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Gov. Brian Sandoval delivers his State of the State address on Jan. 17, 2017. Photo by David Calvert.

Nevada Gov. Brian Sandoval, whose opinions weigh heavily in Republican Sen. Dean Heller’s decisions about pending health care legislation, said his preliminary understanding is that the Senate’s latest version isn’t much different than before and “thus it would cause me great concern.”

Sandoval made the remarks Thursday in an interview at the National Governor’s Association summer meeting in Providence, Rhode Island, where he again raised concerns about an overhaul’s effect on newly eligible Medicaid recipients and the state budget. He said he hadn’t spoken to Heller in the past 24 hours and wasn’t advising him on which direction to take on a motion to proceed.

“I’ll leave it to Heller on what he’s going to decide what he’s doing on process,” said Sandoval, who noted that he’d been in a series of meetings and hadn’t had the chance to fully digest the new proposal. “My staff is working very closely with his staff in terms of how we’re interpreting the bill.”

Sandoval also said he’ll be meeting with Health and Human Services Secretary Tom Price, Centers for Medicare and Medicaid Systems Administrator Seema Verma and Vice President Mike Pence this week. All three are expected to speak at the meeting of NGA — a group Sandoval is chairing in the upcoming year.

Top officials have been eager to bend the ear of Sandoval, Rep. Mark Amodei and others close to swing voting Heller, who has remained mum as some of his Senate colleagues have declared that they will vote against starting debate on the GOP’s’ latest proposal. The measure makes several tweaks to the original bill draft but keeps in place provisions likely to have an outsized effect on Nevada.

The revised bill, released Thursday morning, keeps in place a repeal of the individual mandate requiring most Americans to have health insurance and still makes extensive cuts to expanded entitlement programs that have helped hundreds of thousands of people in states such as Nevada gain health insurance. But it does contain a number of altered and new provisions  designed to garner support from Republicans on the fence, including billions to combat opioid addiction and additional funding to help pay for state-based reforms.

A path forward for the bill seemed murky early Thursday with two Republican senators declaring they will vote “no” on a motion to proceed with debate on the bill and several more still with serious reservations about the legislation. Republicans can only afford to lose two members of their caucus in order to meet the 50-vote threshold required to move ahead with the preliminary procedural motion.

Heller told NBC reporter Leigh Ann Caldwell Thursday morning that he was currently undecided on whether he would support a procedural motion to bring the bill up for consideration on the floor of the Senate. Heller made national headlines last month when he stood alongside Republican Gov. Brian Sandoval, announcing he could not support the original bill and would vote no on a motion to proceed to debate on the original draft of the bill.

Any significant changes to the federal health insurance law could have major effects on the roughly 210,000 Nevadans who gained insurance coverage under the Medicaid expansion allowed under the Affordable Care Act, helping the state significantly lower its uninsured rate over the last five years.

Fast facts about the new Senate Republican health care bill

  • The new version of the bill is 172 pages — 30 pages longer than the original Better Care Reconciliation Act, which was released on June 22. After pushback, the Senate delayed a vote on that bill before its 4th of July recess and instead started crafting the amended version.
  • It tentatively contains a controversial amendment from Texas Sen. Ted Cruz that would allow companies to sell cheaper insurance plans so long as they also offer at least one ACA-compliant plan.
  • Senate Majority Leader Mitch McConnell still can only afford to lose two members of his caucus for the bill to pass; a loss of three would kill the legislation. Sen. Rand Paul of Kentucky and Sen. Susan Collins of Maine have said they will vote “no” on a motion to proceed with debate.
  • Earlier this week, McConnell delayed the Senate’s August recess by three weeks in order to give senators time to work on the health care bill.

What does the new Senate bill look like?

