From health care transparency to a public option, lawmakers largely drilled into non-pandemic health care issues in 2021 session

When lawmakers kicked off their 120-day legislative session in February, the state was still recovering from a brutal winter surge of COVID-19, which saw a thousand new cases of the virus reported across the state each day.

Lawmakers early in the session came forward with some modest proposals to address the pandemic — including a bill to give workers paid time off to get vaccinated — but it was unclear at that point what COVID-19’s trajectory in the Silver State would be. With an influx of federal financial support boosting the state’s pandemic response, it wasn’t always easy to tell where lawmakers could be of most help. With sessions slated for only 120 days every other year, it also wasn’t clear they could craft policy responsive enough to the ever-changing needs created by the pandemic.

Instead, lawmakers generally focused on a host of other important, but perhaps less high-profile, health care proposals, from legislation to support the provision of telehealth services in the state, which became all the more popular during the pandemic, to a bill that would provide for Medicaid coverage of community health workers. They also honed in on data transparency, hearing bills that would make changes to the state’s drug pricing transparency program and establish an all-payer claims database in an effort to better understand the health care landscape in the state.

Lawmakers also took up a last-minute bill to establish a state-managed public health insurance option in Nevada, the second-ever to be approved in the nation. Despite reservations from Republican lawmakers — and even from some Democrats — the Legislature introduced and approved the bill in just a little more than a month with some strong-arming by Senate Majority Leader Nicole Cannizzaro (D-Las Vegas), who spearheaded the legislation. 

Behind the scenes, there were frustrations, though, among health care lobbyists. Industry lobbyists, for instance, were caught off guard that Cannizzaro hadn’t involved them in the process of developing the public option bill and dropped the proposal on them in the final weeks of the session.

“I can tell you that when there are very challenging things that occur within health care, when you lock us all in a room, we tend to find solutions,” Tom Clark, lobbyist for the Nevada Association of Health Plans, said during the bill’s first hearing.

Bobbette Bond, policy director for the Culinary Health Fund, also said it was difficult to craft good policy in a legislative environment so heavily shaped by the pandemic. For much of the session, the legislative building was closed to the public and committee meetings were only able to be attended virtually.

“It was hard to get revisions made. It was hard to have good conversations about what could be done. It was hard to build stakeholders,” Bond said. “It was hard to communicate, and I think the policy suffered for that.”

Bond also expressed dismay in the two-thirds requirement for passing tax increases, on the grounds that it has prevented lawmakers from tackling more ambitious health care legislation. Because there isn’t more funding to go around, including to support health care, she said lawmakers have turned to putting mandates on industry.

“The mandates … end up substituting for actual public health policy,” Bond said.

The Culinary Health Fund, which is the health insurance arm of the politically powerful and Democratic-aligned Culinary Union, did, however, continue to play a significant role in shaping health care policy this session with Democrats remaining in control of both chambers of the Legislature. Other industry representatives, who often work collaboratively with Democratic lawmakers but more often align with Republicans on business priorities, had less of an upper hand.

Mike Hillerby, a longtime lobbyist on health care issues in the state, said Nevada loses “a lot of subtlety in the public policy debate” when the discussion is “driven by the relationship between a couple of unions and a couple of hospital chains.”

“That drives so much of what we do, and it's so contentious. Look at balance billing from 2019. Look at some of the stuff this time, and everything's driven by that. That's not indicative of the market and the rest of Nevada. That's not indicative of what's happening with providers and patients and payers in rural Nevada, in the Reno area, and yet so much of it is driven by that and that financial reality, that bargaining relationship, those contractual relationships,” Hillerby said. “We just lose a lot of the subtlety and the ability to make better decisions.”

Here’s a look at some of the health policies that passed this session and others that didn’t.

Gov. Steve Sisolak signed several pieces of public health-related legislation into law in Las Vegas on Wednesday, June 9, 2021. (Jeff Scheid/The Nevada Independent)

Public option

The highest-profile piece of health care legislation to pass this year, SB420 — Nevada’s public option bill — was introduced with just a little more than a month left in the legislative session by Cannizzaro, the Senate majority leader. Proponents were quiet about the legislation for the first couple of months of the session until Cannizzaro was asked by a reporter in mid-April about the proposal and health care lobbyists started receiving briefings from consultants on the concept.

The bill, which builds upon previous public option proposals introduced in Nevada in 2017 and 2019, aims to leverage the state’s purchasing power with Medicaid managed care organizations — private insurance companies that contract with the state to provide coverage to the state’s low-income population — to get insurers to also offer public option plans. The plans will resemble existing qualified health plans on the state’s health insurance exchange, though they will be required to be offered at a 5 percent markdown with the goal of reducing the plans’ premium costs by 15 percent over four years. The plans won’t be offered for sale on the exchange until 2026.

The proposal cleared both the Senate and Assembly on party line votes and was signed into law in early June by Gov. Steve Sisolak, making Nevada the second state in the nation after Washington to enact a state-based public health insurance option into law. Colorado became the third state to establish such a policy in mid-June.

Though the legislation was heavily opposed by the health insurance industry — with some groups running ads and sending mailers opposing the proposal — Cannizzaro muscled the bill through the Legislature as the clock counted down to the end of the 120-day session. The bill easily cleared the Senate — where Cannizzaro, as majority leader, controls which bills come to the floor — and Democratic leaders in the Assembly threw their support behind the bill shortly thereafter, setting aside concerns about whether the bill can accomplish its goals of improving health care access and affordability.

“It's not a secret I have been skeptical of this bill from the very beginning, but I've seen the amendments, and I have talked to a number of the different proponents of the bill and opponents of the bill on it,” Assembly Ways and Means Chair Maggie Carlton (D-Las Vegas) said in late May, shortly before allowing the bill to be voted out of her committee. “I feel much more comfortable knowing that, in the future, the people that are in this building now that do come back are well aware of what's going on, and I trust them to make the best decisions they can to protect the constituents of this state.”

In her remarks, Carlton was referring to the long runway the bill establishes before the public option actually goes into effect, leaving time for the state to conduct an actuarial study to figure out whether the bill actually accomplishes the goals it sets out to and two legislative session in 2023 and 2025 for lawmakers to make any tweaks to the policy as necessary.

Heather Korbulic, who as head of the state’s health insurance exchange will have a key role in shaping the policy’s implementation, has said she plans to bring stakeholders together to “outline the actuarial study and conduct a meaningful analysis of the public option as it relates to every aspect of health care throughout the state.” 

Richard Whitley, director of the Department of Health and Human Services, said in an interview earlier this month that the public option isn’t “a single solution” but “does definitely enhance the opportunity for individuals to gain access to health care.”

