Progressives, industry representatives debate health care affordability, access during high-profile public option hearing

Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko

There is near-universal agreement that the state of health care in Nevada leaves something to be desired.

Nevada has one of the highest uninsured rates in the nation, with roughly 350,000 residents without health insurance. It ranks near the bottom on health care affordability, with nearly half of Nevadans saying health care is too costly. It also ranks at the bottom for overall health care system performance, including access, affordability, prevention and treatment.

Where there is less agreement, though, is what should be done about it.

Nowhere was that more clear than during a Tuesday hearing on a bill to establish a state-managed public health insurance option: Proponents, including progressive organizations and public health advocates, framed the bill as the next step in expanding affordable, quality health insurance that would reduce costs for Nevadans. Opponents, largely health industry representatives and chambers of commerce, said it would do the opposite.

Since its introduction last week, the bill, SB420, has attracted high-profile support at the national level, including from the nonprofit group United States of Care and the advocacy organization Committee to Protect Medicare, as well as opposition, primarily from a coalition called Nevada’s Health Care Future, an arm of the national organization Partnership for America’s Health Care Future, which is made up of some of the health industry’s heaviest hitters. In advance of the Tuesday hearing, advocates and opponents sent out press releases, polls and statements from doctors both in support of and against the legislation.

The polls, however, reveal just how long both sides have been gearing up for a fight over a public option in Nevada this legislative session: They were both taken in February.

At its core, the legislation, which is being debated with less than a month left in the session, would require insurers that bid to provide coverage to the state’s Medicaid population to also offer a public option plan. While the plans would resemble existing qualified health plans certified by the state’s health insurance exchange in many ways, the legislation would require them to be offered at a 5 percent markdown, with the goal of reducing average premium costs in the state by 15 percent over four years.

Because the public option plans would be offered on the state’s health insurance exchange, people who are eligible for federal subsidies under the Affordable Care Act would be able to purchase a fully or partially subsidized public option plan. In addition to being offered both on and off exchange in the individual market, the plans would also be open to the state’s small group health insurance market.

Apart from its public option provisions, the bill also makes a number of changes to the state’s Medicaid program, including, notably, increasing eligibility for coverage for pregnant women in Nevada to up to 200 percent of the federal poverty level. The changes are expected to cost about $73 million, with an impact to the state’s general fund of about $24 million.

State Senate Majority Leader Nicole Cannizzaro, who is spearheading the legislation, said during the hearing that the public option and Medicaid portions of the bill would, collectively, improve access to health care for Nevadans.

“We are more than a year into a global pandemic that has resulted in job loss, and, consequently, the loss of health insurance. People are struggling to ensure they will have access to health care if they get sick, and that is the plain and simple place that we are in reality,” Cannizzaro said. “Now is an opportune moment to take advantage of the state's considerable bargaining power to make health care more affordable and more accessible.”

Proponents testified on Tuesday that the legislation would expand health insurance options for individual Nevadans and small businesses while reducing costs.

“I cannot wait for this plan to be available to us so we can have better and more affordable options for coverage,” said Annette Magnus, executive director of Battle Born Progress. “This plan is another piece of the puzzle in solving the insurance and health care crisis that Battle Born Progress has been working on for years.”

West Wendover Mayor Daniel Corona highlighted the potential impact the legislation could have in expanding coverage in rural Nevada. Among its many provisions, the bill would require all insurers that offer a public option plan do so in every county and both on and off the exchange, preventing any counties from going without an exchange plan, as almost happened in 2017.

“For the first time ever, Nevadans in the most rural areas of our state will be guaranteed access to affordable coverage through a statewide public option,” Corona said.

Jim Sullivan, lobbyist for the Culinary Union, which runs a union health plan called the Culinary Health Fund, called the bill a “good first step” in making sure Nevadans can receive “quality and affordable health care.” A conceptual amendment Cannizzaro presented to the bill on Tuesday would allow the union to offer its health plan as a public option to members who lose health coverage.

