Mike Willden is considered one of the most knowledgeable civil servants in Nevada — when he spent his final day on the clock last Friday as former Gov. Brian Sandoval’s chief of staff, he ended a 45-year career with the state.

One of the state’s premier numbers guys, he even chose to leave the office at 5:45 p.m. on Jan. 4, so he’d have 45 years, 4 months, 5 days, 45 minutes and 45 seconds of service in the books.

His career spans time as a 17-year-old self-described “lawnmower boy” at a girls’ correctional facility near his hometown of Caliente to stints as a welfare caseworker in some of Las Vegas’ most distressed neighborhoods to head of the state’s Health and Human Services department under three different governors. He’s seen the state through seismic changes in welfare policy and the implementation of the Affordable Care Act and a vast expansion of Medicaid.

But while he spent much time crunching numbers at the helm of a bureaucratic machine, he’s an outdoorsman at heart, and he says some of his favorite memories are of rural Nevada road trips and camping at Great Basin National Park with Sandoval.

Willden hasn’t decided on his next steps, but at 63, he said he’s not yet ready to retire. He sat down with The Nevada Independent on Tuesday to field questions on the origins of Nevada’s health-care and welfare systems and where he thinks it should go under Gov. Steve Sisolak’s leadership.

Willden also talked about the difficulties and successes of Sandoval’s decision to expand Medicaid in Nevada, and why the administration never signed on to any of the proposals to repeal and replace the Affordable Care Act in 2017. Here are some excerpts from the IndyMatters podcast.

The evolution of welfare

Willden was a welfare caseworker when welfare was a program called Aid to Dependent Children and focused on single mothers with children. It evolved in 1996 into a block grant called TANF, or Temporary Assistance to Needy Families, and has a focus on moving recipients into jobs.

He said that effort, launched during the Clinton Administration, has been a mixed bag. Nevada has had trouble meeting the high standards for the percentage of welfare recipients who are working.

“Obviously, a lot of work has gone into that ... but you have to have nearly half of your cases participating,” he said. “So we have not met that marker in the last several years. In fact, I would probably say six or eight years, and so a lot of work has to continue to go in to meeting your employment rates.”

Willden said meeting those so-called work participation rates has been difficult because recipients are typically mothers with at least one child and may also be pregnant. They often don’t have much education, lack transportation, and may be a victim of domestic violence.

“So you have to build with the basic building blocks and a lot of times it’s exactly that. It’s starting about ‘you’ve got to get up in the morning, you’ve got to get ready, your kids have got to get out to school, they’re catching buses, you’re going to have to catch a bus, you’re going to have to take a bus to work or to your training program,’” he said. “A lot of the low-income families have a lot more challenges than you or I would.”

Nevada has been slapped with fines for falling short of those benchmarks, but Willden says the federal government typically doesn’t collect on them if a state is making progress and negotiates a corrective action plan.

He also said other states have slashed cash assistance through TANF, instead using the federal funds they receive from the block grants to pay for services to the poor that would otherwise be paid for by the state and freeing up state dollars to use on things unrelated to helping poor families.

“In my humble opinion, a lot of states, if you will, played some games with the block grant in years past,” he said. “There wasn’t a way for families to get basic aid, and so I think Nevada has tried to do the right thing.”

Change in federal administration

Willden has worked with a range of federal agencies over the past four decades, and he said each administration brings its own priorities. Some have sought to expand enrollment in food stamps or sign up people with Medicaid, the exchange or other health-care programs through Obamacare.

The Trump administration has taken a much different tack, which has complicated things for Nevada when it has tried to continue programs it started under Obamacare.

“I think lately that’s been a huge challenge, particularly for Nevada because we were an opt-in state. We wanted to expand Medicaid ... but it becomes very difficult when your federal partners may or may not believe the same way that state does,” he said. “That’s what I think it is — a battle. When you’re going through repeal and replace and numbers of versions of repeal and replace and constantly evaluating whether they will help or harm your state.”

