XAVIER BECERRA, SECRETARY OF HEALTH AND HUMAN SERVICES v. EMPIRE HEALTH FOUNDATION, FOR VALLEY HOSPITAL MEDICAL CENTER
No. 20-1312
SUPREME COURT OF THE UNITED STATES
June 24, 2022
597 U. S. ____ (2022)
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being done in connection with this case, at the time the opinion is issued. The syllabus constitutes no part of the opinion of the Court but has been prepared by the Reporter of Decisions for the convenience of the reader. See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337.
SUPREME COURT OF THE UNITED STATES
Syllabus
BECERRA, SECRETARY OF HEALTH AND HUMAN SERVICES v. EMPIRE HEALTH FOUNDATION, FOR VALLEY HOSPITAL MEDICAL CENTER
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
No. 20-1312. Argued November 29, 2021—Decided June 24, 2022
Once a person turns 65 or has received federal disability benefits for 24 months, he becomes “entitled” to benefits under Part A of Medicare.
Not all patients who qualify for Medicare Part A have their hospital treatment paid for by the program. Non-payment may occur, for example, if a patient‘s stay exceeds Medicare‘s 90-day cap per spell of illness, see
A 2004 HHS regulation says yes: If the patient meets the basic statutory criteria for Medicare (i.e., is over 65 or disabled), then the patient counts in the denominator and, if poor, in the numerator of the Medicare fraction. See 69 Fed. Reg. 49098-49099. Respondent Empire Health Foundation challenged that regulation as inconsistent with the statute. The Ninth Circuit agreed. That court focused on the statute‘s use of two different phrases: “entitled to [Medicare Part A] benefits” and “eligible for [Medicaid] assistance.” The Ninth Circuit read the latter phrase to mean that a patient qualifies for Medicaid and the former phrase to mean that a patient has an absolute right to payment from Medicare. The Court granted certiorari to resolve a conflict between the Ninth Circuit and two other Circuit Courts, which had approved of HHS‘s regulation.
Held: In calculating the Medicare fraction, individuals “entitled to [Medicare Part A] benefits” are all those qualifying for the program, regardless of whether they receive Medicare payments for part or all of a hospital stay. Pp. 7-19.
HHS‘s regulation is consistent with the text, context, and structure of the DSH provisions. The agency has interpreted the phrase “entitled to benefits” in those provisions to mean just what it means throughout the Medicare statute: qualifying for benefits. And counting everyone who qualifies for Medicare benefits in the Medicare fraction—and no one who qualifies for those benefits in the Medicaid fraction—accords with the statute‘s attempt to capture, through two separate measurements, two different segments of a hospital‘s low-income patient population.
(a) Empire‘s textual argument has a two-part structure. Echoing the Ninth Circuit, Empire primarily contends that the words “entitled” and “eligible” have different meanings. According to Empire, to be “eligible” for a benefit is to be “qualified” to seek it; to be “entitled” to a benefit means instead to have an “absolute right” to its payment. But throughout the Medicare statute, “entitled to benefits” is essentially a term of art meaning “qualifying for benefits,” i.e., being over 65 or disabled. And in the end, Empire basically concedes that point. It must devise a way to give “entitled to benefits” a different meaning in the fraction descriptions than everywhere else in the Medicare statute. So Empire shifts gears, relying now on the parenthetical phrase “(for such days)” to transform the usual statutory meaning of “entitled to benefits” to something different and novel. But those three little words do not accomplish what Empire would like, having the much less radical function of excluding days of a patient‘s hospital stay before he qualifies for Medicare (e.g., turns 65). Pp. 8-15.
If “entitled to benefits” instead bore Empire‘s meaning, Medicare beneficiaries would lose important rights and protections, such as the ability to enroll in other Medicare programs. See
(2) Empire concedes that its interpretation cannot be applied throughout the Medicare statute. To get around this, Empire claims that the parenthetical in “patients who (for such days) were entitled to [Part A] benefits,”
(b) The structure of the relevant statutory provisions reinforces the conclusion that “entitled to benefits” means qualifying for benefits. The statute recompenses hospitals for serving two different low-income populations: low-income Medicare patients and low-income non-Medicare patients. HHS‘s reading of “entitled” comports with this
958 F. 3d 873, reversed and remanded.
KAGAN, J., delivered the opinion of the Court, in which THOMAS, BREYER, SOTOMAYOR, and BARRETT, JJ., joined. KAVANAUGH, J., filed a dissenting opinion, in which ROBERTS, C. J., and ALITO and GORSUCH, JJ., joined.