“I think of this as an option for coverage,” Whitley said. “It definitely enhances that overall framework of health care coverage.”

Nuclear medicine technologist Vanessa Martinez, views scans at Lou Ruvo Center of Brain Health, on Tuesday, June 11, 2019. (Jeff Scheid/The Nevada Independent)

Transparency and data efforts

For the last two legislative sessions, lawmakers have focused on prescription drug cost transparency, passing a first-in-the-nation diabetes drug transparency law in 2017 and expanding that law to include asthma drugs in 2019. This year, lawmakers built upon those transparency efforts by passing legislation requiring transparency from more portions of the health care industry.

This year, lawmakers approved a bill, SB40, to establish what’s known as an all-payer claims database — a state database of claims of medical, dental and pharmacy services provided in the state. The law requires all public and private insurers regulated under state law to submit their claims to the database and authorizes insurers governed by federal law — such as the Culinary Health Fund — to submit their claims to the database. A similar bill proposed during the 2019 legislative session failed to move forward in the final minutes of that session, though the concept was revived by the Patient Protection Commission, which brought SB40 forward this session.

The bill, however, required extensive work when it got to the Legislature, with state Sen. Julia Ratti (D-Sparks) taking the bill under her wing as chair of the Senate Health and Human Services Committee and working with industry advocates — including the Nevada Association of Health Plans, the Nevada State Medical Association and the Nevada Hospital Association — to finalize the legislation.

“We knew the bill was going to pass, at some level ... so we wanted to make sure that the information that was going to be collected was accurate, was consistent with what was required in other states that had all-payer claims databases and also to learn from what those other states had done so we wouldn’t make the same mistakes,” Clark, the Nevada Association of Health Plans lobbyist, said. “Fortunately, Senator Ratti and others were good to work with and we’re comfortable with the way the bill passed.”

The legislation additionally makes data contained in the all-payer claims database confidential, meaning that it is not a public record or subject to subpoena, and specifies how the information contained in it can be disclosed. It can be shared in de-aggregated form to state or federal government entities, including the Nevada System of Higher Education, and any entity that submits data to the database. Anyone else looking to obtain the data can only receive it in aggregated form by submitting a request to the Department of Health and Human Services.

Lawmakers also built upon the diabetes and asthma drug transparency bills passed in 2017 and 2019, respectively, by expanding the universe of drugs the state imposes transparency requirements on. SB380, which was proposed by an interim committee created during the 2019 session to study prescription drug costs, requires the state to compile a list of prescription drugs with a list price that is more than $40 for a course of therapy that has undergone a 10 percent price increase in the preceding year or a 20 percent increase in the two prior years.

The legislation requires drug manufacturers to submit a report to the state explaining the reason for the price increase and explaining the factors that contributed to the price increase. Meanwhile, pharmacy benefit managers, or PBMs, the middlemen in the drug pricing process, are required to submit their own reports with certain data about the drugs, including rebates negotiated with manufacturers and the amount of the rebates retained by the PBM.

The state’s drug transparency program will also, for the first time, have funding behind it, utilizing dollars that have been collected in the form of fines paid by companies for not complying with the state’s drug transparency law. The Department of Health and Human Services put a $780,000 fiscal note on the bill to allow state health officials to transfer the existing drug transparency database to the state’s Enterprise Information Technology Services Division and hire a pharmacist and management analyst to manage the drug transparency program.

SB380 was, however, only one of two bills put forward by the interim prescription drug committee to pass this session. The other was SB396, which allows the state to establish intra- and interstate drug purchasing coalitions with private entities. 

The three bills that did not pass were:

  • SB201, which would have licensed pharmaceutical sales representatives
  • SB378, which would have required at least half of the health plans offered in the state by private insurers to provide prescription drug coverage with no deductible and a fixed copayment and limit the total amount of copayments insured individuals are required to pay in a year 
  • SB392, which would have licensed PBMs and created additional rules for how PBMs can operate.

Nick McGee, senior director of public affairs for PhRMA, the drug industry advocacy organization, in an email expressed disappointment that lawmakers pursued SB380 this session while not advancing the other proposals out of the interim committee. PhRMA did, however, in the end testify in neutral on SB380.

“We are disappointed that the legislature overlooked this opportunity to address patients’ concerns related to their ability to afford and access the medicines they need,” McGee said. “Instead, lawmakers pursued onerous reporting and unnecessary registration requirements that won’t do anything to help patients afford their medicines and fail to provide transparency into why insurers are shifting more and more costs on to patients.”

Bond, the policy director for the Culinary Health Fund, which played a key role in bringing the 2017 bill to fruition, described SB380 as a “step forward,” though she said the bill didn’t end up “as strong as we would have liked.”

“It’s incremental, and it’s progress,” she said.

Lawmakers did not advance SB171, sponsored by state Sen. Joe Hardy (R-Boulder City), which would have barred most insurance companies from implementing copayment accumulator programs for any drug for which there is not a less expensive alternative or generic drug. Such programs prevent drug manufacturer coupons from applying toward patients’ deductibles and maximum out-of-pocket costs.

The Legislature additionally made a budgetary change to boost transparency, approving a request from the Department of Health and Human Services to centralize its data analysis efforts within the office of Data Analytics within the Director’s Office, while the Patient Protection Commission, which is focusing on health care spending and costs, was transferred from the governor’s office to Director’s Office as well.

Whitley, the department’s director, framed the reshuffling as an effort to bring together disparate health data collection and analysis efforts, adding that the pandemic showed the kind of real-time data the department could provide, as in the case of its COVID-19 dashboard, among other dashboards it now maintains.

“Usually people go, ‘We need more money.” Well, in government sometimes what you need is organizational structure,” Whitley said. “Putting data analytics all in one unit in my office … was really because of seeing all of the benefits that were coming out of monitoring the pandemic. That really served to inform what we could be doing.”

The Legislature also made a significant change to the Patient Protection Commission this session, transforming it from a largely industry-focused body to one instead made up largely of non-profit health industry representatives and patient advocates. AB348, sponsored by Carlton, requires the commission be made up of:

  • two patient advocates
  • one for-profit health care provider
  • one registered nurse who practices as a nonprofit hospital
  • one physician or registered nurse who practices at a federally qualified health center 
  • one pharmacist not affiliated with any retail chain pharmacy, or a patient advocate
  • one public nonprofit hospital representative
  • one private nonprofit health insurer representative
  • one member with expertise advocating for the uninsured
  • one member with expertise advocating for people with special health care needs
  • one member who has expertise in health information technology and works with the Department of Health and Human Services
  • one representative of the general public.

