Sandoval makes tough call to join Medicaid expansion

Since he took office nearly two years ago, Gov. Brian Sandoval has been confronted with difficult decision after difficult decision, always understanding that his determinations directly affect the lives and livelihoods of Nevadans.

On Tuesday, he made another tough call, choosing to expand Medicaid eligibility in Nevada starting in 2014 and put the program under the umbrella of the Patient Protection and Affordable Care Act. In becoming the first Republican governor to opt into ObamaCare's Medicaid expansion, Gov. Sandoval described the action as strictly a fiscal decision, not a political one.

The governor's options were stark.

He could refuse to expand the federal-state health care program for the poor, likely assuring that Nevada's uninsured population remains among the biggest in the nation. Opting out would deny revenue to Nevada hospitals that currently provide tens of millions of dollars in uncompensated care to the uninsured through emergency rooms every year; it would require those low-skilled, low-income uninsured to pay ObamaCare's penalty tax for failing to purchase coverage; and it would hit the state's general fund with $16 million in costs for mental health services over the next biennium.

Or he could opt into the expansion, guaranteeing coverage for nearly 80,000 currently uninsured residents at federal expense while increasing federal funding for mental health services - recognizing, of course, that no amount of borrowed cash from Washington is "free," and will have to be repaid at some point by future generations of Nevadans.

Gov. Sandoval believes, as we do, that ObamaCare is bad law. (See the editorial below for more proof of that.) But it's the law. Gov. Sandoval believes, under today's economic circumstances, he has made the best decision for Nevada. We agree for three reasons. First, Nevada retains the ability to opt out of the Medicaid expansion in 2017, when full federal funding of new enrollees expires and the state would begin assuming some of those costs. Second, opting into the expansion guarantees higher primary care reimbursement rates for all Medicaid patients for two years, which should make more doctors willing to see them. And third, Gov. Sandoval wants to introduce a modest co-payment requirement for Medicaid patients - between $2 and $10 - that will give them "skin in the game" and create some measure of consumer responsibility. Unlike anything in ObamaCare, this step holds the potential to curb long-term cost growth.

Currently, only Nevadans at or below 87 percent of the federal poverty line - $16,608 for a family of three - are eligible for Medicaid. By opting into the expansion, Nevada's eligibility threshold will rise to 138 percent in 2014, or $31,890 for a family of three, while also offering coverage to single, childless adults for the first time, provided their income doesn't exceed $15,415.

Of course, once a government program is extended to a new constituency, it's nearly impossible to dial it back or revoke it altogether. In reality, Nevada's new, less restrictive eligibility requirements - like ObamaCare itself - are be here to stay. Gov. Sandoval managed this decision about as well as he possibly could.