Las Vegas Sun

March 29, 2024

President’s ‘opt-out’ stance may force health care law onto crowded docket

Barack Obama

Barack Obama

Brian Sandoval

Brian Sandoval

Nevada has joined 20 states to have the new federal health care law declared unconstitutional. At the same time, Gov. Brian Sandoval has ordered the state to begin implementing it because at this point, it’s the law of the land.

Now, Nevada might not have to travel those divergent paths.

Last week, President Barack Obama surprised the National Governors Association by announcing he supports moving up the date when states can opt out of the law, from 2017 to 2014, when states are to begin the rollout of health care exchanges or markets intended to offer coverage to uninsured people at competitive rates.

“Alabama is not going to have exactly the same needs as Massachusetts or California or North Dakota,” Obama said during his speech. “We believe in that flexibility.”

Sandoval, who opposes the law, has remained tight-lipped about his reaction to Obama’s announcement. But close adviser Pete Ernaut has said the option “may be a great improvement” over the law as it stands.

The announcement throws health care into the limelight at an inopportune time for Sandoval. The budget, education, jobs and economic development have been chief on the Nevada Legislature’s agenda, not potentially scrapping and redesigning a health care system that stands little chance of finding political common ground.

“We’ve got an enormous amount to do, just with our own issues,” Republican state Sen. Barbara Cegavske said. “Health care hasn’t really come up.”

But to get a waiver, Nevada would have to show it can come up with a better system. And if lawmakers don’t act, the state exchange plan will toddle to fruition, which could make it more difficult for the state to change course down the road.

“Frankly, we haven’t thought through what an alternative might be to the proposed exchanges,” said Chuck Duarte, who is in charge of implementing the health care law through Nevada’s Health and Human Services Department. “The devil’s in the details with regard to that.”

In designing alternatives, states must cover the same number of people and at a lower cost. But that’s not the extent of the federal law, and it’s not clear what else has to be replicated for a state’s alternative to be “viable,” Duarte said.

“Is one of the goals quality control? Does it mean we still have to offer an essential benefits package? It’s hard for us to say what has to be part of a plan B right now,” he said. “Whether it’s 2014 or 2017, we’ve still got to cover 400,000 people.”

Nevada’s biggest struggle is with Medicaid, the federal and state-sponsored health care program that serves low-income families.

The state saw a larger percentage increase in Medicaid enrollment over the past year than any other state — a trend fueled by the recession, and one that’s expected to continue. State administrators predict that by the end of 2013, the number of Nevadans receiving Medicaid will grow from 280,000 to 312,000. The Legislature is considering a 5 percent reduction in Medicaid payments, which hospitals are warning will translate into a severe reduction in services.

The federal health care law will expand Medicaid coverage to a larger segment of the population in 2014. Opting out doesn’t lift that obligation.

That’s causing some Republicans to think that Obama’s proposed compromise is no better solution.

“They’re trying to make a bad situation somewhat better ... it’s just a chance to choose between the lesser of two evils,” said Rep. Joe Heck, who is a physician. “Each state has a different demographic and different needs ... We’ve just got to come up with a better starting point than what we have, and letting people waiver out doesn’t give you that.”

Heck is working on alternative health reforms he expects to unveil in the next few months.

Other lawmakers favor the federal government getting out of the health care business entirely.

“States should have the freedom to implement a health care system that serves their residents best,” Nevada Rep. Dean Heller’s communications director, Stewart Bybee, said. “However, until this law is repealed and replaced with market-based reforms, it will not matter if states are allowed to opt out or not.”

This debate is occurring against the backdrop of constitutional court challenges pending against the law — including the one Nevada’s signed on to.

Joe Heck

Joe Heck

“Long before 2014, we’ll have a Supreme Court ruling determining whether the entire law will be thrown out or not,” Reno-based Republican strategist Robert Uithoven said.

And that may be forcing Obama to do some quick political calculus. Ratcheting up the calendar for opt-outs does, in one sense, appear to be a scaling back of the health care law.

“He’ll be in a difficult situation in states that are really having a tough time trying to figure out the compliance aspect of this law,” Uithoven said. “So a lot of his decisions around health care may be more politically motivated based on electoral votes than they will be based on the actual need for relief from the legislation.”

But the Obama administration has objected to insinuations the president is slowly killing his health care bill under political pressure.

Shelley Berkley

Shelley Berkley

“The Affordable Care Act was built upon empowering states in many ways,” said Stephanie Cutter, a senior adviser to Obama. “They’re all calling for flexibility. You don’t get any more flexibility than being able to build a system ... around the needs of your state.”

Democrats control both houses of the Legislature, and although leaders say they’re willing to look at alternatives, they’re not offering them. And if the Legislature doesn’t pick up the health care issue this session, it’s off the table until 2013.

Sandoval has requested a bill that would require the Legislature develop a state exchange. Health and Human Services officials want a state agency to govern the exchange and determine what is going to be offered through it and how.

Meanwhile, no alternative is yet percolating. And that has Democrats calling the Republicans’ bluff.

“If you can do it better and cheaper, go for it,” Rep. Shelley Berkley said. “If you can’t, stop squawking and implement the law.”

Join the Discussion:

Check this out for a full explanation of our conversion to the LiveFyre commenting system and instructions on how to sign up for an account.

Full comments policy