Work requirements and health improvements

In January 2018, the federal government announced a new policy allowing states to require Medicaid recipients to work to continue receiving health insurance. Although Sandoval proposed a similar bill early in his tenure, the Republican governor did not join the handful of states in seeking such a requirement.

Willden said Sandoval supports work requirements in theory, but said the policy would not improve state “health outcomes” and would likely lead to thousands losing their health insurance — a result contrary to the goal of such requirements, which is that people would get better jobs, health insurance through their work and eventually achieve better health.

“What you don’t want to have is a work requirement that is just what I call a ‘Failure to be able to succeed’ system,” he said. “A lot of work requirements say you have to do this, you have to do that, you have to do 20 hours here, you have to show up to a class, and that’s all good, but when you fail for whatever reason ... you terminate their benefits. Now how have you improved their health? They are unemployed again, they’re not on Medicaid, their kids aren’t on SCHIP (Children’s Health Insurance Program). You’ve not improved their health situation.”

Even as Nevada has dramatically improved its uninsured rate after expanding Medicaid, Willden said the “jury is still out” on whether or not the state’s citizens are actually healthier, as most reporting has a year or two lag. But he said early indicators, plus the state’s contracts with managed care organizations, appear to be trending positively.

“So the idea is to get them primary care and address problems early and not wait for your mom or your aunt or your grandma or whatever to take you to the ER at probably 10 times the cost of getting on a nurse hotline and taking care of strep throat or whatever you have early on,” he said. “And so I think they are working, but I think the jury is still out to see how much that overall saves. We’ve had studies in the past. Managed care can save 4 percent to 7 percent. It doesn’t sound like very much, but it’s a lot of money when you’re talking about $4 billion in health care.”

Role in Obamacare repeal talks

Nevada was once part of a lawsuit opposing Obamacare, and Willden says it now feels “schizophrenic” that Nevada leaders including Sandoval have since embraced Obamacare so warmly. But he thinks it’s the right choice.

“I’ve been to a lot of [National Governors Association] meetings and different conferences and I think a lot of states are sorry that they didn’t get in as early,” he said, referring to states that declined to expand Medicaid.

During a 2017 Republican effort to repeal and replace the Affordable Care Act, Willden said the Sandoval administration “never saw a model, if you will, a proposal that we thought was better than what Nevada had.”

That included a measure supported by Republican former Sen. Dean Heller called the Graham-Cassidy-Heller-Johnson amendment, which would have converted Medicaid funding into a block grant. While block grants are often hailed for offering states flexibility on how to spend the money, their downfall is that they rarely grow in response to greater demand for services.

“We were not supportive. It did not pencil out math-wise, it would hurt Nevada, and when I say hurt, people may or may not have lost health-care coverage, but the state would have had to put in significantly more dollars between the state/federal match,” Willden said.

Nevada’s insured rate was “pathetic” before the ACA, he said. State leaders who had seen the uninsured rate drop from 22 to 23 percent to somewhere between 8 and 11 percent — less that half what it was — were skeptical that any repeal package would improve their situation.

“We obviously were pretty pushy to keep what we had. We believed we were on the right path. We still believe, if Governor Sandoval were sitting here with me, still believe we’re on the right path with low-income families,” he said.

Medicaid costs are shared between the federal government and the states, but the Affordable Care Act has shifted more of the burden to the federal government. Willden said that even as the federal government’s portion has declined over the years since the health insurance law took effect, it’s still been a good deal for the state.

Nevada used to spend $500 million of state dollars on Medicaid and received $1.2 billion in federal dollars as a match. Since the Affordable Care Act took effect, the state pays out $750 million for Medicaid and received more than $3 billion from the federal government.

“So for $250 million of Nevada taxpayer dollars investment, we brought in over $2 billion of federal money,” he said. “Anytime you can take one dollar and get eight or nine dollars, it’s a good deal.”