NOTICE: This opinion is subject to formal revision before publication in the preliminary print of the United States Reports. Readers are requested to notify the Reporter of Decisions, Supreme Court of the United States, Washington, D. C. 20543, of any typographical or other formal errors, in order that corrections may be made before the preliminary print goes to press.
SUPREME COURT OF THE UNITED STATES
No. 20-1312
XAVIER BECERRA, SECRETARY OF HEALTH AND HUMAN SERVICES, PETITIONER v. EMPIRE HEALTH FOUNDATION, FOR VALLEY HOSPITAL MEDICAL CENTER
ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
[June 24, 2022]
JUSTICE KAGAN delivered the opinion of the Court.
The Medicare program reimburses hospitals at higher-than-usual rates when they serve a higher-than-usual percentage of low-income patients. The enhanced rates are calculated by adding together two fractions, called the Medicare fraction and the Medicaid fraction. Roughly speaking, the former measures the hospital‘s low-income senior-citizen population, and the latter the hospital‘s low-income non-senior population.
This case raises a technical but important question about the Medicare fraction. The statutory description of that fraction refers to “the number of [a] hospital‘s patient days” attributable to low-income patients “who (for such days) were entitled to benefits under part A of [Medicare].”
I
The Medicare program provides Government-funded health insurance to over 64 million elderly or disabled Americans. (The vast majority of that number are senior citizens.) When a person turns 65 or has received federal disability benefits for 24 months, he automatically (i.e., without application or other filing) becomes “entitled” to benefits under Medicare Part A.
The Medicare program pays a hospital a fixed rate for treating each Medicare patient, based on the patient‘s diagnosis and regardless of the hospital‘s actual costs.
To calculate a hospital‘s DSH adjustment, HHS adds together two statutorily described fractions, usually called the Medicare fraction and the Medicaid fraction. Those fractions are designed to capture two different low-income populations that a hospital serves. The Medicare fraction represents the proportion of a hospital‘s Medicare patients who have low incomes, as identified by their entitlement to supplementary security income (SSI) benefits. SSI is a “welfare program” providing benefits to “financially needy individuals” who (like Medicare patients generally) are over 65 or disabled. Bowen v. Galbreath, 485 U. S. 74, 75 (1988); see
With that under your belt, you might be ready to absorb the relevant statutory language (but don‘t bet on it). The Medicare fraction is described as:
“[a] fraction (expressed as a percentage), the numerator of which is the number of [a] hospital‘s patient days for [the fiscal year] which were made up of patients who (for such days) were entitled to benefits under part A of [Medicare] and were entitled to [SSI] benefits[], and the denominator of which is the number of such hospital‘s patient days for such fiscal year which were made up of patients who (for such days) were entitled to benefits under [Medicare] part A.”
§1395ww(d)(5)(F)(vi)(I) .
That is a mouthful (and without the brackets, it‘s even worse). So again, in general terms: The numerator is the number of patient days attributable to Medicare patients who are poor. The denominator is the number of patient days attributable to all Medicare patients. Divide the former by the latter to get the fraction “expressed as a percentage.” Ibid.
And similarly for the Medicaid fraction. That fraction is described as:
“[a] fraction (expressed as a percentage), the numerator of which is the number of [a] hospital‘s patient days for [the fiscal year] which consist of patients who (for such days) were eligible for medical assistance under [Medicaid], but who were not entitled to benefits under part A of [Medicare], and the denominator of which is the total number of the hospital‘s patient days for such [fiscal year].”
§1395ww(d)(5)(F)(vi)(II) .
