From health care transparency to a public option, lawmakers largely drilled into non-pandemic health care issues in 2021 session
When lawmakers kicked off their 120-day legislative session in February, the state was still recovering from a brutal winter surge of COVID-19, which saw a thousand new cases of the virus reported across the state each day.
Lawmakers early in the session came forward with some modest proposals to address the pandemic — including a bill to give workers paid time off to get vaccinated — but it was unclear at that point what COVID-19’s trajectory in the Silver State would be. With an influx of federal financial support boosting the state’s pandemic response, it wasn’t always easy to tell where lawmakers could be of most help. With sessions slated for only 120 days every other year, it also wasn’t clear they could craft policy responsive enough to the ever-changing needs created by the pandemic.
Instead, lawmakers generally focused on a host of other important, but perhaps less high-profile, health care proposals, from legislation to support the provision of telehealth services in the state, which became all the more popular during the pandemic, to a bill that would provide for Medicaid coverage of community health workers. They also honed in on data transparency, hearing bills that would make changes to the state’s drug pricing transparency program and establish an all-payer claims database in an effort to better understand the health care landscape in the state.
Lawmakers also took up a last-minute bill to establish a state-managed public health insurance option in Nevada, the second-ever to be approved in the nation. Despite reservations from Republican lawmakers — and even from some Democrats — the Legislature introduced and approved the bill in just a little more than a month with some strong-arming by Senate Majority Leader Nicole Cannizzaro (D-Las Vegas), who spearheaded the legislation.
Behind the scenes, there were frustrations, though, among health care lobbyists. Industry lobbyists, for instance, were caught off guard that Cannizzaro hadn’t involved them in the process of developing the public option bill and dropped the proposal on them in the final weeks of the session.
“I can tell you that when there are very challenging things that occur within health care, when you lock us all in a room, we tend to find solutions,” Tom Clark, lobbyist for the Nevada Association of Health Plans, said during the bill’s first hearing.
Bobbette Bond, policy director for the Culinary Health Fund, also said it was difficult to craft good policy in a legislative environment so heavily shaped by the pandemic. For much of the session, the legislative building was closed to the public and committee meetings were only able to be attended virtually.
“It was hard to get revisions made. It was hard to have good conversations about what could be done. It was hard to build stakeholders,” Bond said. “It was hard to communicate, and I think the policy suffered for that.”
Bond also expressed dismay in the two-thirds requirement for passing tax increases, on the grounds that it has prevented lawmakers from tackling more ambitious health care legislation. Because there isn’t more funding to go around, including to support health care, she said lawmakers have turned to putting mandates on industry.
“The mandates … end up substituting for actual public health policy,” Bond said.
The Culinary Health Fund, which is the health insurance arm of the politically powerful and Democratic-aligned Culinary Union, did, however, continue to play a significant role in shaping health care policy this session with Democrats remaining in control of both chambers of the Legislature. Other industry representatives, who often work collaboratively with Democratic lawmakers but more often align with Republicans on business priorities, had less of an upper hand.
Mike Hillerby, a longtime lobbyist on health care issues in the state, said Nevada loses “a lot of subtlety in the public policy debate” when the discussion is “driven by the relationship between a couple of unions and a couple of hospital chains.”
“That drives so much of what we do, and it's so contentious. Look at balance billing from 2019. Look at some of the stuff this time, and everything's driven by that. That's not indicative of the market and the rest of Nevada. That's not indicative of what's happening with providers and patients and payers in rural Nevada, in the Reno area, and yet so much of it is driven by that and that financial reality, that bargaining relationship, those contractual relationships,” Hillerby said. “We just lose a lot of the subtlety and the ability to make better decisions.”
Here’s a look at some of the health policies that passed this session and others that didn’t.
The highest-profile piece of health care legislation to pass this year, SB420 — Nevada’s public option bill — was introduced with just a little more than a month left in the legislative session by Cannizzaro, the Senate majority leader. Proponents were quiet about the legislation for the first couple of months of the session until Cannizzaro was asked by a reporter in mid-April about the proposal and health care lobbyists started receiving briefings from consultants on the concept.
