The Nevada Assembly began and ended day two of the special session yesterday with public comment. Early in the morning, Assembly members heard from constituents representing themselves and a variety of special interests.
As the Assembly was preparing to hear the same reports delivered the day before to their Senate counterparts detailing proposed cuts to the various divisions of Nevada’s Department of Health and Human Services, they heard from several public commenters asking them to reconsider cuts to the state’s Medicaid program. Among them was Jennie Stokes.
“I’m an advocate for people with disabilities,” Stokes said. “I was born with a congenital disability that caused the amputation of my right leg.”
Stokes explained that she’s used a prosthetic leg since she was a toddler but wasn’t always able to afford one that met her needs, which she said led to the degeneration of her hip joint and the need for pain management therapies.
Recently, Stokes said, she had to make the decision between a prosthetic to meet her needs and pain management.
She also spoke about help for seniors, homeless citizens and people living with mental illness.
“We are not ‘Nevada Strong’ until we stop treating people with mental illness, people with disabilities and the elderly like second-class citizens. Please, do better,” Stokes said.
Throughout the public comment period, legislators heard from citizens concerned about cuts to funding for problem gambling programs—a foreshadowing of the bulk of calls to come during the day’s second public comment period.
Steep cuts proposed health programs
After hearing public comment, the Assembly went on to listen to presentations from Richard Whitley, director of DHHS and administrators of the department’s various divisions.
Whitley discussed the department’s proposed $233 million in cuts, saying they’d been made to prioritize direct services and the use of federal CARES Act funding wherever possible.
“Coming out of the last session, we really made great gains in health care in our state,” Whitley said.
He noted investments in mental health care that had been made in recent legislative sessions in the face of challenges to former President Obama’s Affordable Care Act and circled back to how those gains were now jeopardy as a result of the COVID-19 pandemic.
Around 34 percent of Nevada’s General Fund is allocated to providing health and human services. The $233 million dollar reduction in DHHS’s budget for 2020-2021 is based on Gov. Steve Sisolak’s request that all state agencies trim 14 percent from their budgets.
Because Medicaid mandates the coverage of certain services to include diagnostics and inpatient hospital services, Whitley said DHHS had to choose which “optional services”—those not mandated to be covered—to scale back and eliminate. Whitley acknowledged that, to their recipients, many of these services are not optional as he listed cuts ranging from the elimination of optometry for adult Medicaid recipients to the elimination of some hospice care and the steep curtailing of dental care services for children and pregnant women.
Whitley acknowledged that limiting some care will likely lead to individuals having larger health problems later on—and the potential for greater costs in the long-run. This was something legislators also echoed when the questioned new limitations for Medicaid recipients, like a total of 12 physical therapy sessions per year.
Assembly member Maggie Carlton (D-Clark County) pointed out that with a loss in federal matching dollars, cuts to Medicaid, like an impending “6 percent provider rate reductions, a 2.5 percent acute care hospital reduction rate, a 25 percent neonatal reduction, 9.6 from other funds, 6 percent cut to PICU [pediatric intensive care units],” might well cost the state more than it saves.
The estimated $140 million in cuts from the General Fund to Nevada Medicaid could equal out to a figure closer to $500 million in health care costs when considering lost federal matching funds.
A little more than a $30 million reduction is expected for DHHS’s Aging and Disability Services Division. It is also proposing to cap its existing caseloads for people in need of supported living through jobs training programs and children in need of autism treatment.
The proposal also includes an almost $20 million reduction from the Division of Public and Behavioral Health—to include a more than $8 million reduction from Southern Nevada Adult Mental Health Services. This would likely cut housing for 270 individuals in southern Nevada. A cut to funding for problem gambling treatment would leave that program with an estimated 20-25 percent of its usual budget.
Cuts to both Aging and Disability Services and Public and Behavioral Health have the potential to lead to increased wait times for those seeking services, but the administrators of these divisions told lawmakers their staffs will continue working with people and helping them access alternative resources to meet their needs.
Included among its cuts, the Division of Child and Family Services is seeking to reduce the capacity of its three juvenile detention facilities from a total of 224 beds down to 160 and will keep 53 positions—which would normally be filled by “group supervisors,” the juvenile detention equivalent of corrections officers. Only one of the three, the higher security center, has actual corrections officers staffing it.
Legislators question future costs of current cuts
Assembly members took time to ask questions after the presentation from Whitley and between presentations made by the administrators of the various DHHS Divisions.
Several legislators had questions concerning Medicaid’s federal medical assistance percentage (FMAP). It determines the federal government’s share of Medicaid expenditures. To help states address the coronavirus pandemic, the Families First Coronavirus Response Act (FFCRA) provided all states and territories with a temporary and retroactive 6.2 percentage-point increase to FMAP.
