Blog: If I Ran the NVHA, I Would Unlock the Comments
Matthew Brandenburg, OTD, OTR/L
If I ran the Nevada Health Authority, I would go to church. Because being a healthcare provider in Nevada is starting to feel like living on Widow’s Bay.
For those who have not watched the delightfully bizarre Apple TV series (ignore the spoilers and hit me up if you need a way to watch), Widow’s Bay is an island haunted by sea monsters, pagan demons, cursed church bells, and a centuries-old tradition of sacrificing residents to keep the community alive.
Nevada healthcare has its own collection of monsters:
Insurance companies. Productivity standards. Reimbursement-rate suppression. Capitation. Burnout. Prior authorization. Private-equity vultures circling community clinics. An administrative system that punishes evidence-based practice and then releases a colorful (albeit substanceless) infographic explaining how patients are top priority.
Our sea monsters wear quarter-zips and carry spreadsheets.
I recommend you watch the show to fully appreciate this metaphor (SPOILER ALERT). In Widow’s Bay, Mayor Tom Loftis discovers that saving the island may require murdering sweet old lady Ruth Livingston. This is unappealing and appalling to him. Advocating, organizing, attending stakeholder meetings, and trying to convince policymakers to care about healthcare financing is approximately that appealing to me.
I did not become an occupational therapist because I dreamed of analyzing Medicaid eligibility regulations. I wanted to help people participate in the activities that make their lives meaningful.
But we have reached a point where providing excellent care to the person sitting in front of us is rarely an option, and never enough. The building is on fire around us and around them.
Ruth Livingston quotes Tennessee Williams near the end of the season:
“We live in a perpetually burning building, and what we must save from it, all the time, is love.”
“We live in a perpetually burning building, and what we must save from it, all the time, is love.”
Occupational therapy puts the love in healthcare.
We help people return home. Raise their children. Manage their medications. Recover from illness. Participate in school. Keep a job. Prepare a meal. Get out of bed. Build a routine. Find something worth doing tomorrow.
But healthcare in Nevada increasingly resembles Williams’ burning building, fueled by workforce shortages, provider burnout, inadequate reimbursement, administrative barriers, and corporate practices that extract more from patients and practitioners while giving them less in return.
Quick sidebar: For those of you who’ve already gotten the chance to listen to the very first NVOTA Podcast, hosted by yours truly, you’ll have heard this (if you have, thank you! I’m sure you’ll find it just as disheartening a second time and if you haven’t, after you’re done reading check it out!)
Okay back to the topic at hand…
That is why, with a heavy heart, I am exchanging my title as Vice President of Making Occupational Therapy Cool Again for a new and significantly less fun calling:
Reluctant healthcare activist.
The Healthcare Forum That Became a Campaign Event
I recently attended a healthcare forum hosted by Congresswoman Susie Lee and Dr. Jon Penn Junejo, a psychiatric provider and candidate for Nevada Assembly District 36.
Dr. Jon has some compelling ideas. He brings the perspective of a practicing healthcare professional, seems genuinely interested in improving mental-health access, and represents the kind of younger, frontline-informed voice Nevada politics desperately needs.
The event was advertised as a community conversation about healthcare access and affordability. Providers, stakeholders, and concerned residents came together in the same room.
Call me optimistic (or delusional) but when a member of Congress convenes a healthcare forum, I expect discussion.
I expect data.
I expect questions.
I expect someone to say, “Here is the problem. Here is who is affected. Here are the tools Nevada has available. What are we going to do together?”
Instead, I was handed a document titled “Trump Visit Digital Organizing Email.”
It included a QR code linking to a social-media post from Lee’s Republican opponent, Marty O’Donnell, along with seven prewritten responses that attendees could copy and paste to troll Marty online.
Based on some of his recent posts, Marty may very well deserve some trolling.
But let me do that on my own time (It’s insulting for you to even assume my generation needs any help trolling online).
If you bring healthcare providers, patients, advocates, and community leaders into one room, please do not reduce us to a volunteer comment section for your reelection campaign. We are not a captive audience of unpaid social-media interns.
