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Should Medicaid expansion be on the 2019 legislative agenda? Experts say it has to be

Chip Brownlee | The Trace

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In Alabama, Republican politicians have ignored the question of Medicaid expansion or rejected it outright, refusing to bring the issue to the floor of the state Legislature, but an outgoing Republican senator and hospital officials are pushing for it to be on the 2019 legislative agenda.

Voters appear to be on the side against expansion, having overwhelmingly rejected Democratic gubernatorial candidate Walt Maddox, who based a large part of his campaign on Medicaid expansion.

Outside of the Yellowhammer State, though, election day shaped up to be a landmark moment for Medicaid expansion. More states are set to join Medicaid expansion in the next year than in any year since the expansion option created under the Affordable Care Act first became available in 2014.

That momentum in favor of expansion has yet to reach Alabama, which remains as one of the 14 states where politicians have refused to expand the health insurance program for low-income people.

“As we’ve seen more and more states expand, we still haven’t had this issue discussed on the floor of the Alabama Legislature, and we’re now six years down the road, and it looks like we’re emerging to be one of the few hold-out states,” said David Becker, an associate professor at the University of Alabama at Birmingham’s School of Public Health.

Support for the program is spreading to more conservative areas. Voters in three deeply red states — Idaho, Nebraska and Utah — approved ballot initiatives requiring their state to expand Medicaid, and three other states — Kansas, Wisconsin and Maine — elected Democratic governors who are likely to push for expansion.

In Maine, their newly elected Democratic governor is likely to implement a Medicaid expansion plan put on hold by their current Republican governor after voters approved a ballot initiative last year.

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Voters’ decisions at ballot boxes in those seven states come after Virginia’s Legislature earlier this year chose to support expansion, meaning eight states will likely expand or begin expanding their Medicaid programs over the next year. Virginia is already enrolling new beneficiaries.

Despite what appears to be a solid opposition among Alabama Republicans, some public health experts and hospital officials, including the Alabama Hospital Association, are issuing dire calls for a renewed debate.

“Medicaid expansion is the one thing the state can do to prevent more hospital closures, loss of jobs, and cutbacks on services,” said Danne Howard, the association’s chief policy officer.

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The association — and the more than 100 individual hospitals it represents across Alabama, many of them rural and some of them teetering on the edge of closing — view the situation as so dire that the association plans to launch a renewed effort early next year to bring the discussion back to the forefront ahead of the 2019 legislative session, when a new class of state lawmakers will take office.

“It will impact or it will help rural hospitals because there are a large number of uninsured and unhealthy people in rural Alabama,” Howard said. “Alabama is predominantly a rural state, and between Medicare, the uninsured and Medicaid, that is the significant volume of patients in rural hospitals.”

A ‘critical’ need

Rural hospitals across the country, but particularly in non-expansion states like Alabama, are closing at an alarming rate, largely because an influx of money from more folk covered by Medicaid was intended to offset cuts to Medicare reimbursements built into the Affordable Care Act, President Barack Obama’s 2010 health care law.

With no offset there, hospitals have lost money. A solution needs to come quick, experts have said.

Six rural Alabama hospitals have closed since 2011, and more were closing before that year.

Though a few have reopened because of local tax increases, the situation could get worse. Nearly 90 percent of the remaining rural hospitals in Alabama are bleeding money — operating at a loss and routinely cutting back on staff and services, according to the association.

“Hospitals have been living on their reserves, and those reserves are nearing the end, and that’s why you are seeing more hospitals close,” Howard said, noting that a number of issues have led to the dire straits for hospitals, though all of the issues are related to low reimbursement rates one way or another.

Some Republicans have seen the negative impacts in their districts.

“We can’t continue to close rural hospitals and devastate rural Alabama with inadequate health care,” said retiring Sen. Gerald Dial, a Republican who chaired the Senate’s health committee for two years.

Earlier this year, Dial published op-eds in Alabama newspapers calling on the Republican-led Legislature to consider Medicaid expansion. He’s one of the few Republicans who has called for at least a partial expansion under revised rules.

“They can fund this,” Dial told APR. “This is so critical.”

Rural hospitals, the ones in the most danger of closing, are often the only place within a timely distance where rural residents — like those in Dial’s east Alabama district — can get care.

“It even affects the farmers,” Dial said. “If a farmer is out there, and he breaks a leg or gets an arm cut off, is he going to die before he can get 70 miles to a hospital? Or can you run him 10 miles down the road and get him to a hospital and get him some care? It affects every one of us.”

