Nevada Governor Vetoes Medicaid Buy-In Plan

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By Victoria Pelham

A Nevada proposal that would have allowed anyone to buy into a Medicaid-style plan through the state’s insurance exchange failed late last week. But its underlying idea—a bid to cover those ineligible for the safety-net health insurance program while unable to afford or obtain private insurance elsewhere—is still at play.

Gov. Brian Sandoval (R-Nev.) vetoed Assembly Bill 374 June 16, citing the need for more thorough research on the unique plan and how it might be implemented in a way that fills a gap without decreasing health-care provider options across the board. He added that if approved, the measure might have thrown more chaos into a health insurance market already deeply in question.

“Fortunately, my veto of AB 374 does not end the conversation about potential coverage gaps or possible solutions, including Medicaid-like solutions,” Sandoval said.

He said the first-of-its-kind concept could “play a critical role in future health-care policy” and should be studied further, especially in light of a possible winding down of the federal Medicaid expansion under efforts to repeal Obamacare.

Pursuing a `Viable Avenue’

Nevada’s plan, proposed by Assemblyman Mike Sprinkle (D), would have given residents the ability to purchase nonsubsidized Medicaid-like coverage through the Silver State Health Insurance Exchange.

“Health care is a right, not a privilege or a product,” Sprinkle said in a statement in the wake of the bill’s failure. “With this veto, Governor Sandoval has actively decided to veto a right that all Nevadans should have.”

Sprinkle pledged to re-introduce the bill in the Legislature’s next session.

The proposal doesn’t specifically reference the state’s Medicaid program; rather, it would offer a Medicaid-like option through Nevada’s Affordable Care Act exchange.

Those familiar said the silver state’s latest proposal contained echoes of past buy-in ideas, such as those that had offered a similar program for children before the Affordable Care Act or others that hadn’t come this close to passage.

But this bill presented a unique idea at a time when lawmakers are unsure of what will happen to health insurance on the whole.

“It’s definitely a viable strategy for states to explore,” Joan Alker, executive director for the Georgetown University Center for Children and Families, told Bloomberg BNA. Alker is also a research professor at the Georgetown University McCourt School of Public Policy.

She said the proposal reflects how deeply ingrained Medicaid has become. The program currently insures more than 70 million people. And extending it as an option for all could be a valuable tool for states, she added, especially if Obamacare cost-sharing and other financing is maintained.

But the chances of a program like that succeeding are slim if Republican health-care overhauls to Medicaid financing and expansion go through, Alker said.

“There’s a lot of talk about state flexibility, but if hundreds of billions of dollars get cut, states don’t have good choices,” she said. “They only have choices to make cuts.”

The House-passed American Health Care Act could strip $880 billion from Medicaid under proposals to limit federal funding through per-enrollee spending ceilings or lump-sum state grants. The Congressional Budget Office estimates 23 million people could lose insurance over the next decade under that proposal. The Senate is working on its version of the bill.

Matt Salo, executive director of the National Association of Medicaid Directors, said the failed Nevada measure was trying to move closer to universal coverage and shared elements of the national discussion that reinforced the effectiveness of the Medicaid program.

Underscores Larger Debate

Salo said there likely wouldn’t be much attention to a proposal like this from states while they wait to hear more on how the Senate and House reconcile their versions of a health-care bill.

Still, Nevada’s debate showcases the broader conversation about whom Medicaid should cover, he told Bloomberg BNA.

“It’s high-quality health insurance for the people who are on it, but also the dynamic of, ‘Well, should Medicaid be for everyone?’” he said. “Well-intentioned people can certainly have that debate.”

Medicaid serves the very low-income and those who are medically frail, with a strong package of benefits for a very lean responsibility for the cost.

“Do you want to lock them into a richer benefit package without the cost sharing?” he added. “There’s a real debate that’s going to happen there.”

Sandoval, in his veto, warned that insurance does not equate to health care and stressed concerns over whether providing the Nevada Care Plan could move people from other desired types of coverage onto this system, making care actually less accessible.

It could complicate the patient base for health-care providers, leading them to accept fewer patients on public insurance because of reimbursement rates, he said.

Alker said the push toward “affirmative ways to make change,” though, was a beneficial conversation-starter preferable to cost cutting and stripping people of health insurance.

Even without going forward, the Nevada plan highlighted some issues in the health-care system that need addressing, experts said.

“Medicaid has often been used as a tool by state governments to solve problems in the health-care system,” Salo said.

Making Medicaid less necessary, as Salo expects Sandoval and other governors would like, would require building more robust forms of other coverage like Medicare offering a long-term care benefit or private insurance strengthening mental-health care.

“The state doesn’t really have those levers at their disposal, but they do have this,” he said.

Sandoval, a proponent of Medicaid expansion, has been willing to consider health-care decisions others within his party have rebuffed. And while Congress remains deeply split over plans to overhaul the national health-care system, states have been working with the National Governors Association and other efforts to drive the conversation toward less partisan solutions.

The governor’s decision came the same day he signed onto a letter with other state leaders calling on Congress to work on a more bipartisan basis to reach health-care solutions protecting the most needy, including those that would give states more freedom. The letter also decried the House-passed American Health Care Act’s “problematic” Medicaid provisions.

To contact the reporter on this story: Victoria Pelham in Washington at

To contact the editor responsible for this story: Brian Broderick at

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