[Congressional Record Volume 165, Number 114 (Tuesday, July 9, 2019)]
[Senate]
[Pages S4712-S4713]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
Affordable Care Act
Mr. KAINE. Mr. President, I rise today in support of the Affordable
Care Act and to discuss the devastating impact its potential
elimination would have on rural families and rural communities.
My State, Virginia, has so many rural communities, and in that, I am
with every other Member of this body, and I want to talk specifically
about them.
The Trump administration has sought for years to end the Affordable
Care Act using every tool available. They have worked on that task here
in Congress to repeal it and sabotage it and even dismantle it in the
court system. Today marks another milestone in that deeply troubling
effort.
The U.S. Fifth Circuit Court of Appeals will hear oral arguments in a
case that could strike down the Affordable Care Act in its entirety. If
the ACA were struck down, families and communities around the country
would bear life-altering consequences, and the healthcare system would
be thrown into chaos. Tens of millions of Americans would lose
healthcare coverage and protections for preexisting conditions, among
the countless other consumer protections that have been put in place by
the ACA.
A number of my colleagues are going to be on the floor this afternoon
speaking about particular aspects of this that trouble them. I want to
focus on one in particular: how important the Affordable Care Act's
Medicaid expansion is to rural America and how much is at stake for
those communities should the Affordable Care Act be eliminated.
Medicaid expansion enables low-income, rural residents to get
affordable, quality health insurance so they can get the care they
need. It is often the case that insurance companies do not compete with
the same intensity in rural communities because there are just not
enough patients. So it is common in rural America for somebody wanting
to buy an insurance policy on the exchange, for example, to maybe have
only one option. Medicaid expansion has turned out to be a huge benefit
for many low-income people living in rural America. Many of those who
are receiving insurance pursuant to Medicaid expansion were previously
uninsured, and so for some, it is the first insurance they have had in
their lives.
A particular impact of Medicaid expansion has not been on just
individuals receiving that Medicaid but on the hospitals that are sort
of the healthcare and even economic pillars in rural communities. Rural
hospitals often have a difficult time making the finances work. Again,
lower patient volumes make it difficult. Medicaid expansion has meant
that the care they have been providing that in the past might not have
been reimbursed at all--they are now able to at least get a Medicaid
reimbursement, and that has been a significant financial benefit to
these hospitals.
Mr. President, you understand this because your State is like mine,
and there are a lot of rural communities. Rural hospitals are often the
lifeblood of rural communities. They can be the largest employers in a
town or a county. They often do a tremendous amount of outreach on
healthcare and other philanthropic efforts not just within the hospital
walls but outside the hospital walls--sponsoring the Little League
teams and doing the things that make a community a community.
Residents of rural communities need access to healthcare, but they
also need access to jobs and good healthcare information. Rural
hospitals provide that.
I have seen the impact of rural hospital closures in Virginia
firsthand. Two rural hospitals in Virginia closed in recent years
because Virginia did not expand Medicaid initially. In the last year,
Virginia has done Medicaid expansion, but before Medicaid expansion was
done, we saw hospitals close in two communities in Virginia: Patrick
County, which is a south side Virginia county that is on the border
with North Carolina, and Lee County, which is a far southwestern
Virginia county that is on the border with Kentucky and Tennessee. Two
hospitals have closed in those communities.
I got a letter from a mother in Christiansburg, VA, which is actually
up near Virginia Tech. Her name is Robin, and she wrote about the
closure of the Pioneer Hospital in Patrick County in 2017.
She wrote this:
My mother who recently turned 70 still lives in the county,
and we are approaching a point of either moving back to
Patrick County or moving my mother to Christiansburg where we
currently live. My son has severe food allergies that could
lead to anaphylactic shock (which would require immediate
medical attention) so this variable also weighs very heavily
on my mind when considering the options of how to manage my
family's land and take care of my mom. I don't want to live
somewhere without access to emergency health care. It seems
inconceivable that this is the case in the era in which we
live now. . . . Please help get my home county back on the
medical map to give its economy and its people a fighting
chance.
Blacksburg is probably an hour and a half to 2 hours away. The mother
is living in a county that now has no hospital--she has turned 70--so
she doesn't have access to the care that she needs. The daughter is
trying to decide: Do I move back? But I have a son who needs care
because of allergies. Do I have to move my mother out of the home where
she would rather stay?
Rural hospitals across the country are struggling to keep their doors
open for a number of reasons, but here is an amazing set of statistics.
Whether a State expands Medicaid pursuant to the ACA is a massively
significant factor in rural hospitals' financial outlook and
decisionmaking. Without Medicaid expansion, rural hospitals may be
forced to cut vital services or even close. Here is the data point that
really says it all: Since January 2010, 107 rural hospitals have closed
in the United States, and 93 of those 107 hospitals were in States that
had not expanded Medicaid at the time of the closure.
Hundreds more rural hospitals are at risk of closure. Rural hospital
closures disproportionately occur in States that have not expanded
Medicaid. The success of the Texas case would wipe out the ACA,
including Medicaid expansion, and deeply penalize these rural
hospitals.
A comprehensive 2018 study published in Health Affairs found that
Medicaid expansion is directly associated with hospital financial
performance and that expansion substantially reduces the risk of
hospital closure, particularly in rural areas. The study also found
that going back to pre-ACA eligibility for Medicaid would drive even
more rural hospitals to closure.
