The Fate of Medicaid for All in Nevada

An interview with Michael Sprinkle, the legislator behind the bill.

By Mike Sprinkle

Tagged Health CareMedicaidNevadaPublic Option

Friday, Nevada Governor Brian Sandoval vetoed a bill that would have allowed anyone in the state to buy into Medicaid. On Friday morning, Democracy editor Michael Tomasky spoke to Mike Sprinkle, the Nevada Assembly member who introduced the bill.

Michael Tomasky: So, the first most people in Washington heard about this bill was earlier this month, when it passed, but obviously this has been something on your mind for a long time. Why is that?

Mike Sprinkle: The answer to that is really two-fold. Way back when I was in high school it became a concept of mine that the government has a responsibility to provide for adequate health care for all people. The reason why I say that is because with a person who is healthy, they’re able to kind of participate in life in an active way. They’re able to be active members of our society economically, able to show up to work on time, things of that nature, but they’re also able to have the kind of lifestyle that they would enjoy, that makes them happier people.

This was the thing that tumbled around in my head. I had conversations with people back in high school, I think I wrote a paper about it in my government class. So, fast forward to February of this year when this idea was brought to my attention by some of my staff members. We started talking about: What does it look like for the government to take a more active role in providing health care to all of its citizens? So, this is what we came up with. We drafted a bill and introduced it in early March.

MT: So, the novel part of this for most people is Medicaid rather than Medicare. Why is Medicaid the better vehicle for doing this?

MS:  Well, we were listening to two things after the election in November. Some of the talk and the rhetoric coming out of the new Admin was:

  1. States would need to take a more active participatory role in providing for their own citizens and the federal government, the current Admin, would be more supportive of that.
  2. The uncertainty and ambiguity of the different ideas and concepts of what health-care coverage would look like in the future, obviously we’ve been hearing on the campaign trail and after the election that the repeal and replacement of the ACA was a certain possibility, but even until this day we don’t know exactly what that looks like.

So, because of those two dynamics, when we were looking at the best vehicle to offer this benefit package, we looked internally at what we have done as a state to cover our underserved population. We have a pretty robust and comprehensive Medicaid program so we figured that would be the best place to house this.

MT: Have you priced it out at all?

MS: Initially we were trying to come up with some ideas about what would be a legitimate cost for premiums that people would have to pay and very quickly realized that we don’t have enough data to land on a solid number that would be competitive with the private insurance industry marketplace but also wouldn’t undercut and cause pretty significant marketplace destruction.

As soon as the bill was introduced, it became obvious to me that the bill was going to be roadblocked in making it through the legislature and being signed by the governor. So I put together a pretty high-level working group that included senior staffers from the governor’s office, the head of the Health and Human Services department in the state, the head of Medicaid and the commissioner on insurance, and also the head of our health insurance exchange. And we started meeting on a regular basis: The very first thing we realized was that we just didn’t have accurate numbers as a whole for the state. If the bill is signed, the commissioner of insurance has said that he has a $1 million grant for an actuarial study. And with that study we would have a far better idea of what would be the average cost for a premium.

So that’s a long-winded way of saying we don’t have that number right now, but we’re absolutely certain that we would come up with an amount that, once again, is affordable, but that is also not going to cause such marketplace disruption that we lose a private insurance industry that we obviously need in the state.

MT: So by the end of the year you’ll have that number?

MS: Yeah, so the other thing that was really imperative for me was that we have an implementation date for the plan. We extended it out to January 1, 2019. Because of that, yes, we would need to land on a number probably within about a year, because that would give us about six months to finalize the regulatory measures to have this plan in place.

MT: So talk a little about the politics of passage. What did it pass by in the lower house and upper house, who was for it, who was against it?

MS: Yeah, interestingly enough, there was not a lot of debate on this bill. I chair our HHS committee in the assembly, so the bill was heard in my committee. I stepped down to present the bill and my vice chair took over. During the hearing, a lot of my committee members obviously had questions and there was a lot that needed to be explained, but it kind of ended there, once the bill went down to the assembly floor for the whole assembly to take a look at it. There was zero floor debate. I actually did the floor statement and the introduction of the bill and it immediately went to a vote. It passed purely on party lines.

MT: And what was the vote?

MS: A majority in the assembly and then it went on to the Senate. Then Senate HHS had a few questions. And then the hearing ended, and then it went to the senate floor and I actually haven’t watched the video from how it was passed out on the Senate floor, but I’ve been told there was very little if any floor debate there as well, and once again it passed out on party lines.

MT: So in both houses strictly along party lines?

MS: That’s correct.

MT: What were the numbers?

MS: Oh, I’d have to pull it up: 27 and 13 in the assembly and 12 and 9 in the Senate, or something like that.

MT: And what about the interest groups, you know, the insurance companies, the hospitals, the American Medical Association?

