in Clark and Washoe counties, though they expect to see a gradual transition of the vaccination effort from those sites to pharmacies and health care providers over the course of the year.
Addressing vaccine hesitancy, those involved with the vaccination effort say, is also key to making progress on the vaccine equity issues the state continues to grapple with. In February, Sisolak announced a new initiative to address what he described as alarming disparities in the rate at which working-class families, lower-income households and communities of color were receiving the vaccine in Clark County.
Since then, a Nevada Vaccine Equity Collaborative has formed to address disparities in the vaccination effort, but its work is just beginning. While individuals who identify as Hispanic make up 30 percent of Nevada’s population, they represent only about 18 percent of vaccinated individuals today. People who identify as Black make up 9 percent of the population but less than 6 percent of vaccinated individuals.
And while rural counties led the state’s vaccination effort early on, the urban counties are catching up while some rural counties are falling behind. Elko, the state’s largest rural county, for instance, has only administered 3,100 doses per 10,000 residents.
Even so, state officials are hopeful vaccination numbers will soon rise with the recent launch of two mobile vaccination units that will travel across rural and tribal areas to boost access to the vaccine. The vehicles can hold 8,000 doses of the COVID-19 vaccine and are expected to be able to vaccinate at least 250 people per day, per location with the one-shot Johnson and Johnson, also known as Janssen, vaccine.
“In a state like Nevada, there are so many communities that just need to feel comfortable going to a location, whether that’s having folks who are speaking in their first language or, if they’re undocumented, having folks who they would feel comfortable with there,” White said. “The easier we can make that, the more equity we’re going to experience.”
Despite the road bumps in the vaccination process, the COVID-19 situation in Nevada is significantly better than it was several months ago.
In December, at the worst point of the pandemic, the state was seeing more than 2,700 new cases reported on average each day, and more than 2,000 people hospitalized with the virus statewide. Today, that seven-day average is a little less than 400, with hospitalizations just a little more than 300.
“We've learned a lot. We're better prepared,” said Christopher Lake, executive director of community resilience for the Nevada Hospital Association. “If everyone can work together and keep doing what we all know is right, that’s the social distancing, the getting the vaccine ... wearing the mask and controlling the droplets and the aerosols, if we can do that we can definitely manage this, and I feel optimistic about that.”
The trends, though, have started to move in the wrong direction. Though the numbers are still significantly better than they were in December, they’re not as good as they were in March.
It’s an uncomfortable reminder that better does not equal good.
“That’s the problem. People say, ‘Oh it’s better now,’” said Brian Labus, an assistant professor of public health at UNLV. “Well, yeah. ‘A little bit better’ doesn’t mean this thing is over at all.”
Top of mind, for public health experts in Nevada and around the world, are the COVID-19 variants, including the UK, South African and Brazilian strains. As of Friday, Nevada had identified 155 cases of the UK variant, one case of the South African variant and one case of the Brazilian variant. Additionally, two strains identified first in California, which are also considered variants of concern, are now responsible for about 46 percent of infections in Nevada. (The Silver State has the second highest prevalence of the two strains in the country, after California.)
Nevada has also identified 10 cases of the New York strain and one case of a second Brazilian strain. Both of those strains are, at this point, considered only variants of interest, not concern.
For now, most vaccines seem to be at least somewhat effective against the variants, though the strains identified in South Africa and Brazil do appear to blunt the vaccine’s power.
The concern, though, is that as the virus continues to spread, more variants could emerge.
“Each variant consists of numerous mutations. In other words, we're not talking about one mutation for each new variant, we're talking about a whole collection with different effects. Some of those mutations actually decrease the danger of the virus,” said Dr. Kevin Murphy, an infectious disease specialist in Reno. “But obviously if you get the wrong combination of countervailing mutations, then the net effect may be something worse.”
That’s why health officials have encouraged people to be cautious — by continuing to wear masks and practice social distancing — as the vaccination effort proceeds. It’s a race, they say, between the vaccines, which could significantly limit or stop the virus’s spread, and the variants, which could evolve to evade the vaccines entirely.
That race also comes as the state prepares to hand over control of most COVID-19 health and safety rules to local jurisdictions. Counties are in various stages of drafting plans for the transition to local control, which will undergo review by the state’s COVID-19 Mitigation and Management Task Force starting next week.
Unlike some other states that have started to reopen more broadly, Nevada will maintain a statewide mask mandate even once the transition to local control happens on May 1, and Sisolak has said that he has no plans to lift that mandate in the foreseeable future.
But other key decisions, such as whether businesses should be allowed to open to 100 percent capacity, will soon be up to the discretion of each jurisdiction. Counties have generally been looking forward to the transition, which will give them the decision-making authority they have wanted for months.
Even though this transition is happening at a pivotal moment in the fight against COVID-19, state officials still believe it’s the right time for the power shift to occur.
“They certainly want responsibility to make decisions within their own communities. They know their communities very well. We want to empower them to do that,” White, the governor’s chief of staff, said. “Of course there are always going to be concerns about the virus in general, and you do see these increases in other states, you see the variants, et cetera. The most important thing, I think, the state can do is maintain things like a mask mandate.”
Other mainstays of the state’s public health response to the pandemic, including testing and contact tracing, will remain for the time being, though they have already seen somewhat of a shift in focus.
For instance, Mark Pandori, head of the state’s public health lab, noted that COVID-19 testing is no longer just focused on identifying cases of COVID-19 but also in describing those cases — in other words, looking at the genetic sequence of the virus to understand how it is changing. Local health districts, too, continue to contact trace in the usual way, but they’re paying particular attention to figuring out where people who test positive for variants may have contracted the virus and where it may have spread.
“Over the next six months to a year, every public health lab will screen for cases in asymptomatic people. We will do the surveillance we wanted to do a year ago, and it’ll be a routine part of our work,” Pandori said. “When we find cases, they will get sequenced so that we can look at how the virus is changing in the population, because the last battle, the last stand against this virus will come down that avenue, which, if it doesn’t change very much, or if the changes aren’t effective for the virus, really, then we win, and if we find that it’s changing a lot, then it’s guerrilla warfare like we’ve been in with a lot of other diseases, like influenza.”
It’s a reality many are preparing for: Our public health response to COVID-19 may not be as all encompassing as it is right now, but the virus, still, may linger.
“I don’t want to say forever, because I’d like to think that we will eventually be able to go after this with a vengeance — we’re not going to let this thing get away with what it’s done — I mean going after it not just with vaccines and not just with testing, but to go after it pharmacologically,” Pandori said. “This will be chased into the hills and hunted like no virus ever seen. So I’d like to think that we will eradicate it eventually. But in the meantime, we’re going to be faced with controlling it as we do with everything else.”
The good news, public health experts and health care providers say, is that Nevada is far better equipped to do that today than it was a year ago. It’s why, despite the variants and yet-unachieved herd immunity, they still feel optimistic about the future. In fact Asad, the medical director of infectious disease at UMC, believes there’s no room for pessimism in the pandemic response.
“If I have learned anything from this pandemic, it is that in order to survive, you need to be quick thinking and flexible,” she said. “You don’t give up until it’s completely over, so there’s absolutely no room for pessimism, as far as I’m concerned.”
After the last year, many are eager for the pandemic to be over.
The question is: What does that even mean?
Will the pandemic be over when the World Health Organization says it is? When the national state of emergency ends? When Nevada lifts its state of emergency?
It’s unclear when any of those three things might happen. But Caleb Cage, Nevada’s COVID-19 response director, said, from a technical perspective, the latter may be a ways off.
That’s because being under a state of emergency opens up additional doors for the state, including federal aid. Cage said that everything the state and its political subdivisions do in response to the virus right now is considered an “emergency protective measure;” state and local jurisdictions are reimbursed 75 percent for general pandemic-related emergency expenses and 100 percent for vaccine-related costs by the federal government.
Without a state of emergency, it would be more difficult for Nevada to make the case to the federal government that it should be reimbursed, meaning that funding could go away. Cage said that while the decision to end the state of emergency is up to the governor, he doesn’t foresee a timeline right now where staff would recommend he do so.
“I don’t see us closing the door on the declaration process, and the resources that it makes available to us, anytime in the near future,” Cage said.
Even as the state of emergency persists, state officials, public health experts and health care providers are already looking toward the future, including not only how to rebuild and recover but how to prepare for the next emergency, public health or otherwise.
Nevada’s public health system, for instance, has been chronically underfunded. Nevada ranks 49th in the nation in public health spending per capita, with $8 spent on public health per Nevadan, according to a report from the Commonwealth Fund. Even the best funded public health departments in the country struggled to provide necessary services in the time of the pandemic.
It’s unclear, though, whether the pandemic will lead to lasting changes in the way public health is viewed and, consequently, funded.
Richard Whitley, director of the Department of Health and Human Services, is hopeful.
“Public health is that system of infrastructure that the public often doesn’t see. They don’t see that they’re being protected until they’re not, whether it’s water or air or environment. Until it’s a problem, it’s easy to overlook it,” Whitley said. “But I think that the public and I think that elected officials have been able to witness it in action.”
However, Pandori, the head of the state public health lab, is a little less optimistic.
“Right now, money flies into COVID. But in two years, if COVID looks like the flu, are public health labs going to keep being funded? Are we going to build more public health labs? Are we going to build a national network of infectious disease labs? No way,” Pandori said. “Do you think that the government wants to pay for something that’s going to sit and do what apparently looks like nothing for how many years? You’re going to spend a trillion dollars to build a national lab infrastructure and wait for the pandemic that comes, what, 20 years from now? Thirty years from now?”
It all comes down, Pandori said, to the fact that if public health is doing its job, no one ever notices.
“We succeed because you don’t notice something. We succeed because all your friends don’t have chlamydia,” Pandori said. “Our victories, they’re not under the radar, they don’t have the ability to appear on radar because it’s the absence of something.”
Emergency managers, meanwhile, are starting to think about how the lessons learned from this emergency can better prepare them for the next one. The pandemic has underscored the importance of widespread disaster training, thinking big and not underestimating how quickly a situation can develop into something more serious, not relying on mutual aid to come to the rescue and ensuring that personal protective equipment is always in stock and at the ready.
“Hopefully it’s not another pandemic in the next few years, but for wildfires, for earthquakes, for anything else, I think the muscle memory of having to work together, having to ask for help, not being prideful, will be there,” said David Fogerson, head of the Division of Emergency Management. “I think more people have been exposed to how to make bigger decisions with not a lot of information behind it. That decision-making skill is, I think, going to help everyone.”
For Sisolak, the pandemic has underscored the need to bolster the state’s fragile health care infrastructure, an effort that a $25 million allocation in his budget toward the construction of UNLV’s medical school complex aims to support, and also fix the state’s broken unemployment system, an overhaul that could cost nearly $50 million over the next two to three years.
Nevada has to “learn from this tragedy as much as we can,” Sisolak said in an interview last month.
For the rest of Nevadans, the lessons learned may be small but important: Washing our hands a little more regularly, staying home when we feel sick and, maybe, donning a mask during flu season just to be extra safe.
“You think back of all the things we used to do: We just blew on the candles on the cake and now everybody is going to eat that, or you went bowling — while eating your pizza or your chicken wings or your french fries — you just go and put your fingers into that ball, and after, you don’t go wash your hands, you just go back and start grabbing your food,” said Yarleny Roa-Dugan, a nurse in Las Vegas. “I think people are going to be more aware of how clean they are. Hopefully this will last. But as we know in history, people tend to forget, and then history repeats.”
It’s hard to know how to feel right now.
Should we feel optimistic about how many Nevadans have been vaccinated and that case numbers and hospitalizations are still relatively low here? Or should we be concerned that the vaccination effort isn’t going quickly enough, that the variants are spreading too rapidly and that cases and hospitalizations, though low, may once again be on the rise?
In interviews over the last two months, dozens of state officials, public health experts and health care providers have, by and large, expressed optimism about the future. It comes in shades — from “cautiously” to “categorically” optimistic — but they are glass-half-full nevertheless.
“The fact is none of us know what this is going to look like six months from now. But we all know that all we can do is continue to add tools to address the pandemic going forward,” Cage said. “Nobody knows that’s going to happen with the variants.”
Amid that optimism, they are realistic. Cage, in an interview in early April, said state officials expected to see the numbers start climbing in the future. A few days later, they did.
So, what happens from here?
“What we’re watching for is what are the consequences of that climb going to be. Are people starting to catch the virus again but fewer people are going to the hospital therefore fewer people are going to the ICU therefore fewer people are dying?” Cage said.
If so, "that’s a really positive outcome for this and gives us more methods for dealing with this," Cage said.
It can feel impossible to think about recovery when the emergency is still ongoing. It can feel impossible to think about recovery when so much of the damage is unseen.
But Nevada has a lot of healing to do.
White, the governor’s chief of staff, pointed to the throngs of people on the Las Vegas Strip in recent weekends. Those crowds, she said, belie the tens of thousands of hospitality workers and service employees whose jobs aren’t coming back.
“When you walk around the streets of Las Vegas, you see people coming back, you see this excitement in the air, which is great,” White said. “But there are a lot of people who every day are waking up very worried about walking to the mailbox and opening an envelope and seeing another bill.”
Nevada has been presented with the opportunity to rebuild before, including in the wake of 9/11, the Great Recession and 1 October. White, however, said the current moment presents a “once in a lifetime opportunity” to do so.
“It’s a huge opportunity in this state ... to say, ‘We will rebuild,’ and ‘The vision that we believe needs to be achieved,’ so the next time there is a pandemic or a recession or a disaster or whatever else we can’t predict now, we’re not all sitting around the table saying, ‘Nevada is hit the hardest once again,’” White said.
But, the more COVID fades from mind, the harder it may be to do that.
“When things start to get better, that urgency can go to the wayside sometimes,” White said. “When things get better, jobs are coming back and people are feeling more optimistic, it won’t be front of mind that our public health system has some systemic challenges that need to be fixed within it, and we can’t lose sight of that.”
The list of policy areas the pandemic has spotlighted is long: Health care, the economy, mental health, homelessness and education, among them.
But the pandemic, to many, has revealed an even deeper need for healing, the kind of healing that happens not at a policy level but a personal one.
It’s the healing of deep political divisions. It’s the healing of trust between institutions and individuals. It’s the healing of the wounds we have inflicted on each other.
It’s a deep, hard kind of healing.
Nevada, though, is no stranger to adversity.
What is the pandemic, to the resilient people of the West, but yet another hard time.
Steve Waclo and his wife, Zita, have long loved the Hawaiian islands.
Last February, over the course of four days, they took a train ride around a farm on Kauai, sipped margaritas on Oahu, snorkeled with tropical fish off the coast of Maui and visited lava flows on the Big Island. The island cruise was a much-needed respite from the snowy Carson City winter for the retired couple.
As their ship clipped across the Pacific Ocean to Ensenada, Mexico, the final port of call on their cruise, the captain came in over the intercom: They had received word from the mainland that multiple passengers on the previous leg of the ship’s voyage had fallen ill with COVID-19, which was at the time still in the early stages of spreading across the globe. The ship, the Grand Princess, would be changing course and returning to San Francisco, its port of departure, immediately.
At first, the couple didn’t see any reason for alarm. No cases of the new virus had been identified onboard, and the early return seemed precautionary. The most substantial change was that they had to be served at the buffet. But when they reached the Bay Area, they watched with interest as the Coast Guard airlifted test kits onto one of the top decks of their ship.
Shortly after, all passengers were ordered confined to their cabins, their meals delivered to them on trays at their doors and the news of their fate delivered to them largely by the national media. Information on the boat itself was scarce.
“We didn’t know where we were going to go. We were out in the ocean going around, which was kind of disturbing,” Zita Waclo said. “Nobody told us even when we were going to get off the ship.”
The Waclos found themselves entirely at the mercy of the federal, state and local government officials back on land who were struggling to figure out what should be done with them and their fellow passengers.
As the Grand Princess held 50 miles off the coast of Northern California with 3,533 passengers and crew members, President Donald Trump made his preference known: that the boat stay where it was. At the time, 238 people in the United States had tested positive for the virus; results from the airlifted test kits showed the ship would add 21 more to that total.
“I like the numbers being where they are,” Trump said during a visit to the Centers for Disease Control and Prevention in Atlanta. “I don’t need to have the numbers double because of one ship that wasn’t our fault.”
Two days later, on March 8, state health officials in Nevada finally received the full list of the names and contact information for the 49 Nevadans on the ship. (A 50th, the spouse of another passenger, was later identified.) As the Grand Princess docked at the Port of Oakland the next day, state officials scrambled to prepare to bring the Nevadans home so they wouldn’t be sent to an out-of-state military base to quarantine. The final decision, though, was up to Gov. Steve Sisolak.
“You have a situation where there’s this new virus. People are really fearful and scared. You have a group of Nevadans who are on this cruise ship. You want to protect the residents back home, so you don't want to bring in potentially infected folks back into your state, but you also are worried about these Nevadans who are now stuck on this ship and then being told they're going to go to an army base and then, potentially, an army base in a state very far away,” Michelle White, the governor’s chief of staff, said.
The next day, Sisolak emailed the passengers directly to let them know his decision: They would be coming home. In the email, he acknowledged their frustrations and anxiety over the lack of information they had received and said he felt the same.
“I can assure you that my frustration will be loudly and clearly expressed to leaders in Washington D.C.,” he wrote.
Back on the ship, the Waclos watched from their stateroom balcony as ambulances, buses and trucks lined up at the docks in Oakland. Below them, National Guardsmen readied supplies and rearranged tents. People needing medical attention were carried off the ship. It brought the gravity of the situation into focus.
“Watching the ambulances back up and the stretchers being taken off, we realized this is serious business, people are dying,” Steve Waclo said. “We could potentially die if we do something wrong, if someone slips up.”
When the Waclos were finally told one morning it was their turn to disembark, they had no idea where they were going. It wasn’t until they were on a bus to the Oakland International Airport they were told they wouldn’t be heading straight home to Nevada but rather flown to the Marine Corps Air Station Miramar, in Southern California. Federal officials wanted to test all the passengers for COVID-19 before sending them elsewhere.
At home, state officials felt equally in the dark as the federal government provided them with an ever-changing timetable for when the Nevadans could return.
Local health districts made preparations to receive the passengers once they landed on Nevada soil, including securing the personal protective equipment and vehicles needed to transport them home. A representative of McCarran International Airport voiced concerns about even being able to receive the Southern Nevadans when the time came because of flight restrictions associated with a planned visit by Trump that week. State officials sent out flurries of emails each day informing local officials and airport representatives that the Nevadans were coming, not coming, then coming, and then not coming again.
This went on for four days.
“I completely understand the frustration with the lack of timely detailed information from the feds as I too share in this sentiment,” Malinda Southard, manager of the state’s Public Health Preparedness Program, wrote in an email to Clark County’s fire chief on March 11, a Wednesday. “Best I can do is keep pushing us forward to get our residents home soon and safely.”
In Washoe County, local health officials were eager for their residents to be home. They had gone to the airport three times in anticipation of the passengers’ arrival, only to be called off. Officials just hoped that when the operation was finally a go it wouldn’t be in the middle of the snowstorm expected to roll in that weekend.
Of course, it was.
“I have confirmation we have a dedicated plane out of Miramar tomorrow just for Nevada residents. US HHS confirms there are no more maybe’s probably’s hopefully’s — our people are coming home tomorrow!!” Southard wrote in an email to state health officials on Saturday.
That night, nearly two feet of snow piled up in Incline Village, half a foot in Northwest Reno and an inch elsewhere in town. Ski resorts shuttered as an avalanche warning was issued. Washoe County Health District staffers scouted their neighborhoods the next morning to figure out if the roads were passable; they even had to go buy snow chains first thing that morning for one of the vehicles.
