Dr. Mary Guinan was laughing.
“Did you see the—I recommend you looking at Jimmy Kimmel Live, this YouTube on ’Obamacare’ vs. the Affordable Care Act. It’s so funny! They interview all these people and they say, ’Which one do you support? And they say, ’Oh, Affordable Care, not Obamacare.’ ’No, I don’t like anything about Obamacare, I want the Affordable Care Act.’ I mean, it’s sad, but it was very funny.”
It’s a quality that so many politicians lack these days, the ability to joke about things that, as issues, they consider serious. Guinan has seen some deadly serious things in her career, but her sense of humor remains intact.
She’s a typical Nevadan—a transplant. Born in Brooklyn and educated at Hunter College, the University of Texas Medical Branch, and Johns Hopkins University Medical School, she worked early in her career in smallpox eradication in India. Then after a fellowship at the University of Utah, she became a prominent herpes expert. She was a member of the early Centers for Disease Control team working on what would become known as AIDS and was portrayed by Glenne Headly in the movie And the Band Played On.
Somehow, in 1998, Nevada bagged her as its first woman state health officer. She said then that though other states had elaborate and planned health systems, Nevada did not, and it was a place where she felt she could help.
“I thought I could make a bigger impact in Nevada,” she said.
She brought fresh eyes to a Nevada whose health care community was often discouraged by the state’s miserly ways and poor reputation.
She didn’t realize then that Nevada’s health care system was not primitive by happenstance. It was by design. For decades, the Nevada Legislature had starved all human resource spending. There has long been a faction in the state that opposes social programs, tried to prevent their establishment, and contain their sizes when they could not be stopped. The legislature would create certain levels of service, and stop there.
Conservatives complain that Nevada receives far less from the federal government than it sends to Washington, D.C. The reason, though, reflects back on the state’s conservative policies—Nevada declines to participate in many federal programs, kissing off its residents’ share of federal benefits. “Other states are cutting things we don’t even have,” Sen. Sheila Leslie said in 2011. When the state did participate in federal programs, it was often after years of ignoring problems they addressed instead of dealing with them on a state level. For at least 60 years, Nevadans have found remedies to problems ranging from civil rights to pollution only after the federal government entered the picture.
Nevada is one of the most unhealthy states—one of the biggest challenges for the new national health insurance program. If that program works in Nevada, it can likely work anywhere. But there are plenty of people who are so jaded to Nevada’s lousy quality of life that they are not expecting another program to change anything fundamental.
Mary Guinan is not one of them. Her arrival in Nevada in 1998 was exactly what the state needed. Endlessly optimistic, she never doubted that the state’s poor quality of life and health could be improved.
Past is prologue
Nevada is a medical mess. It has become a local cliché to say that the Silver State is at the top of every bad list and the bottom of every good list. That problem has just been dropped on the federal doorstep.
For years, national rankings showed Nevada at the wrong end—teen pregnancy, prenatal care, suicide by senior citizens, suicide generally, tobacco use, tobacco-related death, alcohol- and drug-related death, firearms deaths, health insurance coverage (second worst in the nation, after Texas), homicide against women, toxic releases, child immunizations, infectious disease. This year, whooping cough—a deadly disease that’s preventable—is rising in Nevada. Last year, every nursing home in the state was cited by inspectors. Whole swaths of the population—notably women and children—are deemed at greater risk in Nevada. Nevada minors are the most uninsured in the nation. There is a shortage of doctors and nurses. Some of these problems have been with the state for decades, even generations.
That is certainly true of mental health. In any other state, the Nevada mental health system would be a scandal. In Nevada, it’s the normal, decades-old way of doing business (“Tradition,” RN&R, April 25, 2013). The recent disclosure by the Sacramento Bee of patient dumping by Nevada is continuity.
Non-health rankings also indicate a state not likely to improve any time soon: rate of working people in poverty, voter turnout, reading skills, crimes of all types, dropout rate. According to 24/7 Wall Street, “In general, the likelihood of not having health insurance is much higher for those without a high school diploma. In Nevada, due to a poor graduation rate, the chances of this happening are significantly worse.”
The health problems are susceptible to change. Teen pregnancy, immunizations and obesity have recently seen improvements in the state after education programs were launched. But Nevada has rarely invested in such education programs. And the Affordable Care Act isn’t in the business of changing infrastructure, of creating programs or building facilities or training healthcare providers. Can it, merely by providing insurance, upgrade a state that could easily be named Downgrade?
The working poor
In 2003, Gov. Kenny Guinn wanted to make a dent in those national rankings. He won passage of significant tax increases and he and the legislature plowed more money into health programs. Earlier, most of the state’s tobacco settlement was poured into health.
