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Northeastern Nevada Regional Hospital staff gather in the emergency room area in Elko on Tuesday, April 3, 2018. (Jeff Scheid/The Nevada Independent)

Assemblyman Mike Sprinkle made national headlines last year after the Legislature approved a bill to allow all Nevadans to buy into a state-sponsored Medicaid-esque health insurance plan, a proposal that earned the tongue-in-cheek nickname “Sprinklecare” at the time.

The Los Angeles Times, Vox and CNN picked up the story in the days following the end of the 2017 legislative session, with articles pondering whether Nevada would become the first state to pass a Medicaid-for-all-type bill: “Nevada moves closer to a landmark Medicaid-for-all healthcare model;” “Nevada's legislature just passed a radical plan to let anybody sign up for Medicaid;” “Nevada lawmakers want to offer Medicaid to all residents.”

The legislation itself was short — just four pages long with only two pages of actual bill text — for a novel proposal that would have required a fairly significantly heavy policy lift to actually implement -- that is, if the governor hadn’t vetoed it. In a message accompanying his veto, Gov. Brian Sandoval didn’t entirely shut down the proposal; he praised it for its “creativity” but said it raised too many questions and needed further study.

Since then, a working group established during the session has been expanded and continues to meet, and Sprinkle has begun to host a series of listening sessions to gather input from the community. He’s left behind his “Medicaid for all” bill in favor of bringing forward a new, narrower proposal to provide health insurance to a targeted portion of the population to the Legislature in 2019.

Some involved with the process, including physicians and hospitals, are optimistic about the impact that some sort of innovative health plan could have on the state by creating more competition in the insurance marketplace. But with more than a year gone since the end of the last legislative session and only seven months away from the next one, there are still more questions than answers about what exactly that will look like.

The 2017 legislation had established the broad contours of what a state-sponsored health insurance plan, formally dubbed the Nevada Care Plan, would look like: The state was to enter into a contract with one or more insurance companies to provide coverage under a health insurance plan mirroring the benefits offered through the state’s Medicaid program; that plan could be available for purchase on the state’s health insurance exchange; and Nevadans would be able to use any subsidies they qualify for under the Affordable Care Act to purchase such a plan.

The rest of the details — including whether the state would need to ask the federal government for any waivers to bend the rules of the Medicaid program or the ACA to make the plan workable; whether such a plan would even be able to be offered on the state’s insurance exchange and, if not, how it would be marketed; and whether any insurance companies would even be interested in bidding to offer such a plan — were to be determined over the year-and-a-half-long regulatory process.

Sprinkle acknowledged the leanness of his bill during the session, saying that the working group — which included officials from the governor’s office, Medicaid, the Division of Insurance, and the exchange, as well as some community providers — hadn’t had enough time to develop a fully fleshed-out proposal.

“The language in AB374 is open and broad because the working group will continue to work on it,” Sprinkle explained to the Senate Health and Human Services Committee. “The working group did not have time in the five weeks during session to come up with everything … The working group will figure out what makes sense fundamentally for the people of Nevada and then move forward.”

Sprinkle, in an interview, said that he spent some time following the veto to reflect, and acknowledged that his original bill was “kind of ambiguous” and “meant as a catch all.” He also said that he received some criticism that the working group during the session was too small and expanded it to include insurance companies, hospitals and physicians as well.

His goal now is to bring forward a new bill during the 2019 legislative session likely targeting a smaller segment of the population instead of trying to create a plan to open up to all Nevadans. To that end, the Department of Health and Human Services put out a request for information from insurance companies in late April to explore what that plan might look like.

Specifically, the request for information asked insurance companies to provide feedback on two different proposals: one, to create some sort of health plan that would allow the state to combine its purchasing power between Medicaid, the Department of Corrections and the Public Employee Benefits Program (PEBP), which collectively provide insurance to about 740,000 Nevadans; and two, to create a Medicaid-like plan for individuals who are increasingly priced out of the individual market because they make too much money to qualify for federal subsidies and have borne the bulk of rate increases over the last year.

Julie Kotchevar, administrator for the Division of Public and Behavioral Health, said that the goal of the request was to identify some of the barriers to creating a new type of state health insurance plan — whether a state law problem, a state funding problem or something else.

“The goal was just trying to ask the industry in a really formal way — formal but yet open to anyone who wanted to provide that feedback — what do you think? Because we’re all wrestling with how do we define the population, how do we define what’s missing along the spectrum of insurance that’s still available,” Kotchevar said. “This was an attempt to say, ‘Okay, give us all of the issues that you see’ and ‘Do you have any strategies?’ from the people who insurance is their business.”

