With his signature on a novel Medicaid-for-all-type bill, Nevada Gov. Brian Sandoval could rewrite the way many of his constituents get healthcare, and establish a model that other states might eventually follow in the absence of congressional action to fix or replace Obamacare.
He got the bill delivered to his desk Monday. He hasn't said what he will do with it. If he doesn't sign or veto it by June 16, it will automatically become law.
The Nevada Care Plan, as the bill is known, currently has no way of being sold on the state's healthcare exchange. It has no established cost to the state and customers. It doesn't have permission from the federal government to allow for the use of federal income tax credits for it to be purchased.
It does have a moniker, though: Sprinklecare.
Assemblyman Mike Sprinkle, the Democrat sponsor, sees the bill as, among other things, the first move toward states stepping in and filling the breach that might be left open if congressional Republicans and President Trump get their way and roll back existing benefits of the Affordable Health Care Act.
"It's the responsibility of government to be more involved in providing adequate healthcare to its citizenry," Sprinkle said. "So we spit-balled some ideas around and came up with this: The one package people are highly pleased with is Medicaid. Let's mirror that."
For just a four-page bill, many agree it's ambitious and unprecedented. Other states are trying to push a single-payer option — the California Senate passed such a proposal several days ago, but it still needs to clear the state Assembly. But as for a Medicaid-for-all-type approach, Nevada is going this road alone so far.
The proposal was intriguing enough that even the powerful Nevada Hospital Assn. went from testifying against it in a legislative committee hearing to taking a neutral stand on the bill now as it sits on Sandoval's desk.
Sandoval is mindful of the stakes. He was one of a few Republican governors to sign his state up for the Medicaid expansion under Obamacare. He also opposed the GOP-controlled House of Representatives' vote in March to repeal the Medicaid expansion. If that were to hold, about 300,000 Nevadans would lose coverage.
He issued a cautious statement about his plans Wednesday.
"I will review the final language this week and work with healthcare experts to evaluate how this would impact the current market, potential state costs and risks, make a determination if this is needed, and whether or not this is something that can be effectively implemented," Sandoval said.
One of the provisions of the bill that needs to happen quickly is for the state's Division of Insurance to commit to conducting an actuarial study of how many people might take advantage of the plan and what the average premiums might be. Once baseline numbers are established, Sprinkle said a collection of groups that would be affected by the plan would begin crafting solutions.
If Sandoval signs it, the bill wouldn't take effect until Jan. 1, 2019, just as Sandoval, who is term-limited, would be leaving office, meaning his successor would be responsible for administering the law.
Sprinkle said he understands the concerns raised by healthcare providers who worry about reimbursement rates. George Ross, who represents Sunrise Hospital and Medical Center in Las Vegas, testified in a legislative committee hearing that expanding a pool of patients getting Medicaid-style benefits with Medicaid-level reimbursements would create a big hole.
Ross said the costs of medical care keep going up.
The Nevada Care Plan, however, would operate within Medicaid but wouldn't be Medicaid — meaning reimbursements would need to be hashed out once the bill was signed.
Medicaid — and Medicaid expansion — are specifically set up for the poor, and Nevada has about 600,000 people utilizing it. Of the state's 2.9 million residents, about 11% remain without any healthcare coverage.
Uncertainty about the future of Obamacare appears to be a key driver for Nevada's gambit to offer a state-based health coverage plan that could be — if given a federal waiver — offered alongside 63 other qualified health and dental plans currently offered through the Silver State Health Insurance Exchange. But it also faces a challenge of possibly disrupting the market if it offers more coverage than privately run commercial plans at a cheaper price.
"I think it's a worthwhile endeavor to research options to improve affordability and access for Nevadans," Exchange Director Heather Korbulic said. "Not just for the safety net effect, but also allowing for affordable access for all Nevadans."
Chris Cochran, chair of the Department of Health Care Administration and Policy at the University of Nevada, Las Vegas, said he was surprised by how quietly the proposal went through the Legislature. He said it seemed to creep up on people.
"A lot of people thought efforts to repeal Obamacare [were] dead when the House couldn't muster enough support back in March," he said. "But resurrection of the Republican health plan [In Congress] probably had a lot to do with Nevada state legislators taking action to protect hundreds of thousands of Nevadans who got coverage under the ACA."
During floor votes on the House and Senate floors, there was no debate even as the bill passed along largely party lines. Democrats control both chambers of the Nevada Legislature, which meets every other year. The bill got its first hearing in March, just days after Republicans in Congress failed to pass a repeal-and-replace version of Obamacare.
Cochran said it seemed clear that a primary motive to move the bill was to protect people now insured under Medicaid expansion.
"I think this would be a huge deal and, frankly, what is intriguing about it is it would be one of the areas where Nevada has taken a leadership role in trying to resolve that potential problem," Cochran said. "It's also likely nobody took this bill seriously until the House voted to repeal and replace."