“This is important to allow Culinary Union members and their dependents to continue to see their same doctor, not face a gap in must-needed treatments and have access to the same prescriptions and specialists instead of having to start over with a brand-new insurer if they were to lose coverage,” Sullivan said.

The Culinary Union, which sometimes aligns with private health insurance companies on legislation and also has close ties with Democratic lawmakers, was likely the best chance the insurance industry had in heading off the Democratic-backed proposal.

During the hearing, opponents, including doctors, hospitals and private insurance companies, painted a bleak picture of what the legislation would do to Nevada’s health insurance landscape. One of their key arguments against the bill was that requiring premium reductions and setting Medicare rates as a floor would not actually reduce costs but just lead to cost shifting elsewhere.

“When costs exceed the revenues, then adjustments will have to be made. It’s either passed on, typically, passed on through the commercial market — that is employers that are not eligible to participate — or it can impact into the workforce, with jobs,” said Jim Wadhams, lobbyist for the Nevada Hospital Association.

Proponents, however, argued that cost-shifting already happens when doctors and hospitals provide care to uninsured individuals and that care goes uncompensated.

“The question is really, when we talk about cost shifts, because that is a current reality of our system, there’s plenty of money that is being made in the health care space, so when we talk about cost shifts, what are we talking about?” Cannizzaro said. “Here, we are talking about people who are not accessing Medicare, because they don't have health insurance.”

Opponents also suggested during the hearing that instead of pursuing a public option 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.

“We are opposed to this bill. It's well-meaning but we need to figure out why people are not using the programs that we have now first and fix those,” said Susan Fisher, a lobbyist for the Nevada State Society of Anesthesiologists.

Cannizzaro, however, suggested it was contradictory for providers to be talking about enrolling more people in Medicaid when they have long lamented that Medicaid rates in the state are inadequate.

“If we're talking about implementing something where you're getting reimbursed at higher than Medicaid rates, why that's a reason to oppose this bill is just one that I have struggled to understand, in every sense of the word,” Cannizzaro said.

The statewide doctors’ association, meanwhile, voiced support generally for a public option but expressed concerns that setting Medicare rates as a floor would serve 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 and said the provision could actually lead to doctors backing away from providing care to people covered under those plans.

“We support physicians’ freedom of choice when it comes to health care plan participation, and therefore we oppose the effort to require physicians’ participation in the public option by tying it to the other state-based programs,” said Jaron Hildebrand, executive director of the Nevada State Medical Association. “This mandatory participation provision overlooks the complexities of running a physician practice, the balance involved in determining the capacity and the ability to have a practice that serves a patient mix.”

The association also opposes a provision of the bill requiring payment parity between doctors and advanced practice registered nurses for Medicaid.

Several chambers of commerce also voiced opposition to the legislation, in part because they argued it would undermine the health insurance plans they offer, known as association health plans.

“That is a proven market driven solution based on no premium costs, and comprehensive benefits both buying power for small business,” said Scott Muelrath, executive director of the Henderson Chamber of Commerce.

Opponents also voiced frustration with being left out of the bill drafting process. While the health care industry is often successful at killing legislation it is united in opposing, industry representatives successfully worked together in the 2019 session to reach a compromise to address surprise emergency room billing at the direction of Assembly Speaker Jason Frierson. They suggested on Tuesday that a similar approach could have been taken with this proposal.

“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,” said Tom Clark, lobbyist for the Nevada Association of Health Plans.

Several industry representatives urged the committee not to pass the bill as is but amend it or continue to study the issue further.

“We want to work with you and others to see if we can design a program that works for Nevada, without jeopardizing access to care or the current options for coverage as an integrated health care delivery system,” said Mike Hillerby, a lobbyist for Renown Health and its insurance arm, Hometown Health.

Cannizzaro, however, noted that the bill would allow several years for implementation of a public option, with coverage slated to begin Jan. 1, 2026, and also would allow an actuarial study that would assess impacts to the insurance market before such plans are approved. 

She also chafed at suggestions that the Legislature study the matter further, when it has been four years since a public option bill was first proposed in Nevada.