After days of anticipation, the plane touched down in Reno at 12:27 p.m. on March 15. The Northern Nevadans, at least, were home and the Southern Nevadans, who were on the same plane, soon would be, too.
Many of the Washoe County residents needed help getting down the stairs and out of the plane before they were loaded into two vans. One of them, staffed by health district employees Jim English and Wes Rubio, would make stops in Reno before heading over Mt. Rose Summit to Incline Village. English read the directions and checked in on the passengers while Rubio drove.
Both were suited up in white, full-body hazmat suits, full face respirators and gloves as they plowed through the snow with a van full of weary, N95-wearing, COVID-exposed passengers. An unmarked sheriff’s car trailed them to make sure there was no trouble.
At each stop, they battled snow flurries and their respirators iced over in the freezing temperatures. At one point, they swapped their transit van for a four-wheel-drive Jeep Cherokee in a passenger’s Galena cul-de-sac to make it over the summit to Incline through four inches of snow. They had to keep driving. There was nowhere else for the passengers to go.
“We were trying to do as best we could to protect the public and those people that were on that on that bus just to at least get them home,” Rubio said. “It was a massive effort.”
The repatriation of the Grand Princess passengers was not only a massive effort but also the first major challenge in the pandemic where local, state and federal officials were asked to work together to solve a pressing public health problem. They would be asked to overcome many more together in the months to come, from ramping up testing and contact tracing efforts to deploying a mass vaccination campaign.
“That was a big test,” White said. “Then, it only got harder.”
For state and local officials in Nevada, the repatriation effort was largely a success story, a proof of concept that they could work together and communicate effectively to achieve a common goal. Despite their frustrations with the lack of information onboard the Grand Princess and at Miramar, the Waclos praised the state’s response. Once they were home, Carson City Health and Human Services called them every morning during the 14-day quarantine period to check in on them and offered to bring any food and medicine they needed; the governor even called once to see how they were doing.
“I was very impressed by the Washoe County people and the Carson City people,” Zita Waclo said. “They were ready for us, and they really followed up very well.”
The coming months, however, would strain relationships between state and local governments as they struggled to address a daunting public health crisis with few resources and what much of the time felt like little to no support from the federal government.
Sometimes the adversity brought them together as they allied to face a grim future in the face of no centralized national response strategy. The Grand Princess incident, they say, should have been a harbinger of what was to come in the way of federal communication and support during the course of the pandemic. It also showed that state and local governments could work cooperatively to meet the needs of everyday Nevadans.
But the adversity also sometimes wrenched them apart, widening a growing political divide in the state and turning existing cracks in differences in beliefs over the role of state and local governments into deep chasms. Sisolak’s COVID-19 response plan, formed in the absence of a national response framework, caused rural governments long known for rebelling against the federal government to direct their ire instead toward the state. And even when the state and local governments agreed about how to best address the pandemic, underresourced and overworked officials often struggled to effectively communicate with each other, leaving wounds and eroding trust.
There’s a term doctors use to describe what happens to COVID-19 patients when their immune systems go into overdrive: It’s called a cytokine storm. When it happens, the body’s immune system turns against itself and starts to attack healthy tissue and organs.
It’s not unlike the position Nevada has often found itself in over the last year.
There’s an oft-repeated phrase in the emergency response world about how disasters should be managed: They’re supposed to be locally executed, state managed and federally supported.
But, from the get-go, state officials in Nevada say federal support was lacking in the pandemic response. The tone was set at the top, they say, with Trump’s comments downplaying the seriousness of the virus and supporting unproven treatments. This seeped down to the federal Department of Health and Human Services, which clashed with the state over more mundane, bureaucratic public health policies, including whether asymptomatic individuals should be tested and which COVID-19 tests were reliable enough to use in nursing homes.
“There was never a time when our decisions, the governor’s decisions, at the state level and our partnership with the local governments was not undermined by the mixed messages or new messages coming out of the federal government,” Caleb Cage, Nevada’s COVID-19 response director, said.
Cage, the former head of the state’s Division of Emergency Management under Gov. Brian Sandoval, said the first step in any emergency response is to move past collective denial by getting everyone’s buy-in on the seriousness of the situation. That’s much more easily done with something like the response to a wildfire, where the threat is readily apparent, than it is for a pandemic, where the threat is an invisible pathogen.
That collective buy-in, however, never happened. Instead, Trump painted Democrats’ response to the virus as part two of the January 2020 impeachment trial in an attempt to cost him his re-election; Democrats, meanwhile, were eager to point out all the ways in which they believed Trump was failing to lead on the pandemic.
“Now the Democrats are politicizing the coronavirus — you know that, right? — coronavirus, they’re politicizing it,” Trump said at a rally in South Carolina on Feb. 28. “... And this is their new hoax.”
The politicization of the virus, Cage said, created an incentive for people to stay in the denial phase, hindering the federal government’s ability to move to the collective response phase.
From the state’s perspective, it was trying to communicate one thing to the general public and having it constantly contradicted by federal leadership. A week after Nevada made the decision to shut down nonessential businesses on March 17, 2020, the president was still drawing parallels between COVID-19 and the flu. (Scientists believe COVID-19 may be 10 times more deadly than the flu, though the exact mortality rate is still unknown.)
“We lose thousands of people a year to the flu. We never turn the country off,” Trump said at a Fox Newsvirtual town hall on March 24. “We lose much more than that to automobile accidents. We didn’t call up the automobile companies and say, ‘Stop making cars. We don’t want any cars anymore.’”
The politicization of the virus made it more difficult for the state to get widespread buy-in from everyday Nevadans on the importance of key parts of the state’s pandemic response, too. On one hand, there was Sisolak, the state’s Democratic governor, advocating the importance of mask-wearing; on the other, there was Trump, the Republican president, waffling on the benefits of masks. Even though the scientific evidence only supports one of those two positions, the issue felt — and continues to feel — political to many because of the differences in the way that Republicans and Democrats spoke about masks.
The divide in messaging over public safety measures became, perhaps, the clearest when Trump rallied thousands of supporters in Minden and Henderson in September in defiance of Nevada’s COVID-19 health and safety rules. Dave Fogerson, who at the time managed Douglas County’s pandemic response as deputy fire chief at the East Fork Fire Protection District, said the event put him in a difficult position.
Officials at the county — which is home to more than twice as many Republicans as Democrats — made clear that the event would go on. The local paper, the Record-Courier, summarized the county’s position as this: “Spokeswoman Melissa Blosser said that after careful consideration and weighing the authority of state directives versus First Amendment rights, the county ultimately decided to welcome the sitting President of the United States to our community.”
Privately, though, Fogerson said that people who supported the event were calling to apologize.
“‘Hey, sorry we’re doing this. We want to do this because how often does the president come to town? But we understand what we need to do to keep this going,’” Fogerson recalled them saying. “In the end, the county gave me an award when I left Douglas County for all those efforts — even though we were, it seemed like, on opposite ends of the spectrum — because of trying to do that balance of, ‘Here's where we need to go and here's what you need to do to get there.’”
For state health officials, the pandemic brought a significant shift in the kind of communication they were used to having with their federal counterparts. For one, inconsistent communication from the federal government about what was expected made it difficult for state health officials to do their jobs, Richard Whitley, director of the Department of Health and Human Services, said.
“They weren’t responding to us as a state in the same way that we were familiar with,” Whitley said. “All of those seemed to be in flux and seemed to be being changed while we were needing, perhaps, that relationship to be at its strongest.”
One example state health officials point to from the beginning of the pandemic was the conflicting guidance they received from the Centers for Disease Control and Prevention about which individuals coming in by plane needed to be quarantined.
In one instance, state health officials struggled to get contact information from the CDC’s Division of Global Migration and Quarantine (DGMQ) for three passengers on a Las Vegas-bound Korean Air flight who had recently been in China. The state only discovered the situation after news outlets reported the flight had been diverted to Los Angeles, one of three airports that was screening for COVID-19 at the time.
State officials said that CDC representatives they spoke with seemed not to be aware of their own agency’s latest travel guidance. Melissa Peek-Bullock, the state’s epidemiologist, said one federal official even hung up on her.
“It wasn’t clear that everybody within the organization understood that guidance,” Peek-Bullock said. “The inconsistent messages that were coming from CDC to the states made it very difficult and frustrating for us early on.”
The situation prompted Whitley to pen a letter to the CDC expressing his concern.
“I understand this is a rapidly evolving situation; however, I am concerned about the breakdown between the communication the states have received from the CDC, and information provided to the CDC DGMQ,” Whitley wrote in a Feb. 11 letter. “Our state relies on DGMQ to assist in the response to travelers, and the lack of communication in this circumstance created frustration and confusion for all those involved.”
State health officials also saw politics seep into their everyday work. For instance, they were shocked when Dr. Robert Redfield, director of the CDC, directly telephoned Nevada’s chief medical officer, Dr. Ihsan Azzam, in early March to request his help in getting Adam Laxalt, the former attorney general of Nevada and a prominent Trump supporter, tested for COVID-19 after he was possibly exposed at the Conservative Political Action Conference but showing no symptoms. At the time, the CDC’s own guidance restricted testing to symptomatic individuals.
“We do everything possible to treat all people the same, focusing on their risk and not on who they are in terms of importance,” Whitley said. “That’s not a population approach. That’s a privileged approach, and so they set a tone for that.”
State health officials were also wary when the federal government quietly changed the rules to require hospitals to directly report COVID-19 data to the U.S. Department of Health and Human Services instead of to both HHS and the CDC, and asked nursing homes to directly report their data to the federal government instead of to the state. Those moves made it challenging for the state to get its hands on valuable COVID-19 data, Whitley said.
“We had to figure out our own ways of collecting the data and identifying where the opportunities for intervention were and where the problems were, with not direct assistance from the federal government,” Whitley said.
The state also directly clashed with the federal government in its policymaking as well. The CDC, for instance, released new guidelines in August that said asymptomatic people should not “necessarily” be tested for COVID-19. The move prompted an immediate backlash from Nevada health officials, who made it clear the state would continue asymptomatic testing.
“When you really have large widespread outbreaks of pandemic, this is the time to test more, not the time to test less,” Azzam said.
Nevada also made the decision in late June to follow in the footsteps of more than a dozen other states and enact a mask requirement in the absence of any federal rule. It wasn’t until late January, a little more than a week after President Joe Biden took office, that the CDC finally issued its first mask order, for travelers only.
“We kept on asking the CDC, ‘Should we start implementing masking for everybody?’ and we were told, ‘No, we don’t really need that,’” Azzam said. “If we don’t know who is spreading the virus, it’s better to mask everyone. You can’t prevent 100 percent transmission, but you can prevent a reasonable amount and reduce infection.”
State health officials’ biggest dust-up with federal health officials, though, came in October. The federal government had directly distributed antigen tests — a type of COVID-19 test helpful in identifying people with COVID-19 but generally less accurate for those who don’t have the virus than the gold-standard PCR tests — to nursing homes, with what state officials described as very little guidance on how to use them appropriately. Nursing homes were also given no guidance on how to report the results of those antigen tests to the state to be counted in its COVID-19 data, state officials said.
As state health officials scrambled to develop that reporting mechanism, they noticed that the antigen tests were coming back with a high percentage of false positives. Among 39 positive antigen tests sent for confirmatory PCR testing, 60 percent came back negative for the virus.
State officials’ immediate concern was that some nursing home residents were incorrectly being identified as positive for COVID-19 and sequestered with true COVID-positive patients, thereby exposing them to a virus they didn’t actually have. So state health officials issued a directive to nursing homes to stop the use of the antigen tests as they looked into the issue further.
In a scathing letter in response to that decision, Adm. Brett Giroir, the Trump administration’s COVID-19 testing czar, accused state health officials of “a lack of knowledge or bias” and said their decision would “endanger the lives of our most vulnerable.” He added the federal government would “take appropriate steps” if state health officials did not “cease the improper unilateral prohibition” on use of the antigen tests.
“Your Department’s across-the-board ban on POC antigen tests in such settings is based on speculation,” Giroir wrote. “It may cost lives.”
In response to those threats, state health officials rescinded their directive while reiterating their concerns over use of the tests and asked the federal government to reconsider its stance. (One federal official did, however, note in an email to state health officials the CDC does not recommend that nursing homes group asymptomatic patients into a COVID ward based on a single antigen test; rather, those individuals should be considered presumptive positive and isolated with precautions until a confirmatory PCR test is performed.)
What could have been a civil back and forth over a policy difference turned into a heated clash. Peek-Bullock described the federal government’s response to the state’s decision on the antigen tests as “very unusual.”
State officials say that even when they believe the federal government was genuinely trying to help, it often did so in a way that subverted the state’s role in the pandemic response. For instance, when hospitals struggled to secure PPE early on, the federal government provided it directly to hospitals and other health care providers, instead of sending it to the state to then be sent to the counties to then be distributed to hospitals — the usual chain of custody.
“I believe in their minds they were doing it to fight bureaucracy,” Cage said. “But there's a reason this framework is in place, and that's because these private hospitals, public hospitals, aspects of the health care system in the state are asking us for resources, and we don't know how to prioritize the resources if the federal government is going around us.”
But the federal government was critically helpful to the state in one primary area: funding. As of early March, it has provided nearly $25 billion in federal aid to Nevada with $4.1 billion more on the way from the American Rescue Plan. State and local officials say that federal funding — approved by both Republican and Democratic-controlled congressional chambers and signed into law by both Republican and Democratic presidents — was key to their pandemic response efforts.
And, a year since the pandemic began, the federal-state relationship is healing. State officials say they have seen a night and day difference in their relationships with their federal counterparts since Biden took office earlier this year. They report that communication has significantly improved with federal officials — U.S. Health and Human Services Secretary Xavier Becerra met with Sisolak at the Capitol in Carson City this week — and when they have a request, such as federal support to catch up on a vaccination data-entry backlog earlier this year, it’s usually granted.
They say it isn’t because Biden is a Democrat, either.
“The difference in mutual respect, collaboration, willingness to have hard conversations, willingness to work together, willingness to not worry about who gets blamed for what and all of this — that’s just the starting point,” said Cage, who worked previously under two Republican governors and is a lifelong Republican voter. “The previous administration had what I believe will be long remembered as the poorest disaster response in the nation’s history.”
The state’s frustrations with the federal government, however, have a parallel: Local governments’ frustrations with the state.
The root causes of each are strikingly similar. Local governments, charged with executing the finer points of the state’s overall pandemic response, say they often found themselves struggling to play catch-up when the state publicly announced its latest COVID-19 health and safety policy because they had been given little advance warning. They also grappled to keep up with ever-shifting state policies about which establishments could be open, to what extent they could be open and the timetable for those rules. Some think the state struggled to be collaborative in its response as the pandemic drew on, unwilling to cede its decision-making authority even when circumstances may have necessitated different solutions for different parts of the state.
The frustrations date back to the state’s initial decision to close schools and shutter nonessential businesses in mid-March of last year. To some extent, counties understood the hurried nature of the decision: The state was in an emergency situation and was reacting to a constantly developing situation. But they still found themselves in the uncomfortable position of trying to provide guidance on a local level — to residents and businesses alike — to policies they themselves had just learned about.
“I still remember when we closed everything down and schools were closed, we met in Douglas at 7 o’clock the next morning to, ‘Oh my God, did you hear that yesterday? What are we going to do? How are we going to take care of this?’” said Fogerson, the former deputy fire chief from Douglas County. “Kind of having a panic moment because we were being reactionary.”
Local officials say they often scrambled before each state press conference to figure out what was going to be announced before it was released publicly. In the early days of the pandemic, local officials say they often received no advance information about what policies were going to be announced; they were happy when they started getting even an hour or two’s notice.
“When I was in Douglas, it was ‘What do you mean there is going to be a press conference at 3 o’clock today? Aren’t they going to tell us what it is? Why do we have to watch it on TV?’” Fogerson said. “Whereas now the governor’s office is leaning forward a bit more and getting some information out ahead of time.”
Because local officials had little warning about new state policies, particularly early on in the pandemic, they felt there wasn’t an opportunity for them to voice their concerns and have a consensus-building conversation with the state, which meant some local governments were charged with carrying out policies they didn’t agree with, believe in or understand. The state may not have needed counties’ permission to enact emergency policies under the law, but the state did need local buy-in for those policies to be most effective.
State officials acknowledge the frustrations of their local counterparts. But when they reflect on why they didn’t bring local governments into the fold earlier, they see themselves moving quickly to make choices deep in a crisis response mode that didn’t allow hours for multiple roundtables and scores of phone calls about each policy decision. White, the governor’s chief of staff, said there were dozens of consequential policy decisions the state was making each day.
“It is hard to loop in everyone who feels that they need to be looped in. I'm not saying that they shouldn't be. I'm not saying that their voices don't matter, that they wouldn't have great input,” she said. “But the reality is you have to make those decisions quickly. We have an incredibly small staff that can only make so many phone calls.”
On the flip side, the state’s attempts to centralize certain aspects of the public health response were complicated by the fact that public health in Nevada is historically decentralized. Public health services are provided at the local level in Clark and Washoe counties, as well as Carson City, which together make up more than 90 percent of the state’s population, while the state is responsible for managing public health for the remaining tenth of the population living across 14 rural Nevada counties.
While the localized public health delivery model can be quite effective, in the time of the pandemic it meant the state was often in the position of offering assistance to local health districts for contact tracing or testing, though the decision of whether to accept that help was left to local jurisdictions. That made it difficult, if not impossible, to have a standardized public health response across the state.
“There needs to be a level of statewide response consistency, yes, but there was great latitude and need for them to be completely different locally because they have different resources,” said Julia Peek, a deputy administrator in the Division of Public and Behavioral Health.
As the pandemic drew on, the state made several overtures to local governments to try to create that latitude on the emergency response side as well.
The first came in the form of a so-called Local Empowerment Advisory Panel, or LEAP, which was tasked last spring with assisting counties as they started to reopen businesses after the shutdown. Sisolak, during a late April press conference announcing the new body, said it would be a “disservice” to the state’s residents to pretend its urban and rural counties have the same needs.
When Eureka County Chairman J.J. Goicoechea was asked to join the panel as a representative of the state’s rural counties, he was optimistic. His urban counterpart on the panel was Clark County Commission Chair Marilyn Kirkpatrick, whom he had a longstanding collaborative relationship with and who had recommended him for the job.
But LEAP’s responsibilities ended up being much narrower than Goicoechea initially anticipated, centering primarily around drafting reopening guidelines for approval by the state.
“We thought we were going to have maybe a little more authority and we were going to approve this or approve that or do some things,” Goicoechea said. “It never really materialized.”
Once all businesses — save strip clubs, night clubs, day clubs and brothels — were allowed to reopen, LEAP essentially fell by the wayside. It was frustrating not only for Goicoechea but other local officials who believed the state was finally starting to get things right by delegating more authority to the rurals and bringing more people into the decision-making process.
“LEAP just dissolved, because we were no longer effective. We weren't being talked to,” Goicoechea said. “That’s the unfortunate thing.”
The governor’s office, however, said it was more that LEAP evolved.
“The input and interaction and coordination with a lot of those leaders who were a part of that group, I don’t think, has stopped at all,” White said. “I think things just take on a different form as we’re going through that response.”
In August, Sisolak announced a new pandemic response framework. This one, he said, would also take into consideration counties’ innate differences: Counties would be evaluated based on three criteria to determine whether they are at elevated risk for the spread of COVID-19 and, if so, they would be required to present a mitigation plan to a new statewide COVID-19 Mitigation and Management Task Force.