SprinkleCare

National media outlets took notice of Nevada in 2017 after state lawmakers approved an ambitious bill that would have allowed all state residents to buy into a state-sponsored Medicaid-style health insurance plan, dubbed “Sprinklecare” after bill sponsor Assemblyman Mike Sprinkle.

Although Sandoval ultimately vetoed the bill, other states and federal lawmakers have pursued similar versions of the same idea as part of a push to expand health coverage and lower costs.

Willden said that Sprinkle’s bill “didn’t quite get there in the end” and that the proposal needed to be ironed out further, but lauded the Democratic assemblyman’s attempt to enroll more people in health insurance.

“I would assume Assemblyman Sprinkle will continue to work on that going forward and I believe that’s probably where America is going to continue to go is a sliding scale, if you will, of access and affordability to health care,” he said. “And certainly, as a health-care advocate over my life, everyone should have access to health care, period.”

Health care for undocumented Nevadans

Willden thinks Nevada’s uninsured rate is almost as low as it can go, considering about 7 percent of the state’s population is undocumented and not eligible for Medicaid or certain other insurances.

He noted that the federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide emergency care to people regardless of their insurance status, even though they are not required to provide primary care. But he said Sandoval’s administration took steps to improve care for that population.

“A lot of that work is defining what’s emergent care. And so, for example, we spent a lot of time looking at diabetes,” he said. “We worked to ensure that our rules said that diabetes was urgent or emergent care and not ongoing chronic care. If you don’t get your insulin or your dialysis or your whatever you will be decompensate, you will have a problem shortly and you will be in the hospital and the ER, so we worked along those lines.”

Another effort centered around making sure Medicaid was paying for emergency room care for undocumented people, rather than the bill falling to general Nevada taxpayers.

A third move was signing a bill in 2017, sponsored by Democratic Sen. Yvanna Cancela, that allowed children to sign up more quickly for the government health care. In general, immigrants must be in the U.S. for at least five years before they are eligible for public benefits, so the bill was a workaround to that provision.

Building a budget

Although Sisolak was sworn in as governor on Monday, most of the executive budget preparation has been undertaken by Sandoval’s team, including Willden, throughout the past year. Details of the $8.8 billion budget were released in November, but Sisolak and state lawmakers have the prerogative to fine-tune or change parts of the budget.

Willden said he’s worked closely with Sisolak’s budget advisor Mark Stevens, and that the new governor will have a unique opportunity to make a variety of “one-shot” budget allocations for his policy priorities.

“They have great opportunity,” he said of the Sisolak administration. “They have a lot better situation than …when Governor Sandoval was first elected and then when he was re-elected ... Now going forward, there’s great opportunity, revenue and one-shot capabilities look really good.”

But a healthy budget picture only goes so far — Willden noted that much of the $8.8 billion expected in state tax revenue is already taken up by natural growth in health care, K-12 and college education caseloads.

“Then if you deal with pay raises and things like that, you start narrowing that window” of discretionary spending, he said. “I would assume that Governor Sisolak will be very much like Governor Sandoval. He will focus on education and he will focus on health care.”

Chief of staff advice

Willden’s successor as chief of staff will be Michelle White, the former Nevada head of Hillary Clinton’s 2016 presidential campaign and a longtime legislative adviser for state Senate Democrats.

Though they come from different backgrounds, Willden said he and White had been texting everyday throughout the transition and “communicate a bunch.” He said his advice to her would be to build a strong team and rely on them for tough decisions.

“I guess my advice to her would be it’s not about one person,” he said. “It’s really about surrounding you with some pretty smart people. That’s what I’ve tried to do in my career. I’m not the smartest kid on the block, but I certainly know how to find smart people.”

Listening is also key.

“You really have to spend a lot of time sorting out some pretty complex problems and getting people’s opinions and views and then at the end of the day, make tough decisions,” he said. “You don’t get to kind of just wallow forever.”