2018 legislative update: week 5

Pair of consumer protection bills introduced in House

Two bills that propose stronger protections for consumers in health insurance were introduced last week by a group of House lawmakers led by Representative David Knight.  We are encouraged by the introduction of both bills which aim to provide consumers with increased transparency and enhanced financial protections, along with heightened accountability on the part of health insurers and pharmacy benefit managers. We will monitor and weigh in on the bills as they progress through the legislative process.


HB 872: Provider network transparency

HB 872 requires insurance companies to be more transparent about the structure of and changes within their provider networks, beginning with a provision that requires insurers to make publicly available a plain language description of their provider network standards on their website among other provisions. Importantly, the bill also stipulates that if an insurer advertises a physician as being in a plan’s provider network as a consumer enrolls in an insurance plan, the insurer is required to cover the health care services received from that provider at an in-network rate during the entire contract year. That means that a consumer may select a plan during open enrollment that includes their preferred provider and would be able to receive services at an in-network rate for the entire plan year regardless of changes to the provider’s participation status.


HB 873: Prescription drug formulary & prior authorization transparency

HB 873, titled the Prescription Drug Benefits Freedom of Information and Consumer Protection Act, proposes to improve the consistency and clarity of prescription drug formularies and prior authorization processes. The bill requires that insurers provide an easy-to-find, accurate, and updated formulary list on their website and requires the Insurance Commissioner to create rules about the format and information within the formulary so that consumers can more easily understand what prescriptions are covered under their insurance plan, the cost-sharing associated with the drug, and any prior authorization required to gain access to the prescription. The legislation also requires that a single, standard prior authorization form be developed that would apply to all insurers and pharmacy benefit managers regulated in Georgia to allow consumers and providers to more easily request access to higher cost and more restricted health services and prescriptions. The standard form would be developed by an advisory committee made up of an equal number of consumers, physicians, pharmacists, insurers, insurance agents, and pharmacy benefit managers.


Both chambers busy with health care legislation
House Insurance Committee approves HB 678

The House Insurance Committee, chaired by Representative Richard Smith, considered and approved HB 678 last week. The bill improves transparency for consumers by outlining the information that must be provided to consumers by health care providers and insurers about the consumer’s provider network. HB 678 is expected to receive a vote by the full House today. (For a more detailed summary of HB 678, check out last week’s legislative update.)

Senate approves SB 352 and SB 357

Two pieces of legislation resulting from the Health Care Reform Task Force were approved by the Senate this week. Both SB 352, which establishes the Commission on Substance Abuse and Recovery and creates a director position to lead the commission, and SB 357, which establishes the Health Coordination and Innovation Council among other actions, received strong support from legislators. The bills will now move to the House for its consideration. (For more information on both bills, read the January 29th legislative update.)


2018 Legislative Update: Week 4

Surprise medical billing emerges as prominent issue at the Capitol 

Surprise out-of-network medical billing is emerging as a prominent issue within the Georgia General Assembly. A surprise medical bill can occur when a consumer encounters an out-of-network (OON) provider at an in-network facility or in other circumstances. Three pieces of legislation have been introduced to address surprise billing and each attempts to resolve the issue in its own way. In this week’s legislative update, we will provide a broad look at each bill and its provisions. (If you would like more information about any of the bills, click on the provided links to read the full legislation.) All three bills seek to protect patients, and we will monitor and weigh in on the bills as they undergo the inevitable amendment process in committee. We appreciate all of the bill sponsors for remaining vigilant towards protecting patients from unexpected medical bills.


HB 678: Increased network and billing transparency by health care providers and insurers 

HB 678 is sponsored by Rep. Richard Smith, chairman of the House Insurance Committee, and has the backing of several powerful House lawmakers. The bill improves transparency for consumers by outlining the information that must be provided to consumers by health care providers and practices and by insurers. Providers must inform consumers about their participation in the patient’s insurance network and about how to check the network status of other providers with which the primary provider has coordinated services (e.g. laboratory or radiology services). It also requires insurers to provide consumers with information about when and how to receive approval for services from an out of network provider. Insurers must also communicate to a consumer ahead of a planned procedure if the provider is out of network (OON), and if so, the estimated amount the insurer will cover for the OON services. Lastly, HB 678 provides consumers with 90 days from the time of receiving a medical bill to pay the bill, negotiate payment or initiate arbitration through the Georgia Department of Insurance. After that time period, providers would be allowed to initiate collection proceedings to secure their payment.