  • Largely similar to the first version — the Better Care Reconciliation Act — with no major changes to the Medicaid provisions that would phase out federal dollars given to states who decided under the Affordable Care Act to expand their Medicaid coverage to everyone who makes below 138 percent of poverty. It also keeps in place the switch allocating Medicaid funding either on a per-capita basis, giving states a set amount of money for each eligible individual, or as a block grant, which would gives states a chunk of money to spend on the program as a whole.
  • Makes minor changes to Medicaid provisions, including allowing an expanded block grant option that would let states add their expansion populations under the block grant if they choose to do so. It would also allow states to apply for waivers to continue or improve home and community-based services for the aged, blind and disabled. It also allows expenditures in the event of a public health emergency to not count toward the per-capita or block grant allocations for the period of the emergency. It also changes a calculation to help states provide uncompensated care, changing the Disproportionate Share Hospital calculation from per Medicaid enrollee to per uninsured.
  • Adds back in two taxes imposed on people with high incomes — a 3.8 percent tax on investment income and a 0.9 percent payroll tax that applies to individuals reporting incomes over $200,000 or couples with a joint income over $250,000.
  • Allocates an additional $70 billion on top of the existing $112 billion in the bill to help with state-based reforms, such as help lowering premiums, cost-sharing, and Health Savings Accounts.
  • Allows people to use Health Savings Accounts to pay for their premiums, a policy advocated for by more conservative members of the Senate Republican caucus.
  • Allocates an additional $45 billion for substance abuse treatment and recovery to combat the opioid epidemic.
  • Includes a controversial provision proposed by Texas Republican Sen. Ted Cruz that would allow insurers to sell cheaper health care plans with fewer benefits that comply with the standards in the existing Affordable Care Act as long as they offer at least one plan with a robust set of benefits. Cruz’s so-called “Consumer Freedom” amendment is considered key in obtaining his vote on the overhaul bill, but it concerns moderate Republicans who fear it could lead to spikes in premiums for those with pre-existing conditions. The amendment is included in brackets in the new draft of the bill, and the nonpartisan Congressional Budget Office is expected to analyze the bill both with the Cruz amendment and without.

Reaction from Nevada leaders

  • Sen. Dean Heller: He told Politico on Wednesday that there had been “no breakthrough” in negotiations on the bill, and that he remained in the same camp. “Fundamentally, they haven’t changed the bill,” he said.
  • Sen. Catherine Cortez Masto: “The bill unveiled today is just as much as a sham as the ones that preceded it. If passed, thousands of Nevadans and millions of Americans across the country would lose access to quality, affordable healthcare,” she said in a statement. “'Revisions’ that allow this to remain a fact are an affront to the American people. This is simply unacceptable. I call on my fellow senators to vote no on any motion to proceed to this sham legislation.”
  • Rep. Jacky Rosen, who is challenging Heller for his Senate seat: “I’m disappointed that once again Senator Heller refuses to oppose the Republican health care plan. Instead of fixing the Affordable Care Act, he still wants to get to yes on passing a partisan repeal that will increase costs and strip coverage from Nevadans," Rosen said in a statement. "Before he found himself in the spotlight, Senator Heller voted repeatedly in Washington to dismantle the ACA, defund Planned Parenthood, get rid of Medicaid expansion, and enact more devastating health care plans than the one currently on the table. Nevadans need a Senator they can trust to be an independent voice who will fight to protect our health care.”
  • Rep. Dina Titus, who hasn't ruled out a Senate bid against Heller: "Trumpcare’s latest iteration is a tortured attempt to keep a bad bill on life support. It offers Americans higher premiums and less coverage; high-risk pools for sick Americans and less financial assistance for working families," Titus said in a statement. "Thanks to Ted Cruz, the bill even offers plans that don’t comply with the law. There will be steep cuts and a phase out to Medicaid with no reasonable solutions to help serve the most vulnerable people in our nation. It is no surprise the bill is so bad. There have been no hearings, debates, or public input to openly discuss the legislation. No senator in good conscience can advance this bill.”

Reporter Jackie Valley contributed to this story.

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