That too is a lot to digest. So again, in general terms: The numerator is the number of patient days attributable to non-Medicare patients who are poor. The denominator is the total number of patient days. Divide the former by the latter to get the second percentage the DSH calculation requires.1
Once both percentages have been calculated, they are added together to produce the “disproportionate-patient percentage.” That percentage determines whether a hospital will receive a DSH adjustment, and if so, how large it will be. The combined percentage must usually equal or exceed 15% for a hospital to get an adjustment. See
This case is about how to count patients who qualify for Medicare Part A—because they are over 65 or disabled—at times when the program is not paying for their hospital treatment. Such non-payment may occur for a number of reasons. For one, Medicare usually pays for only the first 90 days of a hospital stay associated with a single “spell of illness.” See
An HHS regulation, issued in 2004, says those patients remain so entitled. See 69 Fed. Reg. 48916. Under the regulation, whether Medicare is actually paying for a patient‘s hospital treatment is irrelevant. So, for example, it does not matter that a patient has exhausted his 90 days of coverage for an illness, or that a private insurer is paying for his hospital stay. As long as the patient meets the basic statutory criteria for Medicare (i.e., he is over 65 or disabled), then the patient counts in the denominator and, if he is poor, in the numerator of the Medicare fraction (as “entitled to [Medicare Part A] benefits“). See id., at 49098-49099. And by the same token, he does not count in the numerator of the Medicaid fraction (which includes only those “not entitled to [Medicare Part A] benefits“). See ibid. As HHS explained in 2004, the effect of the regulation varies depending on the makeup of a hospital‘s patient population. See ibid. But for most hospitals, the regulation has worked to decrease DSH payments, because as beneficiaries are added to the Medicare fraction‘s denominator (even though poor beneficiaries are also added to its numerator), a hospital‘s Medicare fraction generally (though not always) goes down. See Letter from E. Prelogar, Solicitor General, to S. Harris, Clerk of Court (Nov. 23, 2021).
Respondent Empire Health Foundation challenged the regulation as inconsistent with the statutory fraction descriptions, and the Court of Appeals for the Ninth Circuit agreed. See Empire Health Foundation v. Azar, 958 F. 3d 873 (2020). The court focused on the statute‘s use of two different phrases: “entitled to [Medicare Part A] benefits” and (in the Medicaid fraction alone) “eligible for [Medicaid] assistance.” Id., at 885. Relying on Circuit precedent, the
As the Ninth Circuit recognized, two other Courts of Appeals had deferred to HHS‘s contrary view of the statute and upheld the regulation. See Metropolitan Hospital v. Department of Health and Human Servs., 712 F. 3d 248 (CA6 2013); Catholic Health Initiatives Iowa Corp. v. Sebelius, 718 F. 3d 914 (CADC 2013). We granted certiorari to resolve the conflict. See 594 U. S. ____ (2021).2
II
HHS‘s regulation correctly construes the statutory language at issue. The ordinary meaning of the fraction descriptions, as is obvious to any ordinary reader, does not exactly leap off the page. See Catholic Health Initiatives, 718 F. 3d, at 916 (The “language is downright byzantine“). The provisions are technical: They call to mind Justice Frankfurter‘s injunction that when a statute is “addressed to specialists, [it] must be read by judges with the minds of the specialists.” Some Reflections on the Reading of Statutes, 47 Colum. L. Rev. 527, 536 (1947). But when read in that
A
Speaking of twos, Empire‘s textual argument also has a bifurcated structure—but neither part can produce its desired result. Empire primarily contends, echoing the Ninth Circuit, that “different words [mean] different things” when used in a single statute—and so “entitled” means something different from “eligible.” Brief for Respondent 22. To be “eligible” for a benefit, Empire says, is to be “qualified” to seek it; to be “entitled” to a benefit means instead to have an “absolute right” to its payment. Id., at 4, 30. But that reading, even if plausible in the abstract, does not work in the Medicare statute. There, “entitled to benefits” is essentially a term of art, used over and over to mean qualifying (or, yes, being eligible) for benefits—i.e., being over 65 or disabled. And in the end, Empire basically concedes that point. It must devise a way to give “entitled to benefits” a different meaning in the fraction descriptions than the phrase has everywhere else in the Medicare law. See Tr. of Oral Arg. 37–41. So Empire shifts gears, relying now on the parenthetical phrase “(for such days)” to do its work—to transform the usual statutory meaning of “entitled to benefits” to something different and novel. See ibid.;
1
First and foremost, the Medicare statute explicitly identifies which individuals are “entitled to hospital insurance benefits under part A“—all people who meet the basic statutory criteria.
