New amendment proposes making changes to Medicaid portion of public option bill in effort to reduce fiscal impact

Sen. Nicole Cannizzaro (D-Las Vegas) presented a new amendment to her public option bill on Wednesday that proposes scaling back a secondary portion of the legislation aimed at expanding Medicaid services in Nevada.

While Cannizzaro’s proposal to establish a state-managed public health insurance option has garnered significant attention, a lesser-noticed portion of the bill, SB420, proposes expanding certain Medicaid services in the state, including increasing eligibility of up to 200 percent of the federal poverty level for coverage for pregnant women, adding coverage for doulas (trained professionals who often assist in childbirth) and community health workers and requiring payment parity between advanced nurse practitioners and physicians.

Those changes, however, would come with a significant price tag to the state. Nevada’s Medicaid program estimated the changes to Medicaid alone would cost the state $23.9 million in the upcoming biennium and $39.8 million in the following biennium. The public option piece of the bill, by contrast, would cost about $2.3 million in the upcoming biennium and $3.5 million in the following biennium.

The new amendment, however, will allow Medicaid to make those changes in services only if the money is available to do so — in effect, making the changes optional.

Medicaid administrator Suzanne Bierman said her division had not yet had time to analyze the fiscal impact of a prior amendment to the bill proposed earlier this month — which, among other things, kicks back the start date of the public option plan by a year, to 2026 — or the new amendment presented Wednesday. However, she said the previous amendment will likely reduce costs on the public option side of the agency’s fiscal note, and the latest amendment will “drastically reduce” costs on the Medicaid portion.

She noted the community health worker and doula coverage requirements will actually result in a savings to the division and that the “as funding allows” language would allow Medicaid to eliminate the fiscal notes for the other service expansions, since it will not be required to implement them.

Bierman said if Medicaid did, in the future, end up having the funding to put in place the expansion of those additional services, it would seek permission from the Legislature’s Interim Finance Committee before filing a so-called state plan amendment with the federal government to formally add those services.

The Silver State Health Insurance Exchange has also submitted a fiscal note on the bill, to the tune of $500,000 in the upcoming biennium and about $9.9 million in future biennia. Jennifer Krupp, chief financial officer for the exchange, said the two amendments may increase the fiscal impact to the exchange in some ways, while pushing out the implementation dates may change the timeline over which the exchange would incur those expenses.

A third fiscal note from the Division of Welfare and Supportive Services is expected to have a general fund impact of about $168,000, after the previous amendment.

Beyond the fiscal changes, the new amendment also makes more explicit that the state is required to enter into a contract for an actuarial study before it moves forward with implementing the public option bill.

“We heard some concerns from providers, hospitals, from the business industry that an actuarial analysis should be required,” Cannizzaro said. “It is required for certain waivers, but we wanted to make that language very expressly clear so we did agree to an amendment in that regard to ensure that there's an actuarial analysis that takes place, if this bill were to pass, before we would go to procurement to ensure that what we are dealing with in terms of the legislation and what we're trying to solve for really does fit the problem.”

Editor’s Note: This story first appeared in Behind the Bar, The Nevada Independent’s newsletter dedicated to comprehensive coverage of the 2021 Legislature. Sign up for the newsletter here.

Lawmakers plan for enhanced federal Medicaid dollars to last through 2021

Lawmakers are moving forward with the budgeting process as if an enhanced federal matching rate for Medicaid will remain in place through the end of the calendar year, a move that could save the state about $60 million in general fund dollars.

Assemblywoman Maggie Carlton, during a budget subcommittee meeting on Thursday, suggested that lawmakers plan for the extra federal health care funding to exist for an additional six months beyond the current date it is set to expire, June 30. Her recommendation comes as the federal government has indicated that the current public health emergency will “likely” extend through the end of the calendar year, which would, in turn, mean that the enhanced federal matching dollars would be available through March 2022.

Carlton, however, said she felt more confident planning for a December expiration date than a March one.

“I would love to say we could go to March 30, 2022, but I don’t think that would be responsible on my part,” Carlton said. “Boy, I would love to put that on the sheets, but knowing that we’d have to deal with the consequences if we did, I would be very comfortable with a December 31 date.”

Medicaid administrator Suzanne Bierman said that her program had reached out to Medicaid programs in other states to ask how they were planning for the federal matching rate extension. Of the 10 states that answered Nevada’s request, one only budgeted through the second quarter of the calendar year, another budgeted through the third quarter and the remaining eight budgeted for the full calendar year.

Legislative staff said that Medicaid has yet to calculate the fiscal impact of budgeting for the extra federal dollars, though rough projections estimate the move will save the state about $30 million a quarter in general funds — in other words, $60 million over the second half of 2021.

The public health emergency is currently set to expire on April 20, though it is expected to be renewed before the Tuesday deadline. The Biden administration has told states it will provide 60 days’ notice before ending the public health emergency.

That’s important because the enhanced federal matching rate is tied directly to the public health emergency — and will expire at the end of the quarter in which the public health emergency is ended.

If the public health emergency continues to be extended in 90-day intervals through the end of the year, as the federal government has said, it will expire on Jan. 16, 2022. That means the enhanced federal matching rate would continue through March 2022.

Editor’s Note: This story first appeared in Behind the Bar, The Nevada Independent’s newsletter dedicated to comprehensive coverage of the 2021 Legislature. Sign up for the newsletter here.

Audit: Low pay for therapists, confusing systems leave many kids with autism untreated

A group of people releasing blue balloons

A new audit has pinpointed several reasons why the state struggles to deliver timely treatment to the more than 9,000 Nevada children who have autism, even though lawmakers have added millions more dollars toward that objective in recent years.

The review crafted by legislative auditors and approved by lawmakers on Thursday found that the state vastly undershot its projections on the number of children it would serve through publicly funded programs. In 2015, the state predicted that it would cost $35.7 million a year to serve 2,500 children, but has actually been spending only about $15 million a year and helping approximately 1,300 children. 

While the money sits unused, nearly half of the 118 families surveyed for the audit said it was “hard” or “very hard” to get their child formally diagnosed with autism, which is a prerequisite for the aid. The average wait to get approved for enrollment in the Autism Treatment Assistance Program (ATAP) — a state initiative to help families pay for what is often intensive and expensive therapy — was almost half a year as of last summer, and that doesn’t count time waiting for provider slots to open so a child can begin therapy.

