President ending cost sharing reductions would raise premiums, create chaos

Since the efforts to repeal the Affordable Care Act collapsed in the Senate last month, President Trump has been threatening to “let Obamacare implode.” There are several things the Trump administration could do to ensure that implosion happens. One of those things is ending payments for cost sharing reductions (CSRs) that help insurance companies offset the costs of offering low-deductible, low-cost-sharing plans for low-income people. In a series of Tweets, Trump referred to these payments as “bailouts” and threatened to end them. If he does so, it would wreak havoc on insurance markets, driving premiums up and driving more insurers out of the Marketplaces. According to a new report from the nonpartisan Congressional Budget Office, ending payment for CSRs would cause health insurance premiums to increase by 20% next year and would continue to increase in later years.

What are cost sharing reductions (CSRs)? The Affordable Care Act (ACA) provides two kinds of subsidies to help low- and middle-income people pay for health insurance: premium tax credits and cost sharing reductions (CSRs). Premium tax credits help cover the costs of insurance premiums for people with household incomes up to four times the federal poverty level. But even with subsidized premiums, most low-income people can’t afford to use their insurance, because they still cannot pay the high cost-sharing (deductibles, co-payments, co-insurance) required by most insurance plans. To help those who would struggle to pay for cost-sharing, the ACA requires insurance companies to reduce the cost-sharing levels for people making less than 250 percent of the federal poverty level. About 6 million Americans, including over 155,000 Tennesseans, receive cost-sharing reductions. The ACA then instructs the federal government to reimburse insurance companies for the higher cost of offering these low-cost-sharing plans, and the government so far has been making payments to insurers for doing so.

What is the Trump administration threatening to do to the CSRs? The Trump administration is threatening to stop making the payments to reimburse insurance companies for offering the low-cost-sharing plans. If the Trump administration follows through on its threat, insurers will still have to provide low-cost-sharing plans to eligible people. The insurers just won’t get reimbursed for it.

What would happen if the Trump administration stops making the CSR payments? This would throw the individual insurance Marketplaces into chaos and trigger huge premium hikes. Some insurers will choose to leave the Marketplaces altogether, leaving more counties with few or no insurance plans available and more people without access to affordable insurance. Other insurers could compensate for the loss of CSR funding by raising premiums. According to the Congressional Budget Office (CBO), insurers would raise premiums in the individual market by 20% next year to cover the loss of CSR payments, and premiums would continue to rise in later years. Indeed, some insurers are already raising premiums for next year in anticipation of an end to CSR payments.

Ending the CSR payments would also cost the federal government more than continuing to make the payments. This is because CSRs are only available to people who enroll in a silver-level Marketplace plan, so insurers would focus their premium increases on these plans. Silver-level plans are also the “benchmark” for determining premium tax credits, so increasing the premiums on silver-level plans would dramatically increase premium tax credits for everyone receiving them. The CBO estimates that ending CSR payments would increase the federal deficit by $194 billion in the next decade.

Can the Trump administration legally stop making CSR payments? That is debatable. The ACA requires the federal government to make CSR payments to the insurance companies, but it does not specifically appropriate any money for doing so. Critics of the ACA claim this is a problem because the Constitution says that “No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by law.” Supporters of the law argue that ACA implicitly authorizes the expenditures. This Constitutional dispute is already the subject of one federal lawsuit. In 2014, the House of Representatives filed a suit (formerly House v. Burwell, now House v. Price) challenging the authority of the Obama administration to make the payments. The district court ruled against the Obama administration, saying that the CSR payments were illegal and ordering the CSR payments stopped. The order did not go into effect, though, because the Obama administration appealed the ruling.

Then Trump was elected. Until recently, Trump simply could have dropped the appeal and allowed the district court’s order to stop making CSR payments go into effect. But the D.C. Court of Appeals has now allowed 17 states and the District of Columbia to intervene in the case, since their citizens would be hurt by the loss of CSR payments. The Court said that ending the CSR payments “would lead directly and imminently to an increase in insurance prices, which in turn will increase the number of uninsured individuals for whom the States will have to provide health care.” This does not end the lawsuit or decide the legality of the CSR payments, but it makes it more difficult for the Trump administration to dismiss the appeal and claim legal cover for ending the payments.

