State of health

With Congress deadlocked, Nevada may act

The health care battles in Congress have state governments taking the lead.

The health care battles in Congress have state governments taking the lead.

A list of the actions taken by Congress to undermine the Affordable Care Act can be found at

At the 2017 Nevada Legislature—where Democrats had recovered their majorities in both houses—lawmakers tried to respond to what was going on in D.C. to protect the health insurance of Nevadans.

At the time, Congress was in its “repeal and replace” stage of trying to get rid of the Affordable Care Act (ACA). In Carson City, lawmakers enacted a Medicaid-for-all buy-in system sponsored by Washoe Assemblymember Mike Sprinkle that would have preserved health care access if the federal law was repealed.

Gov. Brian Sandoval vetoed it, calling it a laudable attempt but one that contained provisions whose effects were unforeseeable. More time was needed to study its ramifications, the governor wrote in his veto message:

“Fortunately, my veto of AB 374 does not end the conversation about potential coverage gaps or possible solutions, including Medicaid-like solutions. In fact, given the possibility that changes in federal law may put Nevada’s expanded Medicaid population at risk of losing their coverage, the ability of individuals to purchase Medicaid-like plans is something that should be considered in depth.”

Not everyone was willing to wait. Two health care analysts in Arizona recommended it to their state’s legislature in 2017, and New Mexico is now considering a similar proposal, with others likely to join in. At least four states—California, Delaware, Oregon and Washington—are conducting studies of buy-in Medicaid systems.

Sprinkle said after Sandoval’s veto, “I will bring this legislation back next session.” Sandoval has now been replaced with a Democrat, Steve Sisolak.

Last year a group called United States of Care commissioned the Harris Poll to poll people on a Medicaid buy-in system and the survey found 78 percent of registered voters supporting the notion.

“We think 2019 is going to be the year of Medicaid buy-in,” said Allison O’Toole, spokesperson for the group told Stateline.

State proposals are likely to interface with federal plans. Low-income people eligible for federal subsidies under the ACA are permitted to use those funds to pay for state Medicaid buy-in plans. And buy-in plans can be affected by federal requirements. If those plans include certain types of language, approval would be needed from the Trump administration.

Then there is the insurance industry, which is not in love with Medicaid buy-in plans—again, depending on how they are written.

In the subsequent year and a half since Sandoval’s veto, Congress has failed to repeal the ACA, but the act has been undercut by an array of ad hoc actions. The Internal Revenue Service has been ordered by Donald Trump to stop enforcing the insurance mandate law requiring taxpayers to have health insurance.

Trump also took actions on Oct. 12, 2017, ending federal subsidies provided by the law that assisted some citizens buying insurance through ACA exchanges with co-payments and deductibles. That caused the cost of insurance to jump and also brought lawsuits against the federal government by health insurance companies and state governments to enforce the law.

Trump also cut the enrollment period in half, reducing the number of people who obtained health insurance.

In addition, Trump’s administration cut efforts to inform the public about the ACA and when the enrollment periods are. Without that kind of advertising, some people never knew to get insurance or renew, further reducing the number of people who are insured.

Insurance actuaries said Trump’s actions created uncertainty in the marketplace, driving premiums still higher by 30 to 40 percent. The situation became so pronounced that the Center on Budget and Policy Priorities started posting a “Sabotage Watch” on its website, listing the actions taken against the ACA by Trump, congressional Republicans and others.

All of this creates a much different situation than state legislators in Nevada faced in 2017. Democrats have increased their strength in the legislature, but the threat from D.C. is not the same. Republicans have been stymied in repeal efforts but have, particularly through the White House, done some damage to the ACA. Democrats have control of one congressional house, which blocks any legislative efforts to further injure the ACA.

So Democrats in Nevada will need to react less to D.C. this time but still will be affected by the mess that has become of federal health care policy.


Also during the 2017 Nevada Legislature, the lawmakers enacted one measure that amends the state constitution, a measure that does not require approval from the governor and thus avoids the danger of a veto. The resolution, Assembly Joint Resolution 14, forbids emergency room charges “greater than 150 percent of the lowest rate which the hospital or facility has agreed to accept” from Medicare.

Constitutional amendments must be approved twice by the legislature before going to a public vote, so 14 must be approved again this year.

In addition, another Sandoval veto, of 2017’s Assembly Bill 382, sparked a between-legislative-sessions effort to bring the measure back in 2019. The bill would have protected patients from “surprise” billings as a result of out-of-network emergency care.

Surprise billings are caused when patients are taken to hospitals that are not in their insurance network. It also includes patients who are at an in-network emergency room but receive treatment from an out-of-network physician—the kind of thing insurance corporations expect stricken patients to navigate but that drives those patients crazy.

The measure adopted and then vetoed in 2017 resulted in talks between Sprinkle and other health care advocates with industry representatives in the past months, which resulted in some areas of agreement. But the group ran out of time, so final language for legislation was never achieved. Sprinkle is having a bill drafted that will serve as a vehicle in efforts to reach an agreement during the legislative session, which begins Feb. 4. Like Sprinkle’s 2017 measure, the surprise billings effort is causing chatter in the health care industry, with items appearing in places like Becker’s Hospital Review.