The bill also makes the Patient Protection Commission the sole state agency responsible for administering and coordinating the state’s involvement in the Peterson-Milbank Program for Sustainable Health Care Costs, a program that provides technical assistance to states developing targets for statewide health care spending trends. 

Health care industry representatives have, however, chafed at the reduction — or in the case of the drug industry, removal — of their representation on the commission. McGee, from PhRMA, said the change “[undermines] the ability of the commission to provide a comprehensive perspective.”

But Bond, a commission member whose ability to serve will be unaffected by the policy shift, said the change would give patients and consumers more of a voice.

“I understand the concerns about losing representation from the industry, but I also believe that industry has other places where they get represented,” Bond said. “They have the Nevada Hospital Association, the pharmaceutical industry has PhRMA. They get well represented in their core arena. Patients really don't have a core arena they can go to.”

The Patient Protection Commission’s other bill this session, SB5, also was approved by lawmakers, making a number of changes to telehealth in the state. That bill also contains a data transparency component, requiring the Department of Health and Human Services, to the extent money is available, to establish a data dashboard allowing for the analysis of data relating to telehealth access.

Another big bill that tried to tackle health care costs this session, AB347, sponsored by Assemblyman David Orentlicher (D-Las Vegas), died without receiving a vote. The ambitious bill, among other provisions, proposed establishing a rate-setting commission “to cover reasonable costs of providing health care services” while ensuring providers “earn a fair and reasonable profit.” The bill also would have raised Medicaid payments to Medicare levels via a provider tax.

Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko
Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko on Tuesday, April 3, 2018. (Jeff Scheid/The Nevada Independent)

Antitrust in health care

Lawmakers approved two antitrust in health care bills this session. The first one, AB47, requires parties to certain reportable health care or health carrier transactions to submit a notification to the attorney general with information about the transaction at least 30 days before it is finalized. Reportable transactions include material changes to the business or corporate structure of a group practice or health carrier that results in a group practice or health carrier providing 50 percent or more of services within a geographic market.

The bill, which was presented by the attorney general’s office, also prohibits employers from bringing court actions to restrict former employees from providing services to former customers or clients under certain circumstances and bars noncompete agreements from applying to employees that are paid on an hourly wage basis.

The bill attracted opposition from the Nevada Hospital Association and the Nevada State Medical Association. During a May hearing on the bill, Jesse Wadhams, a hospital association lobbyist, thanked the attorney general’s office for working with them on the bill but said the association still could not support the legislation.

“We believe the policy itself comes from a faulty premise,” Wadhams said. “We believe policies should promote more physicians, more access to care and more investment in the health care community.”

Another bill, SB329, requires hospitals to notify the Department of Health and Human Services of any merger, acquisition or similar transaction. It also requires physician group practices to report similar transactions if the practice represents at least 20 percent of the physicians in that specialty in a service area and if the practice represents the largest number of physicians of any practice in the transaction. The legislation, sponsored by state Sen. Roberta Lange (D-Las Vegas) and pushed for by the Culinary Health Fund, requires the department to publish that information online and write an annual report on that information.

Another section of the bill allows the attorney general or other individuals to bring a civil action against a health care provider that “willfully” enters into or solicits a contract that bars insurance companies from steering insured individuals to certain health care providers, putting health care providers in tiers or otherwise restricting insurers. It also makes such an action, known as “anti-tiering” or “anti-steering,” a misdemeanor. (A final amendment to the bill reduced the penalty from a felony to a misdemeanor.)

“I think this is one of the early steps in what will probably be a national trend,” Bond, of the Culinary Health Fund, said in an interview. “I think contract provisions are going to become more and more antitrust looking.”

The bill was opposed by the Nevada Hospital Association and individual Nevada hospital systems and hospitals.

“The technical elements of this and eliminating antitrust provisions by themselves are not the problem we have with this bill — it is making sure that it doesn’t impede the open contracting that occurs otherwise in this highly competitive environment,” Jim Wadhams, a lobbyist for the hospital association, said during a May hearing on the bill.

Tristian McArthur cares for an infant inside the Neonatal Intensive Care Unit at Sunrise Hospital on Tuesday, Dec. 4, 2018. (Daniel Clark/The Nevada Independent)

Medicaid

In perhaps the most substantial victory for health care providers this session, lawmakers rolled back a 6 percent Medicaid rate decrease approved by the Legislature during a budget-slashing special session last summer.

Legislative fiscal analysts projected the move would restore about $300 million in Medicaid funding both in the current fiscal year and in the upcoming biennium, including about $110 million in general fund spending.

“Nevada faced an unprecedented state budget crisis,” Bill Welch, CEO of the Nevada Hospital Association, and Jaron Hildebrand, executive director of the Nevada State Medical Association, wrote in a letter to the governor in May. “The work you did alongside the Nevada Legislature to restore funding to hospitals and providers will be instrumental in safeguarding the health care available to many Nevadans.”

Lawmakers made a number of other changes to Medicaid services as well, providing for coverage of doula services in AB256 and community health workers in AB191. The public option bill, SB420, also contained several Medicaid provisions, including one section providing that pregnant women are considered presumptively eligible for Medicaid without submitting an application for enrollment and another prohibiting pregnant women who are otherwise eligible for Medicaid to be barred from coverage for not having resided in the United States long enough to qualify.

On the mental health front, SB154 requires the state to apply for a waiver to receive federal funding to cover substance use disorder and mental health treatment inside what are known as institutions of mental disease — or psychiatric hospitals or residential treatment facilities with more than 16 beds. Medicaid has long been barred from paying for care in such facilities, but states were recently given the ability to apply to the federal government to cover these services through Medicaid via a federal waiver.

Lawmakers also approved AB358, sponsored by Assembly Speaker Jason Frierson (D-Las Vegas), which will allow for a more seamless transition of incarcerated people to Medicaid upon release from prison. The bill requires a person’s Medicaid eligibility to only be suspended, rather than terminated, when they are incarcerated and specifies that individuals who were not previously on Medicaid should be allowed to apply for enrollment in the program up to six months before their scheduled release date. The bill also requires eligibility for and coverage under Medicaid to be reinstated as soon as possible upon an individual’s release.

In a major victory for families of children with autism, lawmakers passed SB96, which boosts reimbursement rates for autism services.

A member of the Nevada National Guard places a swab in a container after performing a COVID-19 test at the Orleans on Wednesday, May 13, 2020. (Jeff Scheid/The Nevada Independent)

Public health

Lawmakers, by and large, did not spend much time tackling the COVID-19 pandemic head on during their legislative session, likely a byproduct of how rapidly the situation has evolved over the last six months.