Can Congress do anything to ensure the government keeps making the CSR payments? Yes, Congress could appropriate the money, even if only temporarily. Luckily, several senators, including Sen. Lamar Alexander, Chair of the Senate Health Committee, have expressed interest in a new bipartisan effort to stabilize the health insurance Marketplaces. Senator Alexander has asked the Trump administration to continue funding the CSR payments through September to give Congress time to appropriate the money going forward.

Senate Votes No on ACA Repeal

This mural features the signatories of TJC’s sign-on letters, which were delivered on Tuesday, July 25th to our Senators’ Nashville offices as the Senate in Washington D.C. voted on the motion to proceed.

 

In the dark of the wee hours of the morning, GOP Senate Leadership and our two Senators tried to pull a “fast one” on America. They unveiled a plan called the Health Care Freedom Act, also known as “skinny repeal”, late last night and, less than 3 hours later, held a vote for passage.

Around 1:30am ET, this bill failed, with Senator McCain casting the crucial vote to kill the “skinny repeal” bill. He joined the Senate Democrats and GOP Senators Collins and Murkowski to reject the last-ditch effort to repeal the Affordable Care Act.

If the Senate had voted for the Health Care Freedom Act, it would have had future crushing consequences for real Tennesseans. It would have resulted in 16 million people losing coverage and most privately insured people having a 20% increase in premiums. It would have destabilized the insurance market. Four senators held a press conference yesterday announcing they would vote for the “disaster” skinny repeal bill only if they got assurances that it would never, ever become law. As they admitted yesterday, the “skinny repeal” bill was really a pathway to destroy Medicaid once it passed and moved to a conference committee with the House.

Never in the history of this great nation has either party played such games with procedural processes and rules that were written to ensure every Senator had a full and fair opportunity to deliberate on what would become the law of the land. Apart from the procedural shenanigans, the merits of the bill were historically harmful. That’s why all stakeholder groups told Congress it was bad policy- faith leaders, doctors, families, & consumer groups, even insurance companies.

Last night was a miracle. TJC feels so privileged to stand alongside you, the miracle workers. Thank you for continuing to stand up for Tennesseans.

What we are savoring is the extraordinary Tennesseans like you who rose to the challenge and made history themselves. You wrote, you called, you prayed, you told your stories, you made signs, you read policy blogs, you became health policy experts from your children’s hospital bedside, and you told your terrified neighbors that they weren’t alone. The GOP Senators thought no one would be watching last night. Yet, the calls just kept coming to their offices. Again and again, Congress has underestimated the power of love and the strength of resilience born of protecting a suffering loved one for years with countless sleepless nights. If they wanted to pull a fast one on these moms and caregivers, they will have to get more clever than a 2 am vote. Middle of the night stress is families’ home turf!

We know this fight isn’t over. But with each battle, we get stronger.

As the old song goes: “Anything they can do – we can do better!” We urge Tennessee elected officials to listen to the people who pay for their insurance and send them to Washington to work on fixing problems, not creating new ones. The season for political games is over. Our message to our elected officials: get to work solving problems that matter to us!

Don’t be fooled by “skinny” repeal

This week, the Senate has tried and failed to pass two different bills that would repeal the Affordable Care Act (ACA). On Tuesday night, the Senate’s ACA repeal-and-replace bill, the Better Care Reconciliation Act, went down, 43-57, with nine Republican Senators voting no, including Tennessee Senator Bob Corker. Then on Wednesday, the Senate voted down a bill that would have repealed the ACA without a replacement. Seven Republican Senators, including Tennessee Senator Lamar Alexander (but not Senator Corker), voted against it. Both of these bills would have caused millions of Americans and hundreds of thousands of Tennesseans to lose coverage and would have caused millions of others to pay much more for skimpier coverage.

Now, in their last-ditch effort to pass something, anything, that would allow them to repeal the ACA, Senate leaders are promoting a new idea: a “skinny repeal” that would eliminate the ACA’s individual and employer mandate and the medical device tax. The Senate is expected to vote on this bill, which has not even been written as of Thursday morning, by Friday.

If it becomes law, “skinny repeal” would hurt millions of people. The Congressional Budget Office estimates that it would cause 16 million Americans to lose coverage next year and would drive up premiums by 20 percent for millions of Americans. It would also further disrupt insurance markets, potentially causing what health policy experts call a “death spiral” and the markets’ ultimate collapse.