The bill, which builds upon previous public option proposals introduced in Nevada in 2017 and 2019, aims to leverage the state’s purchasing power with Medicaid managed care organizations — private insurance companies that contract with the state to provide coverage to the state’s low-income population — to get insurers to also offer public option plans. The plans will resemble existing qualified health plans on the state’s health insurance exchange, though they will be required to be offered at a 5 percent markdown with the goal of reducing the plans’ premium costs by 15 percent over four years. The plans won’t be offered for sale on the exchange until 2026.
The proposal cleared both the Senate and Assembly on party line votes and was signed into law in early June by Gov. Steve Sisolak, making Nevada the second state in the nation after Washington to enact a state-based public health insurance option into law. Colorado became the third state to establish such a policy in mid-June.
Though the legislation was heavily opposed by the health insurance industry — with some groups running ads and sending mailers opposing the proposal — Cannizzaro muscled the bill through the Legislature as the clock counted down to the end of the 120-day session. The bill easily cleared the Senate — where Cannizzaro, as majority leader, controls which bills come to the floor — and Democratic leaders in the Assembly threw their support behind the bill shortly thereafter, setting aside concerns about whether the bill can accomplish its goals of improving health care access and affordability.
“It's not a secret I have been skeptical of this bill from the very beginning, but I've seen the amendments, and I have talked to a number of the different proponents of the bill and opponents of the bill on it,” Assembly Ways and Means Chair Maggie Carlton (D-Las Vegas) said in late May, shortly before allowing the bill to be voted out of her committee. “I feel much more comfortable knowing that, in the future, the people that are in this building now that do come back are well aware of what's going on, and I trust them to make the best decisions they can to protect the constituents of this state.”
In her remarks, Carlton was referring to the long runway the bill establishes before the public option actually goes into effect, leaving time for the state to conduct an actuarial study to figure out whether the bill actually accomplishes the goals it sets out to and two legislative session in 2023 and 2025 for lawmakers to make any tweaks to the policy as necessary.
Heather Korbulic, who as head of the state’s health insurance exchange will have a key role in shaping the policy’s implementation, has said she plans to bring stakeholders together to “outline the actuarial study and conduct a meaningful analysis of the public option as it relates to every aspect of health care throughout the state.”
Richard Whitley, director of the Department of Health and Human Services, said in an interview earlier this month that the public option isn’t “a single solution” but “does definitely enhance the opportunity for individuals to gain access to health care.”
“I think of this as an option for coverage,” Whitley said. “It definitely enhances that overall framework of health care coverage.”
Transparency and data efforts
For the last two legislative sessions, lawmakers have focused on prescription drug cost transparency, passing a first-in-the-nation diabetes drug transparency law in 2017 and expanding that law to include asthma drugs in 2019. This year, lawmakers built upon those transparency efforts by passing legislation requiring transparency from more portions of the health care industry.
This year, lawmakers approved a bill, SB40, to establish what’s known as an all-payer claims database — a state database of claims of medical, dental and pharmacy services provided in the state. The law requires all public and private insurers regulated under state law to submit their claims to the database and authorizes insurers governed by federal law — such as the Culinary Health Fund — to submit their claims to the database. A similar bill proposed during the 2019 legislative session failed to move forward in the final minutes of that session, though the concept was revived by the Patient Protection Commission, which brought SB40 forward this session.
The bill, however, required extensive work when it got to the Legislature, with state Sen. Julia Ratti (D-Sparks) taking the bill under her wing as chair of the Senate Health and Human Services Committee and working with industry advocates — including the Nevada Association of Health Plans, the Nevada State Medical Association and the Nevada Hospital Association — to finalize the legislation.
“We knew the bill was going to pass, at some level ... so we wanted to make sure that the information that was going to be collected was accurate, was consistent with what was required in other states that had all-payer claims databases and also to learn from what those other states had done so we wouldn’t make the same mistakes,” Clark, the Nevada Association of Health Plans lobbyist, said. “Fortunately, Senator Ratti and others were good to work with and we’re comfortable with the way the bill passed.”
The legislation additionally makes data contained in the all-payer claims database confidential, meaning that it is not a public record or subject to subpoena, and specifies how the information contained in it can be disclosed. It can be shared in de-aggregated form to state or federal government entities, including the Nevada System of Higher Education, and any entity that submits data to the database. Anyone else looking to obtain the data can only receive it in aggregated form by submitting a request to the Department of Health and Human Services.