That broad meaning of “entitlement” coexists with limitations on payment, as several statutory provisions show. The entitlement to benefits, the statute repeatedly says, is an entitlement to payment under specified conditions. To quote one provision: “entitlement of an individual” to Medicare Part A benefits “consist[s] of entitlement to have payment made under, and subject to the limitations in, part A.”
In thus describing the Part A entitlement, the Medicare statute reflects the complexity of health insurance. Consider your own health plan (maybe it is Medicare). You might have hit some limit on coverage as to one medical service—let‘s say, eye care. But you‘re still insured: Your policy will pay for more eye care in the next coverage period and meanwhile will pay for your knee replacement. So it is with Medicare Part A. As the 2004 regulation explains, patients “who have exhausted their Medicare Part A inpatient coverage may still be entitled to other Part A benefits.” 69
If “entitled to [Part A] benefits” instead bore Empire‘s meaning, Medicare beneficiaries would lose important rights and protections. Perhaps most significantly, a patient could lose his ability to enroll in other Medicare programs whenever he lacked a right to Part A payments for hospital care. As noted earlier, a person‘s entitlement to Part A benefits is usually the predicate for his enrollment in Part B (covering outpatient care), Part C (providing coverage through privately managed plans), or Part D (offering prescription-drug benefits). See
Empire‘s interpretation would also make a hash of provisions designed to inform Medicare beneficiaries of their benefits. The statute requires annual notice to individuals “entitled to benefits under part A” concerning all available program benefits, including any “limitations on payment.”
So too, Empire‘s reading of “entitled to [Part A] benefits” would subvert a provision to protect beneficiaries from misleading marketing materials. Under the statute, an insurer offering a Part C (privately managed Medicare) plan may not distribute advertising materials to eligible beneficiaries unless the materials are first cleared by HHS. See
And the problems with Empire‘s interpretation do not stop there. The Sixth and D. C. Circuits have cataloged several other statutory provisions that Empire‘s reading would render unworkable or unthinkable or both. See Metropolitan Hospital, 712 F. 3d, at 260; Northeast Hospital Corp., 657 F. 3d 1, 6–11 (CADC 2011). We could spell out each one in painful detail, but we think the above should suffice. Applying Empire‘s reading of “entitled to [Part A] benefits” across the Medicare statute would diminish the beneficiary protections Congress wrote into law. Those safeguards would apply or not apply, or fluctuate constantly between the two, based on the happenstance of whether Medicare paid for hospital care on a given day.
2
Faced with these many provisions, Empire swerves. Empire effectively (if reluctantly) concedes that its reading of “entitled to [Part A] benefits“—again, to have an “absolute right” to Part A payments—cannot be applied throughout the Medicare statute. Brief for Respondent 30; see id., at 41-42; Tr. of Oral Arg. 37-39. There, over and over—and contra the main thrust of Empire‘s arguments—the concepts of entitlement and eligibility are the same. So Empire must come up with a way of converting the ordinary meaning of “entitled” in the Medicare law to something different in its fraction provisions. The lever Empire proposes to use for that purpose is the parenthetical phrase “(for such days).” See Tr. of Oral Arg. 38–39 (“[T]he key distinction” is “for such days,” which is “language that‘s not found anywhere else“). Empire argues that when “entitled” is married to “(for such days)“—recall the whole phrase, “patients who (for such days) were entitled to [Part A] benefits“—the idea of entitlement morphs.
But we cannot understand Congress to have changed the statute‘s consistent meaning of “entitled to benefits” simply by adding “(for such days).” That slight phrase is incapable of bearing so much interpretive weight. If Congress “does not alter the fundamental[s]” of a statutory scheme “in vague terms or ancillary provisions,” then it ordinarily does not do so in parentheticals either. Whitman v. American Trucking Assns., Inc., 531 U. S. 457, 468 (2001). To the contrary, a parenthetical is “typically used to convey an aside or afterthought.” Boechler v. Commissioner, 596 U. S. ____,
The “(for such days)” phrase instead works as HHS says: hand in hand with the ordinary statutory meaning of “entitled to [Part A] benefits.” The parenthetical no doubt tells HHS to ask about a patient on a given day. But the query the agency must make is not whether that patient on that day has received Part A payments; the query is, consistent with what “entitled” means all over the statute, whether that patient on that day is qualified to do so. Suppose, for example, that a patient turns 65 halfway through a 30-day hospital stay. HHS will then count only 15 days of his stay when computing the Medicare fraction. Or suppose, similarly, that midway through his stay, a patient begins to qualify as disabled—because, under the statutory definition, he has reached his 25th month of federal disability benefits. Then, too, only the second half of the patient‘s stay would go into the fraction—because only then has he met the criteria for benefits.