The potential for economic growth

There are some positives in the conversation. When Becker and his partner at the UAB School of Public Health released their economic analysis in 2012, they were tailoring it for a particular audience.

“We wrote this report kind of realizing the audience who would be receiving it,” Becker said in an interview. “That we kind of understand the political environment of Alabama, and tugging at the heartstrings might not be the most effective strategy in making the case for expansion.”

Their report found that expansion would cost the state about $770 million over the first seven years in costs, but could potentially result in $20 billion in economic growth over the same time period.

Beginning in 2014, the federal government would have financed 100 percent of the costs for those made newly eligible for Medicaid until 2016.

After that, the federal match phases down to 90 percent by 2020, where it will stay, meaning for every dollar the state spends on new enrollees, it would get $9 in return from the federal government.

Though Becker’s report is now six years old, the general takeaways still apply, he said. “The tax revenues generated from expansion would exceed the cost to the state, and so in that sense, it was just sort of a win-win proposition,” Becker said.

Becker’s analysis found that after the first year of expansion, Alabama could likely finance its portion of the new costs with the new tax revenues that would result. The hospital association and Dial have made similar arguments.

“We’re losing about $700 million (in federal matches) in Alabama every year because we haven’t expanded, and we continue to see our rural hospitals close,” Dial said. “That just devastates that opportunity to have economic expansion in rural areas if you don’t have adequate health care. Somebody else is getting our $700 million, and we’re not saving the taxpayers any money.”

For Howard, it isn’t just about the potential for economic growth; it’s about preventing economic losses.

“The fact is hospitals are amongst the top employers in this state. In most rural communities, they are the top employer,” Howard said. “If you look at the health care benefits alone, that ought to be enough to drive the right decision; however, it’s not been. So you have to look at the economics.”

If more hospitals close in rural areas, Howard said the economic impact could be devastating.

“Rural communities cannot continue to thrive, cannot attract businesses, can’t retain the businesses they have now with a hospital failing,” Howard said, adding that the loss of a hospital can further exacerbate population loss, too.

“Young couples are wanting to start families, and they know they are going to have to drive over an hour to a hospital when it’s time to deliver that baby, why would they stay in that community?” Howard said. “You don’t have the prospect of better-paying jobs because you can’t attract business because there’s not a viable health care system.”

But the economic arguments haven’t worked, either, and Republican leaders have pushed back against those, saying the conversation should be about the quality of health care — not job creation.

Funding problems could worsen

As legislators return to Montgomery in March, they’ll face more uncertainty.

Additional cuts to Disproportionate Share Hospital Payments — a payment mechanism that supports many hospitals with a disproportionate number of low-income, uninsured patients and uncompensated care — could go into effect on Oct. 1, 2019, when the fiscal year 2020 begins.

The bulk of those cuts have been routinely delayed by the Republican-controlled Congress since they were set to take effect in 2014 — mainly because it would negatively hit Republican, non-expansion states.

But with Democrats heading into a majority, it isn’t so certain that those cuts will be delayed again.

Cuts to DSH payments could cost Alabama hospitals between $70 million and $156 million. More than 75 percent of Alabama’s more than 100 hospitals receive DSH payments. Those cuts could severely impact both rural and urban hospitals that care for uninsured, low-income patients. Experts fear those cuts could spur a health care crisis that isn’t just confined to rural hospitals and the areas they serve.

That’s because it’s not just rural hospitals that are struggling. Some larger hospitals, including DCH Regional Medical Center in Tuscaloosa, are having issues, too, because they care for a large number of uninsured patients.

Cuts to DSH payments already implemented have cost that system $15 million since 2013, the Tuscaloosa News reported.

Hospitals like those are barely operating in the black, and it wouldn’t take much to put them in the red.

“If the state has not expanded Medicaid in 2020, as the DSH cuts are scheduled to take effect, that will close a significant number of hospitals,” Howard said. “That will cripple. That will be the straw that the hospitals can’t survive.”

Some Republican lawmakers and officials have privately expressed concern about the DSH cuts. If they’re not delayed again this year, they said, it could force the state’s hand.

No appetite for the conversation

Despite the concerns about greater cuts in funding for hospitals and the potential loss of access to comprehensive care in rural areas, Republican leaders have said publicly that there is little appetite to resume a debate about Medicaid expansion.

Gov. Kay Ivey has rejected discussion about Medicaid expansion, and Senate President Pro Tempore Del Marsh, R-Anniston, said in an interview that expansion is unlikely to be on the agenda.

“Among the Republican leadership and Republican caucus, when discussions have been made, there has been no initiative, if you will, to expand Medicaid,” Marsh said. “In fact, the position has been to control the costs of Medicaid and to put pressure on the health care community to find ways to make it more efficient.”

