Novel approach

Gov. Brian Sandoval vetoed a measure giving Nevada a Medicaid-for-all health care system.

The veto brought to an abrupt halt the state’s time in a spotlight as Congress seems unable to come to grips with the health care issue while states, politicians and analysts—financial and health care—scrutinized the Nevada program.

In a veto message, Sandoval wrote that the bill sponsored by Washoe County Assemblymember Michael Sprinkle would create “more uncertainty” in the health care market. He also suggested the bill was uncooked because it had not been preceded with enough research to show the “possible consequences.”

Numerous states are expected to expand Medicaid this year and some—including New York and California—are looking at Medicaid-for-all.

Medicaid-for-all is similar to single-payer, and there were expectations that Sandoval might support it because he has been friendly to expansion of Medicaid. In addition, the governor has been critical of U.S. Sen. Dean Heller’s participation in an effort to phase out Medicaid in seven years.

Even without Sprinkle’s bill, Nevada is trying new approaches.

Enactment of the program by the Nevada Legislature came during a legislative session noted for its experimentation in health care. After the veto, the influential magazine Governing—widely read in state capitols—covered it under the headline, “After Passing Several Innovative Health Policies, Nevada Reaches Its Limit: Medicaid for All.” Reporter Mattie Quinn wrote, “To incentivize insurers to stay in or join its marketplace, Nevada told insurers that their applications for Medicaid contracts would get preferential treatment if they also sold plans on the marketplace—and it’s already paying off. Nevada is the only state where Aetna is still going to offer coverage in 2018. This fall, Nevadans shopping on the exchanges will have five insurance options. In addition, premiums are expected to be lower than the national average.”

And while the state’s Medicaid-for-all proposal was still alive, it generated a lot of dialogue.

CNN Money: “The bill called for the state to create the Nevada Care Plan, which would have been separate from the state’s Medicaid program but offered nearly all the same benefits. … Medicaid recipients pay little or nothing for their coverage. But the Nevada Care Plan would most likely have required participants to pay some premiums, deductibles and co-pays. The goal was to offer coverage that was cheaper than what’s currently available on the individual market. Medicaid pays lower rates to doctors, hospitals and other providers.”

State of Reform: “Nevada is not known for being a hot bed of innovation, but it may have the best idea of the month: letting anyone buy into the Medicaid benefit. If you’re concerned about no individual plan in a county where commercial insurers have left the market … this is a perfect solution. This is a great idea for legislators representing these counties in this legislative session: pass a provision that allows individuals in counties with no individual plan to purchase coverage from a Medicaid MCO that serves the county. The price should be equal to the PMPM the HCA pays the insurer, about $300 per month.”

Arizona health care analysts Daniel Derksen and Will Humble wrote in an Arizona Republic essay after the veto that Nevada had—and threw away—the best health care option: “Had [Sandoval] signed it, and the Centers for Medicare and Medicaid Services [CMS] approved the plan, any Nevadan could buy Medicaid coverage—regardless of income. Assembly Bill 374 would have directed the Nevada Department of Health and Human Services to ask for a CMS waiver, called an 1115 waiver, to allow any Nevadan to buy a Medicaid-managed care plan. Nevadans eligible for an Affordable Care Act tax credit, called an advance premium tax credit, or cost-sharing reductions based on income could have used them to help pay their share of the premium.” They recommended that Arizona adopt the proposal.

During the week before his veto, Sandoval said he immersed himself in study of the Sprinkle plan.

“I’ve been doing a deep dive in terms of the policy,” he said. “I’m keenly aware that the repeal of the Affordable Care Act is pending in front of the U.S. Senate. That’s something I’m looking at in terms of what this bill will do. … It’s an interesting concept, one that I’m taking my time to make sure that I’ve answered all my questions before I decide to take action on it.” (Vox attributed the statement to a local Nevada reporter but did not name him or her.)

In his veto message, Sandoval wrote, “I applaud the sponsor for his creativity, and I believe that the concepts in this bill may play a critical role in future health care policy. However, AB 374 raises more questions than it answers, while adding more uncertainty to an industry that needs less. Both the problems AB374 attempts to fix, and the solutions it proposes, need further study and analysis. Moving too soon, without factual foundation or adequate understanding of the possible consequences, could introduce more uncertainty to an already fragile health care market, and ultimately affect patient health care.”

Sprinkle responded to the veto: “I am disappointed by the governor’s decision to end this landmark and vital piece of legislation, but I won’t give up on the fight to secure access to quality and affordable healthcare for every Nevadan. I will bring this legislation back next session.”

Republican Sandoval could have used the occasion to attack Democrat Sprinkle, but he did nothing with the opportunity, at one point even defending the measure.

“That bill is not—I think it’s giving the impression that it’s free medicine, socialized medicine, which it is not,” Sandoval said. “It is providing people with at least an opportunity to at least buy into at 100 percent cost into the Medicaid system, and if I do decide to sign it, then it is subject to waivers by the CMS. Those are all things, all the different issues I’m thinking about, but I think it’s important to be able to tell people what it is and what it isn’t.”