Empire complains that the phrase “(for such days),” viewed in that way, does too “little work.” Brief for Respondent 38; Tr. of Oral Arg. 40–41. But it does more than enough. Some 10,000 people turn 65 in this country every day, thus qualifying for Medicare coverage. See American Assn. of Retired Persons, The Aging Readiness & Competitiveness Report: United States 2, https://arc.aarpinternational.org/File%20Library/Full%20Reports/ARC-Report---
B
The structure of the relevant statutory provisions reinforces our conclusion that “entitled to [Part A] benefits” means qualifying for those benefits, and nothing more. As earlier explained, the statute is designed to recompense hospitals for serving low-income patients, who are comparatively more expensive to treat. See supra, at 3. The statute determines the appropriate payment (if any) by measuring, through two separate fractions, two separate
HHS‘s reading of “entitled” comports with the statute‘s two-population structure. A low-income Medicare patient always counts in the Medicare fraction. That is so regardless of whether the Medicare program is actually paying for a day of his care—because that fact has no relationship to his financial status. The Medicare fraction, as calculated by HHS, thus captures the entire low-income Medicare (i.e., senior) population. And correlatively, the Medicaid fraction captures the entire low-income non-Medicare (i.e., non-senior) population. The binary dividing line HHS uses—do you qualify for Medicare?—mirrors the statute‘s binary, population-focused framework. All low-income people fit naturally into one or the other box, with the sum of the two leaving no one out.
By contrast, Empire‘s view fits poorly with the bifurcated, population-based statutory structure. Again, its who-paid-for-a-day-of-care test has no relationship to a patient‘s financial status. So on Empire‘s view, a patient could phase in and out of the Medicare fraction even though his income remains the same. Empire responds by asserting that any low-income person excluded from the Medicare fraction (say, because of exhaustion of benefits) would get counted instead in the Medicaid fraction. See Brief for Respondent 15-16, 50-51. But even if that is true we express our
In any event, Empire is too quick to claim that those who (on its view) are tossed from the Medicare fraction for non-income-based reasons would still wind up in the Medicaid fraction. Recall here the role Empire says the phrase “(for such days)” plays. See supra, at 13–15. According to Empire‘s ultimate argument, that phrase is what converts the ordinary statutory meaning of “entitled to benefits” (i.е., qualifying for Medicare) to a special meaning (i.e., actually receiving payments). So where the phrase “(for such days)” does not appear, the usual meaning of “entitled” should govern. Now look again at the description of the Medicaid fraction. It counts “patients [i] who (for such days) were eligible for [Medicaid], but [ii] who were not entitled to benefits under part A [of Medicare].”
III
Text, context, and structure all support calculating the Medicare fraction HHS‘s way. In that fraction, individuals “entitled to [Medicare Part A] benefits” are all those qualifying for the program, regardless of whether they are receiving Medicare payments for part or all of a hospital stay. That reading gives the “entitled” phrase the same meaning it has throughout the Medicare statute. And it best implements the statute‘s bifurcated framework by capturing low-
For those reasons, we reverse the judgment of the Court of Appeals and remand the case for further proceedings consistent with this opinion.
It is so ordered.
SUPREME COURT OF THE UNITED STATES
No. 20-1312
XAVIER BECERRA, SECRETARY OF HEALTH AND HUMAN SERVICES, PETITIONER v. EMPIRE HEALTH FOUNDATION, FOR VALLEY HOSPITAL MEDICAL CENTER
ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
[June 24, 2022]
JUSTICE KAVANAUGH, with whom THE CHIEF JUSTICE, JUSTICE ALITO, and JUSTICE GORSUCH join, dissenting.