The consequences of the bottlenecks can be severe for families. Waiting too long to begin treatment can mean children are unable to live independently, talk or have a normal social life when they are older.

“Children can't wait that long when they have this,” said Democratic Assemblywoman Maggie Carlton, arguing for quick action to resolve slowdowns. “The sooner we get to them and the sooner we help them, the better off the families are and the kids.”

Demand is growing, too — 1 in 55 Nevada children is classified by schools as having autism. That closely aligns with the national autism rate of 1 in 54, which is up from about 1 in 150 two decades ago.

Little incentive to serve poorer clients

The audit underscored a pay differential for frontline therapists — long recognized in Nevada — that has made it easier for privately insured patients to access treatment and much harder for low-income Medicaid clients to do the same.

Medicaid reimburses providers about $31 an hour for the services of a registered behavioral technician (RBT), who provides the intensive therapy that some children with autism do for up to 40 hours a week. About $19 makes it to the RBT, with the rest going to supervision and other overhead costs.

But that’s half the rate providers get from private health insurance, which is about $62 an hour. As a result, about two-thirds of providers choose not to serve clients with Medicaid insurance, and others limit the number of Medicaid clients they’ll take.

A bill in the 2019 session, SB174 sponsored by Democratic Sen. James Ohrenschall, initially called for raising the Medicaid reimbursement rate for RBTs to $48 an hour. But that request was removed from the bill, which evolved into legislation that called for the audit that was unveiled on Thursday.

Auditors recommend raising that reimbursement rate. But the state’s actions surrounding SB174 could have contributed to the reimbursement rate remaining relatively low in spite of the legislative effort to raise it.

The report said state agencies attached an “unreasonable” fiscal note to the bill, telling lawmakers that the price tag of raising the reimbursement rate would be more than $11 million every two years. In fact, auditors’ recalculation found that it was less than $6 million.

The audit warned state officials to be more careful with the underlying assumptions they make when calculating fiscal notes. High cost estimates are a common reason why lawmakers kill or drastically alter bills.

“Accurate information is essential for lawmakers to make appropriate decisions about limited resources,” auditors said. “As such, agencies should develop additional controls to ensure information provided in fiscal notes is based on reasonable assumptions.” 

The market forces putting Medicaid recipients at a disadvantage in the quest for treatment could become even worse as the state grapples with budget cuts spurred by the pandemic. This summer, lawmakers authorized 6 percent reductions to Medicaid reimbursement rates that would be retroactive to August 2020 if federal officials approve them.

“We know that planned reductions to Medicaid rates would further reduce rates as a result of COVID-19 related budget cuts,” said Jennifer Otto, a deputy legislative auditor. “Providers have a greater monetary incentive to serve children with private insurance than those Medicaid.”

Inadequate workforce

There was some good news in the audit — the number of therapists serving clients with autism is on the rise. From August 2019 to October 2020, the number of professionals licensed in Nevada to provide the Applied Behavior Analysis treatment recommended for children with autism had jumped 64 percent, from less than 1,000 to more than 1,600.

It’s still only enough to serve about two-thirds of the estimated 6,000 Nevada children likely to benefit from the therapy.

Most providers — 88 percent of those who responded to auditors’ survey — said their practice has a waitlist. The majority had more than 10 children on that list, and 18 percent said the waitlist was greater than a year.

Older children with more difficult behaviors may wait longer because providers are selective and therapists who can provide the treatment after school hours are “highly coveted,” auditors said.

A confusing process

Auditors noted that families often struggle to navigate the pathway to secure treatment for their children, and said the state has not provided a step-by-step guide or a comprehensive list of providers who offer the services.

Many families do not receive help in finding a provider, and children have to wait for openings with a therapist; placement is “dependent upon luck and caregiver tenacity,” auditors wrote.

The report recommended that the state’s ATAP program should assign care managers to help families monitor factors such as which providers take their insurance and which ones have availability.

“We will be providing this type of information on a regular basis,” said Dena Schmidt, administrator of the state’s Aging and Disability Services Division. “The challenge will be to us that this information changes on a regular basis ... providers come in and out of groups, in and out of networks. So we will do our best to maintain that on a regular basis and get it updated.”

Possible fraud

Auditors identified $6 million of questionable expenditures on autism services since 2016, largely from providers who billed Medicaid for excessive hours, including more than 24 hours in a single day on some occasions. 

A review of claims data in Medicaid fee-for-service — a subcategory of Medicaid-funded services —  found more than 3,000 instances when more than 15 hours of work was logged in a single day. Excessive hours were billed on nearly 3 percent of all claims.

The report concluded that the Medicaid system doesn’t have adequate system controls to detect whether hours billed are unreasonable. Sometimes supervision and planning hours for a child’s treatment are billed to Medicaid, but the majority is for direct, one-on-one treatment.

“Nevada Medicaid needs to determine an appropriate number of service hours for a given day for both individual providers and children to prevent inappropriate payments in the future,” auditors wrote. “Any claims in excess of the limit can be manually reviewed and paid if found to be valid.”

Suzanne Bierman, administrator of the Division of Health Care Financing and Policy, said she expected that within the year, the agency should have a better sense of which cases of excessive hours are intentional fraud that should be referred to the attorney general, and what may have been data entry errors.

“We have accepted all of the recommendations provided in this audit,” Bierman said. “Always appreciate the opportunity to continually improve our program, and have already started digging in looking at these issues in greater detail.”

Audit of Delivery of Treatment Services for Children With Autism by Michelle Rindels on Scribd

Medicaid will have a ‘more certain projection’ on whether it can restore rate cuts closer to the end of the fiscal year

A hallway at Sunrise Hospital

Though hospitals and medical providers were hopeful that cuts made to the state’s Medicaid program last month would be restored after federal matching dollars were extended through the end of the year, the head of Nevada Medicaid told lawmakers Thursday it might be some time before that can happen.

Administrator Suzanne Bierman, during a meeting of the Legislature’s Interim Finance Committee, said that the Medicaid program is still experiencing significant case growth amid economic upheaval because of the coronavirus pandemic. Because of that uncertainty, she said Medicaid might not know until closer to the end of the fiscal year, in June 2021, what funding is available to restore the cuts.