So we think about Robin's dilemma of a mother living in a rural area
where the hospital has closed. If the ACA is struck down and there is
no Medicaid expansion, this is going to be faced by more and more rural
communities across the country, and that means this is a dilemma
individuals and their families will ultimately face.
Research from Georgetown University's Health Policy Institute
indicates that the uninsured rate for low-income adults in rural
communities fell three times as fast in States that expanded Medicaid
as compared to States that did not expand. Turn that around.
[[Page S4713]]
States that expand Medicaid find that rural families have a
dramatically higher likelihood of having insurance than those in rural
areas where the States haven't expanded Medicaid.
As of now, 36 States, including Virginia, have expanded Medicaid and
14 have not. I am thrilled that earlier this year Virginia, after a
multiyear battle, finally announced that Medicaid expansion was
happening. In less than a year after expansion, nearly 293,000 adults
are newly enrolled in Medicaid in Virginia, many of whom never had
health insurance before in their lives--293,000 adults in a State where
the population is about 8.5 million. That is a significant number of
people who have received insurance through Medicaid expansion. They
risk losing their eligibility if the administration is successful in
its efforts to gut the ACA.
If we care about rural residents and rural communities, there are a
number of things we can do.
First, we need to stand up against the administration's attempt to
end the ACA, including its Medicaid expansion.
I have now been in public life for 25 years since I was elected to
the Richmond City Council in May 1994. I will say that in all of the
elections I have been in, up or down, and all the various legislative
and other battles, the single most dramatic moment in my life as an
elected official was standing on the floor of this body at 2 o'clock in
the morning when Senator John McCain, fresh out of a hospital after
being diagnosed with a glioblastoma brain tumor, cast the deciding
vote, and by one vote--one vote--we saved the Affordable Care Act. I
have never in my life in the public realm experienced something that
was so dramatic and so consequential.
We have to continue to stand up. I would have thought that vote might
have moved us to a new chapter where we would be talking about fixing
and improving rather than repealing, but that is not the case, as
evidenced by the lawsuit today. But my hope is that we will resist
efforts to sabotage and destroy and instead join together in efforts to
improve. I have joined with my colleagues to cosponsor a resolution
allowing Senate legal counsel to intervene in the lawsuit, to defend
the Affordable Care Act.
The second thing we can do to help rural communities is focus on the
14 States that haven't yet expanded Medicaid and provide them a clearer
path and encouragement to do so.
I am proud to be an original cosponsor of something called the SAME
Act, which would extend the same level of Federal assistance to every
State that chooses to expand Medicaid regardless of when the expansion
occurs. I think that is important.
Let's use the original Medicaid Program as an example. It was passed
in 1965. It was not a mandate; it was an option. The last State--
Arizona; State 50--that joined didn't join until 1982. There was a 17-
year period between when the first State joined the then-voluntary
Medicaid Program and when the last State joined.
Let's make sure that whenever States join, they are treated the same.
If this bill passes, States that choose to expand now--these 14
States--we would make sure that they get the full Federal level of
assistance as was available to those States that initially joined, and
that should help remaining States get off the sidelines.
Finally, we need to stand up against administrative sabotage to the
Affordable Care Act. We shouldn't promote skimpy insurance plans. We
shouldn't slash funding for enrollment, outreach, or marketing. We
should build on and improve and, yes, fix--because it is not perfect--
the ACA to extend its promise of affordable coverage to even more
Americans.
That is why I have introduced Medicare-X legislation to establish a
public insurance plan that could be offered on the ACA exchanges,
beginning in rural areas. My bill would also make the ACA's tax credits
more generous, expand tax credit eligibility to additional families,
and allow for an enhanced reimbursement rate in rural communities where
low patient volumes often pose financial challenges to healthcare
providers.
In closing, the ACA has meant the difference between life and death
for many families across the country, and I run into them every day.
I am going to be standing with some Senate colleagues on the steps of
the Senate in a few minutes talking about a youngster from Winchester,
VA, who has a series of significant healthcare challenges that would
essentially in the past have made him uninsurable because of
preexisting conditions but who now--because of that protection within
the ACA, he and his family at least have the peace of mind of knowing
that he can't be kicked off insurance or turned down for insurance
because he happened to be born with a condition over which he had no
control.
If the ACA were to be struck down, families and communities would
suffer, and I think that in Virginia, that would particularly be the
case in our rural communities.
Again, I am just going to hold up this issue of our rural hospitals.
We need to protect rural hospitals not only because of the healthcare
they provide but because they are employment centers and centers of
community outreach. When we see the closure of rural hospitals
overwhelmingly being in States that have not expanded Medicaid, that
tells us how valuable that portion of the ACA has been to stabilize the
provision of rural healthcare.
I will continue to fight to protect the ACA and the health of my
rural communities in Virginia and elsewhere. I encourage my colleagues
to do the same.
I yield the floor.
I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The bill clerk proceeded to call the roll.
Mr. THUNE. Mr. President, I ask unanimous consent that the order for
the quorum call be rescinded.
The PRESIDING OFFICER (Mr. Cruz). Without objection, it is so
ordered.