Marsh said perhaps every rural area doesn’t need a hospital.

“But their argument is not that our hospitals are having a hard time,” Marsh said, referring to the hospital association. “Essentially what they’re saying is that they’re having a hard time keeping the hospital the size it is and paying all of their employees. The question is, ‘Okay, is the hospital too big for the area?’”

Dial, who is leaving the Alabama Senate after more than 30 years in the chamber, said this is the year for the conversation as it’s become more and more clear that Republicans won’t be able to repeal the Affordable Care Act within a Democrat-controlled House.

“I think the possibility went from 40-60 to 60-40,” Dial said. “I think it’s a 60 percent chance (they will address expansion).”

Dial said the Legislature should consider a partial expansion that would allow the state to expand the program to a certain degree and still qualify for federal funding.

It’s already extremely difficult for anyone to qualify for Medicaid in Alabama, though the program still covers about 1 million people, most of whom are children or disabled. Virtually no childless adults are enrolled in the program.

Adults with children on Medicaid can only receive benefits if they make 18 percent of the poverty level, which is about $3,740 a year in a household of three. Medicaid expansion as outlined in the ACA would allow those making up to 138 percent of the poverty level, $16,753 for an individual and $28,676 for a household of three, to qualify for benefits

Estimates vary, but between 75,000 and 300,000 Alabamians would qualify for coverage in expansion. At least 75,000 make too much to qualify under current eligibility rules but make too little to qualify for subsidies from the federal government for marketplace programs, according to a June report from the Kaiser Family Foundation.

Some states — Arkansas, Massachusetts and Utah among them — have tried to get a waiver to limit eligibility for adults up to 100 percent of the poverty line, significantly less than the number provided in the ACA. President Donald Trump’s administration reportedly initially denied those requests, but showed some willingness to consider it after midterms and has left the door open for the future.

“We’re talking about picking and choosing different things that could help rural health care,” Dial said, “and looking at only taking those we can afford to fund on our level. I think the state from the General Fund could create anywhere from $75 million to $100 million next year to expand into that area and bring $400 million or $500 million back to the state in benefits that will equate into money for jobs, money for expansion and money for equipment.”

Medicaid is by far the largest budget item in the state’s General Fund budget, which pays for all non-education-related programs. Last year, the costs surpassed $750 million, and it’s expected to grow as lawmakers prepare the FY2020 budget, and Marsh said there isn’t room for much more spending.

Dial said he’s spoken with a number of House and Senate leaders who would be amenable to a conversation, and he thinks there could be action this year.

“It’s not going to be at the top of the agenda like probably the fuel tax, which is probably going to be the No. 1 thing now, but I think it’s going to be critical, and I think you’ll see some action this first year on it, because I think those people understand how critical it is,” Dial said.

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Governor announces auto supplier IAC plans Alabama expansion

IAC is committing $34.3 million in new capital investment to expand its new manufacturing facility located in Tuscaloosa County.

Brandon Moseley

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(STOCK PHOTO)

Gov. Kay Ivey announced Monday that International Automotive Components Group North America Inc. plans to invest over $55.9 million in expansion projects that will create 182 jobs at two Alabama facilities.

“International Automotive Components is a leading global auto supplier, and I am pleased that this world-class company is growing significantly in Alabama and creating good jobs in Cottondale and Anniston,” Ivey said. “IAC’s growth plans show that Alabama’s dynamic auto industry continues to expand despite today’s challenging environment.”

Nick Skwiat is the executive vice president and president of IAC North America.

“Alabama was the logical choice due to its skilled workforce and proximity to the customer,” Skwiat said. “We are excited to see the continued growth of the automotive industry in Alabama and we plan to grow right along with it. We thank the Governor and Secretary Canfield for their leadership in this sector.”

IAC is committing $34.3 million in new capital investment to expand its new manufacturing facility located in Tuscaloosa County. This facility will produce door panels and overhead systems for original equipment manufacturers. That project will create 119 jobs at the production site in Cottondale.

IAC also plans to invest $21.6 million at its manufacturing facility located in the former Fort McClellan in Anniston. That East Alabama project will create another 63 jobs.

This project builds on a milestone 2014 expansion that doubled the size of the Calhoun County facility. There IAC manufactures automotive interior components and systems. Key components produced at the Anniston plant include door panels, trim systems and instrument panels for original equipment manufacturers.

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IAC Group is a leading global supplier of innovative and sustainable instrument panels, consoles, door panels, overhead systems, bumper fascias and exterior ornamentation for original equipment manufacturers.