“I think as more time elapses and we’re closer to the end of the fiscal year, we’ll definitely have a more certain projection in terms of what, if any, additional funding is available for that purpose,” Bierman said.

Last month, lawmakers approved a 6 percent across the board Medicaid rate reduction during a special legislative session dedicated to balancing a billion dollar shortfall in the state’s budget. In total, the rate cut is expected to save the state $53 million over the next fiscal year.

However, providers remained hopeful that Medicaid would soon be able to reverse those cuts after the federal government extended enhanced matching funds to state Medicaid programs through the end of the year, expected to generate an additional $30 million in revenue in Nevada.

Ahead of a hearing on the rate decreases last week, the professional associations representing doctors, hospitals and assisted living facilities wrote a letter to Bierman asking why a restoration of the cuts wasn’t on the table though Medicaid had suggested it would be during the session.

“Given the receipt of additional Enhanced FMAP and a balance forward of $57 million in the Medicaid budget, why are rate reductions being imposed? Why is Nevada Medicaid moving forward with implementation when it indicated in testimony that provider cuts would be delayed?” the associations wrote in the letter.

Bierman, during the meeting on Thursday, said that Medicaid’s budget was still too volatile.

“I can tell you based on our actual caseload, just since last month when we were at the special session, we reported that caseload had increased 9 percent pre-COVID and now we're up to 11 percent,” Bierman said. “So, we are seeing very real increases in our caseload even just over the course of that one month since we last discussed this topic.”

Assemblywoman Maggie Carlton, who chairs the Interim Finance Committee, suggested that Medicaid could see significant case growth after Oct. 1, with a number of businesses reporting to the Department of Employment, Training and Rehabilitation that they will be conducting permanent layoffs. Among those is HMSHost, the vendor for food service employees at McCarran International Airport, which has announced that 940 furloughed workers will be permanently laid off by mid-October.

Bierman said that Medicaid, in partnership with the Division of Welfare and Supportive Services, is preparing for a significant increase in Medicaid applications. She said Medicaid is also working with managed care organizations, the insurance companies that provide Medicaid services for a flat, per-person fee paid by the state.

“This is on the radar and also something that we're thinking about ... once eligibility is established, how do we promote continuity of care and make sure that coverage is not only provided but also available and accessible?” Bierman said.

Assembly Republican Leader Robin Titus raised separate concerns about the impact of managed care organizations on Medicaid’s budget. She noted that although Nevada Medicaid reported decreased utilization at the beginning of the pandemic as people stayed home, it continues to pay insurance companies a flat fee to provide care to Medicaid recipients in the state’s two urban counties.

“Every person that is enrolled in that managed care organization, whether they receive one day of care or not, it's costing money because now you're paying that managed care organization per person enrolled,” Titus said.

Bierman said that Medicaid is in the process of working with those insurance companies to renegotiate rates. Once those rates are determined to be actuarially sound, they will go to the Centers for Medicare and Medicaid Services for approval.

“Right now we have utilized that funding to help avoid a shortfall and absorb the costs associated with increased caseload,” Bierman said.

Medicaid pushes ahead with 6 percent rate decrease proposed during budget-slashing special session

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.”

After years of incremental health care reform, more than $200 million in budget cuts threaten to turn back time

State officials presented to the Senate on Wednesday $233 million in proposed cuts from the health care budget that will slash key programs for low-income Nevadans and significantly pare back mental health services to ease a budget crisis caused by the ongoing coronavirus pandemic.

Many of the proposed cuts will roll back initiatives spearheaded by lawmakers and  the Department of Health and Human Services over the last few legislative sessions in an effort to improve health care in the state, which ranks among the worst in the nation. Health officials also plan to sweep dollars from existing accounts, such as one fueled by tobacco settlement dollars, to help make up the budget shortfall.

The recommended reductions to the Department of Health and Human Services budget will, if approved, make up nearly 20 percent of the $1.2 billion shortfall projected by the governor’s office and more than 42 percent of the proposed $549 million in agency rate reductions. 

The K-12 general fund budget — which represents about 34.9 percent of total general fund spending, slightly more than the 33.5 percent that Health and Human Services comprises — faces proposed cuts of about $166 million.

The proposed health care cuts come as the Department of Health and Human Services continues to play an integral role in the state’s response to the ongoing COVID-19 pandemic. Richard Whitley, the department’s director, noted in his budget presentation the difficulty of cutting hundreds of millions of dollars in health services — most of which go toward supporting the most vulnerable Nevadans — in the middle of a global pandemic.

“What is being identified here is we’re delivering direct services in one hand in a crisis and we’re having to reduce down our spend with the other hand,” Whitley said. “I am doing the best I can at doing that with the least amount of harm possible, but there will be harm, and I’m not here to say that people’s lives won’t be impacted by these proposed reductions.”

Medicaid

The most significant cuts, $140.4 million, will come to the state’s Medicaid program, which has seen a 9 percent increase in its caseload since February as Nevadans lost their jobs and turned to the state for health insurance. No Nevadans will lose their Medicaid coverage as a result of the budget cuts — in part because of a mandate from the federal government that states not terminate anyone from the program in order to receive additional federal matching dollars — but the state is planning to limit or eliminate the services they can receive.

For instance, Medicaid plans to eliminate 12 services deemed “optional” by the federal government, to the tune of $18.7 million in savings. Those services include optometry, tenancy support, occupational therapy, basic skills training and psychosocial rehabilitation — benefits that both lawmakers and state health officials noted Medicaid enrollees rely on and aren’t going to be able to get elsewhere.

“The framework of mandatory versus optional is not, I mean it’s almost embarrassing to use those terms because they’re only relevant to a federal congressional act in terms of what governs Medicaid, not to the people who do need the health care service,” Whitley said.” So I do know that we will have impacts on people and their lives may be worsened by these services being eliminated. I can’t quantify that for you today. I just know I have limited spaces to go to make the reduction in our general fund spend.”

Medicaid has also proposed a 6 percent across the board rate decrease for all services, which will save the state $53 million, and eliminate hard-fought rate increases approved by the Legislature during the 2019 session for acute hospital services, neonatal and pediatric intensive care services and personal care services, a savings of about $12.4 million. Hospitals waged a long, public campaign for their increases and, along with doctors and other providers, have long argued that Medicaid rates overall in Nevada aren’t high enough as is.