Legislators did, however, approve SB209, sponsored by state Sen. Fabian Doñate (D-Las Vegas), which requires employers to provide paid leave to employees to receive the COVID-19 vaccine and requires the Legislative Committee on Health Care to conduct a study during the 2021-2022 interim about the state’s response to the COVID-19 pandemic and make recommendations to the governor and lawmakers for the next legislative session in 2023.

They also passed SB318, also sponsored by Doñate, requiring public health information provided by the state and local health districts to “take reasonable measures” to ensure that people with limited English proficiency have “meaningful and timely access to services to restrain the spread of COVID-19.” 

Beyond COVID, the Legislature passed a number of other public-health related measures this session, including, notably, establishing a public health resource office within the governor’s office through SB424, with the goal of taking a holistic, multidisciplinary approach to public health in the state. 

Lawmakers also approved SB461, which requires the state to disburse $20.9 million of American Rescue Plan dollars to specifically to address needs spotlighted by the public health emergency including “mental health treatment, substance use disorder treatment and other  behavioral health services, construction costs and other capital improvements in public facilities to meet COVID-19-related operational needs and expenses relating to establishing and enhancing public health data systems.”

The Legislature additionally passed a few tobacco-related pieces of legislation including AB59, sponsored by the attorney general’s office, officially raising the tobacco purchase age in the state to 21 — the federal Tobacco 21 law went into effect in December 2019 — and AB360, sponsored by Assemblyman Greg Hafen (R-Pahrump), which prohibits people from selling, distributing or offering to sell cigarettes or other tobacco products to a person under 40 without first conducting age verification. Additionally, SB460, the budget appropriations bill, allocates $5 million for vaping prevention activities.

Lawmakers also approved SB233, sponsored by state Sen. Joe Hardy (R-Boulder City), which appropriates $500,000 to the Nevada Health Services Corps, a state loan repayment program for physicians and other health practitioners aimed at encouraging providers to practice in underserved areas of the state. The Legislature also approved SB379, a health workforce data collection bill that proponents say is critical for the state’s health professional shortage area designation. 

“It’s kind of nerdy, wonky data stuff, but those designations are really critical for Nevada, for loan repayment, for health service corps, for [federally qualified health center] and community health center designation and reimbursement and all sorts of stuff,” said John Packham, co-director of the Nevada Health Workforce Research Center at the University of Nevada, Reno. “We just need better data, period, on the workforce.”

Vitality Unlimited provides substance abuse treatment in Elko
Vitality Unlimited provides substance abuse treatment in Elko. (Jeff Scheid/The Nevada Independent)

Mental health

While mental health advocates have become accustomed to making slim gains each legislative session, Robin Reedy, executive director of NAMI Nevada, believes 2021 was a good session for mental health.

“For once, it’s a long list. It’s just so amazing,” Reedy said of the mental health bills that passed this session. “Everything has just been an uphill climb constantly … but this year, oh my God.”

In addition to SB154, mentioned above, key mental health bills passed this session hone in on mental health parity (AB181), implement the 9-8-8 National Suicide Prevention Hotline (SB390), bolster crisis stabilization services in the state (SB156) and remove stigmatizing language from state law referring to people with mental illness (AB421).

Lawmakers also approved bills put forward by the regional behavioral health policy boards established during the 2017 legislative session, including SB44, which aims to smooth the licensure process to boost the number of behavioral health providers in the state, and SB70, which makes changes to the state’s mental health crisis hold procedures.

Reedy attributed the increased focus on mental health this session to a “perfect storm of things coming together.”

“I think it's incredibly sad that it took a pandemic for people to actually look more at mental health — when everyone was going through some form of anxiety or depression from being isolated, from not knowing what the future held, from it being just really untenable, and everyone has different levels of acceptance of those things, and living through those things, different levels of resilience,” Reedy said. “Suddenly it's like, ‘Mental health.’ We've been working on this forever. Finally.”

But Reedy said there’s still a long way to go. For instance, she wishes that SB390, which authorizes the state to impose a surcharge on certain mobile communication services, IP-enabled voice services and landline telephone services to fund the 9-8-8 line, would have capped that charge at 50 cents instead of 35 cents. She believes had the session been a regular session and had mental health advocates been able to pack the committee room with patients, they would have been able to get that fee cap increased.

“I just don't think 35 cents is going to be enough … We’re 51st in the nation [for mental health],” Reedy said. “I know telecommunications does not want to pay to fill the hole, but that means crisis lines are going to be busy.”

A medical staff member prepares a COVID -19 vaccine during the Amazon employees Covid-19 vaccination event at the Amazon Fulfillment Center in North Las Vegas on Wednesday, March 31, 2021. (Jeff Scheid/The Nevada Independent)

Other health care bills

In addition to reigning in drug pricing costs, lawmakers passed several bills making changes to how Nevadans can access certain kinds of prescription drugs. SB190, sponsored by Cannizzaro, will allow pharmacists to dispense certain kinds of hormonal birth control directly to patients. SB325, sponsored by Senate Minority Leader James Settelmeyer (R-Minden), similarly allowed pharmacists to dispense preventative HIV medication, including PrEP.

Other prescription-drug focused bills passed this session include AB178, a bill sponsored by Assemblywoman Melissa Hardy (R-Henderson) requiring insurers to waive restrictions on the time period in which a prescription can be refilled during a state of emergency or disaster declaration, and AB177, a bill from Assemblywoman Teresa Benitez-Thompson (D-Reno) aiming to expand access to prescription drugs in people’s preferred language.

Lawmakers also passed a number of other health care related bills including:

  • SB275, sponsored by state Sen. Dallas Harris (D-Las Vegas), modernizes state laws on HIV by treating the virus the same way as other communicable diseases
  • SB342, sponsored by the Senate Education Committee, puts the legislative stamp of approval on a major partnership between the UNR School of Medicine and Renown Health
  • SB290, sponsored by state Sen. Roberta Lange (D-Las Vegas), makes it easier for certain stage 3 and 4 cancer patients to receive prescription drug treatment by allowing them to apply for an exemption from step therapy, which requires patients to approve that certain drugs are ineffective before insurance will cover a higher-cost drug 
  • SB340, sponsored by state Sen. Dina Neal (D-Las Vegas), provides for the establishment of a home care employment standards board
  • SB251, sponsored by state Sen. Heidi Seevers Gansert (R-Reno), requires primary care providers to conduct or refer patients for screening, genetic counseling and genetic testing in accordance with federal recommendations around BRCA genes, which influence someone’s chance of developing breast cancer

Several health care bills also died with the end of the legislative session, including AB351, which would have allowed terminally ill patients to self-administer life-ending medication, and AB387, a midwife licensure bill.

