Gov. Brian Sandoval in Carson City on Feb. 14, 2017. Photo by David Calvert.

Gov. Brian Sandoval was hiking Ophir Creek with his daughter when it came to him.

He was thinking about the 8,000 Nevadans across 14 counties who had had no foreseeable access to health insurance coverage after Anthem announced in June that it was scaling back its coverage on the state’s health insurance exchange. The insurer had pointed to uncertainty with the Affordable Care Act in its decision to reduce coverage from 17 counties to only three — Clark, Washoe and Nye counties — leaving the rest of the counties without another option.

“We were walking and I was just thinking about this and thinking about this and it was grinding on me,” said Sandoval at a Tuesday press conference, recalling the hike.

On the hike, he thought about a meeting he had with health insurer Centene’s CEO, Michael Neidorff. SilverSummit, Centene’s Nevada plan, made the decision this year both to provide coverage through the state’s Medicaid program and on the exchange for 2018. Sandoval said that Neidorff had told him at that meeting to call if there was ever an issue.

“So I did the Nevada thing, and I’m on a remote trail and I stopped and I said to my daughter, Marisa, ‘We’ve got to stop for a minute because I have got to call him right now and talk to him,’” Sandoval said. “He took my phone call. We talked about this, and he said, ‘You know what, we think we can do something for you. We’re going to get to work. We’re going to see if we can help out this great state.’”

After months of conversations between the governor’s office, the insurer and the state Division of Insurance, Sandoval and SilverSummit announced Tuesday morning that residents across all of Nevada’s counties will have at least one insurance option on the state’s health-care exchange next year after the health plan agreed to step in to cover 14 rural counties. Officials had called Anthem’s June decision to leave a “health care crisis for rural Nevada.”

“That news of having bare counties in our state was a gut punch for me,” Sandoval said at the press conference at a hospital in rural Silver Springs. “It was inconceivable to me that we would not have health coverage in 14 of our counties in our state.”

The 14 counties that will now be covered on the exchange are Carson City and the counties of Churchill, Douglas, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Pershing, Storey and White Pine.

As other companies have abandoned insurance exchanges, Centene has expanded its presence, stepping in to offer low-premium, high-deductible plans. The company has said that 90 percent of its exchange customers are eligible for federal subsidies based on income, including many who rotate in and out of Medicaid, which is Centene’s core business.

“Our team’s committed to delivering the very best in health care services to the Nevadans we serve every single day,” said SilverSummit CEO Garrett Leaf.

Hometown Health, the health insurance arm of Renown Health, has stepped up to provide a comprehensive provider network of 3,000 doctors, clinics, urgent care centers and hospitals throughout the Northern Nevada market, CEO Ty Windfeldt said. Because of the expedited timeline and the time required to set up a normal network, SilverSummit contracted with Hometown Health to lease its provider network for the time being.

Silver State Health Insurance Exchange executive director Heather Korbulic said that Centene has figured out how to coordinate its business between its Medicaid managed care customers and those it provides coverage to on the exchange.

“There’s not a huge difference or divide between the income levels of the consumers that we see,” Korbulic said in an interview. “We see people churn off of Medicaid into exchange plans and vice versa — maybe they get another job or become eligible for Medicaid benefits. Centene’s very much figured out how to make a business out of making both work.”

SilverSummit and the Health Plan of Nevada will be the only two companies to offer insurance on the Nevada exchange in 2018. SilverSummit will operate in all 17 counties, while Health Plan of Nevada will serve Clark, Nye and Washoe counties.

Both Aetna and SilverSummit had planned to enter Nevada in 2018, covering only Clark, Nye and Washoe counties, but Aetna announced in August that it was pulling out before ever entering the market. Prominence, which currently offers plans on the exchange, decided earlier this year not to return to the exchange for the 2018 plan year, and Anthem announced in August it was pulling entirely out of the state, not just the 14 counties.

Officials with the state’s health exchange have pointed to uncertainty with the future of the so-called cost sharing reduction payments, which help lower deductibles and copays for roughly 7 million low income individuals who buy insurance on the exchange, and the individual mandate as the key reasons insurers have pulled out of Nevada and other states.

Korbulic said she’s “cautiously optimistic” now that all counties are covered under the exchange but that uncertainty with the cost sharing reduction payments still means insurance companies are still shouldering the burden of uncertainty when setting rates this fall. The nonpartisan Congressional Budget Office estimated today that if the president decides to end the payments, premiums will be 20 percent higher by 2018 and 25 percent higher by 2020.

The state’s insurance exchange reported enrolling slightly more than 89,000 customers during the last enrollment period, nearly 1,000 more than the previous year. The next enrollment period is scheduled to begin in November and will run for 45 days.

Outside of Nevada, only two counties each in rural Wisconsin and Ohio could enter the 2018 enrollment period without a single insurer offering coverage on the exchange.

Republican Sen. Dean Heller applauded SilverSummit’s announcement, saying he was “proud” to work with Sandoval to ensure that all Nevadans have access to the health care exchange. But he also said the recent tumult is evidence that “Obamcare is failing” and touted his own alternative plan that would turn federal funds from the Affordable Care Act into a block grant to states.

“Nevadans have been left with dwindling choices when it comes to their health care coverage, and it’s more evidence that Obamacare is failing,” Heller said in a statement. “That’s why I continue to work for health care solutions – like the Graham-Cassidy-Heller plan – that return power to the states, protect Nevada’s most vulnerable, and repeal Obamacare’s onerous mandates that continue to squeeze hardworking Nevadans who can least afford it.”

Heller’s Democratic counterpart, Sen. Catherine Cortez Masto, applauded the governor’s work to bring coverage to the 14 counties as an example of what can happen when politicians come together to achieve bipartisan solutions and thanked Centene for its decision.

“I applaud Centene for its willingness to put Nevadan families first despite the Trump administration’s threats and continued sabotage of the ACA’s health insurance marketplaces,” Cortez Masto said in a statement. “With Centene’s decision to provide coverage in rural Nevada, approximately 8,000 hardworking Nevadan’s will once again have access to health insurance that would have been denied to them. Centene’s actions show that for some insurance companies, it is truly the health and wellbeing of the people it covers that is most important.

Democratic Assemblyman Mike Sprinkle, who chairs of the Assembly Health and Human Services Committee, said that he would continue to work to stabilize Nevada’s health care system. Sprinkle sponsored a bill earlier this year to create a Medicaid-like health insurance system in the state that was ultimately vetoed by the governor.

“Health care must remain affordable and accessible to every citizen of Nevada, regardless of where they live,” Sprinkle said in a statement. “With so much uncertainty about the future of our national healthcare, Nevada must do everything we can to support the notion that healthcare is a right, and not a privilege or a product.”