Nevada Gov. Brian Sandoval (R) has signed a bill that would allow most nurse practitioners and physician assistants in the state to prescribe medications without having to first get permission from a doctor. The new law is expected to help poor and rural Americans gain access to more comprehensive health care services and will help make Obamacare implementation smoother.

Nurse practitioners are advanced practice registered nurses. These types of nurses must go through a higher level of training than ordinary registered nurses and may provide certain diagnoses and treatment recommendations to patients for a host of primary and acute medical problems.

There are 33 other states that still require nurse practitioners to receive written consent from a physician before prescribing common drugs such as painkillers, blood pressure medication, and other medicines.

That can mean less access to essential prescription drugs for poor patients and Americans living in rural or isolated regions, since these groups tend to have less access to hospitals and must rely instead on community clinics that are run mostly by nurses and physicians’ assistants.

In 2009, the University of Nevada School of Medicine ranked Nevada as 48th in the nation for number of physicians per capita. The Association of American Medical Colleges found that Nevada only has 218 physicians for every 100,000 residents — even lower than the already-low national average of 307 physicians per 100,000 people.

Non-physician practitioners will now be able to ease that shortage in Nevada — but other states with a high number of poor and rural families aren’t so lucky. Christy Blanco, a nurse practitioner from Texas who started her own clinic to care for low-income women, has failed to entice a physician to oversee her practice for the last two years. Since the Lone Star State requires doctor supervision of nurse practitioners, that means Blanco’s clinic may as well not exist.

She expressed the frustration of wanting to help vulnerable Americans — but lacking the authority to do so — in an interview with Businessweek. “I’m trying to work for the poor,” Blanco said. “I’ve spent thousands of dollars of my own money [opening a clinic]. I have a waiting list of patients, and I have to tell them I can’t practice.”

That’s why practitioners like Blanco have been lobbying states to ease their restrictions on the services they can provide. But some of the biggest barriers to that effort are the very doctors that nurses and physician’s assistants are trying to gain more independence from.

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One congressman is so vehemently opposed to Obamacare that he’s willing to sacrifice his own health insurance in order to make a point.

Rep. Mark Amodei (R-NV), who entered Congress in 2011, was asked last week prior to the House’s vote to repeal Obamacare whether he would be giving up his own government-sponsored health insurance. “Happy to,” Amodei replied.

QUESTIONER: Will you give up your own congressional health care after voting to repeal tomorrow?

AMODEI: Happy to. Have a nice day.

Watch it:

The Federal Employees Health Benefit Program (FEHBP), which covers all federal workers, is similar in many ways to Obamacare. For example, both provide tax-payer subsidized coverage and allow enrollees to choose private insurance plans from a highly-regulated market.

ThinkProgress reached out to Amodei’s office to see whether he has dropped his government insurance plan yet, but they have yet to respond.

Unless the Nevada congressmen is fortunate enough to attain insurance elsewhere, whether though a spouse or a private insurance plan, Amodei’s decision to give up FEHBP is financially ill advised. Giving up health insurance means he’s more likely to forgo preventive care and would have to pay large medical bills out of pocket or, if he can’t afford them, pass those bills onto taxpayers.

Still, giving up government health insurance was briefly in vogue among Tea Party Republicans on Capitol Hill. At least half a dozen GOP congressmen personally gave up government-sponsored health care in 2011 after running on a repeal-Obamacare platform.

Federal officials have a clear message for Nevada’s Rawson-Neal mental health facility: Stop mistreating patients, or see your federal Medicare dollars disappear. In a curt letter distributed by the Center for Medicare and Medicaid Services (CMS), the federal agency that oversees major entitlement spending warned the hospital — which has been accused of unceremoniously dumping its homeless patients onto buses — that “If we do not receive an acceptable, timely submission, or if a resurvey finds that the hospital is not complying with any [conditions of participation], we will notify you that we are initiating action to terminate the facility’s Medicare provider agreement.”

The beleaguered hospital gained national attention after reports surfaced that it had systematically been dumping homeless patients with serious mental illnesses onto buses to other states. Doctors allegedly told the patients this was necessary due to a dearth of funding for housing and mental health services in the state, suggesting that they would be better off elsewhere. Rawson-Neal allegedly bused at least 100 patients to California in just one year, despite the fact that Golden State is only marginally better at funding mental health care than Nevada is.

Primary reports focused on a schizophrenic patient named James Flavy Coy Brown, who was discharged and placed onto a Greyhound to California with nothing but light snacks and three days’ medication. A follow-up investigation by the San Francisco Bee found that the behavior was nothing new, leading state and federal officials to slam the alleged patient mistreatment:

The Bee followed with an investigative report that said Rawson-Neal had purchased one-way bus tickets for 1,500 discharged patients over five years, some of whom had been sent to locations where they had no contacts.

The revelations prompted the city attorneys of Los Angeles and San Francisco to announce probes into the matter earlier this week. Rawson-Neal patients were bused to both cities, according to the Bee’s findings.