Health care industry proposes amendment to reduce public option bill to actuarial study

A patient checks in at an urgent care

Insurance companies, hospitals and doctors have proposed an amendment to Nevada’s public option bill that would gut much of the existing legislation and replace it with a study, effectively delaying a formal decision on whether to move forward with the proposal for two years.

While the most recent draft of the public option bill, SB420, already requires state health officials to conduct an actuarial study of the proposal as part of a four-and-a-half-year ramp up, it also sets the wheels in motion to establish that public option for purchase for plan year 2026. The new industry-backed amendment would instead turn the bill into just an actuarial study — with no timeline or plan for actually implementing a public option — leaving it up to lawmakers in the 2023 session to decide whether to proceed with the proposal.

“I think that it would be prudent from a policy perspective to have a process whereby you move forward with legislation that creates an option that is consistent with the actuarial study instead of putting the public option into statute, have the actuarial study come back, and then have to claw, potentially, items back or add to it,” said Tom Clark, lobbyist for the Nevada Association of Health Plans.

The amendment is being put forward by the Nevada Association of Health Plans, the Nevada Hospital Association and the Nevada State Medical Association. Industry representatives said they delivered the amendment to the office of Senate Majority Leader Nicole Cannizzaro, the bill’s sponsor, early Tuesday evening, though they haven’t yet had a conversation with her about it.

In bill hearings, however, Cannizzaro has made clear that she isn’t interested in simply another study of the concept. Notably, conversations around a different version of the public option proposal turned into a study at the end of the 2019 legislative session.

“I am just at a little bit of a loss of words with some of those comments where, ‘We should study this. We should figure out why people are uninsured. We should figure out why people aren’t accessing health care,’ because that’s a question that's been raised for as long as I've been in this building,” Cannizzaro said during a hearing on the bill earlier this month. “While that's not as long as some, it's a long enough period of time for me to know that it's time to take action.”

Under the public option legislation, as currently drafted, insurers that bid to provide Medicaid coverage would also be required to bid to offer a public option plan. The public option plans would resemble existing qualified health plans on the state’s health insurance exchange, though they would be required to be offered at a 5 percent markdown, with the goal of reducing the plans’ average premium costs by 15 percent over four years.

The new amendment, at its core, is the sum of the many arguments the health care industry has made against the bill during hearings and through a direct campaign to everyday Nevadans, including that a public option would destabilize the health care landscape in Nevada and that there are better ways of reducing the state’s uninsured rate.

Specifically, the amendment would require the proposed actuarial analysis to hone in on individuals who have been uninsured for at least six months and who are not eligible for Medicaid or subsidies on the state’s health insurance exchange — two groups that collectively make up more than half of uninsured individuals in the state. Opponents of the bill, including representatives of the health care industry and chambers of commerce, have argued the Legislature ought to focus on getting those two groups covered first.

To that end, the amendment would also require the Interim Legislative Committee on Health Care to come up with ideas for how to get people who are currently eligible for Medicaid or exchange subsidies but aren’t enrolled signed up for coverage.

“If we’re looking at capturing those who are uninsured currently, what can we do to encourage them to enroll in the programs that they’re already eligible for? That’s a really important part of the equation,” Clark said.

The amendment lists several areas health care industry representatives would like to see the actuarial analysis dive deeper into, including the effect of the public option on the stability of the health insurance market, accessibility of physicians and network adequacy. 

It also asks that the study look at the effect of mandating “below market or below cost rates” for providers — a reference to the fact that the bill sets Medicare rates as a floor for provider payments under the public option plan, which providers view as an effective cap. Additionally, the study would analyze what insurance coverage benefits may need to be reduced in the plans to achieve the rate reductions mandated by the bill.

The amendment also directs the actuarial study to look into what federal opportunities might exist to support the public option — which bill proponents already plan to do in the form of federal waivers, though the amendment also leaves room for unnamed “other opportunities” — as well as consider the impact of the federal American Rescue Plan, which opens up health insurance exchange subsidies to people who make more than 400 percent of the federal poverty level.

The amendment only proposes to change the public option portion of the bill, not the secondary portion that expands Medicaid services.

Clark said the additional requirements would provide more of a framework for the actuarial study.

“That actuarial study needs some guardrails,” Clark said. “You can't just say, ‘Do an actuarial study.’”

Under the industry’s proposed amendment, the actuarial analysis would be required to be completed by July 1, 2022, and the director of the Department of Health and Human Services, the insurance commissioner and the executive director of the Silver State Health Insurance Exchange would be required to review the actuarial analysis and submit a comprehensive report on “their collective recommendations for effective implementation of the Public Option in Nevada; improving access to and affordability in Nevada’s health care market; and addressing the challenges of enrolling individuals in Medicaid and the Exchange who are eligible but remain uninsured” by Oct. 1, 2022.

Clark pushed back on any framing of the amendment as an attempt to kill the public option bill — as is often the case with many legislative bills that get turned into studies.

“We feel that this isn’t just a blanket, ‘Kill the bill.’ This is saying, ‘Let's take this major step forward first before we put the policy in the statute’,” Clark said. 

The bill passed the Senate on a party-line vote Monday and was referred to the Assembly Ways and Means Committee on Tuesday. It has yet to be officially scheduled for a hearing but will likely be heard in the next day or two.

Read the amendment below:

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.

‘A lot of little things’: Incremental health policy changes favored over sweeping reform in 2019 legislative session

Lawmakers this session took patients out of the middle of negotiations between providers and insurance companies over out-of-network hospital bills in a landmark bill decades in the making and codified the Affordable Care Act’s protections for people with pre-existing conditions amid ongoing threats at the federal level.

But, by and large, the changes that the Legislature pursued this year to improve health care in the state weren’t big or flashy. Instead, lawmakers passed a number of incremental changes — such as establishing a maternal mortality review panel, allocating additional state dollars for family planning services and commissioning studies on prescription drugs and a state public option — that experts say will slowly begin to move the needle on health care.

“There were some little tweaks that were made that are going to have a big impact,” said Catherine O’Mara, executive director of the Nevada State Medical Association. “I think sometimes it doesn’t seem that exciting because there’s not these huge reform bills but, in the aggregate, there were a lot of little things that were done that are actually going to positively impact people.”