Suzanne Bierman, Medicaid administrator, pointed to a Kaiser Family Foundation report that shows that Nevada has one of the highest Medicaid-to-Medicare ratios compared to other states,

Nevada Hospital Association CEO Bill Welch, during a public comment session Wednesday evening, said the cuts will cost Nevada hospitals more than $100 million a year in payments, with hospitals spending another $500 million on uncompensated care.

Medicaid additionally plans to eliminate adult dental and limit dental services for pregnant women and children, limit physical therapy for adults to 12 sessions and eliminate certain duplicative hospice services from being provided in the home, for a total savings of $30.2 million. Remaining savings will come from delaying risk mitigation payments to managed care organizations, the private insurers paid by the state to provide Medicaid services.

Medicaid could see an additional $30 million in savings should the federal government extend the enhanced federal matching rate through the end of the year, a decision that doesn’t have to be made until July 25. Officials are hoping to delay implementation of the Medicaid changes to Oct. 1, at which point they would have more information about their funding situation.

Whitley, asked where Medicaid would put the extra $30 million, said that it was a difficult question to answer.

“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.”

Public and behavioral health

Another $19.1 million in cuts have been proposed to public and behavioral health care programs in the state, with the majority coming from the Southern and Northern Nevada Adult Mental Health Services agencies. 

Some of the savings will be achieved by freezing hiring vacant positions within both mental health agencies. But Southern Nevada Adult Mental Health Services also plans to stop providing residential services to 270 people, referring them instead to other organizations, such as Catholic Charities and Share Village, unless they receive additional funding through the federal CARES Act.

The state has shifted the way it provides mental health services over the past several years, putting the emphasis on enrolling people in Medicaid and directing them to private providers, instead of having the state directly provide services. But Sen. Julia Ratti noted during the hearing that stripping back direct mental health dollars, coupled with the cuts to Medicaid, could essentially mean the state will only be providing mental health services to its prison population.

“With the cuts that we’re talking about here, and then you pair those with the cuts to substance use treatment and mental health that we talked about in the Medicaid budget, and then you overlay housing, and the tenancy support … I feel like maybe we’re reverting back to a place where if you really need behavioral health services, you almost have to be part of the criminal justice to access them,” Ratti said. “It feels like we're heading towards a perfect storm.”

Lisa Sherych, administrator of the Division of Public and Behavioral Health, agreed.

“These are extremely difficult decisions to make,” Sherych said, choking up. “I was very hopeful that this next session was going to be a great one based on last session. So, yes, our focus is primarily going to be the justice-involved population.”

Other cuts to public and behavioral health will come in the form of $1.6 million in cuts to rural clinics, in the form of deferred start dates for staff, $1.5 million in tobacco prevention dollars approved last session, $1.6 million in problem gambling dollars and $2.3 million in sweeps from other funds.

Aging and disability services

State officials plan to find another $30.2 million by freezing caseloads for some of its Aging and Disability Services programs, including, notably, its Autism Treatment and Assistance Program, to the tune of about $5.7 million in savings. 

The Legislature appropriated $17.4 million toward the program last session, including funds to reduce a roughly 800-child backlog in a program that was only serving about 200 children. Now, the program has 892 children enrolled in it, with 191 on the waitlist — but those levels would be frozen under a proposed budget cut, though children will still be moved into the program at its current capacity as children age out or move.

Three other programs will also have their caseloads capped, including supported living arrangement services, which provide residential support to people so they can live in a community-based setting. The division has also proposed deferring a provide rate increase for SLAs, reducing payments for other programs, freezing vacant positions, eliminating travel and training and deferring maintenance on facilities.

Other cuts

Another $18.4 million in savings will come from Director Whitley’s office, including $1.5 million of the $6 million in family planning dollars lawmakers appropriated in the 2019 session. The remainder will come from funds swept from the Healthy Nevada Fund, which was set up with tobacco settlement dollars to fund certain health grants.

The Division of Welfare and Supportive Services plans to contribute another $15.7 million in budget reductions, primarily through funding the salary cost for eligibility workers through December through the federal CARES Act, about $14 million in general fund savings. The rest is proposed to come from a reduced general fund match in child support and other administrative changes.

The Division of Child and Family Services will be responsible for the rest of the budget reductions, about $9.4 million. The majority of that, $5.1 million, will come from changes to child welfare, including a reduction in funds to incentivize Clark and Washoe counties to innovate their child welfare funding streams. Another $3.7 million will come from freezing 53 vacant juvenile correction positions and reducing the number of beds at juvenile correction facilities from 224 to 160.

Even with the reduction, Ross Armstrong, the division’s administrator, said that there should be enough beds to meet the needs, with an average daily census for calendar year 2019 of 157.

“Across the country now for about the last decade, there's been a big push in reducing the number of young people we have locked up in correctional air, and that has occurred in Nevada as well,” Armstrong said. “We made sure we didn't cut the funding to the counties that work on the prevention work, we didn't cut parole, who does the aftercare to prevent them from going back into the facility, and we also maintained all of our children's mental health beds.”

State officials detail increased demand for public assistance, response to nursing home outbreaks at legislative health meeting

State officials projected Wednesday that nearly a quarter of the state’s population will be enrolled in Medicaid, the public health insurance program, by the end of May as the state weathers an unprecedented economic crisis amid the ongoing coronavirus pandemic.

Those projections came at a Wednesday meeting of the interim Legislative Health Committee, where lawmakers received updates from state officials on the apparently improving coronavirus situation in Nevada, the increased demand for public assistance and an expansion of the state’s volunteer behavioral health workforce, among other topics.

A cadre of state health officials, including top administrators within the state’s Department of Health and Human Services, detailed for lawmakers how the department is responding to the novel coronavirus at the group’s first meeting since the pandemic began. That response includes everything from keeping an eye on the state’s nursing homes, which have emerged as a hotspot for COVID-19 outbreaks, to taking advantage of flexibility from the federal government to expand public assistance programs.

State health officials were also forward looking in their assessments, including detailing for lawmakers what legislative changes might be needed down the road. Richard Whitley, director of the Department of Health and Human Services, listed improving the state’s ability to track deaths in real time and boosting Nevada’s lab testing capacity as two of his top priorities.