HB 799: Out of network care in emergency situations

While HB 678 applies only to non-emergency situations, HB 799 applies solely to emergency care and medically necessary follow-up care. The legislation, sponsored by Rep. Sharon Cooper, Chairperson of the House Health & Human Services Committee, disallows managed care plans from denying payment for emergency services and disallows hospitals from billing patients for medically necessary care following an emergency situation except for their standard co-pays, co-insurance, and deductibles. For a patient receiving emergency care at an OON hospital and who is covered by a plan that requires prior authorization for post-stabilization care, the legislation outlines how the OON hospital and insurer must coordinate the patient’s transfer to an in-network facility and defines which entities are responsible for specific costs. Under this bill, if a patient (or their representative) does not consent to be transferred to an in-network hospital, the OON hospital must provide verbal notice to the patient that they may be financially responsible for any further post-stabilization care provided.


SB 359: Consumer Coverage & Out of Network Medical Care Act

SB 359 is the only Senate-side legislation introduced thus far to address surprise out-of-network billing and is sponsored by Senator Chuck Hufstetler, Chairman of the Senate Finance and member of HHS committees. The legislation contains many of the same transparency provisions for non-emergency care as HB 678 with regard to information that health care providers and hospitals must supply to consumers, but provides for more robust disclosure by insurers to consumers about possible OON costs. It also contains provisions similar to that of HB 799 with respect to emergency situations, but goes farther to stipulate that insurers must treat OON emergency care as if it were in-network by applying a consumer’s cost-sharing towards their in-network deductible and out-of-pocket maximum. The legislation also makes mediation available to consumers who receive elective medical care during which an unexpected event arises resulting in surprise bill greater than $1000. SB 359 is expected to be more controversial than the other two bills because it sets a payment resolution process that sank previous legislative attempts.


RSVP today for Cover Georgia Day at the Capitol!

Join us next Thursday, February 15th for Cover Georgia Day at the Capitol when we will ask our state legislators to close Georgia’s coverage gap by putting insurance cards in the pockets of low-income Georgians. This is the most important step that our elected officials can take to slow the growing opioid crisis, strengthen our state’s struggling rural health care system, and improve the health & finances of hard-working, low-income Georgia families. Take advantage of this opportunity to talk with your elected officials about closing Georgia’s coverage gap! RSVP today!

Can’t make it? Send an email to your state legislators asking them to put an insurance card in the pockets of all low-income Georgians.


Legislation prioritized by Senate leaders approved by HHS Committee

At Thursday’s Senate Health & Human Services Committee, the two pieces of legislation resulting from the Health Care Reform Task Force were considered. Both SB 357 and SB 352 received strong support from legislators and stakeholders. GHF’s partners at the Georgia Council on Substance Abuse and Mental Health America of Georgia rose in support of SB 352, which would create a 15-member Commission on Substance Abuse & Recovery supported by a director. Both bills were passed by unanimous voice votes. You can find a description of both bills in last week’s legislative update blog.


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Emory Public Health student joins GHF team for legislative session

Nilofer Chollampat is GHF’s Legislative Advocacy Intern for the spring 2018 semester. In this role, Nilofer will help to monitor the activity of legislative committees, the status of relevant bills, and other legislative activity. Nilofer will also support the Cover Georgia coalition in their advocacy to expand Medicaid in Georgia as well as other legislative and advocacy-related projects.

Nilofer isin her second year at Emory University’s Rollins School of Public Health and holds a bachelor’s degree in Psychobiology and Statistics from UC Davis. She’ll be graduating in May with a degree in Health Policy and Management. Nilofer came to GHF after working on academic research, the Georgia Department of Public Health, and a practicum with a non-profit research organization. Other than her love of health policy work, Nilofer likes to watch all the TV shows.

 


GHF welcomes new Outreach & Education Manager

GHF welcomes Alyssa Green as the organization’s new Outreach & Education Manager. In this role, Alyssa will work with consumers and communities to hear about their experiences with health care and coverage, educate them about how health policy impacts their lives, and provide tools and resources to help them engage in the health policy-making process. Alyssa will also provide strategic direction for GHF’s outreach campaigns in support of policy change and assist in GHF’s coalition building efforts.