Whitley explained the current, enhanced FMAP rate expires at the end of September, but that it is expected the U.S. Department of Health and Human Services will likely extend the public health emergency, which would allow it to declare, without approval from Congress, the continuation of enhanced FMAP rates for another 90 days. Whitley said the deadline for that is July 25—and that this was a large part of the reason Gov. Sisolak has asked for flexibility in the emerging plans for budget cuts. An enhanced FMAP extension may help DHHS avoid some cuts and reductions.
Assembly member Teresa Benitez-Thompson (D-Washoe County) asked if people newly arriving on Medicaid—say those who won’t be returning to work at casinos—will be eligible for the standard or enhanced FMAP rate.
Suzanne Bierman, administrator for the Division of Health Care Financing and Policy, explained that federal requirements to secure the increased rate include that Nevada Medicaid maintain eligibility standards. She noted no changes to eligibility standards had been planned anyway. Premiums are also not to exceed what has been previously charged to Medicaid recipients. The other requirement is that individuals are not to be terminated from Medicaid during the emergency period to which increased FMAP applies.
Assembly members asked several questions of the different division administrators about how the cuts they’ve proposed might lead to greater costs in the long run.
Assemblymember Robin Titus (R-Churchill County) said she was concerned about the possible consequences of reductions to family planning services.
“Along with that family planning, it means you plan for health, for access to care,” Titus said. “If we cut family planning is the access to birth control and prenatal care involved in that?”
Titus said she believes cutting access to birth control and prenatal care will cause a rise in premature births and costly stays in neonatal intensive care units for babies born early.
“I don’t know if I can say it any more clearly,” Whitley responded. “I think that you laid out that family planning is an intervention point…It does serve to upstream, intervene and prevent more costly health outcomes, and so it will have an impact.”
Whitley continued for a moment, taking the time to stress that he doesn’t feel any of the proposed cuts are good cuts—only necessary ones, and difficult to decide upon.
Assembly Speaker Jason Frierson took a moment to note that it’s likely all cuts will result in increased costs down the road that will have to be dealt with.
The major cuts to funding for problem gambling were addressed in a question from Assembly member Steve Yeager (D-Clark County), who asked why funding cuts to the program were so substantial when it’s a treatment not covered by most types of insurance. The proposed cut is nearly $2 million, leaving about $600,000 available.
Lisa Sherych, administrator for the Division of Public and Behavioral Health, told Yeager that, without the steep cuts to the program, her division would have had to make additional cuts to mental health services for adults in both southern and northern Nevada.
Near the end of presentations and questioning of DHHS staff, Assembly member Chris Edwards (R-Clark County) piped up to make a comment.
“I’ve actually waited to make this suggestion till after I heard both education and HHS,” he said. “For the past day and a half I’ve kind of listened to everybody anguish over these cuts, because they’re pretty devastating. We’re about to lose hundreds of millions of dollars of programs and services that are needed.
“I have a solution that will restore about $300 million. It will eliminate just about all of the education cuts with the exception of Read by Three and the new funding formula.”
Edwards went on to explain his plan would put money back into education and Medicaid without increasing anyone’s taxes.
“We spend $10,000 per student per year,” he said. “Eighteen-thousand students cost $180 million. If we were to offer a cohort of those 18,000 students an average of a $3,000 Opportunity Grant, it would actually cost $54 million and save us $126 million to go to HHS for Medicaid.”
Edwards said other savings could go toward education to save various programs currently on the chopping block. He got as far as saying, “You know, the governor was looking for a Republican to step up with a solution of these problems,” before he was interrupted by Speaker Frierson, who told him this type of speech was not appropriate when the Assembly was not having a floor meeting but was meeting as a Committee of the Whole to take testimony.
“What would save time is for members who have ideas to have provided those ideas before the second day of a special session in the middle of a committee of the whole presentation from the DHHS. I am going to redirect you because I don’t think this is a question pertinent to this witness. And we will reconvene as an Assembly and if you want to use your two minutes when we do that, you certainly may be able to do that. But if we are actually trying to accomplish something, I think we should provide that to the folks who can implement it instead of grandstanding on the floor of the Committee of the Whole.”
After checking to see if other legislators had additional questions for DHHS staff, Frierson asked Whitley if there was a dollar amount he could identify that, were legislators able to shift from other areas, would make a large impact in keeping his department and its divisions operating more smoothly and with less hardship.
Whitley—who stressed throughout his presentation that he believes diversifying Medicaid funding and finding ways to support Nevada’s health care provider network to strengthen what he calls the state’s “fragile” health care system—said he would need a bit of time over the course of the evening to identify a dollar figure but would report that figure back to Frierson and the Assembly.
The Assembly went on to hear from the Nevada State Department of Public Works before ending its session day with more public comment—the bulk of which addressed DHHS’ proposal to strip away more than three-quarters of funding for problem gambling.