“The answer to why we should not support SB420 being that we should continue to look at this, or figure out who these people are, or figure out how we should study this a little bit more — we are past that point. We know who these people are. I've talked to them at the doors,” Cannizzaro said. “I would encourage you, go knock 10 doors in your neighborhood and let me know how many people talk to you about the cost of health care because I'm willing to bet it’s a fair number.”

The committee took no further action on the bill on Tuesday. After it passes out of the Senate Health and Human Services, it will need to go to the Senate Finance Committee to review the bill’s financial impact.

State Republican Party chair did little work for second job as dental board lobbyist, records show

September was a good month for Michael McDonald.

Buoyed by endorsements from President Donald Trump’s inner circle and elected officials statewide, McDonald beat back two challengers to win re-election to a fifth term leading the state’s Republican Party, promising that the “Nevada Republican Party is united and ready to deliver our state to President Trump and electing Republicans down the ballot in 2020.”

But leading the state party isn’t the only job on McDonald’s plate. For the past year, he’s worked as the lobbyist for the Nevada State Board of Dental Examiners, the seventh-largest occupational licensing board in the state — although public records raise questions about his work for the board.

Over the last two decades, McDonald has a history of representing unusual clients as a lobbyist, including a rural constable’s office and the Culinary Workers Union Local 226. But his working relationship with the state dental board, which oversees licenses and regulates dental health professionals, has been more than just unusual from the get-go.

Since he was hired in May 2018 (beating out two established lobbying firms led by former lawmakers), records indicate McDonald has spoken at just one board meeting in that 16 months. Public records requests reveal that his only written correspondence with the board since he was hired has been monthly invoices — a request for $3,428.57 every month. 

Lobbyists and lawmakers reported not interacting or seeing him during the legislative session, and say he was invisible on often-technical bills that substantially affect operations of the dental board. McDonald did not return a text message seeking comment.  

In short, it’s difficult to find any public evidence of work completed by McDonald since he accepted the two-year, $72,000 contract to provide government relations services for the board.

It has elicited questions from lobbyists who represent other state boards, who say that McDonald’s scope of work and practices are at best highly unusual for a state board lobbyist and could invite additional scrutiny of state licensing boards, which have a recent history of butting heads with other state government agencies.

“If I were heading up a regulatory board, and I found out my lobbyist wasn’t there on a regular basis, I would not renew that contract,” said Susan Fisher, a longtime lobbyist who represents three other state boards. “Why hire a lobbyist if they’re not going to be there?”

In spite of the unusual arrangement, staff of the dental board say they have no issue with McDonald, though the board’s executive director, Debra Shaffer-Kugel, declined to answer multiple emailed questions about McDonald’s attendance at board meetings and work for the board during and outside of the legislative session. She instead referred all questions to the board’s general counsel, Melanie Bernstein Chapman, who did not answer specific questions but said the board had no issues with McDonald or his activities as the board’s lobbyist.

“I have not been advised of, nor am I aware of, any concerns of the Board with respect to Mr. McDonald’s representation,” she wrote in an email.

Board meetings

A review of the minutes and audio records of the nine meetings held by the dental board since it agreed to hire McDonald as its lobbyist in May 2018 shows that he only spoke at one meeting, on March 22.

There, McDonald gave a roughly 10-minute review of a handful of bills related to dentistry, largely sticking almost word-for-word to the descriptions written by Legislative Counsel Bureau staff. He skimmed over a bill, SB366, which aimed to open up the practice of dental hygienists to operate in the state, and stayed out of a roughly 10-minute discussion on the bill and how it would affect dental practices statewide. 

At one point during the March meeting, McDonald advised the board on SB156, a bill related to the practice of equine dentistry — a topic area overseen by the state’s veterinary board, not the board of dental examiners.


Outside of that meeting, traces of McDonald’s presence on behalf of the dental board are difficult to pin down. Outside of a pre-session meeting between several health-related occupational boards and an appearance at a court hearing involving the dental board (referenced in meeting minutes), McDonald is not listed as speaking or appearing at any additional board meetings or during any 2019 legislative hearings. According to a records request, McDonald sent just 12 emails over the course of his employment to staff and members of the Board of Dental Examiners; one including a signed copy of the lobbying contract, and 11 invoices sent on a monthly basis.