But the goal of Senators pushing “skinny repeal” is not to pass the bill into law, but to revive GOP efforts to repeal large parts of the ACA and make devastating cuts to Medicaid. As Senator Corker has made clear, passing skinny repeal in the Senate is just a “forcing mechanism” to get to a House-Senate conference committee. In other words, skinny repeal is a Trojan Horse.

Once that Trojan Horse gets in conference, a small group of hardline conservatives will meet in secret to draft yet another ACA repeal-and-replace bill. To ensure that it gets enough votes to pass both houses, the final bill will almost certainly include all the damaging provisions that have been in every other repeal-and-replace bill produced by the House and Senate:

  • slashing federal funding for Medicaid by imposing per capita caps;
  • reducing subsidies that help low-income individuals afford premiums and cost sharing in the individual insurance market; and
  • weakening consumers protections like the ban on annual and lifetime limits and discrimination against people with pre-existing medical conditions.

Once the final bill is unveiled, Senate Republicans would then be faced with an up-or-down vote on the final bill in September. Either they vote for a bill harsh enough to satisfy the ultraconservative House Freedom Caucus or the GOP’s seven-year effort to repeal the ACA ends in failure. Senate leaders appear to be betting that moderate Senate Republicans will bite the bullet and vote yes.

If Senators Corker and Alexander are really concerned about the well-being of their constituents—the hundreds of thousands of children who depend on Medicaid to get a healthy start in life, seniors in nursing homes trying to live the remainder of their life with dignity, people with pre-existing conditions who need access to care, people in rural communities with struggling hospitals that could fail if federal funding is cut—they should not support this procedural gimmick that opens the door for enacting a law that will harm those constituents. Instead, they should heed Senator McCain’s call for a return to “regular order” and engage with colleagues in an open and bipartisan fashion to come up with effective solutions that will stabilize the Marketplace, keep coverage affordable, and protect the healthcare of all Americans.

Praying for Medicaid

Prayer Vigils for Medicaid

We encourage all people of faith to have a short prayer service to lift up those whose lives, well-being, and financial security hang in the balance as Congress debates health care.

“I have been driven many times upon my knees by the overwhelming conviction that I had nowhere else to go. My own wisdom and that of all about me seemed insufficient for that day.”

Abe Lincoln

Fighting to protect a health care system that ensures the dignity of all people is such a privilege. It is also an immense challenge that would be impossible without the support of my faith and my community.  In the last 6 months, TJC’s work -- which has always been demanding -- has reached an unprecedented level of intensity and urgency.  In presenting the realities of the Senate proposal to members of my own church members, I was asked a simple question: what can we do? My answer was use your voice, call and write our Senators, spread the facts about the bill, and pray.

I meant it wholeheartedly. I, like President Lincoln, felt like maybe prayer was all I could do to make a difference with the bleak predictions coming out of Washington. I suggested we hold a vigil, and my fellow parishioners jumped on board. We reached out to other faith leaders and the response was amazing. Last Wednesday, 40 Christ the King Parishioners joined their prayers with folks in different denomination and different parts of the state.  We all prayed for our neighbors who are sick or have been sick, for the uninsured and for those who would lose their insurance. We prayed for our elected officials. And we prayed for our country.

It was wonderful to think about my clients who feel so tired and alone knowing that these strangers were holding them in the light. They are not alone. They matter. And as I prayed, I realized that we were making a difference. No longer did prayer feel like a last resort in troubled times. Instead, I left energized and strengthened. As people of faith, strengthened by our communities, we will keep fighting to make sure our public policy reflects the compassionate values we share.

We encourage all people of faith to have a short prayer service to lift up those whose lives, well-being, and financial security hang in the balance as Congress debates health care. Remember the millions of people who would be affected – those at risk of losing Medicaid coverage they need to thrive, who will be unable to afford insurance because of pre-existing protections, who will lose their jobs due to the economic impact, and the rural communities all over Tennessee and the country who will lose their hospitals. 

If you are willing to organize a short prayer vigil in your faith community, let us know. We will help get you what you need to do what other faith leaders did last Wednesday. We need the intentions and compassionate voices of people of faith now more than ever. If you are interested contact Aftyn Behn at abehn@tnjustice.org.