Lawmakers also built upon the diabetes and asthma drug transparency bills passed in 2017 and 2019, respectively, by expanding the universe of drugs the state imposes transparency requirements on. SB380, which was proposed by an interim committee created during the 2019 session to study prescription drug costs, requires the state to compile a list of prescription drugs with a list price that is more than $40 for a course of therapy that has undergone a 10 percent price increase in the preceding year or a 20 percent increase in the two prior years.
The legislation requires drug manufacturers to submit a report to the state explaining the reason for the price increase and explaining the factors that contributed to the price increase. Meanwhile, pharmacy benefit managers, or PBMs, the middlemen in the drug pricing process, are required to submit their own reports with certain data about the drugs, including rebates negotiated with manufacturers and the amount of the rebates retained by the PBM.
The state’s drug transparency program will also, for the first time, have funding behind it, utilizing dollars that have been collected in the form of fines paid by companies for not complying with the state’s drug transparency law. The Department of Health and Human Services put a $780,000 fiscal note on the bill to allow state health officials to transfer the existing drug transparency database to the state’s Enterprise Information Technology Services Division and hire a pharmacist and management analyst to manage the drug transparency program.
SB380 was, however, only one of two bills put forward by the interim prescription drug committee to pass this session. The other was SB396, which allows the state to establish intra- and interstate drug purchasing coalitions with private entities.
The three bills that did not pass were:
- SB201, which would have licensed pharmaceutical sales representatives
- SB378, which would have required at least half of the health plans offered in the state by private insurers to provide prescription drug coverage with no deductible and a fixed copayment and limit the total amount of copayments insured individuals are required to pay in a year
- SB392, which would have licensed PBMs and created additional rules for how PBMs can operate.
Nick McGee, senior director of public affairs for PhRMA, the drug industry advocacy organization, in an email expressed disappointment that lawmakers pursued SB380 this session while not advancing the other proposals out of the interim committee. PhRMA did, however, in the end testify in neutral on SB380.
“We are disappointed that the legislature overlooked this opportunity to address patients’ concerns related to their ability to afford and access the medicines they need,” McGee said. “Instead, lawmakers pursued onerous reporting and unnecessary registration requirements that won’t do anything to help patients afford their medicines and fail to provide transparency into why insurers are shifting more and more costs on to patients.”
Bond, the policy director for the Culinary Health Fund, which played a key role in bringing the 2017 bill to fruition, described SB380 as a “step forward,” though she said the bill didn’t end up “as strong as we would have liked.”
“It’s incremental, and it’s progress,” she said.
Lawmakers did not advance SB171, sponsored by state Sen. Joe Hardy (R-Boulder City), which would have barred most insurance companies from implementing copayment accumulator programs for any drug for which there is not a less expensive alternative or generic drug. Such programs prevent drug manufacturer coupons from applying toward patients’ deductibles and maximum out-of-pocket costs.
The Legislature additionally made a budgetary change to boost transparency, approving a request from the Department of Health and Human Services to centralize its data analysis efforts within the office of Data Analytics within the Director’s Office, while the Patient Protection Commission, which is focusing on health care spending and costs, was transferred from the governor’s office to Director’s Office as well.
Whitley, the department’s director, framed the reshuffling as an effort to bring together disparate health data collection and analysis efforts, adding that the pandemic showed the kind of real-time data the department could provide, as in the case of its COVID-19 dashboard, among other dashboards it now maintains.
“Usually people go, ‘We need more money.” Well, in government sometimes what you need is organizational structure,” Whitley said. “Putting data analytics all in one unit in my office … was really because of seeing all of the benefits that were coming out of monitoring the pandemic. That really served to inform what we could be doing.”
The Legislature also made a significant change to the Patient Protection Commission this session, transforming it from a largely industry-focused body to one instead made up largely of non-profit health industry representatives and patient advocates. AB348, sponsored by Carlton, requires the commission be made up of:
- two patient advocates
- one for-profit health care provider
- one registered nurse who practices as a nonprofit hospital
- one physician or registered nurse who practices at a federally qualified health center
- one pharmacist not affiliated with any retail chain pharmacy, or a patient advocate
- one public nonprofit hospital representative
- one private nonprofit health insurer representative
- one member with expertise advocating for the uninsured
- one member with expertise advocating for people with special health care needs
- one member who has expertise in health information technology and works with the Department of Health and Human Services
- one representative of the general public.