We are people with knowledge, experiences, relationships, and ideas that could help fix healthcare in this state.
Use us accordingly.
This is not just a criticism of Democrats (It’s a criticism of all politicians crafted in the spirit of inclusion). Republicans have perfected their own version of the same trick: identify a villain, distribute the talking points, rile up the audience, collect the email addresses, and send everyone home without building anything.
After a few years of advocacy, one thing has become painfully clear to me: America’s dominant political parties are exceptionally interested in winning elections. Whether winning those elections materially improves anyone’s life feels pretty low on their priority lists.
Healthcare becomes campaign content.
Patients become anecdotes.
Providers become photo opportunities.
Community engagement becomes a QR code directing us back to Twitter.
Meanwhile, all 17 Nevada counties have some form of federal healthcare-shortage designation. Nevada’s uninsured rate remains among the highest in the country. In 2024, 43.3% of uninsured Nevada adults reported skipping needed care because of cost. Clinics across our state maintain waitlists that stretch into the hundreds while struggling to recruit and retain enough professionals to serve them.
People want to show up to improve this sad state of affairs. Maybe it’s time we stop looking to politicians for the road map. May I present how an actual healthcare provider may fix this…
How Would an Occupational Therapist Fix This?
Occupational therapy providers begin by asking what people need and what is getting in their way.
We observe the real environment. We listen to the people performing the task. We identify barriers. Then we adapt the person, the activity, the environment or, when necessary, the entire dysfunctional system.
Applied to Nevada healthcare, that process would begin with open information sharing.
I would create a public Nevada healthcare dashboard showing, in plain language:
- How many Nevadans are uninsured.
- How many delay or skip care because of cost.
- How many live in primary care, dental, and mental-health shortage areas.
- How long people wait for behavioral-health, rehabilitation, and specialty services.
- How many providers accept Medicaid.
- How reimbursement rates compare with the actual cost of delivering care.
- How many community clinics have closed, reduced services, or stopped accepting certain insurance plans.
- How many Nevadans are expected to lose coverage under each federal eligibility change.
- How many claim denials insurance companies issue, for what services, and for what demographic of insured
- Where those people live and which community systems will absorb the consequences.
Then I would unlock the comments (Looking at you @nvhealthauth).
Not because Twitter is a particularly good place to design health policy. It may in fact be one of the worst places ever invented for human communication. But public officials should not advertise “stakeholder engagement” while preventing the people they represent from responding. How many typical Nevadans are aware of state medicaid meetings? What percentage of state medicaid providers and enrollees are on the state medicaid listserv? What percentage of stakeholders is available to attend meetings during 9-5 weekdays?
If you want our trust, let us ask questions.
If you want our partnership, show us the data.
If you want us to distribute your materials, invite us to help shape the plan.
Real community engagement is not giving providers scripted talking points. It is giving communities enough information and power to take meaningful action.
Nevada Is About to Conduct a Very Dangerous Experiment
On August 17, the Nevada Health Authority released a stakeholder toolkit that it says will help partners explain upcoming Medicaid changes to their communities.
The package includes a member flyer, rack card, large poster, counter sign, website-copy prompts, scripted talking points, and “ready-to-use” social-media posts.
The graphics (while lacking in substance) are lovely.
But here is the information Nevadans actually need.
Beginning January 1, 2027, many adults ages 19 through 64 who receive coverage through Medicaid expansion will have to document at least 80 hours per month of employment, education, job training, community service, or another qualifying activity in order to retain their coverage. Many will also have to renew their eligibility every six months instead of annually.
Some people will be excluded or exempt, including certain caregivers, pregnant and postpartum people, former foster youth, qualifying veterans, people participating in certain substance-use treatment programs, and some people with disabling mental-health conditions, disabilities, or serious medical conditions.
But having a diagnosis may not automatically protect someone.
Under the federal guidance, a person seeking a “medically frail” exclusion may need to demonstrate that the condition impairs their ability to satisfy the work requirement. That means someone living with schizophrenia, bipolar disorder, a substance-use disorder, chronic pain, or another serious condition may still have to navigate paperwork, documentation, deadlines, renewals, and functional assessments to preserve access to the treatment helping them remain stable.