The task force, though, ended up doing more management than mitigation. The body spent its first several weeks determining whether bars in seven counties could reopen following a summer surge in cases. As cases began to climb in the fall, counties flagged at elevated risk of transmission spent significant time telling the task force about their plans for community-wide education about the virus and almost no time about any new mitigation measures, such as business closures or limits on gatherings, they planned to put in place.
In fact, in the more than seven months it has existed, the task force has only approved one concrete mitigation measure stricter than the statewide standards. In September, Washoe County proposed keeping its gathering sizes small as the state moved to allow larger events to take place.
“[The task force] made it fairly clear that with the increase in cases that we were seeing in Washoe County that the county needed to do something or the task force was going to do something to them,” Washoe County District Health Officer Kevin Dick said. “That perspective and understanding on the part of local leadership provided some leverage to get them to that commitment.”
Even under the task force model, some counties still felt like they were under the thumb of the state. Scott Lewis, director of emergency management for Nye County, said it sometimes felt like counties were children trying to appease their parents.
“What its intended goal was, as a state, what can we do to best remedy this as a collective team?” Lewis said. “And it was never that. It was always like a parental type of approach, and we had to come up with the magical words to make our parents happy with us.”
Cage, who chairs the task force, acknowledged the body did not work out in practice the way in which he had initially anticipated. Counties, for instance, largely did not bring forward to the task force individual mitigation measures during the fall surge, and the task force didn’t put them forward either; rather, Sisolak enacted a new “statewide pause” that limited occupancy at businesses and again limited gathering sizes homogeneously across all 17 counties.
“The governor always had reserved the right to do so, and that’s where we got in November,” Cage said. “So in a sense it worked as it should. My personal opinion is that the pressure locally was so much that there really wasn’t an appetite locally to put additional measures in place.”
While it may not have been a robust decision-making body, the task force has helped repair some relationships between the state and local governments by providing a regular forum for communication. Some local officials say the task force opened a line of communication to the state.
“From my perspective, and I can only speak for Lyon County, once they developed the task force and put Caleb Cage in charge of it, the majority of my communication complaints went away,” said Jeff Page, Lyon’s county manager. “We were getting good, direct positive feedback from Caleb and the task force as to what they were expecting, what the issues were and what the challenges the state was facing were.”
Dick echoed those sentiments, calling the task force “worthwhile overall.”
“I think that relationship between the health district and Caleb Cage and the members of the task force has really strengthened over time,” Dick said.
Nowhere was the state-local relationship, perhaps, more strained over the course of the pandemic than in rural Nevada, where individual liberty is prized and love of government is scarce.
Initially, as Clark and Washoe counties were hit hard by the virus, rural counties were optimistic that they might be able to avoid the virus altogether. While urban America grappled with SARS scares in the early 2000s, rural America was largely untouched by the virus. Rural counties hoped their isolation and low population density would come in handy this time, too.
It quickly became clear that would not be the case as tiny Humboldt County, with a population of a little less than 17,000, became Nevada’s hardest-hit county, the result of a large family gathering that had exposed many individuals to the virus. As the virus began to spread across rural Nevada, public health experts and rural officials became increasingly concerned about the effect COVID-19 could have on those communities, owing to the fact that rural counties generally have older populations than urban ones and the dearth of medical care in rural counties.
For some rural health officials, the importance of community buy-in about mitigation measures quickly became evident. Rural Nevadans might not take kindly to rules being handed down to them from the federal or state governments, but they could be appealed to on an individual level to take steps to protect themselves and their community.
The rest of the country was grappling with how to balance individual liberty with the need for collective action too, but that tension was acute in the rural West.
“One of the things that makes our country special is all the choices that we have. To me, that is a very sacred thing. It is, I think, to all of us,” Dr. Charles Stringham, Humboldt County’s health officer, said. “But, as a result, when you fight the virus in the United States, your best weapon is information and also trying to encourage people by being compelling, because at no point did we ever have interest in encouraging people by regulating or legislating. We’ve just never really wanted to do that here in Humboldt County.”
Stringham’s approach was particularly introspective: If the residents of Humboldt County weren’t listening to him, he figured his message needed to be more compelling. He started a series of “Ask Me Anything About COVID-19” Zoom sessions to answer community members’ questions about vaccination, viral transmission and the efficacy of mask wearing, among others, in a commonsense, plainspoken way.
“My hope was that if people really did think that masks were ridiculous and that they didn’t work, and if people really did think that six feet seemed arbitrary, and that if people really did think that mutations in the virus would negate the effect of vaccinations, that they could call in and ask those questions and get real answers,” Stringham said.
During one of those Zoom calls in December, Stringham was asked why he and other members of the medical community were so focused on social distancing and mask wearing instead of advocating the benefits of, among other things, the malaria drug hydroxychloroquine. Stringham was calm and deliberate in his answer, saying he wished the drug would have worked to treat COVID-19 but that scientific studies didn’t bear that out.
“There's always an assumption that if allopathic physicians don't do something, that it's because we're holstering that or we're sequestering it, we're not bringing that to bear,” Stringham told the man. “But the bottom line is that in allopathic medicine, we have to be able to prove that something has an effect.”
Another asked why the media makes such a big deal about COVID-19 deaths and not flu deaths. Stringham explained that 34,000 people in the U.S. died of the flu during the last flu season; at the time, 300,000 had died of COVID-19. He also noted that people who contract COVID-19 can go on to develop long-term health conditions that impair their quality of life.
“I can't even really talk about this without getting a little bit choked up,” Stringham said. “This is not the flu. It is not the flu. I wish it were, but it isn't.”
Other rural communities took a similar approach. In Ely, Mayor Nathan Robertson went on the local radio station every day to answer people’s questions about the virus, from technical inquiries about which businesses were allowed to be open and what assistance was available to broader questions about whether martial law had been declared and whether the National Guard would prevent people from getting to their doctor’s appointments in Salt Lake City.
“There was a real vacuum of just credible answers,” Robertson said.
As the state created new COVID-19 health and safety rules, the focus for some rural leaders was how to help their businesses comply. Robertson said Ely’s focus was on assisting businesses at the local level to avoid the state sending out compliance officers.
“Everybody was just kind of in an attitude of cooperation: ‘Hey, how can we help? Our goal is to make sure your business stays open,’” Robertson said. “We can’t afford to lose a single restaurant in our community. We can’t afford to lose any of our businesses. We’re so isolated.”
In Lyon County, Dr. Robin Titus, the county’s health officer and the Republican Assembly leader, advised local ranchers about how to group guest workers into pods so that if someone tested positive for COVID-19, they would know exactly who was exposed.
“They were paying attention. They were calling me,” Titus said. “They wanted to make sure things were safe.”
And though rural Nevada has earned a reputation for opposing the state’s COVID-19 health and safety rules, several rural officials say they believe their residents took the virus seriously when it counted. Titus said she has a 95-year-old patient who was very cautious about the virus and stayed home. Goicoechea, who is also Eureka County’s health officer, said his residents were “really good” at isolating and quarantining when they tested positive or someone in their household came down with the virus.
“They may be chipping their teeth on Main Street saying, ‘This is all fake. This is a hoax. I don’t believe in it,’” Goicoechea said. “But when we called them up and said, ‘You’re positive, I need you to shut ‘er down. You gotta stay home. Let us know what we can do,’ they went home and they stayed home and they cooperated.”
Of course, compliance wasn’t universal. Robertson acknowledged there were some instances in Ely where people called the sheriff alleging a business was discriminating against them because they weren’t wearing a mask. Law enforcement would inform them that businesses could put in place whatever rules they wanted and could kick them out for not following them.
“They were like, ‘Well, what do you mean? They didn’t let me in.’ And they’d say, ‘Well, this is a private business. They don’t have to,’” Robertson said.
Multiple rural officials also noted that there was always going to be some degree of pushback from their residents about the state’s rules simply because of the high price they place on individual freedoms. But they also believe that philosophy shouldn’t stop people from doing the right thing for their neighbors.
“You don’t have to choose either safety or freedom,” Stringham said. “You can absolutely have both, and that was the message that I was trying to deliver.”
But, because of the communication role they took on, some rural officials found themselves in the difficult position of trying to be the bridge between the state and their residents. They didn’t have great answers when their residents asked why the state had allowed casinos to open to 50 percent but churches were required to be limited to 50 people. They didn’t have great answers when residents asked why their kids couldn’t go to school but daycare centers were open. They didn’t have great answers for why casino restaurants remained closed while eateries across the street could open.
“That would be frustrating, because you would be getting calls from these businesses going, ‘Hey, my neighbor across the street, who’s got a restaurant, their restaurant is open. Why can’t mine be open?’” Robertson said. “There would be a lot of calls like that.”
They also didn’t have good answers for their residents about why certain statewide policies should be applied to them when they were experiencing a low level of case growth in their communities or could pinpoint where the case growth was coming from. In White Pine, most cases were traced back to specific gatherings, including a Halloween party and a softball game, Robertson said.
“When the sheriff’s office gets something from the county health officer and that says, ‘Hey, so-and-so tested positive,’ he knows exactly where that person is most of the time. He knows who they hang out with,” Robertson said. “He can say, ‘Well this is how you get ahold of so-and-so and here’s how we do this,’ and bing-bada-boom, it’s done.”
Rural officials who have tried to actively aid the pandemic response by getting their communities to follow the state’s health and safety protocols have often found themselves in the community’s crosshairs as a result.
“There’s some lifelong friends of mine who are very, very upset. I mean, they’re to the point where they don’t want to talk to me because they think I quote-unquote ‘drank the Kool Aid,’ if you will,” Goicoechea said. “But everything I’ve done is to protect people and to protect the economy. I’m not taking unnecessary risks but, at the same time, I’m willing to take some calculated risks because I know where the disease is spreading in my community.”
It didn’t help that the pandemic became a political issue, either. If conservative rural Nevada was already wary of government officials telling them what to do, they were particularly wary of a Democratic governor from Clark County telling them what to do — particularly when that message contradicted the one coming from their local officials and a Republican president most of them supported.
Lewis, Nye’s director of emergency management, said that though local officials have become more supportive of pandemic response efforts “because they see the light at the end of the tunnel,” it used to be “horrific” to come before the county commission at each of its meetings to give a COVID-19 update when many didn’t believe in the severity of the virus.
“The political side of it was probably one of the worst things to deal with when we’re trying to make sure we meet the state’s requirements, we meet the state mandates and yet our local governments were telling us just the opposite,” he said. “They wanted nothing to do with it. They didn’t want to hear the reports. They didn't believe in the masks. They didn’t believe in the numbers and what the numbers meant. The deaths were made up, and it was a huge conspiracy, and that was extremely disheartening.”
In fact, the political discord was so severe that several rural county commissions, starting with White Pine County, passed a series of similar resolutions opposing Sisolak’s emergency directives. Robertson, who leads the only incorporated city in White Pine, framed those measures as chest-thumping by a small contingent of politically motivated individuals.
“I mean, honestly, I think I got more support for just being level-headed and cool and attending to the issues than I would have by screaming and thumping my chest and sending nastygrams to Carson City,” Robertson said.
Goicoechea, who said that he was responsible for drafting 99 percent of the version of the resolution Eureka County passed in January, acknowledged the measure was a statement. But he said it’s also one that his constituents needed to hear.
“People needed to see it in writing,” Goicoechea. “I’m not going to make a demand, knowing that he has the authority granted in the Constitution of the state of Nevada and he was exhibiting that under his emergency powers. But I did want him to hear we want things to be done differently. We expect them to be done differently.”
Looking back, rural officials wish there had been more communication with the state early on.
“We’re the ones down on the frontlines trying to implement what you’re drawing down from the top,” Robertson said. “If you want to know how it’s going, if you want some help on ‘hey, how could this go better?’ talk to your mayors, talk to these people, talk to these county commissioners, and there could’ve been more of that.”
Now, the relationship between the state and rural Nevada may, in some ways, be worse than it has ever been. Rural officials believe there is a healing process that needs to happen.
“It’s too far into it. We’re 12 months in. If it had been six months: ‘Okay guys, let’s get back to work,’” Goicoechea said. “But now we’re 12 months in and I feel that maybe some folks are really starting to entrench: ‘Hey, you guys aren’t working for us and when you do come back, you think you’re just going to come out here and start dictating how we’re going to do this stuff?’ I’m very fearful that the relationship we’re having with the state agencies, there’s going to be a long time trying to build that back.”
Beyond the rural context, the relationships between the state and local governments have continued to have their hiccups.
In response to the state’s decision to expand gathering sizes in September, health district officials in Clark and Washoe counties sent a strongly worded letter to the state, saying that it was “inappropriate” for local health authorities to not be consulted in the state’s public health decision-making process.
More than six months after the state’s first emergency directive, local health districts found out about the decision at the same time as the public.
“Our phones would just light up here. All of those businesses were calling us to find out what was going on, how they were affected, what they needed to do. We didn’t have any more information than they did,” Dick, Washoe County's health officer, said. “That was quite frustrating.”
While they were given slightly more notice before the state put in place its statewide pause this fall, concerns over communication remain. The state’s overtures to local governments — in the form of LEAP, or the task force — while positive have often felt like just that: overtures.
“I think there could be better communications, and more regular communications,” Dick said. “There have been opportunities for those dialogues and discussions but they haven’t been continued. There’s been some activity and initiative to make sure those communications happen and then they sort of go away.”
Counties say they still sometimes have to play catch up when it comes to the state’s policies. Lewis, Nye’s director of emergency management, said everyone had just gotten on board with the state’s tiered vaccination structure — though some believed it didn’t make the most sense for Nye — when the state announced that it was moving to a new, lane-based approach.
“You’ve got to be kidding me,” Lewis recalled thinking at the time. “Here we are toeing the line and the line came back and snapped us right in the butt.”
Even now, a year after the pandemic began, Lewis isn’t sure what exactly his role is supposed to be. With the ongoing rollout of the COVID-19 vaccine, which is supposed to be managed at the local level, he still feels like he doesn’t have the flexibility he needs to make decisions at the county level.
“Every time we made a decision it was, ‘You can’t do that, you have to do what we tell you or what we’re giving you,’” Lewis said. “I’m like, ‘Well, no, no, you can’t have it both ways. You can’t say I’m responsible for the decision and then take the ability away from me.’”
In Clark County, Sisolak and Kirkpatrick, the commission chair, have butted heads at points over the course of the pandemic, including after Kirkpatrick publicly pushed for the state to reopen businesses more quickly after the winter surge and Sisolak targeted Clark County for inequalities in the vaccine distribution process. For her part, though, Kirkpatrick says communication with the state has improved.
“Some days are harder than others, because we try to understand what’s behind the reasoning,” Kirkpatrick said. “But I will tell you there are a lot more meetings, a lot more conversations.”
And then there’s Las Vegas Mayor Carolyn Goodman, who during a CNN interview last year suggested the city serve as a “control group” to determine the benefits of social-distancing measures and recently said the governor’s prolonged emergency power “smacks of tyranny,” indicating that Sisolak had been unwilling to hear her input.
Sisolak, in an interview earlier this month, acknowledged his communication with local governments could have been better. But he also noted that there are hundreds of local government officials around the state and said it’s just not possible to communicate with all of them.
“Some of them were saying, ‘Wait a minute, why don’t you do this?’ or ‘Why don’t you do that?’ There’s 17 counties I’ve got to deal with, not just one,” Sisolak said. “They all want some attention, they all deserve some attention, and we can always do better.”
And, alluding to Goodman’s earlier comments, Sisolak said that he refused “to let the citizens, the residents of Nevada be used as test subjects or guinea pigs.” Whatever criticism he has received for his decisions during the pandemic — whether for being too strict or too lenient in the state’s rules — he bears.
“The buck has to stop with somebody and it stopped with me,” Sisolak said.
Still, multiple local officials said they give the state credit for the way it supported their pandemic response at the county level. Jeanne Freeman, public health preparedness program manager for Carson City Health and Human Services, said that trust between her agency and the state is deeper than it was before.
“They have their perspective and what they see, but then they have inquired, they have listened to us when we’ve said, ‘We see what you’re saying about that, but we’re not sure that’s really going to be how it’s going to work when we get it down to the local level,’” Freeman said. “We’ve met them in the middle. They have given a lot.”
Lewis said there were some state officials with "really spectacular personalities" that "shined" during the pandemic who understood the difficult situation local officials were in.
"I understand there's both sides of that because they're obviously overworked," Lewis said. "There was that lack of compassion and empathy both ways."
And some local officials, despite their complaints, give Sisolak and the state credit for the difficult position they were in.
“Part of my respect for the governor is those tough decisions that he's made to protect the state of Nevada,” Dick said. “I really commend the governor and his courage for the decisions that he's made. But I haven't seen that type of leadership, for the most part, coming at the local level.”
If anything, the pandemic has underscored the importance of relationships — and highlighted how difficult it is to build them in the middle of a crisis situation if they weren’t already there.
“Theoretically we could’ve done listening tours and town halls and developed those relationships as much as we could,” Cage said. “But the resources and the time constraints were so extreme and really remain so extreme right now as we transition to the vaccination effort that there really just was not the mechanism, the capacity to do that.”
Fogerson, who was appointed the head of the state’s Division of Emergency Management this fall, says the value of relationships is something he tries to keep in mind as a local-turned-state official.
“At the state, your job is not to do. Your job is to support and enable the local providers,” Fogerson said. “I used to get very mad at state employees that would come down and tell me how to do something or, ‘Here, we’re going to do that for you.’ … It’s going back to that civics lesson of who really needs to be the sharp end of the stick and how do we help them to sharpen that stick better?”
For some in local government, it finally feels like things are looking up.
In February, Sisolak announced the state would be transitioning the responsibility for COVID-19 health and safety mitigation measures to the counties by May 1. Mask and social distance requirements will remain in place statewide, but it will soon be up to counties to figure out how many people can be inside a business and how large gatherings are allowed to be.
Several counties, at multiple meetings of the COVID-19 Mitigation and Management Task Force last week, voiced their intent to open businesses 100 percent as soon as they can. Most businesses across the state are allowed to operate at 50 percent capacity.
“We can do it safely. We have the plan. We’re ready. We’re looking forward to it,” Goicoechea, the Eureka County Commission chair, said. “We will be ready to go and open up safely in a big way as soon as he lets us.”
For the next couple of weeks, county staff will be working on their plans for the transition to local control and getting them approved by their county commissions. Those plans will then be presented to the task force sometime in mid-April.
“That’s one of the smart things about what the governor is doing is put that decision-making process back in the hands of the people in the state of Nevada to use the sense that they have to take care of themselves and their families, and businesses to take care of their business and their customers,” Page, Lyon’s county manager, said.
Local governments now find themselves grappling with the kinds of questions the state has been facing all along, including how to enforce any mitigation measures.
Once the transition to local control happens, the state’s Occupational Safety and Health Administration will continue to enforce statewide policies but doesn’t have the authority to enforce local policies. That will be left to local code enforcement officers, who may not have the bandwidth to routinely surveil stores, and sheriffs, who, as elected officials worried about their reelection bids, may not be interested in enforcing the measures.
Counties are also pondering what happens if cases once again start to rise: Will the state step back in, or will it be up to them to put in place mitigation measures on their own?
“Go ahead and kick it out to local government control, see a spike in the summer, and then issue some kind of an emergency directive that we’re going to pull back some of these openings, you will have a complete uprising,” Goicoechea said. “That is my biggest fear.”
While Sisolak said the state would remain “flexible” and continue to monitor trends on a county level during the transition to local control, the goal of the new plan is for counties to take the reins and the state to step back. Still, Sisolak will retain the legal authority to issue new statewide emergency directives unless the Legislature takes action to limit the governor’s power.