But since 2007, the old Nevada has reasserted itself. Under Gov. Jim Gibbons, spending of all kinds was slashed. The onset of the recession exacerbated the problem. Budget after budget was cut to cope with revenue shortfalls over a period of years. Higher education, which has a health role, was chopped by more than a third.
There are, of course, those who take criticism of the state’s government policies as criticism of the state itself. David Palmer last month wrote to this newspaper, “I suspect I may speak for more than a few Nevadans when I ask the obvious question: If you dislike our state so much and think it is so terrible, why don’t you move?”
This assumption that one must embrace the policies in order to love the state is unacceptable but often used.
For a long time, the state’s changing demographics aided those who opposed social programs. Senior citizens poured into Nevada in the postwar years, seeking low taxes. In the 1980s, the Nevada Department of Education did polling that confirmed expectations—these elderly new residents tended to vote against school bond issues, suggesting a more general opposition to taxes. These residents were also heavy users of what social programs there were, putting two trends in conflict.
As time went on, though, another factor overtook the state’s elderly growth. Latinos came on strong in the 1990s and the new century. They now make up about a fifth of the state’s voters, they tend to be upwardly mobile (many work more than one job), stable, less hostile to government programs. Their numbers are now well ahead of the 13 percent of Nevadans 65 years of age and older.
Adding to the state’s health difficulties is the problem of poverty, which affects how much health care the working poor can afford. This is one place where rankings can mislead. National surveys released last month showed almost 16 percent of Nevadans below the poverty line, 18th in the nation. They used 2012 data and put Nevada a little lower than the middle among states. The child poverty rate is 24 percent, up 57 percent since the start of the recession. This was seen by most observers to mean Nevada is around the national average. Actually, the poverty rate in Nevada is almost certainly underestimated in national rankings.
These rankings are not weighted for local factors. Nevada is a tax haven. Wealthy people who actually live elsewhere maintain residences here for tax purposes, and that throws off data. That’s why the New York Times could report in 2001, “Pick almost any index of social well being, and Nevada ranks at or near the bottom of the 50 states, although it ranks near the top in personal wealth.”
Moreover, poverty in Nevada is a moving target. The state’s population frequently fluctuates so rapidly that any reading is a snapshot. It can change quickly after it is taken. Nevada remains bogged in recession, continues to lead the nation in foreclosures, and is usually first or second in joblessness.
A more realistic view of the impact of poverty on Nevada health than recent commentary comes from 24/7 Wall Street, which predicts, “Under the Affordable Care Act in Nevada, those earning under 400 percent of the national poverty rate will be eligible for tax credits. Nevada will likely be one state relying on this provision the most. The state also has the highest proportion of residents employed in service jobs, which are less likely than many jobs to provide health benefits.”
That assumes those at the economic bottom will avail themselves of the Act.
After all the sound and fury of the congressional battle followed by the Supreme Court battle, only about half of the uninsured are covered by the Act. In Nevada, there are an estimated 577,000 uninsured residents. The national program can handle perhaps 311,000 of them. That’s 54 percent, if they all enroll.
Early on, Dr. Guinan liked to point out that what Congress was constructing was not a health care program, but a health insurance program (“Nevada health leader believes reform will pass,” RN&R, Sept. 24, 2009). That means the insurance must be purchased, which is not easy for the working poor. Democrats in Congress, who always have faith in government process, saw subsidies as a way to make that happen, akin to the Earned Income Tax Credit, which requires already burdened low-income taxpayers to apply for tax fairness. Low-income workers will now have one more thing to do with all their spare time. How many of the working poor who really need health insurance will take time out from home, children, and jobs for that kind of paperwork?
Esteban and Maria and their children did their laundry last weekend at a Sparks laundromat and took time to chat.
In spite of the heavy news coverage of how the federal program will work, neither of them knew a lot about it. Estaban works two jobs and Maria works one—plus being a mother, so it works out to each of them having two jobs. Maria had read some things about the federal program and knew a deadline of some kind was approaching. But she knew little more and the two of them were trying to decide whether it would be easier to pony up money for insurance or just let the money be taken out of their income tax at the end of the year.
“A simpler program is what I needed,” said Estaban, who works jobs in a restaurant and a beauty shop, neither of which provide health insurance. Democrats were supposed to have learned something from the unpopular complexity of the Clinton health plan, but one group of four Reno/Sparks seniors sat down in a sort of support group to put all their heads together and see if they could figure out the new program. “Complications I can get from Blue Cross,” one of them said.
It’s surprising how little changes under the federal program. Going to the doctor will be much the same. When Congress accepted the notion of a private insurance program instead of a public option, it accepted a lot of the template under which health care has been operating since managed care was introduced. There will still be mini-bureaucracies in doctors’ offices for patients to cope with, and there is no reason to believe that the same corporate behavior that has driven consumers nuts for years will change just because the care is being purchased through the Silver State Exchange.