Alyssa is a recent graduate of UGA’s Master’s in Public Administration program. She has extensive experience in advocacy, program management, and person-centered approaches to community building. Before joining the GHF team, Alyssa led capacity building efforts for an Atlanta-based research study on trans risk and resilience. In addition to this, she coordinated food and fund campaigns at the Georgia Food Bank Association.

We are pleased that Alyssa has joined our team! You can contact Alyssa at agreen@healthyfuturega.org or 404-567-5016 ext 2.


National Association of Insurance Commissioners names GHF’s ED as Consumer Liaison Representative

Today, the National Association of Insurance Commissioners (NAIC) named its 37 consumer liaison representatives for 2018, including GHF’s Executive Director Laura Colbert. The 22 funded and 15 unfunded consumer representatives began their terms Jan. 1.

Established in 1992, the Consumer Liaison Program promotes consumer interaction with the NAIC’s members, the insurance industry and interested parties through the individuals’ dedication and commitment to serving the public interest.

“Our consumer liaison representatives are experts in their fields and we rely on them to provide our regulators with direction and support,” said Julie Mix McPeak, NAIC President and Tennessee Commissioner of Commerce and Insurance. “Their contributions help protect consumers, which is always one of our top priorities.”

“I am excited for this opportunity to represent Georgia consumers in a new way,” said Colbert. “The NAIC Consumer Liaison Program plays an important role in promoting consumer-first public policy among the nation’s Insurance Commissioners and other stakeholders. I look forward to my work with the other consumer representatives and with the broader NAIC.”

You can find the NAIC’s full press release here.


2018 Legislative Update: Week 3

New legislation would establish proposed Health Coordination and Innovation Council

Last week, the first legislation to result from the Lieutenant Governor’s Health Care Reform Task Force was introduced. SB 357, sponsored by Senator Dean Burke, would establish the Health Coordination and Innovation Council, the Health System Innovation Center, and an advisory board to the Council.

Health Coordination & Innovation Council

According to the Task Force’s final report, the Health Coordination and Innovation Council (aka “the Council”) will act as a permanent statewide coordinating platform, bringing together all of health care’s major stakeholders. As the legislation is currently written the Council will be made up of 13 members including the director of health policy & strategic planning, the Commissioners of the Departments of Community Health, Public Health, Human Services, and Behavioral Health and Developmental Disabilities, and eight members to be appointed by the Governor representing Georgia’s medical schools and academia and private health care sector. A consumer representative is not explicitly written into the bill text at this time.

Health System Innovation Center

The Health System Innovation Center is proposed as a research organization that utilizes academic, public health policy, data, and workforce resources to develop new approaches for financing and delivering health care in Georgia. The structure of the Center is not outlined in the legislation, but it is clear that its initial charge will be to synthesize existing studies and data to inform a strategic plan to improve access to health care in rural Georgia. The Center’s work will inform the Council.

We expect more legislation and proposals may emerge from the Health Care Reform Task Force in the coming days. As these proposals emerge, we will continue to keep you updated.


Legislation establishes Commission on Substance Abuse & Recovery

Senator Renee Unterman continues to spearhead efforts to address the opioid and substance use crisis in Georgia and last week, she introduced SB 352 which, among other things, establishes a Commission on Substance Abuse & Recovery. The Commission is to be headed by the director of Substance Abuse & Recovery and will serve as chair of the 15-member commission, including two representatives from the advocacy community. The Commission is charged with coordinating data among relevant government entities; informing strategies to combat the opioid crisis within the Departments of Public Health and Education, the Attorney General’s Office, and other state entities; consulting with the Governor’s office on a potential Medicaid waiver related to opioid abuse; and developing and informing other efforts to expand access to prevention, treatment, and recovery support services across the state.


Come to the state Capitol on February 15th!

Join us on Thursday, February 15th for Cover Georgia Day at the Capitol when we will ask our state legislators to close Georgia’s coverage gap by putting insurance cards in the pockets of low-income Georgians. This is the most important step that our elected officials can take to slow the growing opioid crisis, strengthen our state’s struggling rural health care system, and improve the health & finances of hard-working, low-income Georgia families. Take advantage of this opportunity to talk with your elected officials about closing Georgia’s coverage gap! RSVP today!