IAC is headquartered in Luxembourg and has more than 18,000 employees at 67 locations in 17 countries. The company operates manufacturing facilities in eight U.S. states.

“With operations around the globe, IAC is the kind of high-performance company that we want in Alabama’s auto supply chain to help fuel sustainable growth,” said Alabama Commerce Secretary Greg Canfield. “We look forward to working with IAC and facilitating its future growth in this strategic industrial sector.”

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Danielle Winningham is the executive director of the Tuscaloosa County Industrial Development Authority.

“International Automotive Components is a valued part of Tuscaloosa County’s automotive sector,” Winningham said. “We are grateful for IAC’s investment in our community and the career opportunities available to our area workforce as a result of their investment.”

“The City of Anniston is excited that IAC has made the decision to expand here. I have enjoyed working with the leadership at IAC, the Calhoun County EDC, and the state of Alabama to get this project finalized,” said Anniston Mayor Jack Draper. “This is even further evidence that Anniston is indeed open for business.”

Only Michigan has more automobile manufacturing jobs than the state of Alabama. Honda, Mercedes, Hyundai, Polaris, Toyota and soon Mazda all have major automobile assembly plants in the state of Alabama.

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Bill Britt

Opinion | Prisons, justice reform and the art of the possible

Politics is bound by the art of what’s possible. It is also true that those who never dare the impossible rarely achieve even the possible.

Bill Britt

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(STOCK PHOTO)

For years, prison reform advocates, media outlets and even a few public officials have called for new correctional facilities to address Alabama’s dangerously overcrowded prisons.

Now that it’s happening, some aren’t happy with how Gov. Kay Ivey is addressing the problem.

Is the Ivey Administration’s plan perfect? No. But building new facilities along with criminal justice reform — while all imperfect — is the last best hope to correct generations of cruel treatment, endangered correctional officers and corrupt practices.

German chancellor and statesman Otto von Bismarck said “Politics is the art of the possible, the attainable — the art of the next best,” this is the state of a workable solution to Alabama’s prison needs and criminal justice reform.

Yet, there is a concerted effort underway to stop the Ivey Administration from acquiring three new men’s prisons under a build-lease agreement.

Some lawmakers want another crack at financing additional facilities through a bond issue, and others want more say in the process. Still, the fact is that Ivey’s actions are the result of decades of legislative indifference and inaction to adequately address the appalling conditions at Alabama’s correctional facilities.

Even some advocates are working against the prison plan and while their intentions may be good it seem to their hand wringing is almost as disingenuous as lawmakers whining.

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What’s worse are those who spread disinformation to discredit process.

Many good people have worked hard to bring about an end to the state’s barbaric prison system and unfair justice, but lately it seems there is an outright movement to derail much needed change— simply because it’s not enough. As the saying goes, “Don’t let the perfect be the enemy of the good.”

There have been so many false claims and sly manipulations of facts about the prison plan as to make even a hardened journalist want to cry “fake news.”

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But as for Ivey, frankly, my dears, I don’t think she gives a damn.

Here’s the hard truth. The Ivey Administration is building three new men’s prisons, and nothing will stop it. The fact is that three prisons are not enough; the administration should move forward to build a new women’s facility as soon as practicable.

Politics is bound by the art of what’s possible. It is also true that those who never dare the impossible rarely achieve even the possible.

Failing to recognize when the once impossible is coming to fruition is a sad reality. Still, in politics, as in life, good things happen while most people are navel-gazing or complaining.

Having visited three state prisons, St. Clair, Elmore, and Tutwiler, I can say without a doubt, the conditions in those places are a living hell.

A report from the U.S. Department of Justice released in April 2019, found “reasonable cause to believe that Alabama fails to provide constitutionally adequate conditions and that prisoners experience serious harm, including deadly harm, as a result.”

DOJ’s investigation revealed that prisoners were susceptible to “an enormous breath” of sexual abuse and assault but other types of violence as well, including gruesome murder and beatings that went without intervention.

When the state incarcerates a criminal, it assumes custodial care for that individual. No matter how heinous the crime or foul the person, the state has an obligation to feed, clothe, house and provide essential human services for their care and welfare. Another element is often overlooked; when a person is committed to prison, they lose their freedom, not their humanity. Therefore, under the law, they cannot be subject to cruel and unusual punishment.

Building three new men’s prisons is just the start; it must be accompanied by criminal justice reform.

“We are able to have a serious discussion about prison reform in Alabama because we have a governor who is serious about putting solutions into place,” Ivey’s press secretary Gina Maiola recently told APR. “Prison infrastructure is a key part of the equation, but criminal justice reform is also needed,” Maiola said.