Republican lawmakers have put forward legislation this session that would do just that, though those proposals have not yet been given hearings by Democrats, who control both chambers of the Legislature.
“There’s three branches of government for a reason and this extended emergency stuff really needs to be defined on what the governor’s role should be, and that’s the thing: There’s really no definition of it and that’s the problem,” said Titus, the Republican Assembly leader. “We're trying to put some bills forward to define it, but so far we haven’t gotten any traction with that.”
Counties, however, are finding that taking the reins from the state is easier said than done.
“I want people to open their businesses up to 100 percent capacity, but my fear is if that happens and then we get wave three of COVID and it’s more severe than wave one or two, do we go back to what we’ve been doing? That’s a concern,” Page said. “I’ve said this publicly: I thank God I’m not the governor. I can’t imagine making those types of decisions and impacting people’s lives.”
A year into the pandemic, Titus, who is also a family practice doctor in Lyon County, is of the mind that people are well-informed enough to be able to make choices about what behavior is safe or unsafe. She says it’s the kind of conversation she often has with her patients when discussing treatment options.
“Once a person has all the information, and I give them the information that I have, they have the right to refuse treatment. They have a right to self-determination, even if I didn’t agree with their decision, even if I thought they made a bad choice,” Titus said. “Once we’ve educated everybody as the government, once we give them good informed consent, they have the right to choose not to do that.”
There are, however, limits to that idea.
“You have the right to self-determination as long as it doesn’t impact those around you,” Titus said. “You have the right to get COVID if you want to. You have a right to make a bad choice and get sick, but if your choice then impacts the entire roomful of people that you’ve now exposed, I’m sorry, we have the right to remove you from that room.”
From top state officials down to everyday Nevadans, many are of the belief that the biggest challenge of the pandemic wasn’t the virus itself, but the lack of communication — and, by extension, the relationships, community and trust that come along with that — to respond to it.
Without communication, state and federal governments can’t cooperate, state and local governments can’t work together and governments at any level can’t effectively convey important, potentially life-saving, information to their citizens.
“Communication, it’s always going to be something we have to strive for in government to do a better job of,” Page said. “It’s always going to be our biggest failing.”
The virus came to Nevada slowly, and then all at once.
At the beginning, it was a specter, a theoretical possibility but — public health officials optimistically thought at the time — an improbability. Nevada’s state epidemiologist, on Jan. 13, 2020, penned a report on the developing situation: Health officials in China had identified a novel coronavirus. There were 41 confirmed cases, all residents of Wuhan besides one recent visitor to the city, and one death.
“At this time there has been no evidence of person-to-person transmission, although there is still much to learn in regard to this novel virus,” state epidemiologist Melissa Peek-Bullock wrote in the report.
The primary focus from the Centers for Disease Control and Prevention, she said, was on standing up facilities at the three primary airports travelers to the U.S. from Wuhan pass through in New York, San Francisco and Los Angeles. All passengers from the city were to be screened upon arrival and, if unwell, referred to a hospital for further evaluation.
At that point, all state health officials here could do was communicate that information to local health authorities statewide and continue to monitor the situation. She wrote that the CDC believed the overall risk to the public was low.
The Silver State’s first brush with COVID-19 came nearly two weeks later. A Northern Nevada resident was transferred to a Bay Area hospital for isolation and monitoring after arriving in San Francisco from Shanghai with a cough, shortness of breath, fever and other flu-like symptoms. Her travel companion, who had not been stopped in California and made it back to Washoe County, fell ill too. Though neither of them had been to Wuhan, the first woman’s case was concerning enough to place them formally under investigation for the virus.
Fortunately, they were soon cleared after the first woman tested negative for COVID-19.
A few days later, a Southern Nevada man who had recently traveled to Wuhan was admitted to a local hospital after coming down with a sore throat, fever, cough, chills and body aches. He also tested negative.
The most dramatic early investigation centered around a Southern Nevada flight attendant who had been exposed to a confirmed COVID-19 case while on the job. Health officials had instructed the man to isolate; instead, he traveled with his family to Los Angeles, where he came down with a cough. Health district officials told him not to fly back to Las Vegas. He refused. They suggested he drive back. He refused. They asked for his itinerary. He refused.
For two hours one February evening, state officials, CDC officials and health officials in Las Vegas and Los Angeles scrambled to secure a public health “do not board” order that would prevent the man from flying. Complicating things, because the man was a flight attendant, he could fly standby on any one of the many airlines that flies between the two cities — and his name wouldn’t appear on a flight manifest until he had boarded.
The “do not board” order came too late: State officials received a call from the CDC at about 8 p.m. The man had flown standby and had just landed in Las Vegas. The “do not board” order was issued just after he boarded the plane. But, once again, it ended up being just a close brush with the virus. Health district officials that night made contact with the man, who agreed to cooperate with their investigation and isolate in his home; four days later, he tested negative for COVID-19.
This game of whack-a-mole continued for several weeks as it became clear that finding COVID-19 in Nevada was not a matter of if but when.
State and local health officials from across the nation, during a call on Jan. 26, shared their concerns about asymptomatic spread of the virus; China had reported that such spread was occurring, but the CDC had been unable to confirm. The possibility of asymptomatic spread was important because it meant that a traveler or multiple travelers could have unknowingly already brought the virus to the U.S. With little to no testing available at the time and extreme restrictions in place on how tests could be used, health officials would have no way of knowing to what extent the virus was already here.
Health officials on the call discussed the possibility of school closures and requiring employers to allow remote work, measures to help halt viral spread. But there was still so much they did not know about the virus.
“It was emphasized that decisions are required to be made with a lot of uncertainty and limited knowledge of the infectious period, overall infectiousness and sustainability of transmission and severity of this novel virus, so decisions need to be cautious and re-evaluated as we learn more about the virus,” Peek-Bullock wrote in one of her daily reports about the call.
A month later, a virus that had once been a point of interest was now a cause for concern. Fourteen cases had been identified in the United States, including two cases of person-to-person spread, while an additional 39 people with the virus from the Diamond Princess cruise ship and Wuhan had been repatriated to the country. Nevada health officials held a call with representatives of local health districts, the state public health lab and the state hospital association to discuss federal guidance, testing capacity, hospital preparedness, isolation and quarantine and public messaging.
Peek-Bullock, in her Feb. 24 daily report, underscored the seriousness of the situation, bolding and underlining the following:
“During the weekly national call today, CDC emphasized their goals, stating we cannot stop every traveler now that sustained transmission is occurring outside of China, but it is important to continue to slow and continue to contain the spread in the U.S. CDC stated that we are to expect spread to occur in the U.S. and now is the time for states to assess their readiness and ensure they are prepared. They emphasized this is not expected to go away, and in fact is expected to escalate.”
In short: The virus was here in the U.S., even if we hadn’t found it yet in every state. The only option now: Slow it down.
Four days later, Gov. Steve Sisolak gathered together more than two dozen of the state’s top government and health care leaders — state health officials, hospital representatives, local health district leaders, congressional staffers and education officials among them — in a crowded, standing-room only conference room at the Grant Sawyer State Office Building in Las Vegas. More joined from Northern Nevada by phone.
It was a meeting of the minds, so to speak, except that many had never actually met, according to some who attended. But in the coming weeks and months, their names would be familiar throughout the state: There was Dr. Mark Pandori, head of the state public health lab; Dr. Fermin Leguen, head of the Southern Nevada Health District; and Christopher Lake, the public face of the hospital association on all things COVID-19.
Despite the growing seriousness of the situation, those in the room didn’t have any idea just how quickly things were about to change, how bad it would get or how long it would last.
Afterward, the group descended to the building’s lobby, where they huddled behind Sisolak for his first press conference on COVID-19. He stressed to the public three things: That there were no confirmed COVID-19 cases in Nevada, that the immediate health risk from COVID-19 was low and that there had been no COVID-19-related deaths in the United States.
He did, however, note that more COVID-19 cases were likely to be identified.
“We’re going to prepare, not panic,” he said. “We’re going to choose collaboration over chaos.”
Six days later, on March 5, Ronald Pipkins became the first Nevadan to test positive for the novel coronavirus.
It was the beginning of, perhaps, the most difficult year in Nevada’s history, one that would lay bare the chronic underfunding of public health systems, a lack of investment in aging state infrastructure, including its unemployment system and continued economic overreliance on the tourism industry.
It was a year that would see 1 in 10 Nevadans test positive for the virus and more than 5,000 lose their lives to it, more than all U.S. military casualties in the nearly nine-year Iraq War.
It was a year that would see a quarter of Nevadans unemployed, as the state’s economy came to a sputtering halt last spring in an attempt to stop the spread of the virus. It was a year that would see a sharp rise in depression, anxiety and substance abuse in a state that already struggles to provide mental health services to its residents even in good times.
It was a year that would pit the state’s public health needs against its economic ones, every day a Sophie's choice.
It was a year that would see Sisolak come under heavy criticism for not communicating with the public well enough, for not bringing local governments into the fold early enough and for making policy decisions that seemed, to some, arbitrary and capricious, infringing on their individual liberties.
It was a year that would sow deeper divisions in a state with a long history of bipartisanship that’s increasingly been tested in the last few years. It’s a year that would see rural communities refocus their longstanding mistrust of government from the federal level to the state.
It was a year that would see Nevada’s health care providers pushed to their limits, overwhelmed, scared and at a loss for how to best care for their patients. It’s a year that would see Nevada’s fragile health care system pushed to its limit, too, and, surprisingly, not break.
It was also a year that would see resilience in the face of despair.
It’s a year that would see rank-and-file public health officials work harder than ever under the most scrutiny they had faced in their lives.
It was a year that would allow Nevada to take advantage of its relative nimbleness and lack of bureaucracy and move quickly to devise innovative solutions to meet the state’s needs, even when those solutions didn’t always work out as expected.
It was a year that would make clear to many that Nevada, as divided as it is, is still, at its heart, a scrappy Western state whose residents are accustomed to fighting for survival against the odds.
This is the story of that year.
Early in January 2020, public health experts didn’t see much reason to worry.
There are outbreaks of disease all the time, and a novel coronavirus in of itself wasn’t necessarily concerning.
SARS and MERS, two novel coronaviruses that surfaced in 2003 and 2012, respectively, claimed relatively few lives despite their high levels of mortality, in part because their spread was typically associated with symptomatic individuals. That meant that isolating people who were ill was very effective in containing spread. Plus, there are a bunch of everyday coronaviruses that circulate through the general population that only cause the common cold.
“There are weird things always popping up all over the world, and most of them don't turn into anything,” said Brian Labus, an assistant professor of public health at UNLV and former senior epidemiologist for the Southern Nevada Health District. “That's why it's hard to get really excited early on when you hear about some new virus like this because most of the time they do not spread that easily from person to person, which means we're not going to have a big outbreak.”
Public health officials started to take the virus more seriously, though, as more information came to light about it, including the fact that it could be transmitted person-to-person and spread by people showing no symptoms.
On Feb. 11, Nevada State Public Health Lab officials validated the CDC’s assay, meaning that they now had the capability to test for the virus at their lab in Reno. It was the same day the virus received its official name from the World Health Organization. It would be labeled SARS-CoV-2, and the disease caused by it would be called COVID-19.
Lab officials, though, didn’t want to sit around and wait for the virus to come to them. They were already having conversations with the Washoe County Health District about whether they might be able to start looking for COVID-19 in samples already at the lab that had been collected to be tested for other respiratory illnesses. So much of the focus to that point had centered around testing symptomatic people who had relevant travel history or were close contacts of confirmed cases. Northern Nevada health officials wanted to know if the virus was already here.
But, at the time, the CDC had strict rules about how the test could be used, namely, to test those with travel history or contact. That would’ve made sense, public health experts say, if the virus had behaved more like SARS. But even by that point in February, there were indications the virus was spreading asymptomatically, even if the role of asymptomatic transmission was still unclear.
That meant that Nevadans sick with respiratory illnesses might have COVID even without a relevant travel history or confirmed close contact.
“It's not that I'm trying to point fingers or make fun of anyone, but we already knew how ridiculous that was then,” said Pandori, the lab’s executive director. “The chief [epidemiologist] of Washoe County and myself already wanted to start looking, but we had to wait.”
Heather Kerwin, Washoe’s chief epidemiologist, believes Nevada might have been able to identify cases a few weeks, if not an entire month, earlier had officials been allowed to start screening respiratory specimens for COVID-19. Pandori said it is “very easy to hypothesize” that earlier surveillance testing could’ve had an impact on the trajectory of the virus.
“When you don't react quickly to something or as quickly as you can, from a surveillance perspective, it's essentially a fact that you allow it to make headway or to spread in a manner that you might have had an opportunity to intervene,” Pandori said.
But, at that point, the federal government, at the highest echelons, wasn’t taking the virus seriously. President Donald Trump, at the White House on Feb. 10, said the country was in “great shape” and suggested the virus would disappear “in April with the heat, as the heat comes in.” Two weeks later, he said the virus was “very much under control in the USA” and that the country had had “very good luck.”
We still don’t actually know how early COVID was circulating in Nevada. When the antibody test for the virus came out last spring, the state lab tested old blood samples they had stored from December 2019 and January 2020 but didn’t find any antibodies for COVID-19. Some studies have tried to extrapolate how early the virus was spreading in Nevada and elsewhere across the country. One projects the virus was already spreading in Nevada by mid-February and puts the state among the first 10 to have community transmission.
Doctors here, based on what they now know about COVID, believe they were seeing cases as early as January. At the time, they chalked it up as a particularly severe flu season.
“In January, we were seeing tons of people with flu-like illness, and we were calling it the flu,” said Dr. Scott Scherr, the regional medical director for TeamHealth, which manages five emergency departments in Las Vegas and one in Elko. “When you look back at it, it wasn’t flu at all. It was COVID.”
In those early days, it wasn’t yet clear what kind of an impact the virus would have on Nevada, but government officials and the health care industry were starting to prepare. Clark County started updating its emergency plan. Hospitals started to think through the difficulties they might face in securing personal protective equipment, much of which is manufactured in China. They also dusted off their mutual aid agreements, which let them lean on each other for support in a crisis situation.
What was clear though, by the end of February, was that COVID was coming. For Las Vegas, a city that hosts nearly 50 million visitors a year, the virus was always just a short drive or plane flight away.
“We understood that it had all the makings to be a large scale, global pandemic at the time,” Peek-Bullock said. “But early in January and February, I don't know if any of us would have predicted where we would be sitting here a year from now.”
The situation escalated quickly: Concern became alarm.
On March 5, Nevada went from zero COVID-19 cases to two: Pipkins and a Washoe County man in his 50s who contracted the virus after sailing aboard the Grand Princess cruise ship. Though government officials, public health entities and health care workers had been preparing for the last few weeks, the first two cases brought the seriousness of the situation into sharp focus.
“Once we had the ability to really start identifying cases, those case counts grew very quickly,” Peek-Bullock said. “We know now the virus is transmitted very efficiently person to person, so I think that from our perspective, it really ramped up quickly for us too.”
Within a week, two cases had become 11, and health officials here knew that as they continued to test they would only find more cases.
Publicly, state and local officials put on a brave face: Yes, more cases might be identified. But if Nevadans did their part — avoiding contact with sick people, cleaning surfaces and washing their hands — we would get through this together. After all, Nevadans had leaned on each other in the aftermath of the mass shooting on the Las Vegas Strip two and a half years earlier. Why would this be any different?
“I encourage all Nevadans to prepare, not panic, and to continue to choose to collaborate over chaos,” Sisolak urged at a press conference two days after the first cases were announced.
But panicking happened anyway. Grocery store shelves were stripped bare as Nevadans, and those across the country, stocked up on toilet paper and canned goods, unsure of what was to come.
Behind the scenes, the governor’s office was assessing whether it had enough body bags and having conversations about air quality control standards should the furnaces in the crematoriums start burning overtime. In the governor’s office, a chart on the office wall showed the cases increasing day by day, doubling and then tripling. What they needed was more information, more guidance. Enter the governor’s Medical Advisory Team.
Dr. Paul Sierzenski, chief medical officer of the acute care services at Renown, was in the parking lot of Raley’s one day in early March when he got a call from the governor’s office asking him to join a new five-member advisory team Sisolak had established to help guide his decision-making.
The group’s first meeting was March 14, and the governor’s objectives, according to the meeting’s minutes, were straightforward yet seemingly impossible: He wanted to, one, figure out how to help identify individuals with COVID-19 and, two, define goals for the state to contain and mitigate the spread of the virus.
The governor’s office, the minutes note, wanted guidance only on one initial objective: “How do we inform the governor to make decisions on social distancing, mass gatherings, school closures, based on logic and facts for containing, mitigating, preventing?”
The members of that team, in interviews, praised the science-based approach and the decision to bring them — some of the state’s top minds in public health and infectious disease — into the fold so early on. The group still provides advice to this day, though it doesn’t meet nearly as frequently as it did in March and April last year, when it convened almost daily.
But there was one big problem: The Medical Advisory Team knew about as much about this novel virus as the rest of the public did. Sure, its members were familiar with SARS and MERS. They grasped influenza pandemic planning. They knew the playbooks on what they were supposed to do. But knowing what to do and figuring out how to do it are two entirely different things, they quickly learned.
“We had the plan but not the infrastructure,” said Trudy Larson, dean of the School of Community Health Sciences at UNR and one the members of the governor’s Medical Advisory Team. “This is so new for us as a country. No matter how much we wanted to, we really didn’t know all the pieces to put in place and, really, because of some of the social disruption that the country had gone through, we also didn’t have a common way of looking at these things.”
Caleb Cage, former head of the Division of Emergency Management under Gov. Brian Sandoval, who was pulled in to assist the Sisolak administration’s response to the pandemic, felt similarly. Though the state had previously participated in exercises to drill the state’s pandemic response such as Operation Rabbit’s Foot in 2015, Cage said that nothing could’ve prepared them for what it would be like to live through the last year.
“I’m not saying it is bad training and a bad exercise, but it certainly doesn’t stand up to the experience that we’ve had over the last nearly a year,” Cage, the state’s COVID-19 response director, said. “The stakes are real. In an exercise the stakes are, ‘Oh, you learn a lesson and you don’t do it again next time.’”
Part of the problem was, as the governor was asking his Medical Advisory Team big, important questions about how to respond to the virus, the members were themselves still trying to answer basic questions: How easily does the virus spread? What’s the death rate? What will actually stop the spread?
Those in the governor’s office said they were sure the answer — whatever it was — would be found in science: They believed in science. They trusted the scientists. They wanted to do what the scientists said.
“I think there's always this mindset that we will figure this out, that we will figure out a way as a country to control this and get a handle on it,” said Michelle White, the governor’s chief of staff. “I think that was the expectation of all Americans, that that's what we do, that we will get a grip on this and figure out a way to keep it controlled.”
The virus, however, had other plans.
When Nevadans awoke the morning of March 18, the roar of everyday life had dulled to a quiet murmur. School playgrounds were empty. The state’s four-mile-long adult playground was empty too as casinos famed for never closing chained their doors and boarded up their windows.
Slot machine screens blinked blue. They were out of service, and Nevada was too.
The writing had been on the wall. Two days earlier, schools in Nevada and 25 other states closed their doors, the rest to follow suit in the days to come. By the time Sisolak announced all gambling in the state would cease as the clock struck midnight on St. Patrick’s Day, several major resorts were already in the process of shutting down their operations, facing a wave of canceled bookings. Other nonessential businesses were given until noon to close up shop.
A bevy of people — public health experts, doctors, epidemiologists, business owners and representatives of various sectors of the economy — had provided their input to Sisolak and his staff in the days and hours leading up to the shutdown. But the decision was Sisolak’s alone to make. White said it was an “excruciating” process.