The bill also makes the Patient Protection Commission the sole state agency responsible for administering and coordinating the state’s involvement in the Peterson-Milbank Program for Sustainable Health Care Costs, a program that provides technical assistance to states developing targets for statewide health care spending trends.
Health care industry representatives have, however, chafed at the reduction — or in the case of the drug industry, removal — of their representation on the commission. McGee, from PhRMA, said the change “[undermines] the ability of the commission to provide a comprehensive perspective.”
But Bond, a commission member whose ability to serve will be unaffected by the policy shift, said the change would give patients and consumers more of a voice.
“I understand the concerns about losing representation from the industry, but I also believe that industry has other places where they get represented,” Bond said. “They have the Nevada Hospital Association, the pharmaceutical industry has PhRMA. They get well represented in their core arena. Patients really don't have a core arena they can go to.”
The Patient Protection Commission’s other bill this session, SB5, also was approved by lawmakers, making a number of changes to telehealth in the state. That bill also contains a data transparency component, requiring the Department of Health and Human Services, to the extent money is available, to establish a data dashboard allowing for the analysis of data relating to telehealth access.
Another big bill that tried to tackle health care costs this session, AB347, sponsored by Assemblyman David Orentlicher (D-Las Vegas), died without receiving a vote. The ambitious bill, among other provisions, proposed establishing a rate-setting commission “to cover reasonable costs of providing health care services” while ensuring providers “earn a fair and reasonable profit.” The bill also would have raised Medicaid payments to Medicare levels via a provider tax.
Antitrust in health care
Lawmakers approved two antitrust in health care bills this session. The first one, AB47, requires parties to certain reportable health care or health carrier transactions to submit a notification to the attorney general with information about the transaction at least 30 days before it is finalized. Reportable transactions include material changes to the business or corporate structure of a group practice or health carrier that results in a group practice or health carrier providing 50 percent or more of services within a geographic market.
The bill, which was presented by the attorney general’s office, also prohibits employers from bringing court actions to restrict former employees from providing services to former customers or clients under certain circumstances and bars noncompete agreements from applying to employees that are paid on an hourly wage basis.
The bill attracted opposition from the Nevada Hospital Association and the Nevada State Medical Association. During a May hearing on the bill, Jesse Wadhams, a hospital association lobbyist, thanked the attorney general’s office for working with them on the bill but said the association still could not support the legislation.
“We believe the policy itself comes from a faulty premise,” Wadhams said. “We believe policies should promote more physicians, more access to care and more investment in the health care community.”
Another bill, SB329, requires hospitals to notify the Department of Health and Human Services of any merger, acquisition or similar transaction. It also requires physician group practices to report similar transactions if the practice represents at least 20 percent of the physicians in that specialty in a service area and if the practice represents the largest number of physicians of any practice in the transaction. The legislation, sponsored by state Sen. Roberta Lange (D-Las Vegas) and pushed for by the Culinary Health Fund, requires the department to publish that information online and write an annual report on that information.
Another section of the bill allows the attorney general or other individuals to bring a civil action against a health care provider that “willfully” enters into or solicits a contract that bars insurance companies from steering insured individuals to certain health care providers, putting health care providers in tiers or otherwise restricting insurers. It also makes such an action, known as “anti-tiering” or “anti-steering,” a misdemeanor. (A final amendment to the bill reduced the penalty from a felony to a misdemeanor.)
“I think this is one of the early steps in what will probably be a national trend,” Bond, of the Culinary Health Fund, said in an interview. “I think contract provisions are going to become more and more antitrust looking.”
The bill was opposed by the Nevada Hospital Association and individual Nevada hospital systems and hospitals.
“The technical elements of this and eliminating antitrust provisions by themselves are not the problem we have with this bill — it is making sure that it doesn’t impede the open contracting that occurs otherwise in this highly competitive environment,” Jim Wadhams, a lobbyist for the hospital association, said during a May hearing on the bill.