Can’t make it? Send an email to your state legislators asking them to put an insurance card in the pockets of all low-income Georgians.


House continues to consider state budget bills

The Georgia House of Representatives continues its consideration of both the “little” and “big” budgets this week. HB 683, the FY2018 supplementary budget (also called the “little budget”), makes necessary, mid-year adjustments to the current state budget. The Governor’s proposed amended FY2018 budget provides an extra $5 million to the Georgia Trauma Care Network Commission from increased Super Speeder collections, but includes few other health care-related changes. The House Appropriations Committee and its subcommittees spent much of last week in budget hearings regarding the FY 2019 budget. The House’s consideration of the “big budget” will accelerate when they pass the FY2018 supplementary budget to the Senate for its consideration

 


The Legislature plans to finish work by March 29th

The schedule for the remainder of the legislative session has been set. Crossover Day, the day that legislation must move from one chamber to the other in order to be considered in 2018, will fall on February 28. The legislature will be in session Monday through Thursday each week until Crossover Day. The remaining 12 legislative days will be broken up throughout March, culminating on Sine Die, the last day of the session, on March 29th. The full calendar can be accessed here.


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Legislative update: week 2

Consumer transparency bill introduced in the House

Rep. Richard Smith, Chair of the House Insurance Committee, introduced HB 678, legislation that requires health care providers and hospitals to provide consumers with information about their participation in a patient’s insurance network. The bill requires that a physician tell a patient if they are an in-network provider, and, if asked by the patient, provide an estimate of the total costs for their services. The legislation applies only to non-emergency care. While this bill is a first step towards addressing surprise out-of-network medical billing, we believe that, as written, it does not do enough to protect consumers. We recognize Rep. Smith’s commitment to shielding consumers from surprise medical bills, and we hope that this bill will prompt a robust conversation about solutions that address both network adequacy and surprise medical bills.


Join us for Cover Georgia Day!

Please join us at the state Capitol on Thursday, February 15 from 8:30 to 11:45 am for Cover Georgia Day! We will be asking our state legislators to put insurance cards in the pockets of low-income Georgians who cannot get affordable health coverage under current law. This is your opportunity to speak to your elected officials and let them know that you support closing Georgia’s coverage gap. RSVP here!

Can’t make it? Send an email to your state legislators to tell them to close Georgia’s coverage gap.

 

 


 Budget hearings continue at the Capitol

Last week, the General Assembly heard from Commissioners and other leaders regarding their budget requests for Fiscal Year 2019 (July 1, 2018 – June 30, 2019). While the Governor’s proposed budget is mostly status quo, there are a few items of interest for health advocates:

  • The Department of Community Health has requested a 4% increase (for a total of $236 million) in funds for Medicaid to keep up with the population growth of Medicaid-eligible Georgians.
  • The Department of Public Health (DPH) has requested $627,000 to support the Prescription Drug Monitoring Program (PDMP), which was moved from the Georgia Drug & Narcotics Agency to DPH per 2017 legislation.
  • DPH has also requested $355,000 to support a new Office of Cardiac Care.
  • The Department of Behavioral Health and Developmental Disabilities has requested a budget increase of $50 million. (See last week’s update for more details about DBHDD’s budget increase.)

Children’s Health Insurance Program finally funded

Federal funding for the Children’s Health Insurance Program (known as PeachCare for Kids in Georgia) expired at the end of September last year and remained unfunded for 114 days until yesterday evening when Congress passed a six-year extension for the program. PeachCare for Kids covers more than 130,000 Georgia children and, in combination with Medicaid, has been critical in driving our children’s uninsured rate down to 6.7%. The funding authorized by Congress will allow this critical health insurance program to continue to serve Georgia’s children for several more years. The future of funding for community health centers and Disproportionate Share Hospital (DSH) payments is still unclear.


GHF kicks off 2018 with Health Care Unscrambled breakfast

Georgians for a Healthy Future’s eighth annual Health Care Unscrambled breakfast built on previous years’ successes with another standing room-only crowd. This year’s legislative panelists were:

Senator Elena Parent
Senator Renee Unterman
Representative Bob Trammell
Representative Mark Newton
Representative Sam Park

Each panelist provided updates on emerging health care trends impacting Georgia and took questions from the audience about what healthcare initiatives are likely to be taken up in the 2018 legislative session. Topics included Medicaid expansion, federal funding of PeachCare for Kids (CHIP), surprise out of network medical billing, access to mental health and substance use treatment services, network adequacy, hospital closures, scope of practice for non-physician providers, Certificate of Need reform, maternal and infant mortality, rural health care access, the Prescription Drug Monitoring Program (PDMP), federal health care reform, the opioid epidemic and homelessness.

