Labor Day used to mark the beginning of campaign season, but no more.

Two major national groups — the National Republican Senatorial Committee and the Democratic National Committee — are putting up billboard ads this week attacking Republican Sen. Dean Heller and his Democratic challenger, freshman Congresswoman Jacky Rosen. The ads repeat already familiar attacks about the two candidates, that Heller voted to take health care away for upwards of 300,000 Nevadans and that Rosen has voted against veterans and stands with House Minority Leader Nancy Pelosi.

A mobile video billboard near the Las Vegas Strip shows Heller smiling and laughing at a White House lunch with his fellow senators while the president cajoled Heller over his position on Senate Republicans’ efforts to repeal and replace the Affordable Care Act (ACA). A stationary billboard will display a static version of the same message.

“Senator Heller told us he’d protect our health care. Then he voted to threaten health care for 328,000 Nevadans,” the mobile video ad says. “Tell Heller to wipe that grin off his face and start working for Nevadans. Our health care isn’t a joke.”

(For a fact check of the Rosen ad, click here.)

Asked about the ad, Heller's campaign team called it "simply false."

“From the beginning of the Obamacare debate, Dean has worked and voted in ways to strike the onerous mandates by repealing Obamacare while simultaneously doing what is right for Nevadans and their families," said Heller spokesman Tommy Ferraro in a statement.

So how "simply false" is it really? Heller's campaign did not provide any details to back up why it believes the ad to be false, but after reaching out to the DNC and the group responsible for estimating the 328,000 figure, it appears that the gist of the ad is true, though the specific number upon which it bases that assessment may not be the best figure to use.

328,000

The attack used in the Heller billboard is simple on its face — Heller “voted to threaten health care for 328,000 Nevadans.”

That 328,000 figure is a projection of how many Nevadans would lose health insurance if the original version of the Senate Republicans’ health-care plan, the Better Care Reconciliation Act, had passed. The number was included in a widely cited report compiled by the Nevada Institute for Children’s Research and Policy, a not-for-profit, nonpartisan research center within the School of Community Health Science at UNLV, but was actually calculated by the Urban Institute, a liberal-leaning think tank in Washington.

Projections from the Urban Institute estimated that the BCRA would result in 277,000 adults and 51,000 children in Nevada losing coverage, totaling 328,000. When the BCRA was revised, the Institute released updated projections, showing that 321,000 Nevadans stood to lose coverage if the legislation were passed.

The reports state that their projections are based on “HIPSM 2017,” the Urban Institute’s Health Insurance Policy Simulation Model. It’s a microsimulation model of the health-care system that estimates cost and coverage effects of various health-care policy options by using data from several national datasets, including the Current Population Survey (CPS) Annual Social and Economic Supplement and other surveys matched to the CPS.

On the national level, the nonpartisan Congressional Budget Office (CBO) estimated that the original version of the BCRA would result in 23 million fewer people having health insurance than under the ACA and that the revised version of the bill would result in 22 million Americans losing coverage. The office also estimated that the so-called skinny repeal proposal — which would have repealed the individual and employer mandates, as well as the medical device tax — would have resulted in an additional 16 million uninsured.

The progressive public policy research and advocacy organization Center for American Progress (CAP) also put together its own state-specific projections, based on the CBO’s analysis of the revised BCRA, estimating that 122,500 Nevadans would lose coverage by 2026.

So why the differences between all the numbers?

As with any analysis, it’s always possible to use slightly different modeling or extrapolate data in a slightly different way and end up with somewhat different looking numbers.

The Urban Institute’s first analysis surpasses the CBO’s projections — 24.7 million uninsured nationally by 2022 compared to 23 million in 2026. Its second analysis, based on the revised BCRA, also projects more of an impact than the CBO does — 24 million uninsured by 2022 instead of 22 million by 2026.

But Urban Institute senior research associate Matthew Buettgens stressed in an email actually how close the two comparisons are, given that they rely on different models.

“Our difference with CBO is probably due mainly to different assumptions regarding Medicaid enrollment,” Buettgens said. “However, I would say that what is most notable in comparing our results with theirs is that two very different models give such similar estimates of the impact of the BCRA.”

CAP’s vice president for health policy, Topher Spiro, explained the difference between his organization’s projections and the 328,000 number modeled by the Urban Institute as a matter of the different approaches the two used, saying it’s best to think of the numbers as a range of potential losses, not that one is right and another is wrong.

CAP extrapolated its numbers from CBO, which assumed in its model that some states that opted into Medicaid expansion under the ACA would come up with additional state funding for Medicaid and find some way to retain eligibility for those covered individuals, while the Urban Institute did state-specific modeling.

The votes

That takes us to the second part of the assertion, that Heller voted to threaten health care for those 328,000 Nevadans.