In perhaps the most substantial victory for health care providers this session, lawmakers rolled back a 6 percent Medicaid rate decrease approved by the Legislature during a budget-slashing special session last summer.
Legislative fiscal analysts projected the move would restore about $300 million in Medicaid funding both in the current fiscal year and in the upcoming biennium, including about $110 million in general fund spending.
“Nevada faced an unprecedented state budget crisis,” Bill Welch, CEO of the Nevada Hospital Association, and Jaron Hildebrand, executive director of the Nevada State Medical Association, wrote in a letter to the governor in May. “The work you did alongside the Nevada Legislature to restore funding to hospitals and providers will be instrumental in safeguarding the health care available to many Nevadans.”
Lawmakers made a number of other changes to Medicaid services as well, providing for coverage of doula services in AB256 and community health workers in AB191. The public option bill, SB420, also contained several Medicaid provisions, including one section providing that pregnant women are considered presumptively eligible for Medicaid without submitting an application for enrollment and another prohibiting pregnant women who are otherwise eligible for Medicaid to be barred from coverage for not having resided in the United States long enough to qualify.
On the mental health front, SB154 requires the state to apply for a waiver to receive federal funding to cover substance use disorder and mental health treatment inside what are known as institutions of mental disease — or psychiatric hospitals or residential treatment facilities with more than 16 beds. Medicaid has long been barred from paying for care in such facilities, but states were recently given the ability to apply to the federal government to cover these services through Medicaid via a federal waiver.
Lawmakers also approved AB358, sponsored by Assembly Speaker Jason Frierson (D-Las Vegas), which will allow for a more seamless transition of incarcerated people to Medicaid upon release from prison. The bill requires a person’s Medicaid eligibility to only be suspended, rather than terminated, when they are incarcerated and specifies that individuals who were not previously on Medicaid should be allowed to apply for enrollment in the program up to six months before their scheduled release date. The bill also requires eligibility for and coverage under Medicaid to be reinstated as soon as possible upon an individual’s release.
Lawmakers, by and large, did not spend much time tackling the COVID-19 pandemic head on during their legislative session, likely a byproduct of how rapidly the situation has evolved over the last six months.
Legislators did, however, approve SB209, sponsored by state Sen. Fabian Doñate (D-Las Vegas), which requires employers to provide paid leave to employees to receive the COVID-19 vaccine and requires the Legislative Committee on Health Care to conduct a study during the 2021-2022 interim about the state’s response to the COVID-19 pandemic and make recommendations to the governor and lawmakers for the next legislative session in 2023.
They also passed SB318, also sponsored by Doñate, requiring public health information provided by the state and local health districts to “take reasonable measures” to ensure that people with limited English proficiency have “meaningful and timely access to services to restrain the spread of COVID-19.”
Beyond COVID, the Legislature passed a number of other public-health related measures this session, including, notably, establishing a public health resource office within the governor’s office through SB424, with the goal of taking a holistic, multidisciplinary approach to public health in the state.
Lawmakers also approved SB461, which requires the state to disburse $20.9 million of American Rescue Plan dollars to specifically to address needs spotlighted by the public health emergency including “mental health treatment, substance use disorder treatment and other behavioral health services, construction costs and other capital improvements in public facilities to meet COVID-19-related operational needs and expenses relating to establishing and enhancing public health data systems.”
The Legislature additionally passed a few tobacco-related pieces of legislation including AB59, sponsored by the attorney general’s office, officially raising the tobacco purchase age in the state to 21 — the federal Tobacco 21 law went into effect in December 2019 — and AB360, sponsored by Assemblyman Greg Hafen (R-Pahrump), which prohibits people from selling, distributing or offering to sell cigarettes or other tobacco products to a person under 40 without first conducting age verification. Additionally, SB460, the budget appropriations bill, allocates $5 million for vaping prevention activities.
Lawmakers also approved SB233, sponsored by state Sen. Joe Hardy (R-Boulder City), which appropriates $500,000 to the Nevada Health Services Corps, a state loan repayment program for physicians and other health practitioners aimed at encouraging providers to practice in underserved areas of the state. The Legislature also approved SB379, a health workforce data collection bill that proponents say is critical for the state’s health professional shortage area designation.