Nevada officials have acknowledged that the Medicaid expansion population includes people struggling with unstable housing, mental illness, substance use, inconsistent employment, and difficulty completing paperwork on time.
These are precisely the people most likely to lose coverage because a letter went to the wrong address, a form was misunderstood, an exemption was not documented, or proof of work was not submitted through the correct portal.
Nevada’s own estimate suggests that roughly 100,000 people—about 12.5% of the state’s Medicaid enrollment—could lose coverage during the first two years of implementation.
Most Medicaid adults already work or would likely qualify for an exemption. The evidence from Arkansas found that work-reporting requirements caused more than 18,000 people to lose coverage, produced no significant increase in employment, and led to delays in care, poorer medication adherence, and medical debt. The primary function of these policies appears not to be helping people find work. It is making healthcare eligibility harder to prove.
Nevada is preparing to fight an administrative-barrier crisis with a rack card.
If I Ran the NVHA
If I ran the Nevada Health Authority, I would not simply explain how people might lose healthcare.
I would organize the state to prevent it.
I would release a county-by-county estimate of who is at risk. I would explain exactly what Nevada can decide, what the federal government requires, and where the state intends to push back.
I would automatically verify employment or exemption status using existing data whenever possible so that residents are not repeatedly asked to prove information the government already possesses.
I would train providers, case managers, community health workers, peer-support specialists, navigators, and social-service organizations to recognize who may qualify for an exemption and help document it.
I would fund community-based enrollment assistance through libraries, shelters, treatment centers, federally qualified health centers, rural clinics, family resource centers, and Nevada’s emerging Pathways Community Hubs.
I would create a rapid-response referral system for anyone who loses coverage. That system would connect people with Nevada Health Link navigators, sliding-scale clinics, medication assistance, mental-health and substance-use treatment, crisis services, food assistance, housing support, transportation, and legal aid.
And yes, I would begin developing a Nevada coverage option for people who fall through the new eligibility cracks.
Because losing Medicaid does not make a person’s schizophrenia disappear.
It does not eliminate their diabetes.
It does not stabilize their housing.
It does not make a low-wage job offer affordable insurance.
It simply moves the cost somewhere else. To emergency departments, crisis centers, shelters, jails, families, providers, and communities already operating beyond capacity.
If people are going to lose healthcare, Governor Joe Lombardo and the Nevada Health Authority should be able to answer a basic question:
Where, exactly, do you expect them to go?
What We Can Do Now
Healthcare professionals cannot treat this as someone else’s policy problem:
Read the new requirements. Share accurate information with Medicaid recipients. Help patients update their addresses and watch for eligibility notices. Learn the exemption criteria. Ask your organization what it will do when patients lose coverage midway through treatment.
Then ask the Nevada Health Authority for more than communication materials.
Ask for the data.
Ask for public listening sessions.
Ask for a statewide mitigation plan.
Ask how providers and Medicaid members will participate in implementation decisions.
Ask what will happen to the person with schizophrenia who misses a reporting deadline, loses access to medication, decompensates, and arrives at a crisis center weeks later.
Ask why Nevada can produce seven formats for distributing talking points but can’t (or won’t) share the data to every community about how many of its residents are likely to lose care.
And when a policymaker invites you to a healthcare forum, show up, but do not be satisfied with a campaign pitch. Bring your patients’ experiences. Bring your waitlists. Bring your denied authorizations. Bring your staffing vacancies. Bring your reimbursement data.
Bring questions they cannot answer with a prewritten tweet or a dodgy explanation about how they can’t make things better until they repeal the other dominant party’s repeal of their 8 year old plan to fix the problem.
The world is violent and mercurial. Healthcare policy may have its way with us.
But we are not powerless.
We can organize. We can share information. We can build community systems strong enough to catch people when federal policy tries to drop them. We can insist that public engagement means more than distributing a toolkit or attacking the candidate on the other side.
Occupational therapy puts the love in healthcare.
Now it is time for us to carry some of that love out of the treatment room and into the perpetually burning building.
If I ran the NVHA, that is where I would start.
Right after I unlocked the comments.