Senator Unterman, Chairwoman of the Senate HHS Committee, led the conversation with updates of the findings and recommendations from the myriad study committees she chaired or established in the 2017 off-session including the Senate Study Committees on Homelessness, Georgians Barriers toAdequate Access to Healthcare, as well as her participation on Lt. Gov. Cagle’s Health Care Reform Task Force. New Minority Leader Bob Trammell, along with Representative Sam Park, announced their intention to introduce legislation to expand Medicaid in Georgia (which has now been filed as House Bill 669) and Rep. Mark Newton, an Augusta area ER physician and Senator Elena Parent, Deputy Whip in the Senate Minority Caucus both elaborated on the Medicaid expansion debate, mental health issues facing the state, the opioid epidemic and rural health care access.

This year’s key note speaker was Robin Rudowitz, Associate Director of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. Ms. Rudowitz provided some background information on the federal Medicaid program, as well as Georgia’s program specifically. She pointed out that children are the primary beneficiaries in Georgia’s Medicaid program followed by people with disabilities, pregnant women, and seniors respectively. Georgia’s Medicaid program does not cover adults making less than 138% of the federal poverty level (about $16,000 per year for an individual and $21,000 for a family of 3) because Georgia’s policymakers have thus far refused to extend health coverage to this population. There was an extended discussion by Ms. Rudowitz and audience members about the new flexibility offered by the U.S. Department of Health & Human Services to state Medicaid programs may impact children and other enrollees, as well as how it may change existing Medicaid expansion programs in other states, This information presented by Ms. Rudowitz and subsequent discussion are sure to inform the considerations around the future of Georgia’s Medicaid program. Ms. Rudowitz’s presentation can be accessed here.

To see photos, review materials, and get more information about this year’s Health Care Unscrambled event, please visit the event page.


Legislative Update: Week 1

The 2018 legislative session has begun

The Georgia General Assembly has convened at the state capitol for its annual 40-day legislative session. This year’s session is expected to be quick as legislators prepare for primary elections in May and this fall’s general election. While the legislature is only constitutionally required to pass a state budget, we expect that a number of critical consumer health care topics will be debated. GHF will be monitoring this activity and will keep you up-to-date with weekly legislative updates (like this one!), our legislation tracker, timely analysis of legislation, and more.

The State Budget

On Thursday, Governor Deal addressed the General Assembly in his annual State of the State address and, per tradition, used the opportunity to introduce his proposed budget. The Governor minimally mentioned health care in his address, only highlighting the Commission on Children’s Mental Health. The inclusion of $20.6 million to fund the Commission’s recommendations made up the most significant health care-related change in the Governor’s proposed budget. This money will go to fund behavioral health crisis services ($10.4 million), a school-based mental health initiative called Project Apex ($4.3 million), supported employment and education ($3 million), suicide prevention ($1.1 million), provider training and telehealth ($1 million), and opioid abuse prevention ($790,000). The budget will now go to the House for its consideration before passing to the Senate.

HB 669: Medicaid Expansion

New House Minority Leader (and Health Care Unscrambled panelist) Bob Trammell introduced HB 669 requiring Georgia to authorize state dollars to drawn down additional federal dollars to expand Medicaid. Closing Georgia’s coverage gap by expanding Medicaid (or through a tailored Georgia-specific 1115 Medicaid waiver) would be the most significant step Georgia’s law makers can take to strengthen the state’s weakening rural health care system, address the opioid and substance use epidemic, and provide all Georgians with an insurance card regardless of income. Contact your legislators and let them know that you support closing Georgia’s coverage gap and they should too. Save the date. February 15th is Cover Georgia Day at the Capitol. Make plans to attend! Stay tuned for an official event announcement and RSVP link soon.

