In the sparsely populated state of Nevada, Republican Gov. Brian Sandoval and Democratic lawmakers have been striking one deal after another to address some of the most pressing problems with insurance marketplaces, immigrant health care and birth control. Meanwhile, the GOP Congress remains gridlocked in its negotiations to repeal and replace the Affordable Care Act (ACA), President Obama's signature legislation.
But the days of cross-party agreement on health care have reached a limit in Nevada.
Earlier this month, the state's legislature passed a bill that would have made it the first in the nation to allow anyone -- regardless of their income -- to sign up on the marketplace for Medicaid, the government-run health program that's typically only offered to the poor and disabled. Sandoval, however, vetoed the Medicaid-for-all bill on Friday night, hours before the deadline.
The governor's 11th-hour decision was partially a result of the national uncertainty surrounding health care. In his veto statement, he said the legislation "could introduce more uncertainty to an already fragile health-care market and ultimately affect patient health care." Sandoval also expressed concerns that the plan was being rushed "without factual foundation or adequate understanding of the possible consequences."
The Medicaid-for-all concept is similar to the single-payer system of universal health care that liberals have pushed for years but have yet to see enacted anywhere in the country. California is the latest to grapple with whether and how to implement single-payer. Projections that it would cost California more than triple its annual budget and could trigger significant tax increases, however, may kill the attempt.
Supporters of Medicaid-for-all, including the bill's sponsor, Assemblyman Mike Sprinkle, argued it would have cost less than single-payer. Sprinkle also told NPR it was a response to uncertainty in Washington.
“There is an absolute need for states to become more reliant on providing insurance options to its citizens," he said.
If Congress replaces the ACA with the most recent version of the American Health Care Act, 24 million Americans would lose coverage within 10 years, according to the Congressional Budget Office. Health experts say the replacement plan also would have stunted Nevada's Medicaid-for-all plan.
Nevada Gov. Brian Sandoval(FlickrCC/Travel Nevada)
"It’s an innovative approach that might also be of interest to other states," says Jessica Schubel, senior policy analyst with the Center on Budget and Policy Priorities, "but it clearly rests on the base of a strong Medicaid program and robust marketplace subsidies -- both of which are in danger."
The stability of the insurance marketplace, however, is one of several health-care issues in which Nevada has taken innovative steps to address in the past few months.
Many major insurers have stopped offering plans in counties and states across the country, leaving thousands of people with few -- in some cases, zero -- options for health care. To incentivize insurers to stay in or join its marketplace, Nevada told insurers that their applications for Medicaid contracts would get preferential treatment if they also sold plans on the marketplace -- and it's already paying off.
Nevada is the only state where Aetna is still going to offer coverage in 2018. This fall, Nevadans shopping on the exchanges will have five insurance options. In addition, premiums are expected to be lower than the national average.
New York's governor, Democrat Andrew Cuomo, set a similar policy to Sandoval's earlier this month but with a much heavier hand. He took Sandoval's policy one step further and vowed to ban insurers from Medicaid if they don't offer plans on the exchange.
On the issue of birth control, Sandoval recently signed a bill that will make it easier for women to get contraceptives. The new law requires insurers to offer a 12-month supply at one time, with no co-payment. Several other states -- including Maryland, New York, Oregon and Washington, D.C. -- have similar laws.
Nevada has also made moves, along with 31 other states, to speed up the process for offering government-run health care to children of low-income immigrants, green card holders and refugees. On Thursday, Sandoval signed a bill that -- if approved by the Trump administration -- would end the five-year waiting period.
Sandoval is known for being a centrist, especially when it comes to health care. He was one of the first Republican governors to expand Medicaid under the ACA and has since lobbied Congress to keep that part of the ACA “the way it is because it’s been beneficial to Nevada.” Under the ACA, states that offer Medicaid to more people receive money from the federal government to help cover the extra costs. The AHCA, the Republican replacement bill, would phase out that money over several years.
No matter where one stands on the issues, Nevada’s bipartisanship on health care -- and its limits -- are noteworthy at a time when Washington is paralyzed.