“It’s kind of nerdy, wonky data stuff, but those designations are really critical for Nevada, for loan repayment, for health service corps, for [federally qualified health center] and community health center designation and reimbursement and all sorts of stuff,” said John Packham, co-director of the Nevada Health Workforce Research Center at the University of Nevada, Reno. “We just need better data, period, on the workforce.”
While mental health advocates have become accustomed to making slim gains each legislative session, Robin Reedy, executive director of NAMI Nevada, believes 2021 was a good session for mental health.
“For once, it’s a long list. It’s just so amazing,” Reedy said of the mental health bills that passed this session. “Everything has just been an uphill climb constantly … but this year, oh my God.”
In addition to SB154, mentioned above, key mental health bills passed this session hone in on mental health parity (AB181), implement the 9-8-8 National Suicide Prevention Hotline (SB390), bolster crisis stabilization services in the state (SB156) and remove stigmatizing language from state law referring to people with mental illness (AB421).
Lawmakers also approved bills put forward by the regional behavioral health policy boards established during the 2017 legislative session, including SB44, which aims to smooth the licensure process to boost the number of behavioral health providers in the state, and SB70, which makes changes to the state’s mental health crisis hold procedures.
Reedy attributed the increased focus on mental health this session to a “perfect storm of things coming together.”
“I think it's incredibly sad that it took a pandemic for people to actually look more at mental health — when everyone was going through some form of anxiety or depression from being isolated, from not knowing what the future held, from it being just really untenable, and everyone has different levels of acceptance of those things, and living through those things, different levels of resilience,” Reedy said. “Suddenly it's like, ‘Mental health.’ We've been working on this forever. Finally.”
But Reedy said there’s still a long way to go. For instance, she wishes that SB390, which authorizes the state to impose a surcharge on certain mobile communication services, IP-enabled voice services and landline telephone services to fund the 9-8-8 line, would have capped that charge at 50 cents instead of 35 cents. She believes had the session been a regular session and had mental health advocates been able to pack the committee room with patients, they would have been able to get that fee cap increased.
“I just don't think 35 cents is going to be enough … We’re 51st in the nation [for mental health],” Reedy said. “I know telecommunications does not want to pay to fill the hole, but that means crisis lines are going to be busy.”
Other health care bills
In addition to reigning in drug pricing costs, lawmakers passed several bills making changes to how Nevadans can access certain kinds of prescription drugs. SB190, sponsored by Cannizzaro, will allow pharmacists to dispense certain kinds of hormonal birth control directly to patients. SB325, sponsored by Senate Minority Leader James Settelmeyer (R-Minden), similarly allowed pharmacists to dispense preventative HIV medication, including PrEP.
Other prescription-drug focused bills passed this session include AB178, a bill sponsored by Assemblywoman Melissa Hardy (R-Henderson) requiring insurers to waive restrictions on the time period in which a prescription can be refilled during a state of emergency or disaster declaration, and AB177, a bill from Assemblywoman Teresa Benitez-Thompson (D-Reno) aiming to expand access to prescription drugs in people’s preferred language.
Lawmakers also passed a number of other health care related bills including:
- SB275, sponsored by state Sen. Dallas Harris (D-Las Vegas), modernizes state laws on HIV by treating the virus the same way as other communicable diseases
- SB342, sponsored by the Senate Education Committee, puts the legislative stamp of approval on a major partnership between the UNR School of Medicine and Renown Health
- SB290, sponsored by state Sen. Roberta Lange (D-Las Vegas), makes it easier for certain stage 3 and 4 cancer patients to receive prescription drug treatment by allowing them to apply for an exemption from step therapy, which requires patients to approve that certain drugs are ineffective before insurance will cover a higher-cost drug
- SB340, sponsored by state Sen. Dina Neal (D-Las Vegas), provides for the establishment of a home care employment standards board
- SB251, sponsored by state Sen. Heidi Seevers Gansert (R-Reno), requires primary care providers to conduct or refer patients for screening, genetic counseling and genetic testing in accordance with federal recommendations around BRCA genes, which influence someone’s chance of developing breast cancer
Several health care bills also died with the end of the legislative session, including AB351, which would have allowed terminally ill patients to self-administer life-ending medication, and AB387, a midwife licensure bill.