Ne­vada’s rocky health-care fu­ture

State lead­ers and ru­ral res­i­dents worry about the cost of los­ing what Med­i­caid ex­pan­sion brought

The Washington Post - - FRONT PAGE - BY AMY GOLD­STEIN IN SIL­VER SPRINGS, NEV.

In this speck of high desert, along a stretch of high­way that Life mag­a­zine once called the loneli­est road in Amer­ica, the only doc­tor in town comes just one day a week. In the past few years, though, health in­sur­ance has ar­rived in force.

The county that in­cludes Sil­ver Springs now has more than 3,500 ad­di­tional res­i­dents on Med­i­caid, be­cause Ne­vada’s gov­er­nor was the first Repub­li­can in the coun­try to ex­pand the pro­gram through the Af­ford­able Care Act. Nearly 1,400 oth­ers have pri­vate plans through the law and the Sil­ver State Health In­sur­ance Ex­change.

In­com­plete as it is, with many still fall­ing through the cracks, such progress en­cour­aged the health sys­tem that runs a lit­tle out­post in town to in­vest here in long-dis­tance medicine. The new cov­er­age has paid for back surg­eries and brain surg­eries for peo­ple who oth­er­wise would have been left broke or un­healed.

Yet 2,600 miles away, what Congress is now do­ing — or not do­ing — im­per­ils these two strands of in­sur­ance that lately have cut Ne­vada’s unin­sured pop­u­la­tion by half. Repub­li­can law­mak­ers would start to erase the money that props up Med­i­caid’s ex­pan­sion. And even with a GOP health-care plan tee­ter­ing in the Se­nate, months of un­cer­tainty about the ACA’s fu­ture have height­ened in­sur­ers’

in Ne­vada about whether its mar­ket­place is a fi­nan­cially safe space to be.

The sole com­pany that had been ex­pected to re­main on the state ex­change in Lyon County and Ne­vada’s 13 other ru­ral coun­ties an­nounced oth­er­wise last month and will be gone by Jan­uary. Un­less An­them or an­other in­surer re­verses course, 8,000 peo­ple across hun­dreds of miles will be left with­out any ACA in­surer next year — by far the largest such bare patch in the na­tion.

“In a place where health care was al­ready a dis­as­ter,” said Shaun Grif­fin, a lo­cal poet and com­mu­nity ac­tivist, “it’s crim­i­nal that this is hap­pen­ing.”

The stakes in this land of dusty winds and scarce jobs at­test to the spe­cial vul­ner­a­bil­ity of ru­ral com­mu­ni­ties to the health-care pol­i­tics of Washington. The toe­hold that in­sur­ance has gained, even here in strong Trump coun­try, sug­gests why Ne­vada Sen. Dean Heller be­came an early, overt critic of what his Repub­li­can Party lead­ers want to do. It also ex­plains why even sus­tained pres­sure from the White House has not al­tered Gov. Brian San­doval’s op­po­si­tion to the Se­nate’s bill.

In Sil­ver Springs, where find­ing med­i­cal care is iffy in the best of cir­cum­stances, an in­sur­ance card isn’t a guar­an­tee. But it is a leg up.

Robert Gar­cia was liv­ing in his horse trailer with three crushed disks in his back when a county case­worker told him that, be­cause the state’s rules had changed with the ACA, he could get on Med­i­caid.

Gar­cia used to earn about $50,000 a year do­ing elec­tri­cal work at a nearby gyp­sum mine. He lost his in­sur­ance when he was laid off in 2011. His mar­riage fell apart. Rodeo had been his pas­sion since he was a boy, and he moved into the trailer, filled with cham­pi­onship buck­les and sad­dles, that car­ried his horses to com­pe­ti­tions. It had a gen­er­a­tor for elec­tric­ity, and Gar­cia parked it on dif­fer­ent friends’ land, tak­ing show­ers from hoses out­side in the dark.

He picked up money by break­ing horses un­til the day a young mus­tang with a fiery spirit got spooked and lurched, throw­ing the cow­boy off its left side. He landed on his neck. De­spite the pain, he kept rid­ing and rop­ing for an­other month be­fore pay­ing for an X-ray. He couldn’t af­ford the surgery he needed.

In 2015, a woman at the lo­cal food pantry took him to the county’s health and hu­man ser­vices branch in Sil­ver Springs. There he got on Med­i­caid. Af­ter more rounds of doc­tors, he had surgery last year at a Reno hospi­tal.

But in the kind of see­saw­ing scrap­ing-by that is common here, the So­cial Se­cu­rity dis­abil­ity ben­e­fits for which Gar­cia was fi­nally ap­proved in April meant he could af­ford to rent a mo­bile home. But he no longer qual­i­fied for Med­i­caid — which meant no re­turn to the doc­tor to see whether he could get back on a horse. At 50, with a bad knee, fin­gers still numb from the fall and anx­i­ety, he now is wait­ing on a health plan through the state ex­change. The cov­er­age may be fleet­ing.

“That would dev­as­tate me,” he said. “I don’t know what I would do.”