“At some point, when you’re the leader and everyone’s looking at you, you have to make that choice and you know it’s going to be massively consequential and you know that it is going to be applauded or it is going to be booed by all sorts of people and that that doesn’t matter at some point, that you just have to do what you think is best with the information you have in front of you,” she said.
Sisolak, in an interview, recalled walking out onto the balcony of his office at the Grant Sawyer Building in Las Vegas one evening in early March and looking out at the lights of the Strip.
“I’m saying to myself, if I shut this down, those lights are all going to go dark and 100,000 people are going to be out of work and kids aren’t going to be able to go to school, and I thought about the potential ramifications of what those decisions would be,” Sisolak said, choking up. “I came in and I said, ‘I’ve got no choice, we’ve got to shut it down,’ because too many lives were at risk.”
His primary focus, as he made clear at the time, was the public health crisis at hand. Back then, public health officials didn’t even know how deadly COVID was. Because of limited testing early on, data out of New York City, which was hit early and hard by the virus, showed that nearly 1 in 10 New Yorkers who had tested positive for the virus died from it. Some health experts were recommending people clean their groceries and packages because of concerns about surface-to-surface transmission. Little had been confirmed about the role of asymptomatic transmission.
At a press conference announcing the business closures, many questions focused on cause and effect: Would businesses face penalties if they remained open? How would the government police it? Sisolak, however, seemed irritated.
“I don't know if I can make this any clearer ... This is affecting the lives of our citizens. People are dying. Every day that is delayed here, I'm losing a dozen people on the back end, they're going to die as a result of this,” Sisolak said, bristling. “It's incumbent upon the citizens of this state to take this seriously. Next question.”
It’s not that the governor’s office wasn’t aware of the economic consequences of shutting down and how many Nevadans’ lives would be affected. But the public health crisis seemed so daunting and the shutdown so necessary to get the virus under control.
Furthermore, the shutdown was billed as a short-term situation. The school closures were initially supposed to last only three weeks. Businesses were to be closed only for 30 days. But the virus stubbornly lingered as hospitals scrambled to secure resources and learn how to treat this new disease.
At the beginning of April, Sisolak put in place a “stay at home” order, formalizing what had existed in spirit for several weeks and extended the closures of nonessential businesses and schools. By the middle of the month, the shutdown had been extended to an undetermined date and schools closed for the rest of the academic year.
“It’s a symbol of truly no one really knew how long this was going to last for,” White said of the early emergency directives. “It was this immediate decision making needed to protect the health of the public in that moment.”
Everyone wanted certainty in that time, from everyday Nevadans to the governor himself. Everyone wanted to know that if only we did X, then all of this would be better. But we didn’t know what X was. In those months, the entire world was still solving for X.
“We want to be able to say, ‘This one is 100 percent foolproof,’ and oftentimes in this situation, the options that we had to lay out on the table — not only is it not always a no-win situation, it is, how do we lose the least?” White said. “How do we do the most good for the most people, understanding that each one of these choices is going to have a negative impact on someone or something somewhere?”
At the worst point in April, statewide unemployment hit 28.2 percent, climbing to 33.5 percent in Las Vegas. Today, 1 in 4 Nevadans is enrolled in Medicaid, the state’s insurance program for low-income individuals and families, up from 1 in 5 before the pandemic.
State officials and public health experts say it can be easy to criticize these early decisions with the benefit of hindsight. We now know the virus is not as deadly as we initially thought, though still more deadly than the flu. We also know that COVID got much worse in Nevada this fall than it ever did in the spring. When Sisolak closed nonessential businesses in March, there were only 55 confirmed COVID-19 cases statewide. At the worst point in the pandemic this fall, the state was identifying more than 2,700 new cases a day. But they say that lessons learned during the spring shutdown and the time it bought the state were precisely what allowed many businesses to remain open, at least to some extent, this fall.
Had we known back in March what we know about COVID today, those who helped advise the governor said, they might have made different recommendations about closing businesses and schools. But thinking back to what they knew at the time, they — and the governor himself — believe that shutting down was the only option.
“It was really just a lot of unknowns that led us to all we could do to stop the transmission,” Labus, one of the members of the governor’s Medical Advisory Team, said. “Nobody knew what was going on with this particular virus. We were still trying to understand it.”
In late March, as the refrigerated trucks began to pull up to New York City hospitals, Nevada — a state where people sometimes grimly joke that the best health care you can get is at McCarran, the airport, leaving town for a city with world class medical care — braced for an onslaught.
Health officials worried that if New York City, which has some of the most hospital beds per capita of anywhere in the country, couldn’t handle COVID, how would little Nevada fare, particularly its rural residents, some of whom live more than 100 miles from the nearest hospital?
“If they couldn’t handle it there, we definitely couldn’t handle it in Nevada,” Labus said.
Sisolak temporarily placed the state’s Department of Health and Human Services and Division of Emergency Management under the direction of Major General Ondra Berry, adjutant general for the Nevada National Guard.
It was an operation completely unfamiliar to the Guard. In some ways, it was easier: Guard members weren’t deployed overseas and could return home to their families every night. They didn’t have to face the day-to-day horrors of war. In other ways it was more difficult: They faced the danger of bringing the virus home to their families, as the death toll mounted quickly.
Berry likened the daily COVID death reports on the nightly news to the daily casualty reports they’d get during the Gulf War. Since March 26, at least one Nevadan has died from COVID-19 each day with the exception of one day. At the peak this winter, Nevada lost 47 in a single day.
“It may not be the same atrocity that you may see in war, but you are in a battle for people’s lives,” Berry said. “If the best solutions are not in place, then those who we care [about] and love and matter may not get to see tomorrow. It’s a different kind of similarity, but it’s a fight.”
And it was coming. Nevada, the state born in the heat of battle, readied itself.
When Pipkins tested positive for COVID-19 at the North Las Vegas VA Medical Center in early March, his doctors were in disbelief. It was the first novel case in the VA system nationwide. Higher-ups from Washington, D.C. called every day for an update on his case.
The initial treatments Pipkins’ doctors tried didn’t seem to work, so they did the only thing they could think to do — put him in a medically induced coma and hook him up to a ventilator to keep him breathing while his body continued fighting.
“That’s all that we had at the time. That feeling as a physician — especially when people would come to us and say, ‘Hey, listen, you’re the expert. What can you do to make me better?’ — I had no good answer at the time. All I could say is, ‘Listen, I can keep you alive until something happens, but that’s the best that I can do,’” said Dr. Myron Kung, a pulmonary critical care physician at the VA hospital and one of Pipkins’ doctors. “That’s a frightening position to be in as a provider.”
Kung said he was learning more and more about the virus watching CNN, just like everyone else was.
Scherr, the emergency medicine physician, recalled patients flooding into the ER in March and April struggling to get enough oxygen; doctors’ first instincts were to intubate them and place them on ventilators to keep them breathing. Just as state officials were working with the best information they had at the time, so, too, were doctors struggling to fight a virus with what they knew. Though patients’ chances of surviving significantly dropped once they were ventilated, it still gave those like Pipkins a fighting chance.
The problem was, what would they do when they ran out of ventilators?
“In the beginning of it, our ICUs were full,” Scherr said. “Our ventilator capacity was near 80 percent.”
Once the state effectively shut down, the numbers started to drop. A peak of 711 COVID hospitalizations in early April plummeted to 421 just a month later. In the same timeframe, the state went from having 240 COVID patients on ventilators to only 115.
Doctors, nurses and hospital officials across Nevada say that initial shutdown — painful as they know it was for so many of their friends, family and fellow Nevadans — bought them critical time to prepare. They secured additional resources, including personal protective equipment and ventilators, set up additional bed space and learned more about the virus and how to treat it. That decision, they say, saved an untold number of lives.
It’s impossible to know exactly how many lives Nevada might have lost had it acted differently. If Nevada were New Jersey, which like New York was also hit early and hard by COVID, it would’ve lost more than 8,000 of its residents to the virus. If it were Mississippi, which has taken a relatively lax approach to COVID restrictions, it would’ve lost 7,000.
To date, Nevada has lost more than 5,000 lives to the virus.
“When we first started seeing that surge of COVID, there was not a single hospital in the [Las Vegas] valley that was ready to deal with that,” said Dr. Shadaba Asad, UMC’s medical director of infectious disease and another member of the governor’s Medical Advisory Team. “If the city had not been shut down and that spread of infection had not been halted, or at least reduced, I think it would have resulted in a catastrophe where our hospitals would not have been able to take care of the patients who became ill.”
Early on, hospitals were focused on making sure they had the bed space and staff to handle a sudden influx of COVID patients, who typically require lengthy hospital stays. There were two ways to accomplish that: Facilities could either increase bed space, as Renown did when it made the decision at the end of February to set up an alternate care site in its parking garage, and bring on additional staff, difficult when states were competing for a limited pool of traveling nurses, or they could decrease the number of patients in the hospital, thereby reducing the number of beds and staff needed.
While some hospitals focused on the former, Nevada hospitals statewide did the latter, suspending all non-urgent surgeries. That means people who needed hips replaced could not get them replaced and people who needed tumors removed at some point in the near future could not get them removed.
“It’s really with a heavy heart that you make that decision that we’re going to stop that,” said Lake, executive director of community resilience at the Nevada Hospital Association, which announced the suspensions back in March. “It’s not a financial decision, it’s really a triage decision.”
Nevada hospitals, like those everywhere else in the world, also struggled to secure personal protective equipment (PPE) for their workers as global supply chains collapsed and the cost of basic, necessary medical equipment like masks, gloves and surgical gowns skyrocketed. Because testing was so limited early on, hospitals had to treat every patient as if they might have COVID. So did first responders. That meant expending significant amounts of PPE on every patient — PPE that had quickly become the scarcest resource.
“It was sort of like a shark feeding frenzy with blood in the water,” Lake said.
The situation got so bad that the first mission of a private-sector task force established by the governor to assist with the state’s COVID response raised $10 million dollars to purchase personal protective equipment, including 2 million N95 masks, 2.6 million surgical masks, 1.5 million gloves and hundreds of thousands of face shields and goggles.
Meanwhile, in hospitals some workers say their facilities were keeping PPE under lock and key. Others tried to buy their own supplies and bring it from home. But the heart of the issue was that there just wasn’t enough available in Nevada, across the country or around the globe.
“I can’t even begin to explain this fear and dread even amongst health care providers when we started getting these first patients because it’s a highly contagious disease and knowing very little about it, being exposed to it day and night and not sure if we were actually protecting ourselves, if we were taking the disease back to our loved ones,” Asad said.
And time has borne out how important personal protective equipment is in protecting hospital workers. When Yarleny Roa-Dugan, a labor and delivery nurse in Las Vegas, fell ill to COVID in January 2021, it wasn’t because she had been exposed to a patient but rather to her carpenter husband, who they believe contracted the virus at work from someone who wasn’t wearing a mask and later tested positive.
On one level, the concerns over PPE were about protecting health care providers. But they were also making sure that hospitals had enough staff to treat all of their patients. If health care workers were already a scarce resource in Nevada before the pandemic, what would hospitals do if a significant portion of their workforce had to quarantine because of exposure to COVID or because they fell ill to the virus themselves?
When Pipkins came into the VA hospital in March, 47 employees who came into contact with him had to quarantine at home for 14 days because they weren’t wearing PPE.
“If you started quarantining health care providers exposed to people with COVID, before you knew it, you would have nobody to take care of these patients,” Asad said. “We started learning slowly, and this had primarily to do with availability of health care providers, if a health care provider was exposed to somebody with COVID, as long as they had absolutely no symptoms concerning for COVID, they were allowed to work with precautions, daily symptom monitoring and daily screening.”
The state shutdown also bought doctors critical time to learn how best to treat the illness. They discovered it was better to place patients on their stomachs and give them high flow oxygen for as long as they could bear, only putting them on a ventilator as the last resort. They started giving their patients steroids. They started using remdesivir, an antiviral drug, and convalescent plasma.
Spring, as it turns out, was just the beginning for Nevada’s hospitals. The state would see nearly twice as many COVID-19 patients hospitalized during the summer surge and three times as many during the fall surge compared to the worst point during the spring.
But doctors believe if not for the initial shutdown, they never would have been prepared for what was to come.
“It would have broken down the health care system completely and it would have resulted in innumerable, avoidable deaths,” Asad said.
If the goal had been solely to stop all spread of COVID-19, the best way to accomplish that would have been to lock every single person on the planet inside their home until everyone infected with the virus had either recovered or died from it.
This was, of course, never a realistic option.
Nevada’s lockdown, by comparison, was relatively porous. People were still allowed to go to the grocery store and pick up takeout. Workers in some essential industries, such as manufacturing and construction, were allowed to continue to go to work. Friends and family could still gather privately in small groups in their homes.
Still, some Nevadans may have been hopeful the lockdown would eliminate the virus and they would be able to emerge sometime in late spring or early summer and return to life as they knew it. State officials, however, knew that was not going to be the case. Their focus was mitigation.
They knew a lockdown couldn’t reasonably last forever, and they knew that cases would rise once it ended. That’s why, once the initial tide of COVID-19 cases started to ebb, their focus turned to figuring out how to reasonably stop as much spread of the virus as possible while also allowing Nevadans to do the things they reasonably needed to do to sustain themselves.
The answer was, on its face, simple: One, they needed Nevadans to continue to interact as little as possible to limit the spread of the virus; two, they needed all Nevadans who wanted to get a test to be able to get a test in the event they fell ill; and three, they needed to be able to contact trace all Nevadans exposed to the virus to prevent them from spreading it to more people.
But changing human behavior is a tricky, if not impossible, proposition. Plus, Nevada was already lacking in public health infrastructure prior to the pandemic, which meant it was nowhere near prepared to undertake a testing and contact tracing effort of this magnitude, despite best intentions.
Early projections suggested that states would need 30 contact tracers per 100,000 residents. That would mean Nevada would need nearly 1,000 contact tracers. State officials estimate they had 10, maybe 15, contact tracers at the time.
Other gaps quickly became apparent as well. State officials discovered early on that several counties, which are required by state law to have county boards of health, did not.
“I remember calling one sheriff in a rural county and saying, ‘Who's your county health officer? Tell me about your last board of health meeting,’ and he was like, ‘I have no idea what you're talking about,’” said Julia Peek, deputy administrator in the state’s Division of Public and Behavioral Health. “He scrambled to get it set up, to a ton of his credit.”
The state's two public health labs — the Nevada State Public Health Lab in the north and the Southern Nevada Public Health Lab in the south — were also ill prepared for something of this scope. Both labs were well-accustomed to testing for infectious diseases, foodborne illnesses and sexually transmitted infections on a small scale, but widespread testing for COVID-19 for every Nevadan who wanted it?
“I think people still don’t appreciate or understand that there was not and there still is not and there likely will never be an infrastructure whereby every person can get a test when they want it,” Pandori, head of the state public health lab, said. “Even with disaster and bioterror preparedness, which started to be financed pretty heavily after 9/11, in particular, that money does not come within a trillion miles of making labs and public health labs possible to test anyone who needs a test at any given moment.”
That didn’t stop Nevada from trying. Health officials knew that as soon as Nevadans were allowed back out in public again, the virus would start spreading and they would need a way to find it. The answer, for Southern Nevada, came from an unusual source: UMC, the county-run, safety-net hospital. UMC’s mission, as a public hospital, is to serve the community. In the time of the pandemic, that meant effectively joining the state’s public health response.
“Did I ever think we would be doing COVID testing and running a massive vaccination enterprise? Absolutely not,” Mason VanHouweling, UMC’s CEO, said.
Toward the end of March UMC realized it needed a better solution for COVID testing. It was still the tail end of the flu season, and the hospital couldn’t tell whether its patients were sick with the flu, COVID or both. From there, UMC started talking about how the hospital could not only expand testing for its own patients but also help with the demand for public testing, which was incredibly slow and scarce at the time.
So, the hospital shuffled its funds around, including capital it had originally intended for other projects, and made the decision to set up a second, complete lab that would be able to turn around test results within 24 hours and run up to 10,000 COVID tests a day. To date, UMC has run nearly a million COVID-19 tests across Nevada, about a third of the 2.7 million tests that have been run across the state. The lab ended up costing the hospital about $1.3 million to develop and $57.5 million to operate in labor and supplies.
While there were initially talks with the governor’s private sector task force about bringing in a Chinese company, BGI, to help to establish the lab — which the U.S. government warned against — VanHouweling said the hospital decided on its own to go a different direction.
Jim Murren, former MGM Resorts CEO and head of the state’s private sector task force, helped the hospital secure a contract with Thermo Fisher, a Massachusetts-based company, to provide open source, high-throughput test machines that would allow the hospital to use a wider range of supplies for the machines and meet the demand the hospital anticipated. He did so by selling them on the idea that the company would be able to pitch to its shareholders that their test supplies helped Las Vegas — and by promising them that they wouldn’t face a ton of red tape with the contract and that government officials would move quickly on the decision.
What’s still not entirely clear is why so much of the focus from government officials and the private sector task force was on helping UMC with their entirely new lab instead of assisting the Southern Nevada Health District in expanding its existing public health lab. The Southern Nevada Health District said the answer lies in the governor’s office. The governor’s office said it was just a matter of UMC being ready and willing to quickly step in to fulfill that role. Murren said it was because UMC’s lab was considered one of the best in the nation and that he was betting on VanHouweling, the Air Force veteran who turned the once-struggling hospital around.
“I bet on people,” Murren said. “I’ve done it my whole life.”
Renown, in Northern Nevada, ended up filling a similar public health role in its community by investing $3 million on expanding its testing infrastructure. At the height of demand, Renown was running 7,000 tests a week in a county with a population of a little less than 500,000.
The Nevada National Guard also played a critical role in establishing testing infrastructure statewide, both in urban Clark and Washoe counties but also in rural Nevada and on reservations where they facilitated mobile testing efforts.
“There's nothing in the National Guard playbook that talks about setting up a testing center,” Berry, the Guard’s adjutant general, said. “But these are people who bring a variety of skill sets to the fight every day and they just knew how to do logistics, they just knew how to do planning, they knew how to do communication ... Whatever they were tapped on the shoulder to do, they just figured it out.”
Testing alone wouldn’t halt the spread of the virus, though: Nevada would need to be able to trace the virus by making contact both with the people who tested positive for the virus and with the people they had potentially exposed. Early on, the state was inundated with pitches from vendors promising their platform would be the one to solve all contact tracing ills; it settled on contracts with Salesforce and Deloitte to ramp up a digital contact tracing system and workforce. Though state officials had received early indications that their local counterparts weren’t interested in a new system, the state was hopeful that if they built it, the health districts would come.
While those preparations in the spring set the stage for the state to start reopening, the coming months would push the newly expanded testing and contact tracing infrastructure to its limit. Public health experts say the expectation that the state would be able to test every Nevadan who wanted to be tested and trace every Nevadan who needed to be traced was too rosy, particularly in light of the tremendous case volume the state would see in the summer and fall.
“The way I describe contact tracing is that you're tracing down those embers of a fire, you're trying to put out the last part of it,” Labus said. “When the forest fire is raging, it doesn't make a lot of sense to find all those little embers.”
Still, as April turned to May, the state collectively breathed a sigh of relief. Cases were no longer exponentially increasing. Hospitalizations were on the decline. Testing had ramped up. Health care workers felt more equipped to treat the virus.
But it was still just the beginning. The wildfire was yet to come.
Reopening Nevada was easier said than done.
Shutting down was immensely challenging for businesses, but it was a relatively straightforward policy once it became clear what entities were allowed to stay open and what were not. Reopening, however, would not just be the reverse of closing. It would need to happen slowly and methodically, with an eye toward figuring out which businesses were the safest to open and how to mitigate risk in those deemed less safe.