Part of that emphasis on smaller health policy items over the sweeping change that had seemed possible when a Medicaid buy-in proposal was the subject of conversations between the 2017 and 2019 legislative sessions was signaled early on by Gov. Steve Sisolak, who during his campaign promised the creation of a Patient Protection Commission charged with a top-to-bottom review of health care in the Silver State.

When Sisolak first proposed it last year, the commission was framed as a blue-ribbon panel that would bring together patients, doctors and other policymakers and, after convening for 100 days, recommend changes to be implemented by the Legislature.

In light of that, there was initially some speculation that the panel would operate similarly to an advisory panel that Sisolak established in January to map out sweeping regulatory changes to the marijuana industry. But Sisolak took a different tack with the Patient Protection Commission, proposing legislation, SB544, to create that body in mid-May and charging the body to return to the 2021 legislative session with its recommendations in the form of two bill draft requests.

“For a first-session governor to create a Patient Protection Commission I think is really prudent,” O’Mara said. “The administration didn’t just jump in and say, ‘We’re going to change health care.’ He said, ‘We’re going to jump in and hear from everybody and figure out where all the pain points are and go from there.’”

Some in the industry see a model for the commission in the success of the landmark surprise emergency room billing legislation that passed this session, which was a byproduct of extensive conversations between insurers, hospitals and doctors between sessions and a mandate from Assembly Speaker Jason Frierson that they reach a compromise. Industry representatives who were a part of those conversations said they weren’t completely happy with the end result, but it was something that they were willing to live with.

“The surprise billing issue has been around and hasn’t come to any level of resolution for years, and a giant step was taken in that bill passed,” said Tom Clark, a lobbyist for the Nevada Association of Health Plans. “Kudos to Assemblyman Frierson, the speaker, for taking that bull by the horns and really making sure that all of the stakeholders got together and figured that out.”

Similarly, Sisolak has made it clear that the commission, an 11-member panel made up of industry and patient representatives, will be a working body. He warned at an industry briefing before the legislation was introduced that the overall goal is compromise, and anyone not working toward that could those their seat at the table.

“I think the way it’s being structured is going to give all sides of the issue a chance to be at the table and facilitate the development of good regulation and good legislation, whichever the case may be,” said Bill Welch, president and CEO of the Nevada Hospital Association.

Questions still remain about how the body will work with the interim health committee, a panel of lawmakers that studies issues between sessions to develop policy to bring forward when the Legislature meets again and with two health-care studies that have been commissioned. But industry representatives — from doctors and hospitals to insurers and pharmaceutical companies — are optimistic about the commission’s potential.

“For our part, we want to come to the table with proposed solutions and ideas and an openness to address the challenges Nevada’s health-care system is facing,” said Priscilla VanderVeer, a spokeswoman for the national drug lobbying association Pharmaceutical Research and Manufacturers of America, in an email. “We believe this is a real opportunity to work together across the broader health-care system and the political spectrum to enact real change and we look forward to being a part of it.”

Part of that optimism comes from the hope that the commission will look at the root cause of some of the state’s health-care ills with an eye toward prevention and mitigation early on to prevent poor health-care outcomes down the line. For instance, lawmakers approved rate bumps for hospitals providing intensive care to some of the state’s sickest babies, but the broader question of how to expand access to prenatal care so those babies are born healthy remains.

“When I hear from hospitals or skilled nursing facilities or certain provider types, their messaging is very good, but we need to be looking at the whole landscape of health care and where we need to move the dial and where the opportunity is,” said Richard Whitley, director of the Department of Health and Human Services. “If it can be prevented, if we can intervene early, we ought to intervene.”

Here’s a look at some of the other health policies that passed this session, and others that didn’t:

Studying (again) a state public option

A last-minute bill, SCR10, introduced by Senate Majority Leader Nicole Cannizzaro is tasking the Legislative Commission with studying the feasibility of allowing Nevadans to buy into the Public Employee Benefits Plan, or PEBP, which provides health insurance to state workers.

Cheryl Bruce, executive director of the Nevada Senate Democratic Caucus, framed the legislation as a way for the Legislature to continue to explore the idea of a public option. Conversations on the topic waned following the resignation of Democratic Assemblyman Mike Sprinkle, who had led the interim conversations on a Medicaid buy-in proposal.

“We think this is a good first step to get more information before moving forward with any future legislation,” Bruce said in a text message.

Some in the industry have raised concerns that the legislation is too narrow because it specifically targets the interim study to the feasibility of a PEBP buy-in and that it focuses on access to insurance without also targeting access to care.

“I did talk with the sponsor of the bill, and they assured me that some of the things I wanted to amend into the bill and include the bill are generically incorporated in the bill already,” Welch, the hospital association CEO, said. “I want to make sure they are focusing on the full picture.”

The overarching question that the study will have to address is who a public option plan aims to help. Conversations about increasing access to health insurance in Nevada have generally centered around increasing access to rural residents who only have one plan available to them for purchase on the exchange, improving access to residents across the state who are increasingly priced out of exchange plans or targeting the state’s undocumented population, which faces severe barriers to accessing insurance and care.

Before Sprinkle’s resignation, some of the conversations around Medicaid buy-in focused on how the proposal could help the state’s rural residents and possibly other populations on a limited basis.

“At the end of the day I will be shocked if this study shows much more than that again. I only say that because if you bring all of this uninsured population to the state’s health benefit plan it will change your actuarial mix of who are insured,” Welch said. “You’re going to be bringing in individuals potentially who have chronic medical conditions that will change how you actually set your premiums.”

Codification and stabilization of the Affordable Care Act

The most sweeping bill related to the Affordable Care Act that passed this session was AB170, which codified the federal health-care law’s protections for people with pre-existing conditions into state law. A similar measure last session was vetoed by former Gov. Brian Sandoval, who said at the time that it would have locked into law “requirements that may be unnecessary, imprudent, or simply unaffordable in the years to come.”

Approval of the legislation comes amid an ongoing legal challenge to the Affordable Care Act on the federal level that could strike down the law entirely, including its popular pre-existing condition protections.

“Who knows if the federal administration is ever going to actually overturn the Affordable Care Act, but they certainly are chipping away pieces of it,” said Elisa Cafferata, lobbyist for Planned Parenthood. “It’s good to have those protections in place because what everybody really liked about the Affordable Health Care was the preventative health care and pre-existing conditions.”

The compromise pre-existing condition language was first crafted a different bill spearheaded by Democratic Sen. Julia Ratti who, as chair of the Senate Health and Human Services Committee, worked to ensure the legislation would codify the protections in the Affordable Care Act as they stand now — no more and no less. The work on that bill, SB235, was then folded into Democratic Assemblywoman Ellen Spiegel’s AB170.