Response to Senator Lamar Alexander’s Statements on the BCRA

Senator Lamar Alexander released a statement about the Better Care Reconciliation Act (BCRA), the Senate version of the American Health Care Act (AHCA) on June 22, 2017 and another statement about the subsequent CBO score of the BCRA on June 26, 2017.

We found many problems with Sen. Alexander’s analysis of the bill. Here’s the breakdown:

Sen. Alexander: To begin with, the draft Senate healthcare bill makes no change in the law protecting people with pre-existing conditions

REALITY: The BCRA will allow states to waive essential health benefits. Under the ACA, essential health benefits include hospitalization, rehabilitative and habilitative services and devices, and preventive and wellness services and chronic disease management (among other services), which are critical services for people with pre-existing conditions. The ACA’s ban on annual and lifetime limits only applies with respect to care that is considered essential health benefits, according to the Brookings Institute. Additionally, the consumer protection provision of the ACA that requires plans to cap annual out-of-pocket spending only applies to care that is considered essential health benefits, as well. If state waives requirements for essential health benefits, it undermines these consumer protections that are vital for people with pre-existing conditions. Nominally prohibiting plans from denying coverage to people with pre-existing conditions will be an empty protection, as most people with pre-existing conditions will not be able to afford the care that they need.

Sen. Alexander: no change in Medicare benefits

REALITY: Just like the AHCA, the BCRA repeals the Medicare payroll tax on high-income earners which would deplete the Medicare Part A trust fund in 2025, 3 years earlier than under current law. The Medicare Part A trust fund pays for hospitals, skilled nursing facilities, and home health and hospice benefits.

Additionally, one in five Medicare beneficiaries relies on Medicaid to cover their Medicare premiums. The BCRA’s estimated $772 billion cuts to Medicaid will severely affect these vulnerable older adults.

Americans aged 50-64 will be particularly hard hit by the BCRA due to the provision that allows insurance companies to  charge older adults five times more than younger people, simply due to their age. This will cause many to lose coverage. When they age into Medicare, they will need more and more expensive health services, driving up all costs for the Medicare program, leading to higher premiums for everyone.

Sen. Alexander: increases Medicaid funding— that’s TennCare—at the rate of inflation

REALITY: While this is technically true, it is misleading. The “rate of inflation” for the overall economy is significantly lower than the rate at which medical prices inflate. For example, the out-of-pocket costs of prescription drugs grew two times faster than other goods. The Congressional Budget Office has pointed out that the effect will be to shift to states, and state taxpayers, the burden of additional inflation, which will grow to billions of dollars with each passing year.

Right now, Medicaid is a federal-state partnership whose funding adjusts proportionately to market forces like medical inflation, epidemics, medical innovation, and economic recessions. Per capita cap or block grant systems are completely inadequate and inappropriate to deal with the variances in the coverage needed by many Americans.

That leaves the state with having to continually decide where to cut? Nursing home care for the frail elderly, hospitalization for cancer patients, prenatal care for high risk pregnancies, treatment for opioid addiction. All are at risk.

The following graph shows how much TN would have lost if similar inflation limits on federal spending had been in place in the past.

Sen. Alexander: Let me repeat: it makes no change in the law protecting people with pre-existing conditions

REALITY: As explained above, the nominal consumer protection that does not allow insurers to deny or charge more for people with pre-existing conditions is still there, but because of the ability of states to waive essential health benefits, insurers will still be able to price people with pre-existing conditions out of the market.

It’s actually easier for states to waive these benefits in the BCRA than in the House-passed version of the AHCA by allowing states to bypass proving they are still protecting patients and allowing governors to make this decision without input from their state legislatures.

Sen. Alexander: increases funding for Medicaid—that’s TennCare—at the rate of inflation.

REALITY: This statement is misleading, for it masks the great harm the BCRA does to Medicaid and the children, families and frail elderly whom the program serves. The bill does not keep up with actual health care costs, which is why the Congressional Budget Office estimates that 15 million people will lose Medicaid coverage, and millions more will face reductions in care. An estimated 395,000 Tennesseans will lose Medicaid coverage.   The cuts in Medicaid payments to providers will lead to the closing of many hospitals, clinics, pharmacies and nursing homes across rural Tennessee.