Sisolak, at the end of April, announced the state would begin an “active transition” toward reopening. He emphasized that it would be done in a data-driven way and that the state would be required to see a “consistent and sustainable” downward trajectory in COVID-19 cases and hospitalizations, sufficient hospital capacity and health care workforce and the ability to test all symptomatic patients.
The governor laid out his reopening plan in a winding, 28-page document titled the “Nevada United Roadmap to Recovery” that strove to offer certainty to an uncertain public. It outlined a four-phase reopening plan complete with Nevada-themed nicknames for each phase: "Battle Born Beginning," "Silver State Stabilization," "On the Road to Home Means Nevada" and "Home Means Nevada — Our New Normal." Each phase would allow time for the state to reassess the data and make sure that it was on track before proceeding to the next phase of reopening.
The roadmap broadly laid out the contours of which businesses would be allowed to open in each phase. Outdoor spaces, small businesses and “select retail” would be allowed to open under the first phase with strict social distancing, hygiene measures and occupancy limits. But the finer points of which businesses, exactly, would be allowed to open and how were still yet to be determined.
That responsibility largely fell to a new Local Empowerment Advisory Panel, or LEAP, established by Sisolak to help counties assist businesses with safely reopening. The name made it sound, perhaps, more formal than it ended up being in reality.
How it actually worked was that three of the panel’s members — Clark County Commission Chairwoman Marilyn Kirkpatrick, Eureka County Commission Chairman J.J. Goicoechea, and Dagny Stapleton, executive director for the Nevada Association of Counties — would spend hours on the phone on the weekend brainstorming what guidelines they thought made the most sense, which Clark County staff would then spend hours typing up. They’d then send those over to the state Department of Business and Industry for a first review and then onto the governor’s office for final review.
“I'll tell you, it's super easy to close things down, it's very hard to open things up,” Kirkpatrick said. “You're trying to think of every single business and trying to put some common sense and public health in the same conversation so that people could navigate and be open and be open safely.”
The biggest challenge, though, was figuring out how to safely reopen casinos.
“If you look from purely a public health angle, the fact that our casinos are open seems like a really bad idea,” Labus said. “But, at the same time, that's what the economic basis of our state is, and there is going to be all sorts of public health fallout if we close them. People will lose their jobs, they'll lose health insurance, they won't be able to feed their families, all those kinds of things, and those cause health problems as well.”
Because keeping the casinos closed forever was not an option, the state focused on what could be done to open them safely. Conventions, at the beginning, were out. Table games, while not ideal, could be done with strict spacing requirements and other precautions. Other establishments inside casinos, like restaurants, would adhere to the statewide guidance for those kinds of businesses.
Even public health experts from outside Nevada emphasize there isn’t necessarily anything riskier about a casino than any other establishment that brings large numbers of people together, so long as the appropriate mitigation measures are in place.
When it comes to data on points of exposure — an imperfect science for many reasons — hotels and casinos are not at the very top. Recent data show they’re behind restaurants and grocery stores in Southern Nevada.
“You can open a casino and, yes, you can put measures in place to make sure that you reduce it to a very low level of spreading,” said Ali Mokdad, an epidemiologist at the Institute for Health Metrics and Evaluation at the University of Washington. “To blame the casino and say, hey you guys have to do your part, and yes they have to, but also the community and everybody has to do their part.”
Both the state and the resorts had a vested interest in making casinos as safe as humanly possible. Resorts didn’t want to earn a reputation for being superspreaders, and the state worried about being put on other states’ travel blacklists, both of which would defeat the point of reopening casinos in the first place.
“We knew that it would be this tricky, delicate balance of wanting to make sure people could come here in the safest way possible at each time throughout this pandemic and protecting the reputation of the state, and particularly of Las Vegas, to make it a place where people felt safe coming and where other leaders across the country felt safe sending their own residents,” White, the governor’s chief of staff, said. “When people come here, it means Nevadans have jobs, it means Nevadans feed their kids, it means they can pay their electric bills.”
But, as safe as state officials and resorts could try to make the Las Vegas experience, bringing people together from all over the world is inherently a risky proposition. Just look at the polio scare centered around Mecca in 2005 or the superspreader conference in Boston that led to more than 300,000 cases of COVID-19.
“I would be concerned if I am a health official in Nevada, especially in Las Vegas, about who’s coming to us and what kind of variants and how much this will impact circulation of the virus in my community,” Mokdad said. “We’re not attacking the casinos, but we have proof that such events when people meet for a conference or for a wrestling game or a football game, it spreads the virus.”
For the many Nevadans who were unable to work from home this spring, the governor’s reopening plan was greeted with a sigh of relief. They would be able to go back to work. Their family members would be able to go back to work. Life would start returning to some semblance of normalcy. The four-step plan laid a clear path forward for the state.
On May 9, Nevada entered “Phase 1” of business reopenings, which allowed dine-in restaurants, hair salons and nail salons to open with capacity restrictions. Churches, gyms and bars were allowed to open as Nevada moved into “Phase 2” later that month. Finally, on June 4, tourists started to trickle back to Las Vegas as casinos once again opened their doors.
The “new normal,” it seemed, was within reach.
It was clear that cases were going to increase.
But what state officials perhaps didn’t fully comprehend as Nevada started down the path of reopening is how quickly they would do so as many Nevadans, who had for the most part been shut inside their homes for months, rushed back to their daily lives.
“It looked like, for a large proportion of people in our community, there was this sense of a kind of victory over the virus,” said Leguen, district health officer for the Southern Nevada Health District. “As you look back at the months of May, June and July and compare it with today, you will see there wasn’t that high level of compliance of people with mitigation measures, the use or masks, social distancing or the avoidance of public places. They felt at the time that the pandemic was over, everything is great, let’s go relax and party.”
At the low point in May, fewer than 100 people were testing positive for COVID-19 each day. By mid-July, that number had skyrocketed to more than 1,000.
Local health districts were quickly overwhelmed by the number of cases they needed to investigate and contacts they needed to trace. Before the pandemic, Nevada’s contact tracers were responsible for tracing relatively small outbreaks of illnesses. Even syphilis, which poses a significant public health challenge for Nevada, was nothing compared to COVID. There were only 2,000 cases of syphilis reported in 2018; over the summer, Nevada was seeing that many COVID-19 cases in two days.
While the state was able to step in and offer up its contact tracing platform and workforce, local health districts were still overwhelmed by the number of disease investigations — that’s the initial interview with a person who has tested positive for COVID-19 — they had to complete.
With the help of the Nevada System of Higher Education, the state was eventually able to scale up the number of trained public health professionals who could do disease investigation and contact tracing work. But it took time and, in the meantime, people got frustrated. Some Nevadans reported it was taking days to weeks to get their test results back and even longer to receive a call from a disease investigator — if they received one at all. At some point, health districts had to triage, focusing on the most recent positive cases first before working through their backlog.
As summer drew on and the number of new cases being identified each day began to drop, the state finally started to settle into a good rhythm. Leguen said he was even starting to feel optimistic because the health district’s workforce had expanded to such an extent that it seemed to be almost too much for the number of new cases being reported each day. At the low point in September, the state was seeing fewer than 300 new cases a day on average.
But when the fall surge hit, they were once again overwhelmed. The health district again went into triage mode. At the worst point in early December, more than 2,500 cases of COVID-19 were being identified each day, still far too many for the more than 500 people currently dedicated to contact tracing in Clark County.
State and local health officials are the first to acknowledge where their efforts fell short.
“Is any of it perfect? By no means and no stretch of the imagination,” said Peek, who helped coordinate contact tracing efforts at the state level. “Honestly, we’ve probably had more tears over building up contact tracing in the end.”
In Northern Nevada, Washoe County District Health Officer Kevin Dick said, they were essentially racing against rising case numbers to get computers, phones and space set up for contact tracing staff. Complicating matters was that even when the health district was able to contact cases in a timely fashion, there was no guarantee that people would follow the guidance given to them to quarantine and monitor for symptoms.
“In a perfect, theoretical world, maybe we could succeed with that approach,” Dick said, addressing whether it would have been possible for the state to prevent case growth with contact tracing. “In the world that we live in, I think it's fraught with difficulties.”
But the system, imperfect as it was, represented a massive improvement from the state’s capabilities a year before. To date, 1 in 2 Nevadans has been tested for COVID-19 and 58,667 cases have been identified as a result of contact tracing efforts statewide, or about 20 percent of cases reported.
The state also launched a privately funded contact tracing app, called COVID Trace Nevada, in late August to help the contact tracing effort. Though the rollout of the app was initially slow, 687,244 Nevadans have downloaded the app or opted into exposure notifications on their smartphones to date and 265 Nevadans have entered a verification code into the app confirming their positive result which has resulted in 973 exposure notifications being sent.
Looking back, public health experts say perhaps the only way Nevada could’ve ramped up testing and contact tracing to the levels we eventually ended up needing in the fall would likely have been to have a cohesive national plan and federal financial investment back in February or March.
“At the time, there were few enough cases that it was actually practical to perform contact tracing around every case. But of course, that was also the period when the [Trump] administration felt that because there were so few cases we have very little to worry about,” said Dr. Kevin Murphy, an infectious disease specialist in Reno. “That was a golden missed opportunity.”
The hospitals, meanwhile, were not all right.
By fall, Nevadans and others across the U.S. had grown weary of mitigation measures and had started to engage in riskier behaviors. Increasing numbers of COVID-19 cases soon followed here and nationwide. By then, the doctors inside the hospitals responsible for treating COVID-19 patients were growing tired too.
“I think it went from a sense of, ‘Okay, let's get this done. We're on the frontlines. This is a pandemic. We're going to see the light at the end of this tunnel,’ to, six months after that, ‘This is fatiguing. I'm tired of it,’” Scherr, the emergency room physician, said. “We had tons of endorphins at the beginning, our adrenaline was up, ‘This is what we do,’ to, ‘Damn, I’ve got to see this every day, all day.’”
Things got so bad that Renown finally started putting patients in the alternate care site — a parking garage-turned-medical unit. At Sunrise, the hospital was squeezing in patients in its old emergency departments and surgical post-op spaces. Some hospitals had patients in hallways waiting for rooms to open up. At one point, Scherr’s emergency medicine group offered its services to cover the night shift at one smaller hospital where two ICU physicians were responsible for covering 60 to 70 patients, just so the doctors could get some sleep.
“Ten days after Thanksgiving, that was the longest, probably hardest hit time during COVID,” Scherr said. “Especially in Vegas, we were over 100 percent hospital capacity. Our ventilator capacity was not close to being threatened because of our new treatment strategies, but our ICU capacity was.”
As bad as things were, hospital association officials said Nevada never reached ICU collapse at any time over the last year. That’s the point where hospitals no longer have the equipment, supplies and people to provide the needed level of care to their patients. Though hospitals individually were stretched to 100 percent or more of their capacity, the system held.
But Lake, the hospital association’s executive director of community resilience, said Nevada “got pretty close,” particularly during the summer surge. At one point, ventilators loaned to the state from both California and the Strategic National Stockpile were being FedExed around the state to the hospitals that needed them.
“If you envision it as a rubber band that you’ve pulled so tight that if you add one more patient — the straw that broke the camel's back — that rubber band will snap,” Lake said.
It’s not exactly clear why the hospital situation in Nevada never was as severe this fall as it was in Southern California, which hit zero percent ICU capacity in December. There are, however, a number of theories.
One is that maybe Southern California hospitals are much more siloed and don’t lean on each other the way that Nevada hospitals do through their master mutual aid agreement. During each surge, Nevada hospital CEOs were on calls with each other every other day discussing capacity and who could take more patients.
Another is that maybe because Nevada experienced a significant surge in cases over the summer in a way that California didn’t, doctors had significant clinical competency by the fall. Doctors say that although this fall surge was stressful, there are now clearer protocols for treating COVID-19.
Maybe it’s just that Southern California is much more densely populated than Nevada so that when things got bad, they got really bad. Or maybe, for whatever reason, Southern California’s surge picked up speed faster than Nevada’s did and the mitigation measures that the governor put in place in late November successfully halted the spread.
Or it could be that it still helps to be a small state where everyone knows everyone. They have to, in some ways, to survive in a health care landscape that at times still feels like the Wild West.
“One of the upsides to being a small state and a state that doesn’t invest a lot of general fund [dollars] into public health is that we have to know our system and we know our partners,” said Richard Whitley, director of the Department of Health and Human Services. “One thing you have to do when you don’t have a lot of resources, you have to know what you do have and what you can rely on.”
The last year has been a rollercoaster.
As cases went up, down, up, down, up again, down again and now have plateaued, state officials tried to balance public health needs against economic needs. Businesses closed, businesses opened, there was a mask mandate, bars closed again, bars opened again, restrictions on large gatherings loosened, businesses and gatherings faced new restrictions and, now, finally, those restrictions are once again loosening.
Those ever-changing guidelines were part of an effort to respond to the current milieu and to ensure that the restrictions in place matched the current severity of the public health crisis. But oftentimes, they left residents confused and frustrated that things were changing once again.
As it turns out, the governor’s “Nevada United Roadmap to Recovery” plan from the spring would be just the first iteration of many documents outlining how the state would manage through the pandemic.
It would be followed by “Road to Recovery: Moving to a New Normal” in August, a plan that shifted much of the responsibility for implementing mitigation measures to a new statewide task force. Then, there was the “statewide pause” in November, which saw new limits be placed on businesses and gatherings. Now, we’re operating under “Nevada’s Roadmap to Recovery,” which plans to transition almost all responsibility for COVID-19 mitigation to local authorities.
It’s hard to say which mitigation measures have been the most effective.
Public health experts believe the case trends are probably, in part, psychological. Cases go up when people hear that cases are going down and feel safe to go out and do things; cases go down when people hear that cases are going up and they should be careful and limit their exposure. But they also believe the mitigation measures themselves have blunted the impact: When there are fewer people visiting a business or a smaller number of people at a gathering, there’s less of a chance that someone there has COVID and, if they do, hopefully more space to minimize transmission.
The one mitigation measure, though, that top public health officials say has been key to limiting case growth: the state’s mask mandate, which was announced on June 24 and went into effect two days later.
While Nevada was among the first 20 states to enact a mask mandate, multiple public health experts said they would’ve liked to see the state enact one sooner. At least seven states enacted mask mandates in April, six did in May and Nevada was one of five states to do so in June.
“[The Medical Advisory Team had] been discussing it for a while, trying to get support for that. It was just one of those things, it’s a political decision as much as it is scientific. We recognize those issues. But at the same time we were told, just think of the science. So from a scientific perspective, it's really easy to say, this is what you should do,” Labus said. “When you actually have to put it in place, it's a little different, and that's what the governor had to decide.”
The governor, for his part, said he didn’t even have a full understanding of how effective masks were when he put the mask mandate in place.
“It's easy to look back and say, yeah, I wish I’d have done it earlier, but I didn't know then what I know now,” Sisolak said. “I think at the time we made the decision as quick as I thought there was enough evidence to warrant that decision being made and that's why we did it when we did it.”
As other states like Texas and Mississippi have now begun to lift their mask mandates, Sisolak has made clear that Nevada won’t be heading in that direction. When the state transfers control of coronavirus health and safety measures to local governments in May, the statewide mask mandate will remain in place.
“I think that’s an irresponsible thing to do now,” Sisolak said of governors who are lifting mask mandates. “There’s no science or medical advice that says that’s the appropriate thing to do.”
The last year has been difficult, to say the least, for most. But Nevada’s public health workers, stoic as they may outwardly appear, are struggling.
They will acknowledge that they weren’t prepared and that there were areas where they might have done better. They’re sure that even more of that will become clear with time. But they also believe it wasn’t for lack of trying, and many of them are near their breaking points.
“It’s like we were pushing a wagon, and it worked when we had four people holding the wheels on and now you’re expecting us to enter NASCAR. Guess what? We’re not prepared, and it’s not for creativity or lack of effort,” Peek said, tearing up. “We're doing the best we can with the resources that we have.”
The deck was stacked against Nevada’s public health system from the start. Nevada ranks last in the nation for public health spending per capita. As recently as 2019, public health officials had pleaded with lawmakers for additional public health dollars, which they said would allow them to be more proactive in responding to Nevada’s health needs as they develop, instead of reactive, to no avail.
In some ways, it’s a miracle the situation hasn’t been worse in Nevada. But it has taken a toll on those trying desperately to hold the wheels on the wagon.
Hateful emails stacked up in their inboxes, health officials say. Peek-Bullock, the state’s epidemiologist, recalled someone suggesting picketing outside her house after she appeared at a press conference.
“That was the moment for me that it really hit home because that crosses the line between your work life and your personal life, and you think about your family,” she said.
Like every other Nevadan, the pandemic has taken a toll on their personal lives in other ways as well.
Cage, the state’s COVID-19 response director, has seen his brother and sister struggle to run their family-owned bars and restaurants in Reno. Both he and Sisolak have also been public about their experiences testing positive for the virus. Peek recalls trying to essentially homeschool her kids in real time while also working 12 hours a day. In the evenings, Kirkpatrick, the Clark County Commission chair, spends her evenings helping her 6-year-old granddaughter with her homework and getting her ready for bed before doing even more work. Dr. Tony Slonim, Renown’s CEO, learned he lost his dad to COVID the day the hospital held a press conference in April announcing the opening of their parking garage alternate care site.
“You want nothing more than to do whatever you can to make their pain go away, right? In this case, it's the frustration, the uncertainty, the economic challenges, all of that, and trying to get to a place where you can do something that makes sense based on policy, based on science, and all of those things,” Cage said. “It doesn’t square with the emotional pull of doing something for a family member that you love dearly.”
They’ve felt overwhelmed and exhausted. They don’t know what to do with comments from people who suggest they have an agenda or are financially benefiting from the public health emergency. Many of them didn’t have their first day off from work until many months into the pandemic. As salaried employees, the state’s top health officials don’t get overtime and, in fact, have had their pay cut because of mandatory state worker furloughs. But, then, some of them have struggled with feelings of guilt because they feel lucky to have a job when so many others were and still are out of work.
They know they don’t always get it right. But they say their number one goal has been to wake up each day and do the best they can possibly do for the state of Nevada.
“The story is that the government is horrible and the government's doing something wrong, not that these people are working an ungodly number of hours per week and they rarely get to see their children for the good of Nevadans,” Peek said. “At some point we will have to exhale and we’ll have to shift down and go back to normal life. I don’t know how that’s going to look, honestly, we’ve been on full speed for forever. I don’t know how we’re going to go back to normal.”
The pandemic was always going to be an uphill battle, particularly for Nevada.
How is a state supposed to respond to a pandemic when it’s economy is built on the idea of bringing lots of people together from all around the world to a four mile patch of earth to have fun drinking and clubbing and gambling in close proximity to one another and then return home — exactly the things one ought not to be doing during a pandemic?
To the rest of the world, it may have appeared as if Nevada was being cavalier in its public health response when it made the decision to reopen casinos. But then, to the rest of the world, the totality of Nevada is Las Vegas and the totality of Las Vegas is the Strip, where we presumably all eat and drink all day long before going back to our high rise condos to go to sleep at night.
The rest of the world sees the waitresses, bartenders, bellmen and guest room attendants when they visit, the humans that make the casinos, and by extension, the state run, but they don’t see the homes those workers go back to and the families who rely on them to put food on the table. They don’t see the grocery store clerks, the delivery drivers and the teachers who make everyday life here possible. They don’t see how the taxes they loathe paying on their hotel rooms go to fund things like schools and Medicaid. They don’t see that — without the Strip, without the tourists, for better or for worse — life in Nevada ceases to exist.
