The Affordable Care Act was transformational for Nevada, helping its uninsured rate drop from 22 percent in 2012 to 8 percent this year.

Experts describe the Trump administration’s recently passed “One Big Beautiful Bill Act” as the biggest health care shake-up since Obamacare was enacted in 2010. It’s one that could drive up the state’s uninsured rate not only by reducing the number of people covered by Medicaid through work requirements, but by adding restrictions to a health insurance option used by more than 100,000 Nevadans — a state-run marketplace where the federal government heavily subsidizes premiums based on income. 

For many receiving insurance through the marketplace, the subsidies help ensure the plans are premium-free.

Billed by proponents as a way to prevent waste and abuse in the health care system, the legislation includes nearly $1 trillion in federal health care cuts over nine years — with more than $930 billion coming from Medicaid. The cuts are likely to affect states differently.

“Some states may replace some of the cuts, or they could slow walk some of the policies, like work requirements,” Drew Altman, CEO of the independent health policy organization KFF, said during a July 7 media briefing.

He noted that uninsurance rates could worsen with this year’s looming expiration of the Biden administration’s enhanced subsidies for insurance on the marketplace. The changes boosted existing Affordable Care Act subsidies and expanded eligibility for them, further lowering out-of-pocket costs.

If the subsidies are not renewed, premiums are projected to increase approximately 75 percent in 2026.

In Nevada, where Medicaid covers 1 in 4 residents, a fiscal analysis from the state’s Medicaid program projects relatively minimal cuts of $60 million in the next five years — a small percentage of Nevada’s Medicaid budget, which is more than $15 billion over the next two years.

State estimates, however, indicate that roughly 100,000 Nevadans — or 12.5 percent of Medicaid enrollees — could lose coverage in the first two years after the budget bill’s work requirements are implemented in 2027 or two years later if the state applies for, and receives, a waiver. 

The changes to the Affordable Care Act within the bill add new bureaucratic requirements, such as more income documentation, that make it more difficult to enroll in the marketplace and end an automatic renewal policy. The measure withholds premium subsidies until eligibility is verified, requiring applicants to pay full price until they are approved, and shortens the open enrollment period to just one month from a little more than two months. 

The legislation also prevents lawfully present immigrants — including DACA recipients, people with Temporary Protected Status and asylum seekers — from accessing insurance through the marketplace.

In a statement, Jennifer Krupp, a spokesperson for the Nevada Health Authority, said the state anticipates “some coverage losses,” but it’s too early to tell the effect of the expiration of the enhanced subsidies on Nevada.

Rates without the enhanced subsidy amounts for 2026 won’t be finalized by the Division of Insurance until later this summer. 

Krupp added that the state is set to launch the public health insurance option with reduced premiums in 2026, along with a reinsurance program that essentially works as insurance for insurance companies, paying a portion of high-cost claims that allows insurers to lower premiums for individual health insurance plans. 

“These two factors will help mitigate the loss of the enhanced subsidies,” Krupp said. “The Nevada Health Authority is exploring all options to reduce the impact … but those options would be dependent on the willingness of the federal government to grant approval.”

During more than a dozen interviews, local and national health care experts who spoke to The Nevada Independent said the changes in the more than 1,000-page budget reconciliation bill will play out in the state over the next decade, cautioning that the outlook could change.

“The house is not on fire, and it won't be on fire for the next year or two,” said UNR medical school associate dean for statewide initiatives John Packham, noting that many provisions don’t take effect until 2027 or 2028. “But there will come a day in which the state of Nevada has to think about how they're going to make up what we're not getting in federal support over the next decade.”

Work requirements

One of the most significant changes in the bill is the implementation of work requirements and increased renewal requirements for the Medicaid program, projected to result in more than 100,000 Nevadans losing Medicaid coverage within the first two years of implementation.

Traditionally, Medicaid covers certain low-income individuals and families, including children, pregnant women and people with disabilities. Under the Affordable Care Act, states could extend Medicaid coverage to most adults younger than 65 with incomes up to 138 percent of the federal poverty level — $21,597 for individuals, as of 2025. 

Nevada joined the extended program option in 2012. For those covered under that expansion, the new bill requires eligibility checks every six months, instead of annually, and work requirements, beginning 2027. States can delay that date through a waiver, though federal guidance on how to do so has not yet been issued.

Under the work requirements, the expansion population must prove that they are working, volunteering or attending school for at least 80 hours a month. The requirements exempt pregnant women, individuals with disabilities and parents of children younger than 13. 

Approximately 66 percent of all Nevadans enrolled in Medicaid are employed, qualifying for the program based on their income status.

National and local health care experts who spoke with The Nevada Independent said the work requirements will likely drive up the state’s uninsured rates, which could create greater reliance on emergency rooms and translate into higher costs for health care providers. Those higher costs will need to be absorbed somewhere, which means premiums for private payers may increase, or counties and states may need to take on the increases. 

“It's going to have ripple effects across the entire medical ecosystem,” Packham said.

KFF Executive Vice President for Health Policy Larry Levitt said in a media briefing on July 7 that the work requirement provision generates the most savings for the federal government.

“The vast majority of these adults are either working or would qualify for an exemption, but millions are expected to lose coverage because they fail to navigate the reporting process,” Levitt said.

As uninsured people drop primary care visits and rely more on hospital emergency rooms when health issues arise, Chris Cochran, a UNLV professor and chair in the Department of Healthcare Administration and Policy, said any effects on the bottom line to providers in the health system will likely be passed on to consumers in the form of higher premiums or higher out-of-pocket costs.

“The bigger effects will be on local taxpayers in general,” Cochran said. “In the case of public or nonprofit hospitals in Nevada, the effects may fall more on UMC and Renown.”