‘Sign me up’

Strad­dling U.S. Route 50 in a moun­tain-ringed val­ley stud­ded with salt­bush, Sil­ver Springs sits about an hour from the neon of Reno and even less from the state capi­tol build­ing in Car­son City. It is not as re­mote as Ne­vada’s huge fron­tier coun­ties, where the near­est hospi­tal can be hours away.

Still, it is ru­ral enough that Bret Bel­lard, the fam­ily doc­tor who works at Renown Health’s clinic on Mon­days, sees pa­tients bit­ten by their don­key or kicked by their goat, along with di­a­betes and ad­dic­tions. Wild horses run through the clinic’s park­ing lot.

The area’s big mo­ments were dur­ing the Pony Ex­press and gold rush days. To­day, the eco­nomic glit­ter of a Tesla Gi­gafac­tory un­der con­struc­tion less than an hour away has stoked hopes that good jobs might spill down a road be­ing built from Route 50.

They are pipe dreams for now. The Sil­ver Strike Casino and a Nugget Casino branch each of­fer some jobs. So do a Fam­ily Dol­lar and Dol­lar Gen­eral, the only stores. With no lo­cal gro­cery, the two gas sta­tions’ food marts are the only places to buy even a car­ton of milk; the Sil­ver Stage Food Pantry, which serves the town and tinier Stage­coach just to the west, is try­ing to foster gar­den­ing.

In this en­vi­ron­ment, the cin­der block clinic that had been here for decades called it quits dur­ing the Great Re­ces­sion. Renown, a Reno-based non­profit, took over in 2008 and man­aged to get it fed­er­ally cer­ti­fied as a ru­ral health clinic. Since at­tract­ing health-care pro­fes­sion­als to the area is hard, the des­ig­na­tion means a young nurse prac­ti­tioner and a physi­cian as­sis­tant can work to help re­pay stu­dent loans. This year, Renown in­stalled a tele­health sys­tem so that pa­tients with bad hearts or trou­bled men­tal health, for ex­am­ple, can sit in an exam room and talk with a doc­tor via a com­puter screen.

The fed­eral la­bel also al­lows the clinic the lux­ury of see­ing any pa­tients who can get an ap­point­ment, no mat­ter how much they can pay. But Renown’s president, An­thony Slonim, is prag­matic about what could hap­pen if the Se­nate Repub­li­cans’ Bet­ter Care Rec­on­cil­i­a­tion Act be­came law. “None of us are mak­ing money in the ru­ral en­vi­ron­ment, trust me,” Slonim said. “If more peo­ple be­come unin­sured, ex­penses will go up and rev­enue will go down. . . . It gets in­creas­ingly chal­leng­ing for us to sus­tain those prac­tices. Peo­qualms ple’s care will suf­fer.”

The scarcity of health ser­vices dove­tails with an in­di­vid­u­al­is­tic streak that has long coursed through the West. Yet even the most in­de­pen­dent at times need help.

Tom Lovelace, who has a land­scap­ing busi­ness in Sil­ver Springs, didn’t vote in the last elec­tion. He says he doesn’t be­lieve in gov­ern­ment, though he thinks President Trump is “cool.” He also doesn’t like the idea of health in­sur­ance — just take care of your­self or tough it out.

Still, Lovelace re­flects the re­al­i­ties plumbed by a re­cent Washington Post-Kaiser Fam­ily Foun­da­tion sur­vey, which found that most ru­ral Amer­i­cans con­sider Med­i­caid very im­por­tant to their com­mu­ni­ties — in­clud­ing nearly three peo­ple in five who voted for Trump.

The day af­ter he turned 30 in 2014, Lovelace woke up at 4 a.m., sweaty, his speech slurred. He told his cus­tomers he thought he’d had a stroke. He was liv­ing in Car­son City at the time, and, two weeks later, a friend took him to an emer­gency room. He got an MRI but left be­fore find­ing out the re­sults.

The next month, he had an aw­ful headache one day and start­com­mu­nity ed to see dou­ble, then triple. When he went back to the emer­gency room, the doc­tor told him he was re­lieved to see him. He had an aneurysm, a weak­ened spot in a blood ves­sel in his brain. At Renown’s hospi­tal in Reno, he had it re­paired and — unin­sured — re­ceived a $99,000 bill.

Nearly three months later, as Lovelace was sign­ing up for food stamps, a worker at the wel­fare of­fice asked whether he wanted to get Med­i­caid. He was sur­prised. He knew of it as help for his three kids — their names tat­tooed on his arms and chest — and their mothers. Not for a guy like him.

“Sign me up,” he replied. Med­i­caid retroac­tively paid his hospi­tal bill.

‘Why do we have to change?’

On June 27, the gov­er­nor sent a let­ter to all four in­sur­ers that have been sell­ing health plans through the state’s ACA mar­ket­place this year and are part of Ne­vada’s man­aged-care Med­i­caid in its ur­ban ar­eas. “The re­duced foot­print of car­ri­ers on the ex­change,” San­doval wrote, “is a na­tional em­bar­rass­ment for a state that has made great strides in re­duc­ing our unin­sured pop­u­la­tion.” He asked them to “find a . . . so­lu­tion.”