The Legislative Calendar

The schedule for the first eleven days of the 2018 legislative session was set on Monday, January 8. The General Assembly has already worked four days of the constitutionally capped 40-day session (January 8 through January 11). Tuesday, January 16 and Wednesday, January 17 are slated for budget hearings, and the next seven legislative days are as follows:

  • January 18: Legislative Day 5
  • January 19: Legislative Day 6
  • January 22: Legislative Day 7
  • January 23: Legislative Day 8
  • January 24: Legislative Day 9
  • January 25: Legislative Day 10
  • January 29: Legislative Day 11

 


GHF releases 2018 policy priorities

Georgians for a Healthy Future released its 2018 policy priorities at this morning’s eighth annual Health Care Unscrambled legislative breakfast. These annual priorities outline the issues that GHF believes are most pressing for Georgia consumers and are best addressed by the state legislature. GHF will work to move all of these issues forward by engaging state policy makers, consumers, and coalition partners throughout the legislative session and the remainder of the year.

    1. Increase the number of Georgians with health insurance. Thousands of Georgians have signed up for low-cost coverage through the Health Insurance Marketplace. Because Georgia has not accepted federal funds to cover low-income Georgians though, approximately 300,000 people remain stuck in a coverage gap. These Georgians do not qualify for Medicaid under current rules and do not earn enough money to qualify for financial help through the Marketplace. Georgians for a Healthy Future supports closing this gap by opening up coverage through Medicaid to all Georgians with incomes up to 138 percent of the federal poverty level.
    2. Guarantee access to quality health care services for Medicaid and PeachCare beneficiaries. The Medicaid and PeachCare for Kids programs provide health insurance for many of our state’s most vulnerable citizens, including low-income children, seniors and people with disabilities, and some low-income parents. Enrollment in these programs is growing as uninsured families explore health insurance options and that their children meet the eligibility criteria. This presents an opportunity to reduce our state’s uninsured rate and improve access to care. Georgians for a Healthy Future will support policies that facilitate continuous coverage and enrollment for eligible Georgians, ensure robust provider networks, and improve health outcomes. Georgians for a Healthy Future will oppose changes to Medicaid that would shift financial risk and cost to states and result in program cuts that would harm many of our state’s most vulnerable citizens.
    3. Ensure access to care and financial protections for consumers purchasing private health insurance. Health insurance plans with the lowest premiums are often a first choice for consumers, but these plans are commonly more a affordable because of narrow provider networks. Although narrow networks can hold down the cost of health insurance and may provide adequate care, they can result in insufficient coverage for some conditions, inhibit continuity of care for some consumers, and lead to burdensome surprise medical bills if consumers unknowingly receive services from out-of-network providers. We encourage Georgia’s policymakers to address network adequacy and surprise out-of-network billing in tandem by developing a comprehensive network adequacy standard, based on the National Association of Insurance Commissioners’ (NAIC) model act released in the fall of 2015 and by passing legislation that protects consumers from surprise out-of-network billing by placing limits on allowable out-of-network charges, setting disclosure and transparency requirements for health care providers, and establishing a process to resolve billing disputes between patients, providers, and health care facilities.
    4. Set and enforce standards that provide for equitable coverage of mental health and substance use treatment services by health plans. The 2008 passage of the federal Mental Health Parity and Addiction Equity Act (Parity Act) required that health plans cover behavioral health services as they would physical health services. The Parity Act is only meaningful if health plans are implementing it well, consumers and providers understand how it works, and there is appropriate oversight. GHF supports legislation that sets standards and oversight procedures to ensure that Georgia consumers receive the coverage for mental health and substance use disorder benefits to which they are entitled by law and for which they have paid.
    5. Support partners in integrating health and equity in the policies across every sector to address social determinants of health that prevent equitable access to care and equitable health status. Factors outside the health system such as adequate housing, education, and economic opportunity impact the health of individuals, families, and communities. Left unaddressed, these and other complicating factors can inhibit the effectiveness of approaches that are strictly within the health system. Georgians for a Healthy Future supports policies that aim to advance health and health equity by addressing the social determinants of health.

     

    To download GHF’s 2018 policy priorities, click here.


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GHF In The News
Jan 25, 2018
Say ‘yes’ to expanded coverage, ‘no’ to work requirements
Laura Colbert

Editorial: Laura Colbert of Georgians for a Healthy Future cites Georgia’s high uninsured rate, the opioid epidemic, and the financial struggles of rural hospitals in calling for the state to…

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