The Nevada Independent contacted several other lobbyists employed by state boards to ascertain whether or not McDonald’s apparent lack of public-facing activity was out of the ordinary. 

Fisher, who represents the Oriental Medicine, Osteopathic Medicine and Professional Engineers and Land Surveyors, said that it would be “highly unusual” for her not to check in at least weekly with each of the boards during the legislative session, on the status of bills that directly and indirectly affect her boards.

Fisher said she alternated between emails and phone calls depending on the issue, but found it strange for a board to employ a lobbyist who wasn’t physically present at the Legislature during the 120-day session.

“What’s the point of having a lobbyist if they’re not going to be in Carson City during session?” she said. “That’s a silo, and you’ve got to be in the silo.”

Michael Hillerby, a lobbyist for Kaempfer Crowell who represents several boards (Accountancy, Nursing and Pharmacy) said that it was “unusual” in his nearly three-decade career to see an occupational board lobbyist not be physically present during the legislative session. Hillerby, who lobbied on behalf of the dental board several years ago, said that the lobbying role for an occupational board was a little different from other clients, in that they were expected to largely stay out of policy fights and contribute as the “subject matter experts” as to how various proposals would affect the licensure and operation of certain professions.

“It would be odd not to be there to at least be ready to answer questions as to how it impacts you and why it impacts you,” he said.

SB366, the bill creating a new mid-level dental provider type (dental therapists), is a prime example. Although it was initially opposed by the state dental association, the task of implementing the regulations required under the bill falls to the dental board, which also submitted a fiscal note estimating that the first version of the bill would result in close to $300,000 in lost annual fee revenue (The Governor’s Office of Finance wrote that the board did not provide a spreadsheet with their calculations and ultimately concluded that the board’s estimated financial impact was not “reasonable.”)

The initial version of the bill would have created a separate dental hygienists board, removing that profession from the purview (and fees) of the state dental board — a change that would have major implications for the board.

McDonald was not present — at least, he did not sign his name on sign-in sheets reflected in board meetings — at any committee meeting where SB366 was discussed. Dental board Executive Director Debra Shaffer-Kugel attended and testified in the neutral position during the first hearing of the bill on March 29, but no representative from the dental board or McDonald attending any of the subsequent six committee meetings where the bill was heard or voted on — even after three substantial amendments overhauled major portions of the bill. 

Democratic Sen. Julia Ratti, the bill’s sponsor, told a reporter during the legislative session that she had no interaction with McDonald on the bill or on any subject. Nevada Dental Association lobbyist Chris Ferrari said he spoke with Chapman, the board’s general counsel, at the state of the session but otherwise did not interact with McDonald or anyone else from the dental board on the bill. 

“It’s unusual to have such a big bill and not have a lobbyist there,” said Neena Laxalt, a lobbyist for the Nevada Dental Hygienist Association and several other boards.

Members of the dental board discussed the bill in depth during meetings in May and July of 2019, neither of which McDonald attended. Minutes from the board’s July 19 meeting show McDonald was absent; the board’s executive director said he was “ill.” A week later he was in Charlotte, North Carolina for a Republican National Committee event.

In an email, dental board general counsel Chapman said that the board was not directly asked for its position on the bill, did not introduce any legislation during the session and was committed to implementing regulations for any bills in its purview that were approved by state lawmakers.

“SB 366 was not the Board’s bill and, to my knowledge, the Board was never asked for, nor did it take a position for or against the bill but Mr. McDonald or a member of his staff did appear at the various hearings regarding the bill,” Chapman wrote in an email.

Boards and Commissions

As with contractors, nurses, private investigators and social workers, dentists in Nevada are overseen by one of Nevada’s occupational licensing boards. Dentistry is one of 50 occupations, professions or businesses overseen by 31 state boards.