He added that one of the unaddressed questions surrounding the work requirements is that there are no real accommodations for people making low wages even if they’re working quite a few hours, and part-time workers are often subject to the whims of their employers. 

If business is down, Cochran said, hours get cut, and it’s not yet clear what provisions are in place for those who can’t meet work requirements through no fault of their own.

With the implementation of work requirements not expected to occur within the next two to four years, the state has projected a minimal impact on its Medicaid budget. However, there are still outstanding questions about the outcome of the legislation.

Packham and other experts interviewed by The Nevada Independent described the implementation dates of 2027 or 2028 as one of the cynical aspects of the bill.

He described the delays as “an unvarnished political calculation,” which means providers, facilities and voters are not immediately affected ahead of the upcoming midterm elections. 

Increased copays

Under the Republican bill, Nevadans in the expansion population who earn more than the federal poverty level could pay up to a $35 copay per service, when they currently have low or no cost sharing.

Assm. David Orentlicher (D-Las Vegas), director of UNLV’s Health Law Program, said an expected rise in copay costs for people on Medicaid from the budget bill, coupled with the reduction in food stamp benefits within the budget package, are likely to discourage people from seeking preventative care.

“When [people’s] nutrition benefits are reduced, they're not going to eat as healthy a diet, and that's going to make them sicker and need more hospital care,” Orentlicher said. “And then they're just going to have to make difficult choices. You know that [a] $35 copay is hard enough, and as you're having to spend more money on food, it compounds the problem.”

In a May interview, Nevada health care consultant Mike Willden, who previously headed the state’s Department of Health and Human Services, said state officials have experimented with copays in the past, and it was difficult to implement. He added that copays could impose challenges for staff or discourage people from getting health care.

“[There will likely be] more eligibility work to see where you fit and whether you don't have a copay or do have a copay. And then people's income can fluctuate month to month,” Willden said. “One of the questions I would have is, does the bureaucracy work, [is it worth] what you're going to get out of the $35 copay?”

Community health centers

Sharon Chamberlain, the CEO of the nonprofit community health center Northern Nevada HOPES, said the bill is projected to lead to the closure of 40 percent of the nation’s community health centers, which serve the most vulnerable populations and are often referred to as the backbone of health care services for low-income people.

Chamberlain estimated that more than 60 percent of her health center's Medicaid patients could lose coverage under the budget bill, resulting in a loss of more than $34 million.

Northern Nevada HOPES is implementing contingency plans, she said, but costs are going to rise as more patients lose coverage and are unable to pay for services.

“To continue to have tax cuts and incentives for some of the wealthiest individuals in our country, we are sacrificing that on the backs of our most vulnerable populations,” Chamberlain said. “If 40 percent of community health centers close around this country … that's millions, millions of individuals who will no longer have access to care.”

Hospitals

Hospitals are bracing for reduced provider tax payments — a widely used “creative budgeting” maneuver through which states tax hospitals and return the dollars to them for Medicaid patient care.

In Nevada, hospitals that have opted into the provider tax program will see an annual decrease in the cap, from the current level of 6 percent of net patient revenues to 3.5 percent by 2032.

Originally, when matched with federal Medicaid funding, Nevada’s provider tax brought in $800 million per calendar year, with the state leveraging a portion of the funding to overhaul Nevada’s worst-in-the-nation children’s behavioral health system. Estimates show that children’s behavioral health funding is projected to have a loss of between $20 million and $30 million over the next five years.

The provider tax payments in Nevada are expected to decrease by $600 million to $800 million over the next five years. Still, hospitals’ base payments for services rendered to Medicaid recipients will remain unchanged.

Nevada Hospital Association CEO Pat Kelly told The Nevada Independent that provider tax payments help supplement lower Medicaid rates but hospitals may want to reevaluate whether they continue in the provider tax program if the taxed amount is greater than the return.

“Right now, our emergency rooms handle more primary care and behavioral health than they should, and I think that the changes that are going to occur have the potential of actually increasing, instead of decreasing, the level of primary and behavioral health services we may have to provide,” Kelly said. “The sad part is that we've really had a good plan to move forward to improve behavioral health, and it's going to be interrupted. I'm not saying that it'll end, but it's definitely going to be impacted.”

As rural hospitals also face cuts, Blayne Osborn, president of the Nevada Rural Hospital Partners, said that rural hospitals are unlikely to close or shut down services, but expansion of programs is doubtful. 

Osborn said his biggest concern is that services being shut down would include childbirth offerings and long-term care units for seniors, forcing rural residents seeking those services to travel to Reno, Las Vegas or out-of-state facilities. 

“Those seniors have nowhere else to go; they're going to end up in Reno or Las Vegas or out of state,” he said. “And families have to pay for that.”

Advocacy and future preparedness

Since the passage of the budget package, hospitals, industry groups and community health centers have raised concerns about the financial effects of the legislation, working to undo them at the federal level. In the past, Congress has delayed or repealed similar policies, which some said indicates room for that to happen over the lifetime of the budget bill.

Some experts who spoke to The Nevada Independent noted that a $50 billion relief fund for rural hospitals included in the budget package that’s set to be allocated over five years, shows that there’s an acknowledgement of the harm that hospitals are likely to experience. And, with effects projected to hit in 2028, it’s not going to be popular to cut hospital funding during an election year.

Although Osborn said the state will feel strains from the legislation, he noted that the final version is toned down from the original proposal. 

Recent and upcoming health care changes in Nevada could also blunt the impact. He pointed to the implementation of the Nevada Health Authority, the public health insurance option and a reinsurance program that’s in the works.

“I think Nevada might be in better shape than some of these other states on some of those things,” Osborn said.