Sen. Alexander: Here are some other benefits for Tennesseans I see in this draft: Offers health care coverage to 162,000 Tennesseans who make less than $12,000 a year, and under the current law, receive zero help buying insurance.

REALITY: As a reminder, the reason this accommodation is needed is because Tennessee’s legislature rejected Gov. Bill Haslam’s “Insure Tennessee” plan to use federal Medicaid funds to cover low-wage workers, leaving 280,000 people without access to coverage under the law. Unfortunately, this bill does not offer effective health coverage: instead, it offers meager assistance through premium tax credits for the poorest adults in our state to buy catastrophic, high deductible plans.

coverage gap

According to the Congressional Budget Office’s assessment of the bill, “Some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”

Sen. Alexander: Means the 350,000 Tennesseans who buy their insurance in the individual market – these are Tennesseans who don’t get their insurance on the job or who don’t get it from the government – are more likely to be able to buy insurance next year instead of being in the collapsing Obamacare exchanges where there may be only one option – or even zero options – to buy insurance.

REALITY: Instability in the insurance market is real, but Sen. Alexander’s diagnosis is wrong, and so is his cure. Politicians’ vows to repeal the law, and uncertainty whether they will even allow the federal government to honor commitments to pay insurers for costs they have already incurred, have made participation in the market risky and uncertain. No wonder insurers are pulling out.

The right solution is to honor the government’s financial commitments to insurance companies and those who have bought insurance on the federal Marketplace. Politicians, including Sen. Alexander, should quit vowing to destroy the current law and should instead work to fix its problems. Only then will stability return to insurance markets.

Unfortunately, that is not the approach Sen. Alexander advocates. He would lure insurers by subsidizing the sale of shoddy coverage that will make money for the insurance companies without providing real protection for their customers. Sen. Alexander would allow companies to sell skimpy plans that don’t include critical services like emergency services, prescription drugs, and pregnancy, maternity, and newborn care. Only the most desperate will pay for the illusion of coverage. With fewer people overall (and mostly sick people) buying plans, insurance companies will seek to spread their costs across a smaller group of people, so co-pays and deductibles (patient’s responsibility) would likely rise. Coverage will continue to deteriorate.

Sen. Alexander: Gives the state more flexibility and continues federal cost-sharing, which our state insurance commissioner said will help bring down the cost of premiums.

REALITY: Of course premiums would go down if you cut off access to insurance for 22 million people, people who will typically be older, poorer and have pre-existing conditions.

The BCRA allows the state to cut services like the 10 Essential Health Benefits required by the ACA, which include, ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, pediatric services, including oral and vision care.

More flexibility can have bad results if states are not required to ensure that plans provide essential health benefits. Trading vital services for cheaper premiums is a bad deal.   An overwhelming majority of Tennesseans support Gov. Haslam’s Insure Tennessee plan, but the state legislature has refused for three years to even bring it to a vote. Entrusting the future of Tennesseans’ health and financial security to state legislators is not a good idea.

Sen. Alexander: Slows down sky-rocketing premiums, which in Tennessee have gone up 176 percent over four years.

REALITY: The Affordable Care Act actually staunched the rise of premiums. Premiums have risen at a slower rate since the implementation of Affordable Care Act than the 5-year period before the ACA, and it has protected moderate income people from those increases by providing tax credits that defray the cost.  There are still problems with affordability, but Congress is only making those problems worse, rather than fixing them.

Sen. Alexander: Repeals the medical device tax on one of our state’s largest exports.

REALITY: This is a corporate tax break that has nothing to do with the goal of “patient-centered care.” It isn’t even a tax break that gives much help to Tennessee businesses. The Senate health bill will close rural hospitals, clinics, pharmacies and nursing homes across Tennessee, and it will cost the state 28,000 jobs.

Sen. Alexander: Repeals the employer mandate penalty, which should mean that employers should be able to offer employees more choices of insurance at a lower-cost—and about 60 percent of us get our insurance on the job.

REALITY: This approach could leave people with watered down coverage that doesn’t really protect them.

Sen. Alexander: Ends the tax on individuals who choose not to buy insurance.