To figure out whether that’s true, we have to look at all of Heller’s stances and votes on Senate Republicans’ various proposals to repeal and replace the ACA. (The Nevada Independent created a helpful table to summarize the votes that happened that week.)

To begin with, Heller has long opposed the ACA, voting against it back in March 2010 when he was a congressman and voting several times to repeal or tweak portions of the federal law when Republicans took control of the House in the spring of 2011. He also voted in favor of a clean repeal of the ACA in 2015, which President Barack Obama vetoed.

The 2015 bill would have phased out subsidies given to low- and middle-income individuals to help them purchase insurance, eliminated tax penalties for not purchasing insurance and the “Cadillac tax” on high-cost, employer-sponsored health insurance. It also would have eliminated Medicaid expansion as created under the Affordable Care Act over two years.

In June, Heller came out strongly against the original draft of the BCRA, which he said would take health care away from hundreds of thousands of Nevadans and tens of millions of Americans, expressing serious concern about the 210,000 Nevadans covered under Medicaid expansion.

A month later, Heller voted “yes” on the motion to proceed to debate on the revised version of the BCRA. He justified the vote by saying that it would “give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices.”

However, when it came time to vote on the revised BCRA, Heller was one of the key Republican votes to sink the bill. He also voted against a “clean repeal” of the ACA, which would have repealed the legislation without a plan to replace it.

But after 20 hours of debate, Heller cast a vote in favor of skinny repeal, the Senate Republicans’ last-ditch effort to pass some sort of repeal bill in the hope of sending the legislation to a conference committee with members of the House to work out a final compromise bill. Though many Republican senators justified their votes in favor of skinny repeal by framing it as a vehicle to get to the conference committee, Heller actually seemed supportive of the concept as a whole.

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” Heller said in a statement to the Las Vegas Sun. “While not perfect, the Health Care Freedom Act protected coverage for our most vulnerable and provided relief to many hard-working Nevadans by repealing the most onerous provision of Obamacare, the individual mandate.”

But it was unclear how safe funding for the nation’s Medicaid program would be in conference committee with only a handful of senators opposed to cutting the program and members of the Freedom Caucus in the House pressing for a more conservative solution to the ACA.

Though skinny repeal is the more recent vote, the DNC said it intended to highlight both of Heller’s “yes” votes through the billboard ads.

“By voting for the Republican’s so-called ‘Skinny Repeal’ Dean Heller turned his back on Nevada’s families and was complicit in trying to take health care away from millions of Americans,” said DNC spokesman Vedant Patel in a statement to The Nevada Independent. “His dismal approval rating is indicative of what happens when you secretly try and strip health care away for millions of Americans. "

Verdict

So did Heller’s votes on the motion to proceed and to support skinny repeal threaten the health care of 328,000 Nevadans? Maybe.

The 328,000 figure — if you agree with the methodology behind it — is based on the original draft of the BCRA, which Heller opposed and wasn’t even on the table at the time that he voted for the motion to proceed. It would be more accurate to say he voted to threaten health care for 321,000 Nevadans, given that the revised BCRA was the primary proposal on the table at the time of the motion to proceed. But, even then, Heller voted against that exact proposal just hours later.

It’s also imperfect at best to say that Heller’s vote on skinny repeal threatened the health care of specifically 328,000 Nevadans. As far as The Nevada Independent is aware, there have been no state-specific projections of the impact of the skinny repeal; the DNC did not provide any links to such an analysis either.

One would assume that because the CBO projected only 16 million Americans would lose insurance under skinny repeal compared to 23 million under the original draft of the BCRA, only some fraction of 328,000 Nevadans would have lost insurance under skinny repeal.

All that said, Heller did say that he wouldn’t support a bill that took away health care from hundreds of thousands of Nevadans and millions of Americans. He did vote in favor of skinny repeal, which the CBO estimated would take health care away from 16 million Americans.

And, although Heller recently voted against a full repeal of the ACA (which the CBO estimated would result in 32 million more uninsured Americans), he voted in 2015 to support a similar measure, which probably would have resulted in even more than 328,000 Nevadans losing health insurance.

At the end of the day, all of the numbers are projections with a high degree of variability. The point of the ad is less about the specific number — the 122,500 estimated by CAP or the 328,000 projected by the Urban Institute — and more about the overall sense that the plans put forward would have stripped health care from hundreds of thousands of Nevadans and tens of millions of Americans.

The number used in the ad is technically inaccurate in that it conflates an estimate based on an original version of the Senate Republicans’ health care bill with Heller’s vote on a motion to proceed with a revised version of that initial proposal and his later vote on an entirely separate measure. But the gist that the DNC is trying to convey — that Heller voted to move forward the discussion and support a proposal that could have affected tens of millions and hundreds of thousands of Nevadans — is true.

While the underlying message from the DNC is accurate, the specific number that the organization uses was calculated based on a proposal that Heller never voted for. We rate this claim Almost Abe.