State officials and public health experts knew on some level the casinos had to open. Perhaps only congressional approval of a universal basic income could’ve kept them closed. But the state’s decision to many felt — and still feels — contradictory, hypocritical even. Sisolak, during a press conference in mid-November, asked Nevadans to voluntarily stay home for two weeks as cases spiked statewide. But, when asked, he said the measure did not apply to tourists, who he urged to continue to travel to the state while following all health and safety protocols.
Sisolak, in an October speech, called it Nevada’s “great balancing act.”
“The public needs to understand that if we don’t step up together and follow all public health measures, hard decisions and trade offs lie ahead. This pandemic has been framed as a false choice, shut it all down or do nothing. But we know that's not the case. We know that doesn't have to be a reality. We know we can't afford it. We can continue doing our best to balance the health and safety of Nevadans with the need to protect our economy, keep people employed, provide an education to our kids, and more,” Sisolak said. “I promise that I'm doing everything I can to manage this balancing act, and that balancing act in Nevada is perhaps the toughest than any other state.”
But it was maybe less a balancing act than an attempt to make two inherently contradictory priorities live in harmony, like trying to force the negative ends of two magnets together. On one hand, there’s general agreement that bringing people together for lots of face to face interaction in casinos was probably not the best idea for stopping the spread of COVID. But if the casinos remained closed and tourists were warned against coming to the state, tens of thousands of Nevadans would be out of work, struggling to feed their families and keep a roof over their heads. They would be thrown into poverty, which brings its own set of negative public health consequences.
Nevada didn’t have the options some other states had. White, the governor’s chief of staff, recalled a conversation with an official from another Western state and wondering how leaders there had lessened the impact of the pandemic on their economy. The official told her that most of their employees were able to work from home.
“She goes, ‘Have you considered that?’ I’m like, ‘Well, we have, that would be phenomenal, but you can’t have the dealer or the valet or the cocktail waitress or the busser work remotely. We are a state that is funded primarily on face to face social interactions in large groups with a lot of people you don't know,” White said. “It's what makes us stay fun and great and amazing. In a pandemic, it puts policymakers and decision-makers in an almost impossible situation.”
In truth, maybe it wasn’t a balancing act between COVID and the economy but rather a balancing act between preventing people from dying of COVID now and preventing people from dying from poverty, mental health and substance abuse issues later.
From the perspective of those in the governor’s office, this was exactly what they thought they had been saying all along. But they realized the sentiment had, perhaps, only been peppered here and there in the governor’s speeches, in 20-page guidance documents and calls with the press. Perhaps it wasn’t clear enough to the public. That’s why they decided to have the governor drive the point home during an October press conference.
White said that the governor’s October speech was designed to speak to the frustrations of everyday Nevadans. The governor’s office understood that Nevadans were frustrated that their favorite family-owned restaurant was struggling while Strip properties were apparently bustling with tourists.
“As people view these decisions and form opinions on them, I don't blame them if they are sitting there saying, ‘This isn't fair, I'm mad.’ because they're looking at it through the lens of their world,” White said. “Putting myself in their seat, I might be mad too.”
Those close to the governor say that, as the pandemic progressed, he got more comfortable with living with, and governing through, the uncertainty. Sisolak has a reputation for being decisive — his critics would call him headstrong or a bully, even — and he’s someone who likes to make a decision and stick with it. They’re not qualities that naturally lend themselves to leading well during a pandemic.
“One of the things he had to come to grips with here — and it took a few months — is there wasn't a decision he was going to make that might still be the right decision in two weeks. He began to really live that moment and live with the need for flexibility and agility and constant adjustment — monitor, measure and adjust — knowing that when he did some of the reopenings that he might need to pull that back,” said Billy Vassiliadis, a longtime Democratic campaign consultant who is close to Sisolak. “It was more living in that moment and knowing that decisions needed to be done and revisited and done and revisited, I think he started to communicate that more confidently. He became more confident in the certainty of the uncertainty."
Sisolak, reflecting back on the last year, acknowledges that it was difficult for him as a leader to come to terms with the fact that there were no right answers and that he might choose to do something today he’d have to reverse tomorrow. And he knows that people have disagreed with him — there have been people carrying AR-15s outside the Governor’s Mansion in Carson City telling him so.
But he said that what he focused on was doing what he thought was right at the time and knowing that when he put his head on his pillow at night that he made his decisions with the right intentions.
“Can you have a disagreement on timing or on the severity of some decisions? Sure. People are always going to be there to disagree,” Sisolak said. “I'm telling you, when I looked at that Strip and those lights and saw them all going off, it's like, man, am I doing the right thing? Is this the right thing to do? And, yeah, I know it's going to be criticized. I know people aren’t going like it. I might have lost sleep over it, but I know I did the right thing.”
There are, of course, things that Nevada could have done differently.
We could have shut down earlier, harder and longer. We could have never shut down at all. Our schools could still be closed, or our schools could have opened fully months ago. We could have devoted even more time and resources to testing and contact tracing. We could have concentrated more power in the hands of the Legislature or local governments. We could have invested more in public health over the last decade. We could’ve invested in an aging unemployment system. We could have put much more effort into true economic diversification instead of, as always in good times, once again hanging our hat on the resort industry.
“When I look back at outbreaks, and I've been working outbreaks for two decades, at the end of the outbreak, it always plays out differently than you would expect it to at the beginning. The question I always have is, well, if I were in the same position, would I make those same decisions?” Labus said. “If I can say, yes, I’d make that same decision today, even knowing ultimately that it was wrong, but based on that information it was the right decision at the time, that’s how I look at our success.”
But even the death of one Nevadan to this virus was always going to be too many, let alone 5,000.
“You talk to a surviving family member of somebody that lost a family member to COVID and couldn't get into the hospital even to say goodbye to them, and it puts things in a different perspective,” Sisolak said. “That chair where that person sat at the kitchen table is always going to be empty.”
Gov. Steve Sisolak is proposing a two-year budget that reverses cuts to Medicaid and other key K-12 programs made last summer, after financial projections left the state at what officials are calling an “inconsistent, if not positive, ending point” for tax revenue.
The proposal, which was released Monday evening and comes a day before the governor’s biennial State of the State address, sets the state budget at $8.68 billion over the next two years, as revenues are about $500 million less than what was allocated during the last two-year budget cycle. The state’s tourism-dependent economy remains battered by the COVID-19 pandemic but economists are hopeful that a vaccine will usher in recovery.
State officials, in a press briefing ahead of the proposal’s release, said the budget reflects a more positive view of the state’s forecast than the worst-case scenario projections made last year as the governor and lawmakers were forced to reengineer their budget because of economic fallout from the COVID-19 pandemic. Still, it represents a roughly 2 percent cut to the budget approved during the 2019 legislative session.
Notably, the proposed budget includes a restoration of some, though not all, of the cuts made during the 2020 special session, where lawmakers slashed nearly a billion dollars from the previously approved budgets as the state faced massive shortfalls in key revenue streams such as the gaming tax and sales tax.
“I am committed to remaining flexible and working closely with the Legislature in this unprecedented and evolving fiscal situation,” Sisolak said in a statement accompanying the release of his budget. “Throughout this dynamic process, the priorities will remain the same: recovering from this crisis and creating jobs, educating our kids, promoting justice and equality, and most importantly now, protecting the health of our people.”
Officials said their task of balancing the state’s budget was aided by passage of another federal stimulus package near the end of 2020 that in part extended the deadline for use of funds in the original $2.2 trillion CARES Act. That additional federal funding, they said, gave them additional flexibility even as tourism remains anemic and tax revenues continue to suffer through the pandemic.
But the budget proposal still needs to survive a thorough review by state lawmakers through the upcoming 120-day legislative session, plus additional guardrails that may be imposed by the state’s Economic Forum, the five-member economist panel that will meet in May to give lawmakers a final tax revenue projection that must inform the budget.
Michelle White, the governor’s chief of staff, said during a call with reporters on Monday that the state’s economic situation is still extremely fluid given uncertainty over the COVID-19 virus and vaccine rollout and that the budget should be viewed more as a snapshot in time based on what is known now with portions likely to change in the future.
“We are feeling positive but knew that it would be the most responsible thing to use the information we have in front of us, just like Nevada families are doing right now,” she said.
White also said there were “no changes” in proposed taxes included in the recommended budget, but stressed that the state’s future unknown financial health could potentially lead to changes.
“The governor is going to be working with the Legislature to see if there's any augmentation or refinements that need to be made as we go forward,” she said.
In addition to reversing a 6 percent Medicaid reimbursement rate cut, the budget also begins the process of implementing the long-awaited revision to the state’s 53-year-old K-12 education funding formula.
The budget calls for a “phased-in” approach to the new funding formula recommendations developed over the past two years, with the first phase being implemented between 2021 and 2023 modifying the distribution of state revenue, and the full implementation happening between 2023 and 2025 with changes in distribution to state and local revenue.
Budget officials said the plan would hold school districts harmless and not see any district receive less funding until the new funding formula is fully implemented.
The budget additionally calls for emptying out about $97.5 million from the state’s “Rainy Day” emergency fund to the 2022-23 fiscal year to “mitigate budget reductions.”
In a statement, Democratic Senate Majority Leader Nicole Cannizzaro said the budget proposal recognizes the "stark reality of the on-going COVID-19 emergency while also laying the groundwork for Nevada’s economic recovery."
Here’s a look at highlights in the governor’s budget proposal:
Health and Human Services
The governor’s proposed budget includes $15.2 billion in combined state and federal funding for the Department of Health and Human Services — $2.6 billion more than is being spent in the current biennium.
That includes a $1.6 billion increase to the Medicaid budget, which will swell to $10.2 billion in the upcoming biennium to cover an 18.7 percent increase in the public health insurance program’s caseload. The ongoing coronavirus pandemic has left hundreds of thousands of people unemployed and increasingly reliant on the state to receive their health care.
As of November, more than 761,000 people — or one in four Nevadans — were enrolled in Medicaid, 120,000 more people than had been projected when the Legislature approved its budget for fiscal year 2021 in 2019. State officials anticipate that more than 778,000 people will be enrolled in Medicaid by the end of the upcoming biennium, a 2.2 percent increase over the current caseload.
The state of Nevada will, however, be responsible for footing only a portion of that Medicaid bill, as the federal government is responsible for paying the lion’s share of the public health insurance program through federal matching funds. Nevada, specifically, will spend an additional $153.5 million in fiscal year 2022 and $146.9 million in fiscal year 2023 to account for Medicaid caseload growth.
The governor is also, notably, recommending restoring the 6 percent cuts the Legislature made to the state’s Medicaid program during a special session this summer and increases to the neonatal ICU rate approved during the 2019 legislative session. That rate will increase from $1,487 to $1,858, an increase of 25 percent.
“This is obviously going to be incredibly impactful to families and providers throughout Nevada, and it's something that I know is a big priority for the governor and (DHHS) Director [Richard] Whitley, understanding the impact that this would have,” White said.
The governor’s recommended budget also includes $3.7 million to reduce waitlists for the Autism Treatment Assistance and Home and Community Based Care Programs, as well as $863,000 in the Assistance to Aged and Blind budget for caseload growth of about 4.4 percent. The budget will also account for caseload growth for programs that serve children with disabilities, people with intellectual disabilities, adults with physical disabilities and seniors.
Funding for state family planning, a budget account that was first created during the 2017 legislative session, will remain flat under the new budget.
The budget will also reflect a structural reorganization within the Department of Health and Human Services — moving the Office of Analytics from the Division of Public and Behavioral Health to the Director’s Office. The office is responsible for maintaining multiple data dashboards, including the state’s comprehensive COVID-19 dashboard.
“The work that they have done in the Office of Analytics over the past 11 months, starting from nothing and building up, has been incredible and a great resource and they are building and building all that data every day,” White said, “and certainly, point out the growing need for things like this in the state of Nevada and why we need to invest to these things.”
The budget does, however, recommend deferring start dates for positions in both the Division of Public and Behavioral Health and the Division of Welfare and Supportive Services, within the Department of Health and Human Services. White noted that those deferrals will allow for cost savings but “may increase wait times or cause delays for Nevadans seeking assistance.”
“We are still in a crisis,” White said. “This is still a state of emergency and, again, this budget reflects the very precarious fiscal situation our state finds itself in.”
K-12 education is expected to take a hit in the coming biennium, but the budget anticipates Nevada will receive $450 million in federal aid from the stimulus bill passed in late December to compensate for “learning loss” and technology infrastructure.
In all, the state expects to spend $4.9 billion in state funds in the coming biennium, and $6.63 billion when local and state funds are added together.
But guidance on how the state can use the federal funds is not yet out and therefore not included in the budget proposal.
The budget reflects how the pandemic has thwarted plans to modernize Nevada’s half century-old education funding and move to a weighted model called the “Pupil-Centered Funding Plan” (PCFP). A commission has been meeting in the interim trying to work out the details of the model.
“The Governor’s Executive Budget recognizes the importance of modernizing education funding formulas while addressing the realities of the economic landscape by proposing a phased approach to PCFP implementation,” the budget document states. “This approach will ensure equity and transparency while allowing flexibilities to accommodate the current economic circumstances.”
Sisolak recommends implementing the first phase of the plan in the coming biennium, using only revenues that are currently distributed by the state: per-pupil state allotments and “categorical funds.” A second phase of implementation will kick in the following biennium.
The governor’s office says it will be holding districts harmless, meaning no district will receive less money under the new formula than they did in the fiscal year that ended in mid-2020.
The state’s main education funding pool, called the Distributive School Account, includes enough money for a 2 percent merit salary increase for each of the next two years, at a cost of $59.1 million in the coming fiscal year and $119.5 million in the second.
Enrollment numbers in the state’s public schools are expected to be nearly flat. The incremental costs of the growth are expected to be $4.7 million in fiscal year 2022 and $11.8 million in fiscal year 2023.
The growing cost of health insurance for K-12 education employees is a greater expense. For the first year of the biennium, medical inflation is expected to be an added expense of $11.2 million in the first year of the biennium and $23.6 million in the second compared to current levels.
Sisolak’s proposal melts a number of “categorical” programs that were program-specific into the basic per-pupil funding amount that the state provides to schools. The programs that will no longer be standalone initiatives with restricted funding include Class Size Reduction, Read by Grade 3, Nevada Ready 21 (technology programs), Financial Literacy, School Safety, Social Worker/Mental Health providers, School Resource Officers, Advanced Placement Exams, and College and Career Readiness.
Other streams of funding that have been helping serve students with special needs for the last five to seven years will still exist in some form. Zoom Schools, an initiative created in 2013 that serves more than 17,000 English language learners, will transform into a “weight” where an extra boost of funding follows students who fit in that category rather than flowing to schools with a high concentration of English learners, as it has under the previous system.
Victory Schools, which supported schools in the state’s poorest ZIP codes, will also transfer into a “weight” so it follows students from low-income households rather than applies to entire schools. Sisolak’s budget calls for $23.1 million each year for that purpose — a slight increase over current funding levels.
And the “New Nevada Plan” — $69.9 million per year for students within the lowest quartile of achievement levels — is being restored after being canceled through the special session. It will also exist as a “weight.”
Similar to K-12 education, the Nevada System of Higher Education (NSHE)’s budget is also facing a funding cut of about $80 million, but officials expect to receive more than $100 million in federal aid to help address lost revenue, distance learning, financial aid and other expenditures. The state is still waiting on guidance from the federal government for specifics on how to use the funds.
The proposed budget includes $24 million per year for student enrollment growth and $4.4 million each year to fund the Silver State Opportunity Grant, a need-based financial aid program for low-income students at NSHE community and state colleges.
About $11.2 million of the NSHE budget is dedicated to various capacity building projects including expanding existing programs, workforce training and certification courses. The governor’s budget also includes $73.6 million for a new engineering building at UNLV and $6.3 million for a welding lab at Great Basin College in Elko.
Though the Graduate Medical Education does not fall under the NSHE’s umbrella, the budget recommends a reduction in state funds from $10 million to $8.5 million. That program supports residency programs for doctors in training.
The Knowledge Fund, dedicated to commercializing the research coming out of Nevada’s higher education institutions, is also set to increase by $2.5 million to $5 million over the biennium. The goal of increasing the Knowledge Fund is to help diversity the state’s economy and help the state’s businesses, officials wrote; its projects have included turning water technology research from the Desert Research Institute into business opportunities.
Public safety and corrections
The Department of Corrections’ budget, meanwhile, will reflect a small decrease in caseload from 12,395 to 12,349. State officials expect that the number of people in the state’s custody will continue to decrease as a result of criminal justice reforms passed during the 2019 legislative session that seek to reduce the prison population.
The governor’s proposed budget also will restore the “Going Home Prepared” program to help inmates plan where they will live upon their release and offer other supportive services. It also accounts for the implementation of a modified supervision model for low-risk offenders that will create cost savings for the department.
Employee compensation and benefits
State worker furloughs approved by the Legislature during a summer special session that were implemented Jan. 1 will not be continued in either fiscal year of the governor's budget, meaning they'll come to an end in June 2021. As it stands, state employees must take six furlough days a year.
State workers will also receive expanded coverage options through the Public Employees’ Benefits Program in the upcoming biennium, including a new, low-deductible, co-pay based option.
Additionally, the governor’s proposed budget calls for higher contributions to the Public Employees’ Retirement System (PERS). Regular employee- and employer-paid rates are recommended to increase from 15.25 percent to 15.5 percent. Police and fire employee and employer rates are recommended to increase from 22 percent to 22.75 percent.
The governor’s budget proposes setting aside $226.5 million in general fund dollars for one-shot and supplemental expenditures in fiscal year 2021, which runs through this June. Funds for the expenditures come from revenues that were higher than original projections and include federal reimbursements to the state.
The proposed budget calls for immediate approval of the funds to support businesses, health care workers, scholarships, maintenance projects and technology needs.
The budget proposes allocating $25 million toward the construction of UNLV’s medical school complex — funding that was slashed during a special session last summer. It also recommends spending $6 million for testing and treating hepatitis C among the prison population.
It also sets aside $44 million for the merit-based Millennium Scholarship and $7.3 million for the Nevada Promise Scholarship, a last-dollar award that aims to make community college effectively free. Though assistance for small businesses affected by the pandemic is included in one-shot expenditures; no set dollar amount is noted and the governor’s staff said more details on those initiatives would be discussed in Tuesday’s State of the State speech.
Deferred maintenance projects are set to receive $2.3 million — $1.2 million of which will go to the Department of Health and Human Services, $530,000 to National Guard facilities and $667,000 to the Division of Forestry.
In addition to $3.9 million for new equipment, including computer hardware, printers, and medical and dental equipment, the governor is also proposing dedicating $78.7 million to information technology projects — specifically, $23.2 million for a new human resources and financial system, $17.4 million for child support enforcement system and $18.6 million to replace the state’s criminal justice information system.
Capital Improvement Projects and other projects
The proposed budget calls for about $415.9 million in the Capital Improvement Projects budget, the account dedicated to state buildings, maintenance and other building expenses.
The budget includes 91 “CIP” projects, including 13 construction projects. Those include:
An addition to the Washoe County Training Center for the Nevada National Guard
Aircraft storage hangar and sitework at the Harry Reid Training Center in Stead
Initial funding for programming and conceptual design of a state forensic crime laboratory
The proposed budget also includes $342 million in what’s called supplemental appropriations, or dollars required to meet obligations for the current fiscal year. The bulk of those appropriations ($331 million) will go to K-12 education, along with $10 million for fire suppression and $500,000 to the state prison system.