REALITY: Elimination of the individual mandate will destroy insurance markets unless there is some other requirement that does not allow people to avoid buying insurance until they get sick. The Senate bill replaces the tax with a much harsher, unfair penalty requiring uninsured people to go without coverage for six months – a death sentence in some instances – without taking into account their inability to afford coverage.

Sen. Alexander: Provides more money for hospitals that serve low-income Tennesseans who don’t have insurance.

REALITY: The bill gives with one hand but takes away more – much more – with the other. Tennessee already has the dubious distinction of having the highest rate of rural hospital closure of all states, and there are 32 more that are at risk for closing, including Blount Memorial Hospital on Lamar Alexander Parkway in Maryville, Tennessee. This bill further threatens the financial viability of many hospitals that are already barely surviving in Tennessee. The American and Tennessee Hospital Associations, Children’s Hospitals of America and the National Rural Health Association all oppose the Medicaid cuts, because it will damage or close many hospitals.

Sen. Alexander: Provides new funding for opioid abuse, and opioid abuse is a rampant epidemic in our state.

REALITY:  The amount of this new funding is only a tiny fraction of the $772 billion the BCRA will take from Medicaid, which is the main source of funding for treatment for people with addiction. The Senate bill will devastate the effort to curb the opioid epidemic. That is why the Tennessee Coalition for Mental Health and Substance Abuse Services has asked Sen. Alexander to vote against Medicaid cuts such as those in the BCRA.

This amount isn’t nearly enough to address every state’s needs.

Sen. Alexander: Provides new Medicaid funding for mental health to double the number of days of in-patient treatment.

REALITY: The amount of this new funding is only a tiny fraction of the $772 billion the BCRA will take from Medicaid, which is the principal source of coverage for the prevention and treatment of illness. Fewer people will receive mental health treatment under the BCRA. That is why mental health organizations like the National Alliance on Mental Illness vigorously oppose these cuts.

Sen. Alexander: I’m going to continue to review this draft. I’m going to see what it costs when the Congressional Budget Office gives its report. Then, I’m going to stay focused on it next week as the bill goes to the Senate floor – where it will be subject to virtually unlimited amendments – and my focus will be on how it affects Tennesseans. We are going to wait for the CBO score and hope to goodness there are public hearings with experts to make you see what a stinker this bill is for Tennessee and America.

Update: On June 26, 2017, Senator Alexander released a statement on the CBO score that said: The Congressional Budget Office report is helpful information for every senator to consider as we review the draft Senate bill and look at how it will affect our states. I’m encouraged that CBO says premiums would begin to fall under this bill starting in 2020, especially in states that take advantage of the new flexibility available under the bill. It’s important to remember that the alternative to this bill is current law that leaves 162,000 Tennesseans who make less than $12,000 a year without aid to buy insurance, and as many as 350,000 Tennesseans in the individual market facing the real possibility of having zero insurance options next year.”

REALITY: Sen. Alexander has apparently not given thought to the 22 million people (including 634,600 Tennesseans) who will lose coverage and the $772 billion that will be cut from Medicaid.

***

In response to Senator Alexander’s statement, Michele Johnson, Executive Director of the Tennessee Justice Center, said, “We are perplexed – as many Tennesseans are – about Senator Alexander’s statements about the Senate version of the American Health Care Act. Many organizations and experts are contradicting Senator Alexander’s claims about the bill. The Senator himself said ‘it’s important to get every voice heard in this discussion’ a few weeks ago. This process has been so rushed and secretive. We are calling for full disclosure and respectful vetting. Let’s get to the bottom of the questions this raises and include the public and all of these expert organizations. The American Cancer Society knows how it affects cancer patients, AARP knows how it affects seniors, Rural Health Association of Tennessee knows how it affects rural communities – let’s hear them out.”

It seems like Senator Alexander has a fundamental misunderstanding of the bill that he helped draft. Will he come back home to Tennessee next week for Independence Day recess, where we will be celebrating the decades of progress our great nation has made, and defend a bill that would reverse this progress and threaten the lives of millions of Tennesseans? Is he willing to hold public forums to explain to Tennesseans the statements that he has made? Will he stand behind the so-called “benefits” of the bill when faced with the reality of his constituents and the dire circumstances our rural hospitals and communities face?

 

For a one page response to Senator Alexander’s statement, please click here.