“I think to be better prepared to have some of these things in place so that we could activate them and not sort of stand them up while we're trying to deal with a crisis would be helpful,” Whitley said.

But the biggest overall need, Whitley said, is for public health funding.

“We don't invest much general fund into public health, and it's not identified until it's needed,” Whitley said. “I mean it's clean air, clean water, safe food, and until it goes wrong, it's not really valued by many people.”

Below, The Nevada Independent explores some of what was discussed at the meeting.

Increases in Medicaid, SNAP and TANF caseloads

Unemployment rates have skyrocketed in Nevada and across the nation as states required nonessential businesses to close their doors to reduce the spread of the novel coronavirus. It is unsurprising, then, that the demand for public assistance in Nevada is up as well, though the increases they have seen have not been as extreme.

Data presented to lawmakers on Wednesday show that about 760,000 people will be enrolled in the state’s Medicaid program by the end of May, or about 22 percent of the state’s population. As of April, there were about 670,000 people enrolled in the public health insurance program statewide, about 3.4 percent more than the previously projected caseload and up about 3.7 percent from March’s totals.

However, state health officials noted that while Medicaid enrollees are up, utilization of non-COVID medical care may be down. Suzanne Bierman, the administrator of Nevada’s Medicaid program, said that preliminary data show “deep reductions” in dental services, primary care and pediatric vaccination rates, though there is a lag in reporting medical claims that makes it difficult to make any definitive conclusions yet.

“We are definitely seeing those sorts of decreases in utilization, it's just given claims lag and a number of other factors, we don't really have complete or reliable data yet,” Bierman said.

Medicaid covers all medically-necessary services related to COVID-19, including testing, treatment and hospital care.

Medicaid has also made or plans to make a number of changes to its program in the time of the pandemic. For instance, the state Medicaid program is asking the federal government to reimburse 100 percent of COVID-19 testing for a new uninsured eligibility group. It is also asking for COVID-19 testing and treatment to be covered for undocumented individuals and other non-citizens.

Bierman framed the changes as “one critical part of doing what we can to secure the flexibilities needed from the federal government to make sure that we are keeping access to services available and doing everything that we can to support providers in terms of leveraging additional flexibilities through the program during this time.”

At the same time, caseload for the Supplemental Nutrition Assistance Program, or SNAP, was up by about 2.7 percent of projected levels, at about 430,000 SNAP recipients as of March, or about 14 percent of the state’s population. The state’s analysis shows that actual SNAP enrollments are following the state’s worst case projection, which anticipates about 490,000 people enrolled in the program by the end of May.

Steve Fisher, administrator of the Division of Welfare and Supportive Services, told lawmakers that the state has issued $56 million in emergency allotments to about 140,000 SNAP households in March and April. He said that the additional funding has gone toward providing additional benefits to households that had not yet reached their max allotment.

Fisher also noted that beginning around the first week of June, SNAP recipients in Nevada will be able to use their benefits to purchase food online through Walmart and Amazon and have it delivered at no charge. 

A third change is allowing the state to provide temporary emergency SNAP to children who lost access to free or reduced price lunches at school; families can receive $5.70 a day for each school day their child misses, expected to total about $228 per child. More than 324,000 children across Nevada are expected to qualify for the benefit, costing about $74 million.

Other adjustments being made to the SNAP program include suspending work requirements for able-bodied adults without dependents and allowing SNAP recipients to substitute different kinds of milk if the eligible products are not available for purchase.

A third public assistance program, Temporary Assistance for Needy Families, or TANF, is about 7.3 percent above the legislatively approved caseload for April at about 22,000 recipients enrolled, or less than 1 percent of the state’s population. However, it does represent a 10.3 percent increase in enrollees since March. The state projects that 24,000 people will be enrolled in the program by the end of May.

For comparison, 462,396 people filed a new unemployment claim this year, which represents about 30 percent of the state’s workforce, and Nevada’s insured unemployment rate — the rate of people who are eligible for unemployment benefits who are unemployed — stands at 23.5 percent, up from 1.4 percent pre-pandemic.

Fisher said that there is now continuous eligibility for all three assistance programs, meaning that anyone who was eligible for any of the programs in March cannot be terminated unless they left the state voluntarily or voluntarily removed themselves from the program.

COVID-19 updates

Kyra Morgan, the state’s biostatistician, told lawmakers some good news on Wednesday morning: The state’s overall test positivity rate — that is, the number of total positives as a percentage of total people tested — has continued to decrease as testing ramps up, down to 7.9 percent as of Wednesday morning. Morgan said that if that number continues to decrease, the state will be “pretty comfortable” that it is testing everyone who needs to be tested.

“If you have a really high percentage of folks coming back positive, you know that that's an artifact that you don't have sufficient testing. It's very likely that if you have a high percentage of tests coming back positive, that means that you're still restricted in access to tests to those who are not even just symptomatic but fairly severely symptomatic,” Morgan said.

However, at this point, the state isn’t sure how many people who are testing positive are asymptomatic. Morgan said that disease investigators in Southern Nevada have faced such a high volume of positive cases that they have not been able to contact every positive patient individually to track their symptoms and the onset date of their symptoms.

“We don’t have that information on every single case,” Morgan said.

There is another piece of good news, though. Though Nevada saw big spikes in the growth of COVID-19 cases and deaths at the beginning of the pandemic, the growth rate has leveled off. Morgan said that the number of new cases has grown by about 1.6 percent daily over the last week, while the number of deaths has grown about 1.1 percent daily.

“This means that social distancing and restrictions have worked. Models indicate a very high likelihood that Nevada reached our peak in the number of new cases being recorded daily, and we've actually been declining in new cases since the end of April,” Morgan said.

However, she noted that models assume continuation of current control measures and that as the state starts lifting the restrictions it has put in place, it expects to see more cases.

“We realized in DHHS that outbreaks will continue to happen, but the goal is to be able to contain those outbreaks,” Morgan said. “At this point, Nevada has built the infrastructure required for our health care and our public health systems to be able to adequately respond.”

Morgan also told lawmakers that while some people have assumed that COVID-19 deaths are being overreported, she said the opposite is the case in Nevada, which only counts COVID-19 deaths that have been laboratory confirmed. That means the total could be missing people who died at home because of complications associated with the virus without ever getting tested, or other individuals who for whatever reason were not tested.