MS: Absolutely, the feedback that I’ve received so far has been a lot of questions, certainly a fair amount of interest and people really wanting to participate in the process, should the bill be signed by the governor. When it was first heard in my committee in the assembly, the only opposition that actually came up was from the hospital industry. To paraphrase their comments, once they got up, they said we actually are intrigued and like the concept that the bill presents. Our concern is about the reimbursement rates and how this will be detrimental for us. Once the bill got to the Senate, the hospital association didn’t even show up to the hearing. And a pretty prominent lobbyist for one of our large hospitals that spoke in opposition in the assembly ended up coming in with a neutral position in the senate, saying that they just wanted to watch and see what happened, but that they were very much interested in the concept.

MT: Interesting. What’s the state of play of Obamacare in Nevada right now? How many uninsured are there? How much has that situation improved?

MS: Yeah, so, the state of Nevada took a very active role with the ACA, it tried to implement many of the suggestions that came from it including the Medicaid expansion. I’m not sure the exact number. I want to say around 47th in the nation in terms of uninsured before the Affordable Care Act that dropped down to currently we’re at, around 11-12 percent. When the expansion occurred, we were anticipating roughly 75,000 to 90,000 people would qualify for the expansion and would apply. Right now we have over 300,000 that are participants in the expansion population, so that’s what caused a lot of those numbers to drop so significantly.

MT: How many remain uninsured? And what percentage of that remnant do you think would be able to take advantage of your plan?

MS: This is a very grey area. That’s one of the reasons why we’re excited to do the actuarial study. We have a very transient population in Nevada, as you might imagine, especially in the Las Vegas area. To get an accurate count of who is uninsured in Nevada has proven to be difficult. Right now, the best idea we have is roughly 11-12 percent of the population. However, we’re hoping to have a much better idea of what that number actually is once that study is done. So, it’s a little difficult. Is that the population that would be served by this? Obviously, it would be nice if we could continue to chip away at that uninsured rate, but again this is going to be a benefit package that a person has to purchase, so it may not target them. The ones that we’re really interested in looking at is this expansion population. The reason that I say that is, the continued talk coming out of DC is that funding for the expansion population may be coming to an end in as little as two years—I think the most recent that I heard was around seven years from our own senator. But either way, that expansion population may find that they no longer qualify for Medicaid. Here is a program that, at a premium cost, obviously that would be different, but at a premium cost they would be able to maintain the same benefits, the same provider network, the same individuals that they go to from a management point of view, the same officers, everything that they know of would be the same. So that’s going to be very appealing to them. Because of that, that’s certainly one of the target populations for this plan.

MT: Interesting. So, what kind of signals has the governor sent?

MS: [Laughs] You and about a hundred other reporters want to know. Today is the last day, today being Friday the 16th, and I still honestly don’t know what the governor is going to do. I know that he has been very active in researching what we’re going to do, once again, everybody on my working group, they work for the governor, they’re part of his staff. I do believe that he has received very honest information and I was going to say unbiased, but maybe biased because most of them are supportive of what this bill is trying to do. Nonetheless, I think he’s in a very good position to make up his mind whether he wants to move the state in this direction. So for that, I think the bill is in a good place and if he chooses to veto it he’ll do it for his reasons and that’s the process. Hopefully it won’t be that.

MT: Tell me more about the timing, so this is the last day of the session and if he doesn’t sign it by then it dies for this session?

MS: So the session itself ended almost ten days ago on the fifth of June. The governor has up to ten days to take action on a bill. So today’s the tenth day. He has until midnight to either veto, sign, or do nothing at all. If he does nothing at all, in the state of Nevada the bill becomes enacted. It will still become law if he chooses to do nothing. He has until midnight tonight.

MT: Is he getting pressure from the right, from the national right-wing?

MS: I have no idea whatsoever.

MT: Yeah. It sounds like he might not be the profile in courage here.

MS: What I heard, the one thing I have heard, is that he will make a decision. It doesn’t sound like he will just let the bill be enacted without any action whatsoever. What that decision is going to be I don’t know, but it sounds like that is what he wants to do. And I think a lot of that has to do with the national attention this bill has received.

MT: Tell us a little about yourself, what’s your district, where’s your district?

MS: So first off, Nevada has a citizen legislature. So we all have other full-time jobs. I work as a firefighter paramedic in the city of Reno in northern Nevada, and I’ve been with them for 19 years. This is my third term representing Assembly District 30, which is in the Reno-Sparks area. So about two-thirds of my assembly district is in the city of Sparks, which is a sister city of Reno, and about one third is in the city of Reno itself. I represent about 64,000 people. This last session I was the chair of HHS, and I was also the majority whip for our caucus.

MT: So it’s a purple district, mixed district, blue or red, or what?

MS: At this point it’s about a 11 percent Democratic advantage, so it’s a pretty blue district.

MT: What makes you a Democrat?

MS: [Laughs] Well certainly my love for people and my desire to really help those who are underserved or need somebody to look out for their rights. I always committed myself, as you can see with my other professional career, to helping others, and that’s been an incredibly important part of what I do. And I think my ideas about what that means align more with the Democrats.

MT: Thanks for your time.

MS: I’m glad we had a chance to talk.

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Mike Sprinkle is a Democratic member of the Nevada Assembly representing District 30.

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