The legislation also requires health insurance plans to provide to the Governor’s Office for Consumer Health Assistance the phone number of a navigator or case manager who can help patients make an appointment with a doctor in a timely fashion. The bill had initially proposed requiring insurance companies to cover out-of-network doctor’s visits at no additional cost to patients if no in-network physician was readily accessible, but was amended down in a compromise with insurance companies.

Though it’s a small change, those in the health-care industry say it stands to improve access to care for patients.

“Our take is that AB170 is a very simple little bill that will actually have a practical impact in helping patients,” O’Mara said. “It’s one of those bills that isn’t flashy but will make a difference.”

The Legislature also passed two Affordable Care Act stabilization bills — SB481 and SB482 — that place additional restrictions on two types of health insurance plans with potentially skimpier coverage than that required under the federal health-care law and direct the state to apply for a federal innovation waiver to allow the state to explore other options to stabilize the individual health insurance market.

Heather Korbulic, executive director of the Silver State Health Insurance Exchange, said that together the bills “could have a dramatic impact on getting people connected to plans that are right for their needs.”

Lawmakers additionally approved the exchange’s budget, which included the funding necessary to become an entirely state-based exchange instead of the hybrid model that the exchange has been operating under now. Exchange officials have said that a Nevada-run platform will both save the state money and allow them to know who is actually purchasing individual plans through the exchange and better target their outreach.

“That itself lends a lot of autonomy and control,” Korbulic said. “Lawmakers were cognizant of that potential flexibility.”

Changes for hospitals

Lawmakers passed two bills this session that strike at the core of what it means to be a hospital and what services those facilities should and ought to provide.

One of them, Democratic Assemblywoman Maggie Carlton’s AB317, shifts the responsibility of determining whether to establish any additional trauma centers from the local level to the state. It comes amid renewed discussions over Southern Nevada’s trauma need and whether to approve additional trauma centers. Welch said that the change “might potentially create some additional time to make those determinations going forward” but that “overall the approach is a balanced approach.”

The legislation also requires every off campus facility that a hospital operates — such as a microhospital or freestanding emergency department — to have a unique national provider identifier number. The goal is to help the state better track and understand how those facilities are utilized compared to traditional hospitals.

Another bill advocated for by the hospital association, Democratic Assemblywoman Rochelle Nguyen’s AB232, requires all hospitals in the state to be certified by the federal Centers for Medicare and Medicaid Services (CMS). The legislation specifically targets a tourist-focused microhospital near the Strip, Elite Medical Center, which doesn’t bill Medicaid or Medicare.

In hearings on the bill, Elite argued that its business model isn’t based around providing care to Medicaid and Medicare patients and that it would rather write off the cost of uncompensated care it provides to those individuals than go through the onerous process to become Medicaid and Medicare participating. But lawmakers sided with the hospital association, which argued that hospitals should have the responsibility of taking care of all patients.

“We’re not opposed to microhospitals,” Welch said. “We’re supportive of microhospitals, but we’re supportive of them coming in and being a part of the integrated health-care delivery system.”

The legislation gives Elite until July 1, 2021 to be certified by CMS.

The Legislature also took steps to address the financial needs of the state’s hospitals, which have long argued that they are increasingly strained by the number of Medicaid patients they treat. Lawmakers approved a 25 percent bump in the per diem Medicaid rate to care for babies in the neonatal intensive care unit (NICU) and a 15 percent bump in pediatric intensive care unit (PICU) rates to ensure that hospitals are able to maintain the current level of services that they are providing to the community.

Welch said the hospitals are “ecstatic” about the increases.

“What it is going to do is ensure that those beds that we do have are not going to close, because there has been a lot of discussion over the last 18 months about whether certain hospitals were going to be able to continue providing services at that rate,” Welch said.

Hospitals also got a last-minute boost in the form of SB528, an appropriations bill passed in the final two hours of the legislative session that included a 2.5 percent increase to the state’s acute care per diem rate for Medicaid. Welch said that he had asked for a 20 percent increase at the beginning of the session but didn’t know whether hospitals would get any rate bump until those final minutes.

“Between those three things, that will help us immensely,” Welch said. “It won’t get us anywhere near cost, but at least it’s moving us in the right direction and hopefully will help us be able to sustain the services.”

After negotiation between proponents and the hospitals, lawmakers also passed SB364, Democratic Sen. David Parks’s bill requiring hospitals to identify patients by their preferred name and pronouns, representing a significant victory for the state’s transgender community.

Drilling down on drug costs

At the beginning of the session, there were several sweeping proposals to tackle the high cost of prescription drugs, including a mandate that the middlemen in the drug pricing process pass along rebates they negotiate with drug manufacturers to consumers and a Prescription Drug Affordability Board with the ability to examine high cost prescription drugs and limit what payers can spend on them.

Neither of those ambitious proposals moved forward this session, but lawmakers did vote to expand a diabetes drug transparency bill passed in 2017 to require manufacturers of asthma drugs and drug pricing middlemen, or pharmacy benefit managers (PBMs), disclose certain costs and profits to the state.

The bill, Democratic Sen. Yvanna Cancela’s SB262, requires manufacturers of asthma drugs whose prices have increased significantly in the past year or two to report specific data to the state for each drug including the cost of producing it, administrative expenditures such as marketing and advertising costs, profit earned, financial assistance provided to help patients, and coupons and rebates offered. PBMs are also required to report any rebates they negotiated and any profits they retained associated with asthma drugs that experienced significant price increases.

“The hundreds of thousands of Nevadans living with asthma deserve to know that the price they’re paying for their medication they need to breathe is fair, and this bill will help shed some light on factors affecting these drug prices,” Sisolak said at a bill signing last month.

But drug manufacturers, who sued over the diabetes drug transparency legislation two years ago, raised concerns during hearings on the bill that regulations adopted by the state in 2018 to keep confidential information companies deem to be trade-secret protected would only apply to diabetes drug reporting and not the new asthma drug reporting.

VanderVeer, the PhRMA spokeswoman, said that she couldn’t speculate on whether there will be litigation related to the new asthma drug transparency law.

“We will be closely monitoring and engaging in the regulatory process,” VanderVeer said.

Another bill, Republican Assemblywoman Melissa Hardy’s AB141, builds on some of the prohibitions on gag rules inserted by PBMs into contracts with pharmacists — preventing them from disclosing certain information to patients — passed in the 2017 session. The legislation prevents PBMs from stopping a pharmacist from providing information to patients about the availability of a less expensive drug and from penalizing a pharmacist for selling a less expensive generic drug to a person.