“Everyone here that’s attributed here to COVID-19 as having a death is in fact a confirmed laboratory positive COVID case,” Morgan said. “Most of these are also dying during their hospitalization, which is directly related to COVID as well.”

Whitley also told lawmakers on Wednesday that the state has not yet had a reported case of a new multisystem inflammatory syndrome affecting children with COVID-19, though it has taken the steps necessary to track it. Assemblywoman Robin Titus, a doctor by trade, told committee members that she had received guidance from the state on what to look for to spot the new syndrome.

“The goal here is just education and keeping us aware and keeping our feelers out, our antennas up and making sure that we don't get complacent about this that, yes, kids can get this and, and we may see an emerging process of this disease,” Titus said.

Nursing home issues identified

So far, three outbreaks of COVID-19 in congregant living facilities have been in Northern Nevada — Willow Springs, a residential treatment facility in Reno; Lakeside Health and Wellness, a nursing home in Reno; and Arbors Memory Care, an assisted living facility focused on memory care in Sparks. A fourth, at the Heights of Summerlin nursing home, was reported by the Las Vegas Review-Journal on Wednesday afternoon.

Whitley, speaking to lawmakers earlier in the day on Wednesday, said the outbreaks have been largely attributed to three specific violations of best practices for infection control, including improperly worn personal protective equipment, the lack of isolation of patients who were infected and improper hand washing. He said that the state has a team of health inspectors and epidemiologists that go into each facility as soon as a case is identified to make sure they are following best practices to limit the spread of the virus.

“Those are all sort of improvable behaviors that could occur in the facility,” Whitley said. “So actions were taken, the issues identified, corrective action put in place.”

In the case of Arbors Memory Care, Whitley said that an infected patient, who was known to wander, wandered through the facility. The state has also identified a list of high-risk facilities that have had known infection control violations in the past to inform its regulation, Whitley said.

The good news, Whitley said, is that deaths in Nevada nursing homes only account for about 20 percent of the state’s COVID-19 deaths, where they have accounted for more than 50 percent in other states. Nationally, one-third of COVID deaths have been linked to nursing homes.

“There have been these three big outbreaks in Northern Nevada, but overall the state is doing well,” Richard said. “I think we're being responsive, we get a team in there, we make the corrections. That's not always as transparent.”

The hard part has been communicating with the loved ones of those inside who are no longer allowed to visit because of the potential to unknowingly introduce the virus to the facility. Whitley said that the state has encouraged and made available videoconferencing to facilities, but acknowledged that can’t replace face-to-face visits.

“Nothing replaces being able to be present with a loved one in a facility, and this is where our regulatory role to protect the patient and the spread of the disease does override that accessibility piece of people entering into the facility,” Whitley said.

Other services provided by the state

Like Medicaid and the Division of Welfare and Supportive Services, the Aging and Disability Services Division has also asked the federal government for additional flexibility in the time of the pandemic. 

For instance, services that were once required to be provided in a congregant setting, such as jobs and day training, can now be provided at home, guardians and spouses, who serve as someone’s legally responsible individual, may now provide in-home services, and support services, such as helping someone with personal hygiene tasks, can be conducted via a phone call or FaceTime prompt.

At the same time, the aging side of the Aging and Disability Services Division has partnered with community-based services, clinical providers and the Nevada System of Higher Education to form the Nevada COVID-19 Aging Network, or Nevada CAN. The network is focused on using its team of more than 120 student and community volunteers to connect with elderly individuals to check in on their needs and connect them with services, including telemedicine and food delivery, as needed.

“This group is a collaboration of folks trying to make sure that seniors have the ability to continue to stay connected to one another, continue to stay connected to their family members, their community, and those types of activities,” said Dena Schmidt, the division’s administrator. “Our goal was to be able to make sure that seniors and vulnerable populations have the ability to stay home and stay safe.”

Schmidt shared the story of a 76-year-old man and his wife who live in Southern Nevada but have no family in town. The police had been conducting regular wellness checks on the couple, but those stopped once the pandemic hit.

“When he called our agency and spoke to the social services support group, he basically indicated that without somebody calling, nobody would know if he was alive, which was heartbreaking for us,” Schmidt said. “And so we connected him to our one-on-one checks, and they are enjoying those conversations with a volunteer and making sure that they're staying connected.”

Volunteers are stepping up on the behavioral health side of the equation too. Stephanie Woodard, the state’s senior advisor on behavioral health, told lawmakers that the state has set up a mental health counselor volunteer pool, which has signed up 53 individuals with another 40 being researched, and a psychological first aid volunteer pool, with 63 people who have been accepted and another 66 being researched, as part of the state’s SERV-NV, or State Emergency Registry of Volunteers-Nevada, program.

“We really do try to stand at the ready so that if there is a need by local jurisdiction for specific resources, in this case, psychological first aid counselors, as well as mental health counselors, that they can submit a request for those resources and then we can push out that request to all of the individuals that are in SERV-NV, and they can then volunteer specifically to answer that request,” Woodard said.

Woodard said that the state held a psychological first aid training in early April that saw 500 registrants and 320 people actually finish the two-day course.

It’s part of the state’s efforts to prepare for a surge in demand for behavioral health services, Woodard said. Other steps the state is taking include securing grant funding from the federal government to expand access to mobile crisis services for children, boost crisis counseling services and support suicide prevention efforts.

“All of us have been impacted by isolation and stay at home orders, as well as just the changes to our day to day life,” Woodard said. “When we try to establish what is the population of focus when responding to a disaster. We need to look very globally, when we're talking about a pandemic, knowing that every citizen has been impacted in one way or another.”

Nevada gave millions in tax incentives to businesses with many employees on Medicaid

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

Gov. Brian Sandoval called it a “major boost for Southern Nevada.” Las Vegas Global Economic Alliance CEO Jonas Peterson said it marked a “reflection of our friendly business climate, favorable workforce, and aggressive approach in recruiting companies.”

News of Sutherland Global Services’ 2016 expansion into Las Vegas was met with wide acclaim by state leaders and economic development officials, who touted the company’s decision to build and expand a business center that came with the promise of 2,163 full-time jobs. Sutherland’s decision was aided by roughly three-quarters of a million dollars in tax abatements approved for the company by the Governor’s Office of Economic Development.