Kotchevar said the state has received the most interest in the opportunity to create some sort of overlapping health plan between Medicaid and the Department of Corrections, since a significant number of people who are incarcerated are likely to be Medicaid-eligible upon release. She said that there might be an opportunity for insurance companies to manage inmate health care inside the corrections system and then more smoothly transition people onto Medicaid upon their release.

She said that there was not much interest from insurers in also including the PEBP population in a potential plan, as PEBP has more retired state employees than it does current employees and more closely resembles the federal Medicare plan in terms of population than it does Medicaid.

There were also more questions than answers from insurance companies with regard to devising a plan to cover the portion of the population that makes more than 400 percent of the federal poverty level — about $98,400 for a family of four in 2017 — and does not qualify for federal subsidies to purchase insurance through the exchange, Kotchevar said. There are an estimated 229,000 uninsured individuals in Nevada, or 8 percent of the population, though it is unclear how many of those individuals would qualify for this type of plan.

In total, insurance companies sent 78 questions to the state in response to the request for information in an attempt to tease out details of what the state was looking for: How big is the population the state wants to cover? What should the plan network look like? What should costs look like? How many contracts would the state award? What happens next? The state’s answer, in most cases, was that it was simply exploring the universe of “innovative” options that might be available to address the state’s health-care needs.

“I think one of the things that we’ve all been struggling with in the working group is trying to put enough parameters around it that people can offer ideas but not putting so many parameters around it that you close yourself off to ideas,” Kotchevar said.

New members of the working group, including the Nevada State Medical Association and the Nevada Hospital Association, are optimistic about what could be developed out of the working group. But far from coming up with an answer, they’re still not even quite sure what the question is.

“I know there’s a lot of angst and uncertainty about the insurance world, especially in Nevada. We don’t know what’s happening at the federal level,” the medical association’s executive director, Catherine O’Mara, said. “I think [Assemblyman Sprinkle] is responding to concerns he’s seeing out in the community. We’re working with him to determine what exactly is the population you’re trying to enhance their benefits or get them benefits.”

The hospital association sees an opportunity through the working group to improve coverage for the uninsured, who represent about 11 percent of their patient volume.

“Anything that we can do to help improve coverage for the uninsured, the underinsured or people who might fall out of the standard Medicaid program if that were to change or if at the national level the ACA changes,” said the association’s CEO and President BIll Welch. “It’s important that that population is able to access insurance. I think that’s what the assemblyman has been focused on. We’re very supportive of that.”

Both the physicians and hospitals originally had concerns that creating a Medicaid-like plan would mean Medicaid-like rates, which providers have long complained about in Nevada as being too low for the cost of providing services. But both associations said that they have been assured by Sprinkle that the goal is to create a plan that mirrors Medicaid benefits but still allows insurance companies and providers to negotiate their own rates.

The state’s health insurance exchange has also participated in the working group in a technical advisory capacity. Most of the exchange’s questions have been centered around who would be responsible for administering the plan and what federal waivers might be necessary to make the plan a reality, but the exchange says it’s too early to answer most of those questions.

“It’s very difficult to go through any of these exercises and analysis without having clarity around the who, what, when, where, and why,” the exchange’s executive director Heather Korbulic said.

Sprinkle has hosted several listening sessions in Las Vegas, Henderson, Reno, Carson City and Pahrump over the last couple of weeks to gather community feedback. More will be held in Las Vegas and Reno later this month after what Sprinkle described as a “tactical error” of scheduling the earlier sessions during the day when most people are at work.

The goal, he said, is for legislative staff to turn what was collected from the request for information from the insurance companies, the listening sessions and any input received through the Nevada Care Plan’s website into a final report by August to be presented to the Interim Legislative Committee on Health Care in September. But he said that he doesn’t expect that report to be conclusive and that he anticipates the working group to continue until December, at which point he hopes to submit a bill draft request with whatever proposal he will bring forward during the 2019 session.

Heidi Sterner, who is the legislative chair of the Nevada Association of Health Underwriters and attended one of the Las Vegas listening sessions, said she was “disappointed” that more people weren’t interested in offering their input on the health plan, with only about 15 or 20 people in attendance. However, she said that she and other insurance brokers are excited about the possibility of Nevadans having more health insurance options available to them.

“We are all for the competition and increasing the number of carrier options that people have through the exchange,” Sterner said. “I guess it’s kind of like [Henry] Ford said. We want to get away from, ‘If you have a car, you can have whatever you want as long as it’s black.’ We’d prefer to give them more options to choose from.”

She said that she will be keeping an eye on how affordable whatever plan that is eventually developed is, but also that it has a robust enough network of doctors that patients are able to actually take advantage of their health insurance.

“It’s great if you have a health plan and can afford your health plan, but if the network is so small they only schedule visits with my plan one day a week and I can’t get in…” Sterner said. “There has to be a balancing act there.”

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