Nevada Gov. Brian Sandoval said in a statement that his office had launched three separate investigations and that disciplinary actions had been taken. The governor’s office determined that policies were not followed in at least one instance. The new policy, he said, provides “additional oversight” to ensure the hospital follows proper discharge procedures.

“I take the concerns regarding Rawson-Neal Psychiatric Hospital very seriously and it is not the policy of the state of Nevada to engage in ‘patient dumping,’” he said in a statement.

State officials have also claimed that the problem is limited to Rawson-Neal, and not reflected through other state-operated facilities.

Now that Rawson-Neal’s Medicare dollars are in jeopardy, doctors and hospital administrators might be more eager to take action. But if the facility buckles under the weight of losing its federal funding — in addition to Nevada’s steep cuts to mental health services through its Medicaid program — then other public facilities in the state would be forced to absorb its patient load. Considering the multiple barriers to providing the homeless with mental health treatment, that could end up being a tall order.

Last week, a Nevada jury found that the state’s largest health maintenance organization (HMO) owed $24 million in damages for signing a penny-pinching contract that led to at least nine people being infected with hepatitis C. On Wednesday, that same jury went further, ordering the Health Plan of Nevada and Sierra Health Services — two companies that are now part of insurance giant United HealthCare — to pay an additional $500 million in punitive damages to the three plaintiffs in the case.

The trouble started in 2008, when Southern Nevada Health District in Las Vegas informed over 50,000 people that they might be at risk for hepatitis, AIDS, and other blood-borne illnesses. The subsequent investigation led officials to the endoscopy clinics of Dipak Desai, where at least nine people — and possibly up to 114 — were infected with hepatitis C during procedures in 2007:

[The two] companies…signed a low-bid contract with the physician who ran the clinic where the outbreak started, despite warnings that he sped through procedures and pinched pennies at his clinics so much that patients were at risk of contracting blood-borne diseases, attorneys for those suing the companies argued. [...]

“The jury sent a strong message not only to HPN and Sierra Health, but to every HMO and health insurance company in this country,” [plaintiffs' attorney Robert Eglet] said. “You’ve got to provide a fair and responsible reimbursement rate to medical providers so that they are able to provide quality health care to their insured members.”

Desai allegedly rushed through the outpatient procedures in an effort to reap as many reimbursements as possible from the UnitedHealth group, which hired him through a paltry contract allowing them to skimp out on spending too much money.

Lawyers for UnitedHealth plan to appeal the ruling, arguing that Desai alone should be held accountable for the consequences of his slapdash medical services. But private HMOs’ systematic use of these so-called “low-bid contracts” in an effort to preserve profits often leads to a race-to-the-bottom that trades public health for bigger profit margins. Without adequate reimbursements, providers have less incentive to spend more time on patient care, particularly when it comes to relatively quick outpatient procedures such as the ones involved in the Nevada case. That kind of corner-cutting can seem harmless until it leads to a public health disaster.

Such bottom line-oriented behavior is particularly worrying in light of states’ increasing use of privately managed Medicaid plans that contract with HMOs. These plans offer lower costs and premiums that can make private providers money while easing pressure on state governments’ budgets — but they can also lead to low-quality, dangerous medical care that disproportionately affects low-income Americans on the supposedly public entitlement. Several GOP-led states have declared that they will only participate in Obamacare’s Medicaid expansion if given the option to completely privatize their Medicaid programs.

Nevada, which has one of the highest rates of unintended teen pregnancy in the nation, is considering updating its abstinence-only education policy to require more comprehensive sexual health instruction in public schools. This week, in a debate over that proposed legislation, Nevada Assemblywomen Lucy Flores (D) testified in favor of the bill, sharing her own personal story about the consequences of inadequate sex ed — all of her sisters became teenage mothers, and Flores herself decided to have an abortion when she became pregnant at 16.

Flores said that, since she was well-aware of the financial struggles that her sisters were experiencing as teen moms, she knew she wasn’t ready to have a baby. So she asked her father for money for an abortion. “I don’t regret it,” Flores told the Assembly Education Committee during her testimony, explaining that her decision was the right one for her. Now, she wants to make sure other young women in Nevada are better equipped to prevent pregnancy than she was. “We prevent this by giving them the information and the resources that they need, so they don’t have to go to their dad and say, ‘I need $200 for an abortion,’ ” Flores said.

But, as The Sin City Siren reports, Flores faced some serious repercussions for her honesty about her own experience with sex education, pregnancy, and abortion. The right-wing media jumped on her quoted testimony, with headlines proclaiming “Democratic Legislator: I Don’t Regret Killing My Baby in Abortion.” That coverage may have inspired some people to reach out to Flores, because local television producer tweeted on Thursday that the state lawmaker cancelled her appearance on a political news show after receiving death threats from people who had heard about her abortion story:

Assemblywoman Lucy Flores, who testified at sex ed hearing re abortion as a teen, recipient of threatening messages. Cancels Ralston Thur.

— Dana Gentry (@DanaGentryLV) April 3, 2013

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