Since then, the company has indeed created thousands of jobs — but it’s still costing the state today.

In 2018, the state reported that 1,024 of the company’s employees earning full-time wages and 1,116 of their dependents were on Medicaid — the state-run health insurance program for low-income Nevadans — at a cost of upwards of $5.7 million a year to taxpayers. (Those numbers include any employees who worked full-time for Sutherland as well as those who made the equivalent of full-time wages but may have split their time between Sutherland and another company.)

Sutherland, which didn’t respond to a request for comment, isn’t alone. According to an analysis by The Nevada Independent, more than 60 businesses given tax incentives by the state over the past four fiscal years had about 13,000 employees — and their dependents — enrolled in Medicaid in 2018, with the government spending upwards of $34.5 million to care for them.

Those funds aren’t all state dollars — the federal government pays about 65 percent of costs for the traditional Medicaid program and 93 percent for those covered under Medicaid expansion — but it still represents a sizeable hit to the state’s general fund budget.

Data showing that thousands of companies have shifted at least some of the burden of providing health insurance to their employees to Medicaid, compiled as a result of 2017 legislation from Democratic state Sen. Yvanna Cancela, comes as lawmakers and national groups debate the effectiveness of tax incentive programs, as well as structural issues that make employer-sponsored health insurance more expensive and less accessible than it was in the past.

“I would have concerns that we're giving a company a privilege of a tax abatement but yet we're picking up the cost of health care for their employees,” Democratic Assemblywoman Maggie Carlton said. “That's just not a good deal for the state.”

Economic incentives

Since its major overhaul in 2011, the Governor’s Office of Economic Development (GOED) has been active in granting tax incentives and a variety of abatements on property, sales and real estate taxes to businesses that meet certain qualifications of job growth, wages and capital investment.

In total, the state has granted more than $395 million in tax abatements and “Catalyst Fund” grants from the state to incentivize nearly 170 companies over the past four fiscal years, many of which have few or no employees receiving government-backed health insurance. That total doesn't even include a $1.25 billion special tax incentive, abatement and credit package approved by lawmakers for Tesla in 2014.

To receive economic incentives, companies are required to pay at least 65 percent of health insurance costs and meet requirements set out by the Affordable Care Act for large employers, including offering a health insurance plan with an employee premium no more than 9.86 percent of their household income. Even so, those plans can be pricey for minimum wage workers trying to make ends meet, especially if they have high deductibles, copays and coinsurance.

Many of the more than 60 employers who received tax incentives and were listed as having a large number of full-time equivalent employees on Medicaid have large-scale warehouses or logistics and distribution centers in the state.

A prime example is Amazon, the employer with the third highest number of people on Medicaid in the state, which received a $1.8 million tax incentive in 2016 for construction of a logistics center in Clark County.

According to the application, the company planned to employ 1,000 full-time employees at the center at an average hourly wage of $14.64. Although Amazon met GOED’s required standards for annual out-of-pocket maximums — $4,000, beneath the $6,000 threshold at the time — and covered 78 percent of employee health insurance costs, the company’s average annual wage was just a little more than $30,400 a year. If that was the sole income source for a family of four, they would be considered below the poverty level and eligible for Medicaid.

Amazon did not respond to a request for comment for this story.

A similar situation occurred for customer service company Sitel, which in 2016 received $136,000 in tax incentives to expand operations in Las Vegas by hiring an additional 153 employees at an average wage of $15.49. But the company — which also didn’t return a request for comment — pays for only 65 percent of employee health insurance costs, with out-of-pocket maximums for employees running up to $6,350 per year and premiums costing 8.6 percent of annual wages. As with Amazon, a family of four would be considered to be eligible for Medicaid if that $15.49 an hour wage was the household’s sole source of income.

Even Tesla, which received a record-breaking $1.25 billion mix of tax incentives, abatements and credits from the state in 2014, is high on the list of employers with workers on Medicaid. In 2018, the company had 426 employees and 439 dependents on Medicaid — the 13th highest total for any employer in the state.

Derek Armstrong, deputy director of the Governor’s Office of Economic Development, said that the office does not directly track any relation between companies receiving incentives and the number of employees on Medicaid. But he said that the number of companies receiving tax breaks with employees on government health insurance was concerning.

“If they're hiring one person, and it's the sole income for a family, is it possible that somebody making $15 or $16 an hour could then qualify if they have a family of five or more?” he said. “I think it might be possible. I wouldn't rule out that possibility.”

Armstrong said the agency can’t pick winners and losers, noting that it’s required to approve any applications that meet standards laid out in state law, regardless of how close to the cutoff line they are in terms of average wage or size of investment.

Republican state Sen. Ben Kieckhefer said the initial creation of the tax incentive menu offered by the state came during a period of such high unemployment that “we needed jobs, period.”

“We have since made changes to our incentives structure to increase wage thresholds and things like that based on various unemployment rates. So we've tried to make it more difficult to qualify for incentives as the labor market has tightened,” he said.

Trends in employer-sponsored health insurance

For companies, the cost of providing health insurance to employees has become an increasing burden as premium increases outpace wage growth. According to a recent Kaiser Family Foundation report, the average employer-sponsored health insurance premium in 2018 was $6,896 for a single person, a 3 percent increase over the prior year, and $19,616 for family coverage, a 5 percent bump. In the same time period, wages grew about 2.6 percent.

In Nevada, those premiums are only a little lower: $5,756 for a single person and $17,221 for family coverage, according to a 2017 fact sheet from the State Health Access Data Assistance Center.

Employers have long offered health insurance as a benefit in order to keep their employees happy. But Gary Claxton, a vice president at the health policy non-profit Kaiser Family Foundation, said that companies may make the cost-benefit analysis that higher wages are going to make their workers happier than better health benefits.

“If they can go on Medicaid and it doesn’t cost you anything, why would you take some of their compensation that could go to wages and turn it into health benefits they can’t appreciate anyway because they’re not very good?” Claxton said.