The gov­er­nor and his chief of staff, for years Ne­vada’s health sec­re­tary, waited three days be­fore San­doval sent an­other let­ter say­ing he was “dis­ap­pointed” in the in­sur­ers and sum­mon­ing them to his of­fice Tues­day to try to ham­mer out a plan.

The prospect of los­ing ACA cov­er­age in ev­ery ru­ral county is a re­ver­sal of for­tune for a state whose em­brace of the 2010 health-care law has brought dra­matic re­sults. Be­fore the ACA, 23 per­cent of Ne­vadans were unin­sured, one of the worst rates in the coun­try. To­day, it is 12 per­cent.

Mike Willden, the chief of staff, said of­fi­cials are talk­ing with the Trump ad­min­is­tra­tion about how much it can bend the ACA’s rules to ward off the ex­change’s ru­ral melt­down next year. Per­haps they could let peo­ple en­roll in the health plans avail­able in Reno and Las Vegas, though their doc­tors would be far­ther away. Per­haps the state’s four ACA re­gions could be col­lapsed into one, so that any in­surer want­ing to stay in the ur­ban ar­eas would have to sell health plans in the ru­ral places, too. And a study is go­ing to look at a novel strat­egy en­dorsed this spring by the leg­is­la­ture — let­ting any Ne­vadan pay to join a Med­i­caid health plan.

No one knows whether any of these ideas might work.

In the mean­time, San­doval, like Ne­vada’s se­nior U.S. sen­a­tor, has been speak­ing out against what his fel­low Repub­li­cans are try­ing to do in Washington. The state has doc­u­mented ways the ex­panded in­sur­ance has im­proved res­i­dents’ well-be­ing, es­pe­cially in ac­cess to men­tal health care.

“If it is work­ing in Ne­vada,” Willden asked, “why do we have to change?”

Over at the Sil­ver State ex­change, Ex­ec­u­tive Di­rec­tor Heather Kor­bu­lic is al­ready wor­ry­ing about what will hap­pen this win­ter to peo­ple who sud­denly may be with­out cov­er­age in coun­ties such as Lyon.

“It’s such a ten­u­ous time,” she said. “It’s not that we are not try­ing. . . . But in­sur­ers in Ne­vada have been re­sis­tant to these ru­ral coun­ties for a very long time.”

It was the 5 p.m. news on KOLO-8 out of Reno that told Jenny Clay­pool her new health plan is go­ing away next year.

“What!?” she ex­claimed. De­spite her job with a com­mu­nity health group and $350 in a monthly in­sur­ance sub­sidy through the ACA, Clay­pool re­lies on help from her 78-year-old mother in Cal­i­for­nia to af­ford the $300 she still must pay in pre­mi­ums ev­ery month. Only ACA cov­er­age comes with sub­si­dies.

Fifty-one and di­vorced for a decade, she lives in Day­ton, a bit west of Sil­ver Springs. She had in­sur­ance when she worked for the county school sys­tem, but then she changed jobs and went sev­eral years with­out any. Her men­tal health is frag­ile — bipo­lar and bor­der­line per­son­al­ity dis­or­der. Dur­ing one bad spell, she went to an emer­gency room in Car­son City, which trans­ferred her to a state hospi­tal.

When Clay­pool heard in 2014 that Med­i­caid was ex­pand­ing, she signed up right away, started ther­apy and be­gan fill­ing her pre­scrip­tions at the phar­macy in­side the Smith’s gro­cery store in Day­ton, just like any­one else. Last year, Med­i­caid paid for surgery to re­pair a tear in her hip. Last fall, she be­came in­el­i­gi­ble for the pro­gram af­ter she got a raise at work that lifted her pay from $15 an hour to $17. She turned to the ex­change, pick­ing a health plan called An­them Sil­ver Path­way. The plan will be gone Jan. 1.

That cov­er­age “is a huge sense of se­cu­rity,” Clay­pool said. “I am go­ing to be out there with noth­ing.”

PHO­TOS BY MELINA MARA/THE WASHINGTON POST

TOP: Pro­fes­sional cow­boy Robert Gar­cia prac­tices his rop­ing skills ev­ery even­ing at his home in Sil­ver Springs, Nev. ABOVE: Jean Anne Smalls closes the gate to Sil­ver Stage Food Pantry, which serves res­i­dents of Lyon County, Nev.

PHO­TOS BY MELINA MARA/THE WASHINGTON POST

TOP: His­toric west­ern ar­ti­facts, old cars and other col­lectibles sit among Sierra hill­sides Wed­nes­day in an area called “The Yard” in Lyon County, Nev. ABOVE: In Day­ton, Nev., Jenny Clay­pool lost Med­i­caid cov­er­age af­ter she got a small raise, but she was able to sign up for a health plan on the state in­sur­ance ex­change. She wor­ries that she’ll lose that, too, be­cause her in­surer is pulling out of the lo­cal mar­ket next year. BE­LOW: Res­i­dents wait to be checked in Wed­nes­day at the Sil­ver Stage Food Pantry, which also of­fers pe­ri­odic health ed­u­ca­tion and screen­ings in Sil­ver Springs, Nev.

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