Lawmakers, in passing Cancela’s SB276, have also directed the Legislative Commission to appoint a committee to conduct an interim study concerning the issue of the costs of prescription drugs, including the impact the PBM rebates have on prices.

VanderVeer said that PhRMA was “glad to see a discussion about the broader pharmaceutical supply chain taking place in Nevada this year,” though the association still believes it was unfairly targeted in 2019.

“While we continued to see a one-sided political attack that took place in 2017, we are glad that there was some recognition of the broader pharmaceutical supply chain and the importance of protecting patients’ access to needed medicines and the future development of new treatments and cures,” VanderVeer said.

Access to care

Lawmakers tackled a number of broader access to care issues this session, too, including patients’ ability to access mental health, dental and family planning services.

One bill, which emerged from one of the regional behavioral health policy boards created by the Legislature in 2017, establishes a new endorsement for psychiatric hospitals to be deemed a crisis stabilization facility and mandates that those stabilization services be covered under Medicaid. The need for crisis mental health services in the state was brought into sharp focus in 2018 when WestCare abruptly closed its crisis triage center in Reno and Clark County had to shell out additional funding to keep the doors of the company’s Las Vegas crisis triage center open.

“These could be game changers from the impact they could have on reducing emergency room and jail holds on patients,” said Chuck Duarte, CEO of Community Health Alliance and chair of the Washoe Regional Behavioral Health Policy Board. “I’m hopeful we’ll see some of these facilities developing in Nevada. I think they’ll have a significant impact on unwanted institutionalization.”

The bill, AB66, also requires the state to adopt regulations to license and regulate providers of nonemergency secure behavioral health transportation services to transport people experiencing a mental health crisis. Right now, a significant portion of the burden of transporting individuals undergoing a mental health crisis falls on law enforcement, particularly in rural Nevada.

Another piece of legislation passed, Cannizzaro’s SB425, requires Medicaid to provide additional home and community-based services, including tenancy support services. Under federal law, states are allowed to implement tenancy support services for people who are elderly or disabled.

“It doesn’t solve the housing problem” Duarte said. “But this establishes the sustainable revenue stream.”

Other bills drilled down into the issue of access to dental care. One of them, Ratti’s SB366, establishes a new mid-level dental provider type, known as dental therapists, who will be allowed to perform a number of routine dental procedures currently performed only by dentists, including extracting loose teeth, filling cavities and applying sealants.

The dental therapists will only be allowed to practice in underserved areas, including federally qualified health centers, rural health clinics, tribal health clinics, and any other clinics that primarily serve Medicaid patients or other low-income, uninsured individuals.

Duarte said that it “makes a lot of sense” for federally qualified health centers, including Community Health Alliance, to be able to lean on dental therapists to provide services, particularly when non-emergency adult dental services are not covered by Medicaid in Nevada.

“Right now with Medicaid not covering adult dental services, it’s hard to provide comprehensive care to adults without insurance,” Duarte said.

Lawmakers also approved AB223, sponsored by Democratic Assemblywoman Dina Neal, requiring the Department of Health and Human Services to seek permission from the federal government to establish a pilot program to provide dental care to adults with diabetes.

Women’s reproductive rights were another key focus for lawmakers this session with the passage of SB179, a bill sponsored by Cancela that removes longstanding criminal penalties on abortion and removes requirements that doctors explain to women the emotional implications of undergoing the procedure, and SB94, which clarifies how state family planning dollars can be spent. Sisolak also allocated and lawmakers approved $6 million in state family planning funds this session.

“It’s going to significantly increase the access to family planning services around the state,” Cafferata, the Planned Parenthood lobbyist, said. “Especially for rural Nevada that bill is going to be significant.”

One family planning bill that did not advance last-minute was Cannizzaro’s SB361, which would have required the state’s chief medical officer to issue a standing order allowing for self-administered birth control, essentially allowing patients to skip a doctor’s visit and go straight to the pharmacy for their medication. Those involved with the legislation said there were some last-minute tweaks to the bill and that lawmakers ran out of time to get the bill finalized.

But Whitley, the director of the Department of Health and Human Services, said it may be possible for the state to take action on the issue in the interim, particularly to increase access to birth control in communities where it’s difficult to get in to see a doctor.

“The Board of Pharmacy has authority to explore their existing authority through regulation for that,” Whitley said. “I’d like to work with them to see if there is something we can do since we do know that much of our state is a health-care workforce shortage area.”

Public health solutions

Beyond the industry-specific changes they made, lawmakers also signaled their interest in focusing on public health issues, from maternal mortality to vaping.

AB169, sponsored by Democratic Assemblywoman Daniele Monroe-Moreno, established a maternal mortality review panel amid rising concerns nationally over the recent rise of maternal deaths and complications. To fund the board, Nevada is applying to the federal government for a slice of a $43.5 million grant from the Centers for Disease Control and Prevention dedicated to investigating the causes of pregnancy-related deaths and complications.

“It wasn’t controversial at all but the Maternal Mortality Review Board, which actually passed quite early, was a really an important step for the state to take,” Cafferata said. “It was one of those quieter bills, because it didn’t have a lot of controversy around it, but I think it will be a significant bill for all of us.”

Lawmakers also made changes to an opioid prescribing law passed in 2017 that was aimed at tamping down on the overprescription of opioids but that doctors said was unduly burdensome and harmful to patient care. The new bill, AB239, allows providers more discretion when writing prescriptions for controlled substances to treat acute pain.

Another bill, Ratti’s SB263, places a 30 percent tax on e-cigarettes and their accessories and directs a significant portion of the $8 million a year in revenue it is projected to generate back to vaping prevention activities. Whitley said the legislation puts Nevada ahead of the curve when it comes to prevention in this area.

“[It] is really a first in our state for taking a behavior and not waiting” for the FDA to take action, Whitley said. “If you look at the history of tobacco use or alcohol use or gambling or other behaviors that can in excess cause harm, really the response in vaping, we’re with the group of states that are ahead in starting to tackle this.”

A final public health-focused bill to establish an all-payer health insurance claims database, SB472, failed to move forward in the final minutes of the session. The bill would have required the state to compile a database of billing information from insurance companies to better understand health-care costs.

Whitley said that he believes it was another case where lawmakers ran out of time, but that he’s already exploring options for the department to pursue such a database on its own in the interim in conjunction with the UNLV School of Public Health.

“An all-payer database would allow us to actually see where services are occurring and where maybe we need to give focus,” Whitley said. “We’re going to continue to work with community partners and the university to see if we can do it as a voluntary database to build the system.”