CARSON CITY — Looming over the upcoming legislative session is the big unknown of whether Congress will repeal the Affordable Care Act and what it would mean for Nevada.
It’s a worry for the administration and lawmakers, who have to build a two-year spending plan that could be blown to bits if the federal government yanks subsidies for Medicaid expansion and policies purchased through the state health exchange.
Right now, there’s nothing they can do except wait.
Throughout his campaign, Republican President Donald Trump pledged to repeal the Affordable Care Act, former President Barack Obama’s signature health care law that became known as “Obamacare.”
GOP members in Congress, who hold a majority in both the House and Senate, have targeted the law for years and recently initiated actions to “repeal and replace” it, though details are elusive.
Nevada Gov. Brian Sandoval was the first Republican governor in the nation to expand Medicaid under the Affordable Care Act to include adults without children who meet income eligibility requirements. Under the law, the federal government picked up the full tab for the first few years, and the state’s Medicaid rolls soared to more than 630,000, many being “newly eligibles.” The state projects Medicaid caseloads could reach 682,000 by 2019.
Repealing the law and ending federal subsidies could leave the state with a tough decision on whether to increase its own funding to continue the program or curtail it.
For now, the state’s hands are tied.
“We’re not going to forecast what repeal will look like,” Mike Willden, the governor’s chief of staff, told reporters at a budget briefing last week.
“The governor’s budget is based on who is eligible and who will be eligible under some similar lookalike,” he said.
“We certainly think the Affordable Care Act can be improved,” Willden said. “But we don’t want to see 400,000 Nevadans lose their health insurance — 320,000 on Medicaid and 80,000 through the exchange.”
Sandoval’s $8.1 billion general fund budget proposal includes an additional $173 million for Medicaid caseload growth and adjustments to the federal matching assistance formula.
Assemblywoman Maggie Carlton, D-Las Vegas and chairwoman of the powerful Ways and Means Committee, said the ramifications of immediate repeal without a replacement plan would be significant.
“I’m definitely concerned about it,” she said. “I think everybody who’s trying to figure out their state budgets around the country has to be concerned about it.
“The uncertainty is just weighing on everybody,” she said.
Researchers at George Washington University estimate repeal of Medicaid expansion and loss of premium tax credits to people who buy coverage over insurance exchanges would lead to 2.6 million jobs lost nationally in 2019 and cost state and local governments $48 billion in tax revenue over five years.
In Nevada, a report published by The Commonwealth Fund projects 22,000 jobs lost in both the public and private sectors and $377 million lost in tax revenue by 2023.
Sandoval, after agreeing to expand Medicaid eligibility, said in 2013 that he would insist Nevada be able to “opt out” of the expansion “should circumstances change.”
He’s urged Republican leaders in Congress to consider consequences and confer with states before taking action.
In a Jan. 5 letter to leadership in the U.S. House of Representatives, Sandoval said Nevada’s uninsured rate dropped from one of the worst in the nation at 23 percent to about 12 percent.
He also said the state invested $95 million to upgrade its eligibility and Medicaid management systems needed to comply with the ACA.
“To adopt another system that disregards these investments will have an adverse effect on our health care system, waste millions of dollars and cost hundreds of Nevadans their jobs,” the governor wrote.
“Going forward, we must ensure first that any new reforms do not mandate additional costs, and second, leverage the advancements already made and paid for under the ACA.
“Moreover, you must ensure that individuals, families, children, aged, blind, disabled and mentally ill are not suddenly left without care they need to live healthy, productive lives.”
Willden said Nevada will remain engaged in the process as repeal and replacement plans take shape and hope for a workable outcome.
“Everything worries us,” Willden said.
But he added, “Everything we’ve read so far, we don’t think (the federal government) will be dumping millions of Americans off the rolls immediately.”