Boards operate as a kind of quasi-governmental agency — board members come from the profession itself, but are appointed by the governor to serve three or four year terms. The boards don’t receive funds directly from the state, but are instead fully funded through licensure fees (registration, license renewal, etc.).  

Boards serve a variety of roles, including investigating complaints, disciplining licensees and helping write regulations that affect their industry. Although the governor appoints — and can, in limited circumstances, remove — board members, most oversight of boards comes from the legislative branch, which both creates the scope and abilities of the boards through legislation and oversees them through an interim subcommittee

Boards also vary in size and activity; the state Contractors Board reported more than $7 million in expenditures in 2018, while many smaller boards such as Athletic Trainers, Oriental Medicine and Landscape Architecture made it through the 2018 fiscal year with a budget under $100,000.

But unlike other state agencies, occupational boards (such as school districts and municipalities) have the budgetary freedom to hire lobbyists to represent them in front of the state Legislature and during the interim period between legislative sessions.

A previous Nevada Independent analysis of lobbying efforts by state boards and commissions found that at least 21 boards had hired a lobbyist in 2018, spending in total more than $577,000 for outside lobbying and public relations. Contracts varied widely in length and scope; the median amount spent by the boards was $21,000, though some were for less than $2,000, while on the other end of the spectrum, other more prominent boards inked six-figure lobbying and public relations contracts.

Lobbyists for state boards say they perform a necessary function for the agencies without requiring full-time staff or appointed board members spending time and resources at the Legislature. Some conservative leaning groups have criticized the arrangement, stating that hiring lobbyists allows boards to consolidate power and limit competition. At least 10 states have placed some limits on the ability of state agencies to hire lobbyists.

McDonald

Though he has no apparent experience in health care or dental work, McDonald beat out two other lobbying firms (one run by former Democratic Assembly Speaker Richard Perkins and the other by former Democratic Assemblyman William Horne) to win the lobbying contract for the dental board in May 2018. In a previous email, Chapman said his position as head of the state Republican Party “was not discussed or considered as part of this process and was not a factor in the discussion or deliberation resulting in the decision to contract with him.”

According to registration records, his past lobbying experience includes representing the Nevada Republican Party in 2017, and several clients in 2015 including trial lawyer Glen Lerner, the Laughlin Constable’s office, the Armenian American Cultural Society of Las Vegas and the Southern Nevada Rural Constable’s Alliance. He also appeared as a lobbyist for the Culinary Workers Union Local 226 in 2012.

In 2015, McDonald was also briefly employed in another state government-related job; working for the Nevada State Treasurer’s Office as a senior deputy treasurer, but resigned within three months of taking the position amid criticism that he was hired given his close relationship with then-state Treasurer Dan Schwartz, previously a finance director for the state Republican Party.

A former Las Vegas Metropolitan police officer, McDonald got his start in Nevada’s political world by winning election to the Las Vegas City Council in 1995. His momentum stalled amid ethics and tax investigations (McDonald was never charged with a crime and later said he had been “wrongfully accused”) and contributed to his defeat in a 2003 municipal election.

His path back to relevancy began in 2012 when he was elected chair of the state Republican Party, and he later won contentious re-election campaigns in 2013 and 2015 against party establishment-backed candidates. He’s cultivated a close relationship with President Donald Trump, including getting the then-candidate to appear at a 2016 fundraiser for the party in Lake Tahoe.

His company that received the lobbying contract, Alpha-Omega Strategies, has played a role in several non-lobbying related business interests. The company was incorporated in 1998, initially operating as a “consulting” firm for private investigations, and later received approval from the Las Vegas City Council to operate a senior housing and retail center in Northwest Las Vegas.

Reaction and opposition

The hiring of McDonald has done little to quell the often tempestuous relationship between the board, vocal critics in the dental community and state government. 

McDonald was notably not present at a June meeting of the Executive Branch Audit Committee — composed of Gov. Steve Sisolak and other statewide elected “constitutional” officers (lieutenant governor, secretary of state, attorney general, treasurer and controller) — where an at-times scathing audit into the dental board was publicly presented for the first time.