Last year, nearly 230,000 full-time workers in Nevada and their children received care through Medicaid, which provides health insurance to families making up to 138 percent of the federal poverty level, and Nevada Check Up, the equivalent program for children in families that make up to 205 percent of the federal poverty level. A family of four needs to make $35,535 a year or less to qualify for Medicaid and $52,788 or less for Nevada Check Up.

With Medicaid caseload sitting at about 670,000, that means that roughly a third of Nevadans covered by the state’s health-insurance program for low-income individuals were either adults working full time or their children. (Medicaid also covers pregnant women, the elderly and people with disabilities.)

The state’s latest report on Medicaid recipients working full time concluded that caring for these full-time workers and their children cost the state $638.5 million in 2018. The average company with 50 or more employees had 26 employees and 30 dependents on Medicaid.

Suzanne Bierman, the state’s Medicaid administrator, said the data speaks to some of the challenges of rising insurance premiums for workers, and the way that Medicaid, which was expanded in 2014 to fill in historical eligibility gaps for adults, has stepped in.

“It really shows the importance of expansion, especially when you look at some of the affordability issues that go hand in hand with employer-sponsored insurance,” Bierman said.

Nationwide, a shrinking number of working-age adults are covered under health insurance plans offered by their employers. A little less than three in five nonelderly adults were covered under employer-sponsored health plans in 2017, down nine percentage points from the turn of the millennium, according to the Peterson-Kaiser Health System Tracker.

Kieckhefer noted that businesses have to juggle other labor costs — including federal and state taxes — beyond just the hourly wage paid to workers.

“Mandates for health insurance on top of that add significant cost,” he said. “So when someone's making $10 an hour, the cost to that employer is a lot more than just $10.”

The situation is worse for the lowest-income workers, whose wages put them beneath the federal poverty line. Only 33.2 percent of people below the poverty line are covered by employer-sponsored health coverage.

The Affordable Care Act, by requiring large employers to offer affordable health insurance to their full-time employees and dependents, provided a small boost to the employer-sponsored insurance market. But rising premiums with high employee contributions have left those plans out of reach for some of the lowest-paid workers, with the average employee contribution to health insurance in Nevada for individual coverage at $1,255 a year and family coverage at $5,528.

For context, someone working full time at a $7.25 an hour minimum wage would only make about $15,000 total in an entire year.

To address those concerns, the ACA defined “affordable plans” as those that don’t exceed 9.86 percent of the employee’s household income for individual coverage. But those plans, while required to cover all of the ACA’s essential health benefits, can be less protective of catastrophic expenses, and come with high deductibles, coinsurance and copays that low-income workers can’t afford.

Given a choice between a high deductible employer-sponsored plan they have to pay for and Medicaid, which they don’t, many workers are going to choose Medicaid.

“Everyone would like to have health insurance, but you’d also like to eat and you’d also like to have a place to live. That’s not going to be their first choice,” Claxton said. “They need to feed their kids and get them to school and all those things.”

Looking forward

After several sessions of expanding and creating new tax incentives, lawmakers in 2019 appear eager to see the pendulum swing back and take a more critical look toward how the state offers tax breaks.

In addition to two bills reducing abatements or adding oversight, legislators said they were eager to take a more critical look at the overall effectiveness of abatements. Democratic Assemblywoman Dina Neal is sponsoring AB444, which would create a legislative committee to regularly review and oversee existing tax abatement programs offered by the state.

“Instead of this report … that we see every two years, it’s going to create a committee to do a deeper dive,” she said.

Although a similar concept backed by former Assemblywoman Irene Bustamante Adams failed to make headway last session, Neal said she thought the 2019 version had more support among legislative leadership. She said she was still reviewing the connection between companies granted incentives and employees on Medicaid, but said her initial reaction was concern.

“We want to know if the wage that is being paid to those employees is pretty much keeping them in poverty,” she said.

In 2017, Nevada’s oversight of tax abatements was described as “trailing” by the Pew Charitable Trust, which identified 31 other states that have some structure in place to regularly review tax incentives. Chaaron Pearson, a Pew researcher who helped compile the report, said state budgets generally benefited by the regular review, especially as economies change over time.

“A lot of times, these incentives get baked into the tax code and so they're there in perpetuity,” she said.

Additionally, Democratic Assemblywoman Teresa Benitez Thompson is sponsoring AB400, which would prevent GOED from approving any new abatements reducing the local school support tax, and prohibit any double-dipping from companies applying more than once for abatements related to a business expansion or initial move to the state.

Carlton, chair of the powerful Assembly Ways and Means Committee, said that there isn’t any appetite at this point for additional tax abatements. If there ever were in the future, she said that “there would be much stronger language in there about making sure that the state didn’t pick up the tab.”

“I would hope that we would stop this race to the bottom on tax abatements,” Carlton said. “We don't necessarily want everybody in our state. If they're not a good corporate citizen and they're not going to take care of the citizens of the state, if you're going to be more of a burden than an asset, then we need to re-evaluate.”

Cancela, sponsor of the bill that created the report on employers and Medicaid, said it’s a different conversation when talking about small businesses and startups trying to make ends meet than it is for the “Walmarts of the world.” Walmart has the most workers and dependents on Medicaid in Nevada — 6,464 in total — which cost the state $18.6 million in 2018, although the company has not received any recent tax abatements.

But she said that the state shouldn’t be sacrificing Nevadans’ financial stability or ability to access affordable health care when it decides to bring new companies and jobs here.

“It should be about quality economic development and not just quantity,” Cancela said.

Think tank fellow hired to lead Nevada's Medicaid program

A health-care fellow at a Nevada think tank has been hired to oversee the state’s division overseeing Medicaid and low income children’s health insurance

According to the state’s website for the Division of Health Care Financing and Policy, which oversees the state programs for Medicaid and Children’s Health Insurance Program (CHIP), Suzanne Bierman will serve as administrator of the department. Cody Phinney, previously the acting administrator, is now listed as a deputy administrator for the division.

According to her biography, Bierman most recently worked as a fellow at the Guinn Center for Policy Priorities and worked at a Las Vegas federally qualified community health center. She also spent five years as the Assistant Director of Arkansas’ Medicaid program, helping the state expand its Medicaid population under provisions of the Affordable Care Act.

The division oversees both Medicaid and Nevada’s version of CHIP, called Nevada Check Up, which provides health-care benefits to uninsured children below 200 percent of the federal poverty level.