The state had to kick in more money for schools to account for local revenues that took a major hit. Nevada’s education funding operates like a see-saw, with the state putting more funding toward schools when local revenue streams suffer and vice versa.
The budget also makes some administrative changes to departmental organization for state government, including:
Moving the Division of Emergency Management from the Department of Public Safety to the Office of the Military
Moving the Office of Workforce Innovation from the Governor’s Office to the Department of Employment, Training and Rehabilitation
Transferring the Western Interstate Compact for Higher Education from the Governor’s Office to NSHE
Other funding included in the budget proposal includes dollars to fund an annual statewide inventory of greenhouse gas emissions, and dollars to support additional positions in the state Cannabis Compliance Board. The budget also includes $75 million dedicated to the State Infrastructure Bank, an agency created in 2017 to provide matching loans for infrastructure projects.
Updated at 7:23 p.m. on Jan. 18, 2021, to include a statement from Senate Majority Leader Nicole Cannizzaro. Updated at 10:55 a.m. on Jan. 19, 2021 to remove erroneous information about the state Modified Business Tax rate, and again at 11:56 a.m. to correct information about state worker furloughs.
The statement came in response to growing concerns in Nevada, notably among the undocumented immigrant community, over privacy protections provided by the program. Those concerns were addressed by Gov. Steve Sisolak during his Monday press conference.
“Immigrant and refugee communities are among the hardest hit by the COVID-19 pandemic and we want to ensure they have equal access to the COVID-19 vaccines and participate in the State’s vaccination program,” Sisolak said. “We take their concerns seriously and the State of Nevada is committed to protecting our immunization data as outlined in our statutes.”
Richard Whitley, director of the Department of Health and Human Services, explained that the state’s privacy laws allow for the state’s vaccination program to share personally identifiable information only with a set of authorized groups that excludes federal agencies.
“The program is only sharing aggregate, de-identified information regarding numbers of doses administered in Nevada to meet the federal reporting requirements,” said Whitley.
In accordance with privacy laws, the state records all administered shots in an immunization information system called NV WebIZ, which is managed by the state’s Division of Public and Behavioral Health.
The information entered in NV WebIZ is confidential and can only be accessed by specifically authorized groups, including health care providers, the Nevada System of Higher Education, childcare facilities, public and private schools, the health department, an insurer, an agency that provides child welfare services, and the Department of Corrections.
The ONA also promises to aid efforts in ensuring that the state’s immigrant and refugee community has “access to the COVID-19 vaccine and to critical information regarding the vaccine rollout.”
Despite improving metrics on the spread of the coronavirus, members of the state COVID-19 Mitigation and Management Task Force rejected requests to reopen bars and taverns that are still closed in Clark, Washoe, Nye and Elko counties, while approving the reopening of non-bar countertops in Clark County starting next week.
Members of the task force on Thursday approved a request by Clark County to open up non-bar countertops by Sept. 9, subject to social distance guidelines, but agreed to continue with bar, tavern, winery and brewery closures in four of the state’s largest counties with a promise to revisit the closures in two weeks. Bars in the state's largest counties have been closed since early July as the state tried to stop a spike in cases, but the countertop provision was framed as a way to help a subset of businesses swept up with liquor establishments.
“We are impacting tons of people because of the countertops that are not open,” said Clark County Commission Chairwoman Marilyn Kirkpatrick. “If a sushi bar can’t open their countertop, I want to understand what is the science behind that? If there is an establishment that has Plexiglass at their countertop in between different partition eaters, I'd like to know why is that any different than sitting across from somebody at lunch.”
Nevada’s COVID-19 Response Director Caleb Cage, who chairs the task force, said that metrics measuring spread of the novel coronavirus improved across the board over the month of August, but that he did not want to risk reversing the progress made thus far and return to dangerously high levels of infection. He also noted that the White House still considers the state to be in a “red zone.”
“All those states in the country are watching the outbreak in Nevada to determine whether or not they're going to impact our economy by allowing visitors here or not,” he said. “We have an economy that is based on visitors. And the reality is visitors will not come here, if we are seen as a hotspot nationally.”
Members of the task force praised Clark County for “drastic” improvement in health metrics since July, but noted that the test positivity rate — while down from more than 17 percent in July, is still about 12.6 percent, which is about twice the recommended level.
They did not take action on another of Kirkpatrick’s requests — that playgrounds and parks be reopened and youth sports restarted — because they said it was outside the scope of their authority. But Kirkpatrick, and Health and Human Services Director Richard Whitley, said it was part of a focus on addressing the social and emotional fallout of the pandemic.
“I think that Commissioner Kirkpatrick has been leading efforts to address perhaps a second epidemic which will be a mental health crisis related to isolation,” Whitley said. “I think there's a concept here of, opening something can also be a mitigation for spread of disease.”
The task force was created early in August as a replacement for the previous statewide “phases” of business and other restrictions. It’s composed of members of several state health and business agencies, Nevada Hospital Association, the Nevada Association of Counties, the Nevada League of Cities and the Nevada State Public Health Lab.
The task force’s more targeted approach looks at cases, tests and test positivity rates in each of the state’s 17 counties to determine individual risk level. Those metrics include:
The average number of tests per day per 100,000, calculated over a 14-day period. If this number is less than 150, a county could be considered at risk.
The case rate per 100,000, calculated by taking the number of cases diagnosed and reported over a 30-day period. If this number is greater than 200, a county could be considered at risk.
The case rate per 100,000 and the test positivity rate, calculated over a 14-day period with a seven-day lag. If the case rate is greater than 50 and the test positivity rate is greater than 7.0 percent, a county could be considered at risk.
Counties that exceed one or more of those criteria thresholds are required to work with the task force to implement additional steps or mitigation efforts to help push their disease transmission statistics down.
Cage said that the task force’s structure under Gov. Steve Sisolak’s orders were clear; if a county exceeds those thresholds for three or more weeks, they should begin implementing increased mitigation measures and other restrictions — not request a loosing of existing restrictions, such as opening bars.
“I don't think any one of us want to arbitrarily force mitigation levels on counties, and so that sort of working together with the local governments is critical for us to get on the same page,” he said during the meeting. “And instead of seeing increased mitigation measures or ways of dealing with this, what we're seeing right now is requests for loosening of restrictions, which is the exact opposite of the plan.”
But several bar owners in Las Vegas and Reno called in during the meeting to complain that the restrictions on bars were overly selective given that restaurants and other businesses were allowed to continue operating. Jeff Carter, owner of The Glass Die board game bar in Reno, said his establishment loses about $10,000 a month while being closed and that he expected to go bankrupt in January if bars continued to stay closed.
“It's not fair; we can operate safely,” he said. “Every weekend is a 5 percent higher likelihood of closing.”
Cage said he wanted to see a higher level of “sophistication and planning” on mitigation efforts and enforcement mechanisms from county officials in Elko and Nye counties before moving forward with plans to open bars and taverns.
While praising Clark County’s plan as “excellent,” Cage noted that the county is in a “tenuous” spot and could easily lose its gains if it opens too quickly.
"We said we would close down quickly and we would reopen slowly," he said.
As of Thursday, Elko County is the only county to exceed the threshold in all three categories. Six additional counties exceed two of the three categories, including Churchill, Clark, Lander, Lyon, Nye and Washoe.
The task force approved enhanced mitigation plans for all seven of those counties on Thursday, while denying requests to re-open bars.
In past meetings, the task force rejected requests from Clark, Washoe and Elko counties to reopen bars and taverns that do not serve food, expressing skepticism that such a step would help control or lower spread of COVID-19. It did allow bars and taverns in Nye County outside of Pahrump (home to 85 percent of the county population) to open last month, though.
Members of the task force acknowledged that all counties are showing general improvement among the tracked metrics; Clark County’s case rate over a rolling 30-day period fell from 650.8 people per 100,000 to 573.6 per 100,000 in just a week.
Overall, the state’s cumulative test positivity rate has stabilized or slowly increased through the month of August, and hospitalizations have decreased continually since Aug. 3.
“We are seeing improvement across all counties,” state biostatistician Kyra Morgan said during the meeting. “And even though some of them are still being flagged as elevated, they're definitely moving in the right direction.”
Nevada Medicaid is moving forward with a planned 6 percent across-the-board rate reduction approved by lawmakers during a special session last month to balance a billion dollar shortfall in the state’s budget.
Though lawmakers were able to restore many proposed cuts to Medicaid programs during the course of the session, Medicaid still bore $130 million in budget cuts, including the 6 percent rate reduction, expected to save the state about $53 million. Health care providers, who have long argued for increases in Medicaid rates, opposed the reductions.
Medicaid is moving forward with the cuts, which will be discussed during a public hearing on Thursday, even though it is expected to take in an additional $30 million through enhanced federal matching dollars that were extended last month through the end of the year.
Though there was much talk during the special session about restoring some of the proposed cuts should the $30 million come through, Medicaid Administrator Suzanne Bierman, in a statement Wednesday, said that it was too soon to start discussing that. She said that the division will continue to monitor several variables, including federal funding, utilization trends and caseload, which has increased 11 percent since February.
“These variables are volatile and it is too early in the current state fiscal year to determine whether the current budget will allow for restorations,” Bierman said.
Additionally, Bierman noted that the language of the budget cuts bill passed by the Legislature, AB3, specifically requires the rate reductions.
“The meeting on August 13, 2020 includes rate cuts mandated by Assembly Bill 3 and a statement will be given at the start of the agenda so that stakeholders are aware of the bill's requirements,” Bierman said.
Nevada Hospital Association CEO Bill Welch, during a public comment session on the bill last month, said the cuts would cost Nevada hospitals more than $100 million a year in payments, with hospitals spending another $500 million on uncompensated care.
During the session, Department of Health and Human Services Director Richard Whitley indicated that it would be difficult to decide where to spend the $30 million if it came through.
“Doing math on the page may be simple for budgetary people, but does turning something down really amount to turning it off? Does reducing the rate lose providers?” Whitley said. “The nuance of all of that would be considered and we’ll work day and night to provide if resources become available.”
Members of the Senate preliminarily approved a long-awaited proposal to protect businesses from liability in the event that a customer contracts COVID-19 after a four hour-long hearing Monday evening that stretched past midnight.
The bill, which is likely to be the last piece of legislation introduced during the special session, cleared the Senate Committee of the Whole early Tuesday morning, 18-3, with Republican Sens. Ira Hansen, Joe Hardy and Pete Goicoechea in opposition. The legislation, SB4, has dominated the behind-the-scenes conversations during the session and is the culmination of a deal between some of the state’s most powerful political interests, including casinos, business groups and the Culinary Union.
But the bill also attracted the ire of other powerful interests in the state, including trial attorneys and progressive groups, who generally bemoaned the bill’s liability protections; teacher unions, who wanted a set of worker protections in the bill afforded to hotel workers extended to educators; and hospitals, who felt they were unfairly excluded from the bill’s liability protections.
“My main concern is about all of the workers, and not just the Culinary,” said Sen. Marcia Washington. “What about the other essential workers and the school district and the hospitals, construction, etc.?”
In opening remarks, gubernatorial Chief of Staff Michelle White reiterated the dire economic situation facing the state amid decreased business demand among Nevada’s casino and tourism industry, saying the bill was a desire to strike a balance between protecting business from “those seeking to capitalize on our current situation” without granting total immunity from lawsuits related to spread of the disease.
“I want to be clear, the bill being presented tonight does not provide total immunity to all businesses, under all circumstances, far from it. These inevitable bad actors that have ignored and continue to ignore executive branch directives and published health and safety protocols will not be protected from liability for those failures,” White said. “Those bad actors will continue to face legal consequences.”
While there was general agreement among lawmakers on the general liability and worker protections, several senators raised concerns during a lengthy question and answer session about the decision to exclude hospitals and other health care facilities from the legislation.
Brin Gibson, Gov. Steve Sisolak’s interim general counsel, said during the hearing that the legislation was the byproduct of conversations between “some of the most important members of Nevada’s economy” and suggested that the decision was theirs.
“They struck this language, and they decided that based on how the various weights and balances that are out there, that these elements should be included in here in this way, and what I would say is that based on that yield, this is where we ended up,” Gibson said. “There's potential that this deal falls apart if we start amending out certain provisions. They’re there for reasons that aren't— may not be obvious, some are messaging related, some are optical, some are substantive. There are various reasons why.”
But that answer didn’t satisfy all lawmakers. Hansen, one of the three “no” votes out of committee, suggested that health care facilities were being asked to be the “sacrificial lamb” so that “the other guys can get protection.”
“That is just unacceptable,” Hansen said. “We cannot have our entire medical community being subjected to lawsuits while we give exemptions.”
Cleaning standards and worker safety
The bill, which was released in full on Monday, covers three topics: creating an outline of enhanced cleaning policies for large casinos and hotels in Las Vegas and Reno; enhanced protections for workers at those casinos and hotels; and, most controversially, broad immunity from COVID-19 related litigation for businesses, government agencies including schools, and nonprofits, but not hospitals or health care facilities.
First, the legislation directs the director of the Department of Health and Human Services, Richard Whitley, to promulgate regulations on cleaning standards for casino resort or hotels, including regular cleaning of high-touch areas used by the public such as fixtures, door handles, countertops, keycards, elevator buttons and other objects.
The bill requires Whitley to adopt another set of regulations to limit transmission of COVID-19, including protocols on social distancing, access to hand cleaning, sinks and soap, hand sanitizer and personal protective equipment, such as gloves or masks, at no cost to the employee.
The bill mandates that local and state health officials regularly inspect resort hotels every two months and hotels with more than 200 rooms every three months for compliance with the health standards. It also authorizes them to administer fines of $500 for an initial violation and $1,000 for each subsequent violation.
It also allocates $2 million to the Southern Nevada Health District and $500,000 to the Washoe County Health District to implement and enforce requirements in the bill.
The legislation also includes requirements that employees at casino hotels receive paid time off while awaiting COVID-19 test results if they are in close contact with a guest or other employee who tested positive for the virus. Any employee who tests positive will be allowed a minimum of 14 days off, including 10 paid days.
Those provisions were hard won by the politically powerful Culinary Union, which represents about 60,000 workers in Las Vegas and Reno. The union has been pushing for many of the same worker protections — including enhanced safety and cleaning standards, free COVID-19 testing and detailed processes for when a worker contracts the virus or is exposed to someone who has it — after Adolfo Fernandez, a Caesars Palace utility porter, died after contracting the virus in June.
In her testimony, Culinary Union Secretary-Treasurer Geoconda Arguello-Kline voiced the union’s support for the legislation.
“This Special Session is important for all workers and the hospitality industry,” she said in written testimony. “We hope today that we will ensure workers and their families are protected from the spread of COVID-19 in the workplace.”
But much of the attention on the bill has centered around the sections on liability protections for businesses, nonprofits and government agencies, with hospitals and other health care facilities excluded.
Essentially, the bill sets up a higher standard before a COVID-19-related personal injury or death lawsuit against a business or entity can be filed. It requires any claim to be pled with “particularly,” meaning the plaintiffs have to meet a higher standard of proof than normal before even filing the case.
The bill states that all entities covered under the bill — including businesses, certain nonprofits and government agencies — are immune from such litigation if they are in “substantial compliance with controlling health standards,” unless the plaintiffs can prove that the entity violated those standards with gross negligence, causing personal injury or death.
The legislation defines “controlling health standards” as any federal, state or local law or regulation, or any written order by a governmental body, that “prescribed the manner in which a business must operate at the time the person allegedly failed to comply.”
That includes existing mask-wearing mandates and limits on gatherings of more than 50 people, but would not encompass many of the technically nonbinding recommendations made by the governor’s office and health officials over the many months of the pandemic.
That controlling health standard language was tightened from an original draft of the bill obtained by The Nevada Independent, which referred to any state, local or federal health policies, laws or ordinances that were “clearly and conspicuously related to COVID-19 and which were in effect at the time of the alleged exposure.”
But the other part of the liability equation is determining whether or not the business is in “substantial compliance” with those controlling health standards.
That term (“substantial compliance”) is also defined in the bill — as “good faith efforts” to help control spread of COVID-19, including establishing policies to enforce and implement controlling health standards in a “reasonable matter.” It also excludes “isolated or unforeseen events of noncompliance,” meaning that one-off contracting of the virus would not meet that standard required to bring a lawsuit.
The legal liability sections of the bill are set to expire whenever the governor lifts his declaration of emergency related to the pandemic, or by July 2023.
Multiple business and casino companies testified in support of the bill, citing the liability protections in particular. Sasha Stephenson, a lobbyist with MGM Resorts, said the casino company believed the litigation protections were necessary to help with the state’s economic recovery.
“Unfounded litigation has the potential to cripple Nevada's businesses, leading to more closures and greater economic difficulties,” she said. “The targeted liability protection itself will have the opposite effect. It will allow good actors to stay open as long as they remain vigilant in keeping employees and guests safe.”
But the bill met staunch opposition from left-leaning groups, teacher unions and the state’s trade association for trial attorneys. Both the Nevada State Education Association and Clark County Education Association opposed the bill, citing concerns that it would incentivize schools to cut corners and not take full safety measures thanks to the lifted threat of litigation.
“While it is encouraging that kids don’t get sick and die in the same numbers as adults from COVID-19, evidence is mounting that they can be significant vectors,” NSEA lobbyist Chris Daly said. “Now, as thousands of educators and families prepare to go back to school, we believe essential school supplies should mean pencils and paper or Chromebooks and wifi, not wills and trusts.”
Nevada Justice Association board member Matthew Sharp, a trial attorney, said that supporters had provided no “coherent explanation” for what “controlling health standards” would include, and that there had been few if any such COVID-19 related personal injury lawsuits filed in the state thus far.
“This Legislature, convening literally at the dead of night, is considering giving essentially complete immunity to certain businesses,” he said. “This isn't what a special session is for. And what we are looking at is a solution looking for our problem.”
The legislation also came under heavy fire during the hearing from hospitals and other health care facilities, which argued that they were being treated unequally by being excluded from the liability protections. Hospitals also argued that if they were not extended the liability protections, they would have to make significant changes to hospital operations, including restricting visitors, students and vendors.
Bill Welch, CEO of the Nevada Hospital Association, also said that the legislation would hinder the ability of hospitals to be able to discharge their patients to long-term care and hospice facilities, limiting bed space to treat COVID-19 patients.
“Throughout this pandemic, we have worked closely with Governor Sisolak and his office to fully support his goals to flatten the curve and protect hospital capacity. As written, this bill puts that capacity at risk, and undermines our efforts to protect Nevadans’ health,” Welch said. “Nevada hospitals are the frontline of this pandemic. Hospital capacity is critical for providers to treat this fast-spreading virus.”
Gibson, during the hearing, argued that hospitals are already afforded certain immunities and protections under an emergency directive exempting them from liability “except in cases of willful misconduct or gross negligence” because of their role in responding to the pandemic.
Later, he acknowledged that the decision to exclude health care facilities was a byproduct of conversations with stakeholders and suggested that the deal between casinos, the business community and the Culinary Union might fall apart if legislators were to propose an amendment.
Gibson then backtracked slightly, after he was pressed by Sen. Keith Pickard about who exactly was involved in drafting the legislation, with the governor’s counsel saying that he may have “oversimplified” his response. He suggested that health care facilities are already held to a higher standard because of the type of business they run.
“They're able to manage illness in a way that other businesses are not because they're experts in these spaces,” Gibson. “Our role was to try to not overburden the bill, but at the same time to extend it into every possible business that we could, with limitations.”
However, not all health care facilities will be treated equally under the bill. Legislative legal staff confirmed that University Medical Center, the county-run hospital in Clark County, would qualify for the liability protections since it is a government entity, and any county-run rural hospitals would be eligible as well.