The audit found that at least three board members, including board President Yvonne Bethea, may have violated state ethics law between 2015 and 2018 by failing to disclose familial or professional relationship prior to casting votes, and raised questions about the board’s use of Disciplinary Screening Officers to broadly screen complaints made to the board.

Sisolak, who found the audit to be “very concerning,” at one point in the meeting asked if the board’s lobbyist — McDonald — was present.

He wasn’t. 

Only Chapman, the board’s general counsel, appeared that day and took questions from the audit committee.

The 2019 audit was itself preceded by a 2016 audit, this one from legislative branch auditors who found the board had overcharged almost half of licensees under investigation, and allowed some offenders to make charitable donations in lieu of fine in contrast to state law. 

Not unlike McDonald himself, the board has been a lightning rod for controversy. Former Gov. Brian Sandoval even asked the board to tackle the patient complaint process, saying “I’ve never seen that happen before with people as upset as they are with … the board of dental examiners.”

Correction: Updated at 1:55 p.m. on Oct. 7, 2019 to reflect that the Nevada Dental Association initally opposed, and did not support, SB366.

Occupational boards and commissions spent more than $500,000 on lobbyists in 2018

The Nevada Legislature building

To an outside observer, SB355 seems like one of the top battles of the 2019 Legislature.

It’s a bill that sparked a fight drawing in top lobbyists, last-minute amendments, lengthy hearings and even a contentious (and disputed) legal opinion from legislative attorneys.

But the bill doesn’t deal with headline-friendly topics such as education, minimum wage or raising taxes.

Rather, it’s all about acupuncture — namely whether the state board of physical therapy can authorize the practice of dry-needling against the wishes of the State Board of Oriental Medicine.

How such a limited topic drew in some of the state’s top lobbyists and chewed up a significant amount of time in the 120-day legislative session has come about mostly for one reason — the ability of the state’s 31 occupational licensing boards to hire professional contract lobbyists.

“Without a doubt, this is heavily lobbied and they’ve brought a lot of people around,” bill sponsor Democratic Sen. David Parks said. “Every occupational board is trying to protect their turf, and they don’t want anybody to invade their territory.”

Although local governments and school districts can and have hired lobbyists in addition to their in-house lobbying teams, the state’s numerous occupational licensing boards — typically composed of industry professionals appointed by the governor — stand unique as the only state-level agencies with the power to hire professional lobbyists.

But hiring lobbyists doesn’t come cheap; according to reports filed with the Interim Finance Committee earlier this month, at least 21 state boards and commissions spent more than $577,000 for outside contract lobbyists and public relations throughout 2018. Although licensing boards aren’t funded by the state (instead operating off on fees from licensees), they’re given wide authority by the state Legislature and governor — who appoints board members — to oversee, regulate and license more than 50 professions in the state representing an estimated 28 percent of the state’s workforce.

Lobbyists for the boards say the arrangement is beneficial; boards and commissions typically don’t have the staff or financial ability to employ full-time lobbyists and hiring an experienced lobbyist to shepherd legislation or keep tabs on bills or measures that could affect their operations is an important and necessary function for state boards.

Susan Fisher, a longtime lobbyist for the McDonald Carano law firm, said her representation was a better cost value for an entity like the State Board of Osteopathic Medicine, which can’t afford a full-time lobbyist or to have their executive director camped out in the Legislature for 120 days amid their other duties as a board.

“They don't have somebody that they can spare to come here full time and when there's something going on, you tend to need to be around a lot,” she said. “You can't just float in on the day of the hearing and float out. You need to be here and you've got to work the committee and educate people on the issues before it's ever even heard.”

It isn’t unusual to have a single lobbying entity represent several state boards — McDonald Carano, for example, represents three occupational boards; Oriental Medicine, Osteopathic Medicine and Professional Engineers and Land Surveyors. In total, just 12 individual lobbyists or government relations firms are registered to lobby for the 21 boards and commissions.

Fisher said that arrangement works out as long as the firm avoids conflicts, such as representing boards with potentially overlapping areas of practice or a professional association in the same industry.

