[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.