Under the Medicare statute, HHS pays higher reimbursements to hospitals that serve a significant number of low-income patients. The statutory formula for determining exactly how much HHS will pay to those hospitals is mind-numbingly complex. But embedded within the complicated overall formula are various subsidiary calculations, some of which are relatively straightforward.
This case concerns one of those straightforward subsidiary calculations. Consistent with traditional insurance and coordination-of-benefits principles, Medicare by statute cannot pay for a patient‘s hospital care if, for example, the patient is covered by private insurance, the patient has exhausted her Medicare benefits, or a third-party tortfeasor is liable for the patient‘s care. The retrospective reimbursement question raised by the statutory provision in this case is this: Was a patient “entitled to” have payment made by Medicare for a particular day in the hospital if the patient by statute could not (and did not) have payment made by Medicare for that day? In my view, the answer to that narrow question is straightforward and commonsensical: No.
Importantly, from the time the statute was enacted in
Whatever HHS‘s precise motivations for the 2004 change, we now must focus on the statutory text and HHS‘s current interpretation of it. To begin, both parties offer a dog‘s breakfast of arguments about broad statutory purposes, real-world effects, surplusage, structure, consistent usage, inconsistent usage, agency deference, and the like. But this case is resolved by the most fundamental principle of statutory interpretation: Read the statute.
The relevant text of this reimbursement provision refers to “the number of . . . patient days . . . which were made up of patients who (for such days) were entitled to benefits under part A.”
Zero in on the phrases “entitlement to have payment made” and “for such days.” In my view (and in HHS‘s view from 1986 to 2003), a patient was entitled to have payment made by Medicare for particular days in the hospital if Medicare was obligated to pay for the patient‘s care for those days. Stated the other way, a patient was not entitled to have payment made by Medicare for particular days in the
To be sure, patients who satisfy certain criteria (for example, those who are age 65 or older) are generally “entitled” to Medicare hospitalization benefits. No one disputes that point. But this reimbursement provision looks to whether the patient was entitled to have payment made by Medicare for a particular day in the hospital. And the answer to that question is no if Medicare by statute could not (and did not) pay for that day in the hospital.
Suppose that a college says that your academic record entitles you to a scholarship for next year if your family‘s income is under $60,000, unless you have received another scholarship. And suppose that your family‘s income is under $60,000, but you have received another scholarship. Are you still entitled to the first scholarship? Of course not. So too here.
The Court concludes otherwise, mainly by (i) saying that “entitled to benefits” is a term of art in the Medicare statute, (ii) diminishing the value of the statutory phrase “(for such days),” in part because the phrase appears in a parenthetical, and (iii) invoking a parade of horribles about what could happen to other provisions of the Medicare statute if the Court were to read this provision as I would.
With respect, none of that adds up. First, although the Medicare statute generally uses “entitled” to refer to those who meet the basic statutory criteria for Medicare benefits, the retrospective reimbursement provision at issue here focuses laser-like on whether the patient was actually entitled to have payment made by Medicare for particular days in the hospital. A patient cannot be simultaneously entitled and disentitled to have payment made by Medicare for a particular day in the hospital.
Third, properly interpreting this specific reimbursement provision will not “make a hash” of other provisions or render the Medicare statute “unworkable.” Ante, at 11–12. We need not speculate about that point: For nearly two decades from the time that the statute was enacted in 1986 through 2003, HHS interpreted this reimbursement provision in the same way that I do. And HHS did so without any noted problems for other provisions in the Medicare statute.
To sum up: A patient was not entitled to have payment made by Medicare “for such days” in the hospital if the patient by statute could not (and thus did not) have payment made by Medicare for those days—for example, because private insurance was already covering the patient‘s care, or the patient had exhausted his Medicare benefits. Both statutory text and common sense point to that conclusion. HHS‘s contrary interpretation boils down to the proposition that a patient can be simultaneously entitled and disentitled to have payment made by Medicare for a particular day in the hospital. That interpretation does not work. And HHS‘s misreading of the statute has significant real-world effects: It financially harms hospitals that serve low-income patients, thereby hamstringing those hospitals’ ability to provide needed care to low-income communities.
In my view, HHS‘s 2004 interpretation is not the best reading of this statutory reimbursement provision. I respectfully dissent.