“Since I'm representing the Osteopathic Medicine (Board), I would not be able to represent the Board of Medical Examiners, which is very well-represented anyway,” she said. “I couldn't do both of those because a lot of the time we're lock step, on the same page, but just to be on the safe side, once in a while we may not be.”

Compensation for lobbying contracts is typically done through retainer, as opposed to a certain per-hour wage. The median amount spent by the 21 boards on lobbyists is just north of $21,000, though certain boards pay more depending on the scope of lobbying work — from just monitoring bills to actively pushing for specific legislation. Three boards — Board of Examiners for Social Workers, Podiatry and Psychological Examiners — either did not file reports with the state despite having a registered lobbyist or didn’t report compensation totals on their report.

Payments to lobbyists also vary widely; on the top end, the Contractors Board paid $144,000 to the Ferraro Group for lobbying and public relations, while on the lower end the State Board of Dispensing Opticians paid just $1,500 in 2018 to lobbyist Neena Laxalt. The spending totals are available under a 2013 state law requiring state boards and commissions, school districts and higher education institutions to publicly disclose spending on any consultants every six months.

Michael Hillberby, a lobbyist with Kaempfer Crowell who represents three occupational boards (Accountancy, Nursing and Pharmacy), said part of his job was having the expertise and knowledge to know what was possible in the current, Democratic-controlled Legislature. He said the nursing board has long had the goal of joining an interstate nursing compact, but that the political clout and opposition from the Service Employees International Union made such a goal unattainable.

“I regularly go to the board meetings, walk through here's all the people we met with, here's the strategy we laid out, here's what we've done,” he said. “But ultimately it comes down to this, and this is a tough environment to do that.”

Beyond shepherding bills, Hillerby said his work includes monitoring bills that affect boards in other ways, such as open meeting law changes or noticing requirements. But he said often the most difficult aspect was navigating through the choppy waters of dispute that arose when boards tangled over overlapping areas of regulation — such as in the battle between physical therapists and the Oriental Medicine Board over dry-needling.

“I think of staying out of those turf battle issues between professions are always tough, and it's not much fun for legislators,” he said. “The boards really need to be there to answer questions about how they would regulate it.”

Like Fisher, Hillerby said it was easier for licensing boards to contract with outside lobbyists rather than pay for a full-time staff lobbyist. But at least some groups, including the conservative-leaning Foundation for Government Accountability, have advocated for prohibiting occupational licensing boards from hiring contract lobbyists amid concerns that it allows boards to consolidate power and limit competition.

The conservative-leaning Nevada Policy Research Institute, long a critic of what it calls Nevada’s overburdensome occupational licensing laws, cited a 2015 report by former President Barack Obama’s administration that stated a ”licensed profession’s degree of political influence is one of the most important factors in determining whether States regulate that occupation.”

In other words, the lobbyists for these boards are the reason Nevada has such an oppressive licensing regime,” NPRI’s Robert Fellner wrote in an email. “No licensing board is ever going to argue for its own elimination, even when that is the right thing to do.”

At least 10 states have some limits on the ability of state agencies to hire lobbyists, and Arizona Gov. Doug Ducey in 2016 issued an executive order in 2016 prohibiting licensing boards from hiring contract lobbyists.

The boards in Nevada, though, are granted a certain amount of autonomy. Former Gov. Brian Sandoval expressed some frustration with having to “bang heads” with occupational licensing boards and commissions, saying the offices tended to act independently and ignore directives from his office.

“I do feel like some of the boards and commissions feel like they’re autonomous, and they don’t answer to anyone, and once I’ve made an appointment, that’s it,” he said at an audit meeting in June 2018.

Other governmental agencies also contract with outside lobbyists, though typically they don’t operate at the state level. The Clark County School District has 12 people registered as lobbyists in Carson City, seven of which are contract lobbyists and don’t work directly for the school district. Several local governments, including the city governments of Reno, Las Vegas, Fernley, Henderson, Sparks and Mesquite, employ a mix of contract lobbyists and individuals employed by those government entities.