On the surface, Nevada should not be so far along in ACA implementation. The state joined the lawsuit against the Affordable Care Act, and it has a Republican governor. Yet now, Nevada could become Exhibit A in how a state with a high uninsured rate and a barebones Medicaid program adapts to the law's changes.

Nevada approved the Silver State Health Exchange in 2011, when the healthcare reform law was still in limbo pending a Supreme Court ruling. Gov. Brian Sandoval opposed reform, but accepted it as the law of the land. In the end, federal funding for exchange preparation was too good a deal for the state.

The same rationale applied to Sandoval's Medicaid decision. At 23 percent, Nevada trails only Texas in the percentage of uninsured residents. Nevada's unemployment rate has been in the double digits since February 2009. Consequently, enrollment in the state's Medicaid program has swollen since the housing market collapse and the recent recession clobbered the state's economy.

But Nevada has a bigger problem looming ? it has a high rate of Medicaid eligible residents who are not enrolled. If it had not expanded, Nevada would have been on the hook for those members without the enhanced federal match.

Now Nevada is in prime position to launch its exchange, along with other early adopters. The state should see heavy participation in the exchange. Participating plans will include the state's Consumer Oriented and Operated Plans, such as Hospitality Health, which the Culinary Health Fund and Health Services Coalition will administer.

Expanding Medicaid will test the exchange's uniform eligibility system, in which residents go to a single web portal to determine eligibility for Medicaid, the exchange and/or subsidies. Nevada will combat churn by requiring its Medicaid MCOs to participate in the exchange, reducing interruptions in care for people whose income pushes them in and out of Medicaid eligibility. With a green light for Medicaid expansion, the state will be more attractive to MCOs that haven?t participated in the program before.

Nevada illustrates the economic reality of healthcare reform. With federal indigent care dollars for hospitals likely to dry up, Medicaid funding will boost Las Vegas? troubled safety-net hospital, University Medical Center of Southern Nevada. As Las Vegas's primary source of indigent care, UMC of Southern Nevada typically runs $70 million annual deficits. Medicaid expansion will give it much-needed fiscal breathing room. Hiring among the state's providers could rise as patient volume increases.

If the healthcare reform cards Nevada has played turn out right, those high uninsured and unemployment rates could head downward. In this case, success will ensure that what goes on in Las Vegas doesn?t stay in Las Vegas.

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