On Politics: The weight of Medicaid in Nevada

Jim Clark
On Politics

My last column dealt with efforts to “repeal and replace” Obamacare (Affordable Care Act or “ACA”).

To briefly review, the original Obamacare bill was introduced and passed in 2010 in a highly unusual manner with no debate and no amendments so the majority of its provisions were left to the Secretary of Health and Human Services to implement.

With Trump’s election,n the House easily passed a “repeal and replace” bill but it failed in the Senate. However, Trump appointed a new Secretary of Health and Human Services, so the inability of GOP senators to agree on a repeal measure has been somewhat offset by an administrative “dissembling” of numerous parts of the ACA.

Although statutory repeal failed, Republicans had little trouble agreeing on a tax cut measure so they sandwiched a scuttling of Obamacare’s individual health insurance mandate into the tax bill, gutting the ACA’s most intrusive provision. I concluded with an explanation of how the states are using Obamacare’s waiver sections to reduce the scope and costs of expanded Medicaid coverage.

“Repeal and replace” legislation may not be entirely dead. Now that Republicans have voted tax reform into law and may be on the brink of immigration reform and border security legislation, solons may dust off a Senate version of “repeal and replace” legislation sponsored by Sens. Lindsay Graham (R-S.C.), Bill Cassidy (R-La.) and Dean Heller (R-Nev.) dubbed “Senate Amendment 586” or more popularly “Cassidy-Graham.”

Cassidy-Graham would repeal Obamacare’s medical device tax, retain protections for preexisting conditions and limit taxpayer subsidies of insurance premiums. The measure would also restructure Medicaid from an entitlement program to a per capita scheme with a block grant option. That is, each state would receive an annual maximum based on its actual historic Medicaid spending.

Heller summed up this provision: “By allowing states to address the unique health care needs of their populations it gives states the flexibility to innovate and come up with a tailored approach that is more appropriate for their citizens. In Nevada this means supporting programs that are currently working in our state and exploring new options to address coverage and cost.”

Some may claim annual Medicaid caps treat the poor heartlessly. but market rate insurance plans have annual caps as well. There’s just so much blood you can squeeze out of a turnip. As it is now, the ACA phases out federal subsidizing of state Medicaid costs so one way or the other this hot potato will become principally the responsibility of the states.

To ease that pain somewhat, Cassidy-Graham would layer another funding source called “Short Term Assistance for States and Market-based Heath Care Grant Program” onto its block grant provisions, phasing out in 2026. To complicate things further, each state’s entitlement would be formula driven including factors such as per capita income, population density and Medicaid extension status.

So what does all this mean for Nevada? An analysis by the Kenny Guinn Center for Policy Priorities in Las Vegas, a non-partisan think tank, estimates that under Cassidy-Graham the reduction in federal funding would by 2026 result in a loss of $257 million.

If that sounds bad here’s a worse problem: In 2010, Nevada Medicaid enrollment was 232,000 and cost $1.7 billion per year. As a result of the ACA enrollment has ballooned to 661,000 (20 percent of our population) and costs $3.3 billion per year.

The federal subsidy to Nevada Medicaid phases out and will leave Nevada with an annual Medicaid bill equal to about one half our total state budget. What will that do to education, public safety, and tax rates?

There is no easy answer. Maybe the best we can hope for is an answer that doesn’t bankrupt the Silver State.

Jim Clark is president of Republican Advocates and has served on the Washoe County and Nevada GOP Central Committees. He can be reached at

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