“I think I didn’t know what to expect when I came here,” Mary Guinan said. “And it’s been, yes, a difficult time, but anything worth doing is difficult. … Public health changes in small steps.”
She did two stints as Nevada state health officer, in 1998-2002 and 2008-2009, during which she participated in the state response to a cancer/leukemia cluster in Churchill County, an anthrax scare in a Reno Microsoft office a month after 9/11, a 2007 hepatitis outbreak at a Las Vegas endoscopy center and the early stages of the H1N1 flu scare.
She learned some of the facts of life early. “Nevada has not traditionally invested in prevention,” she told Associated Press in 2001. But she had been at the CDC during the years when the Reagan administration held down efforts to deal with AIDS and still saw things accomplished.
During, between and after her turns as health officer, she pushed for efforts to bring Nevada up to date. She can count a number of advances in public health in the state.
• The casino industry always clamped hard on the Nevada Legislature when anti-smoking legislation came up. So health advocates went around them and took the issue to the ballot, cautiously exempting casinos from its impact (and thus subjecting casino workers to their toxins). The public approved a ban on smoking in most public places. Guinan still gets excited when describing the victory. “That was the most incredible thing that happened,” she said. “The number of heart attacks have decreased. The asthma attacks have decreased.”
• “In southern Nevada, we had the worst oral health in the nation of children,” Guinan said. “Of the top 10 reasons for visiting the pediatric emergency room at [University Medical Center in Las Vegas] was dental problems, dental abscesses.” It took legislative action, Gov. Guinn’s signature, plus a public vote in Clark County, but finally fluoride was added to the water in that county, which includes most of the state population.
• “When I came here, nobody knew what was happening in cancer in Nevada. Nobody analyzed the data. We’d collect data. There [weren’t] enough people to analyze it. Now we have people analyzing the data from the Nevada Cancer Registry.”
• Since passage of a new state law—the first of its kind—providing for AIDS testing of pregnant mothers which can result in quick treatment, there has not been another HIV -positive newborn.
• The supply of health care workers is slowly growing. “We have sophisticated public health workers now who can analyze data—bio-statisticians, epidemiologists, environmental health specialists.”
“We have actually improved our immunization rates over the past few years,” Guinan said. “We have also improved—we’ve decreased our smoking rates. So things are going down. It’s just not ever going to be very fast. But in maybe the next ten years I think we’re going to see dramatic changes here.”
But Guinan also learned how the old Nevada could reassert itself. At the 2011 Nevada Legislature, a few days before a cigar and pipe retailers national convention convened in Las Vegas, lobbyists slipped a bill through in the closing hours relaxing the voter-mandated restrictions. It left most of them in place, but no one believes lobbyists have given up.
Such setbacks notwithstanding, she said, “I feel that Nevada has really come out of the dark ages. And it’s hard for the general public to see those advances. But we’re trying.”
With all this experience dealing with Nevada’s deep-seated and seemingly unsolvable health care problems, does Guinan believe that the new national health program is a remedy for what ails the state, or can at least contribute to easing it?
It was the only moment when the ever-optimistic Guinan sounded at all discouraged. She sighed, then said, “I don’t know. I’m hoping that it will, because the access to health care has been a terrible problem for Nevada.”
Some of the coverage provided by the ACA, she said, seems almost designed for Nevada. The problem of Nevada’s poor record on women’s health, for instance: “For women, mammograms and pap smears, there’s no co-pay on any insurance for that. So that prevention is—I hope there’ll be much more screening.”
She said under the ACA, prevention would likely become more important than it has been in Nevada’s past, when the state preferred paying for consequences than for putting money up front on prevention (“Spending dollars to save dimes,” RN&R, March 10, 2011). “We can’t see prevention very well,” she said, meaning that illness is apparent, but prevented sickness is invisible.
The ACA can facilitate the state improving its own infrastructure.
“That was one of the problems—we didn’t have the health insurance,” Guinan said. “Now we have the health insurance. We can hopefully increase the number of health care providers.”
The ACA has money for increasing health workforce development, training health care providers. But that requires state officials who opposed ACA in the first place to apply to expand its presence in the state.
Gov. Brian Sandoval, who opposes ACA, agreed to run a state exchange under the Act, though he had little choice—it was imposed on him by the legislature—and he said his reason for doing it was that otherwise the U.S. government would run it.
Guinan praises Sandoval for expanding the state’s Medicaid caseload. (Medicaid is a federal/state low-income medical program.)
“We do have a shortage of doctors and nurses, but it’s always been that way,” she went on. “The Affordable Care Act will not directly affect it, but they will try to help you build the workforce. And that would hopefully—we will get money, maybe, to expand the medical school.”
“It’s a first step,” she said.