By executive order on July 18, 2019, Ivey established the Study Group on Criminal Justice Policy. The Study Group released its findings on Jan 31, 2020.

The Study Group entered its mission with one pressing question; “What policies and programs can the State of Alabama implement to ensure the long-term sustainability of our prison system without jeopardizing public safety?” according to Supernumerary Associate Supreme Court Justice Champ Lyons, Jr., who led the effort.

In a letter to Ivey on the Study Groups finding, Lyons wrote [T]he challenges facing our prison system are exceedingly complex—ranging from the elimination of contraband weapons and drugs to the recruitment, retention, and training of correctional staff to the size of the inmate population and to the physical condition of an aging and far-flung prison infrastructure.” He further wrote, “But having thought through many of these issues with my Study Group colleagues, especially our legislative members, I can report to you that some meaningful answers to this question are not just possible; they are within our grasp.”

Prisons without justice reform is a hollow victory, and the Ivey Administration is committed to bringing about reasonable reforms.

“Prison infrastructure is a key part of the equation,” said Maiola, “but criminal justice reform is also needed.”

The issues facing Alabama’s prisons and criminal justice system are complex, and generations in the making; therefore, arriving at a universally acceptable solution is not imaginable for the moment if ever. But what once seemed impossible is soon to be realized.

No one gets everything they want, but it’s a great step toward getting what is needed simply because it’s possible.

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Governor

Federal judge refuses to temporarily block governor’s mask order

Following the issuing of those orders, the state saw noticeable drops in both COVID-19 positive cases and deaths.

Josh Moon

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Gov. Kay Ivey held a Coronavirus update Press Conference Wednesday September 30, 2020 in Montgomery, Ala. (Governor's Office/Hal Yeager)

A federal judge on Wednesday denied a petition for a temporary restraining order that would have blocked Gov. Kay Ivey’s statewide mask ordinance and a prohibition on large, non-work gatherings.

U.S District Court Judge Keith Watkins said, essentially, that the plaintiffs in the case had waited too long to file the request. In his order, Watkins said that a key component in determining the necessity of a TRO is “a need for speedy and urgent action to protect a plaintiff’s rights” while the case as a whole works its way through the legal system. 

The seven plaintiffs in this case, Watkins noted, didn’t file their complaint until late last month — some five months after the initial ban on large gatherings was issued in May and two months after Ivey, along with State Health Officer Dr. Scott Harris, issued the mask ordinance. 

The time discrepancy, Watkins said, indicated that there was no “imminent irreparable harm” that could come to the plaintiffs without immediate action. 

“Plaintiffs waited an impermissible amount of time to seek … a temporary restraining order,” Watkins wrote. 

The lawsuit specifically challenges Ivey’s and Harris’s authority to issue health orders that ban all non-work gatherings of more than 25 people, order certain businesses and houses of worship temporarily closed and require that people in public areas in the state wear facial coverings. The plaintiffs claim the orders violate their constitutional rights, specifically their First, Fifth and 14th Amendment rights.

Following the issuing of those orders, the state saw noticeable drops in both COVID-19 positive cases and deaths. So far, the state has more than 140,000 cases and nearly 2,500 deaths.  

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The lawsuit will move forward, with attorneys for Ivey and Harris expected to file a motion to dismiss in the coming days. 

Former Alabama chief justice Roy Moore is representing the plaintiffs.

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Bill Britt

Opinion | Gov. Kay Ivey didn’t cave

Ivey stood her ground on Wednesday, refusing to cave to those who want to end the mask order.

Bill Britt

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Gov. Kay Ivey held a Coronavirus update Press Conference Wednesday September 30, 2020 in Montgomery, Ala. (Governor's Office/Hal Yeager)

Gov. Kay Ivey extended the statewide mandatory mask ordinance on Wednesday despite pressure from her party’s right-wing. Nationally and here in Alabama, many Republicans have complained that any restrictions on their behavior during the COVID-19 outbreak is a violation of their individual liberty.

Ivey stood her ground on Wednesday, refusing to cave to those who want to end the mask order. For most of the COVID-19 pandemic here in the state, Ivey has followed health experts’ advice rather than politicos. Standing up to the Republican Party’s right-wing is not an easy task even in the best of times, but these days, with the party more radicalized than ever, Ivey is taking a huge political risk.

But like Shadrach, Meshach and Abednego, she hasn’t bowed, she hasn’t bent, and she hasn’t burned.

These are divisive times when even the best of people seem to be at war over the nation’s direction.

“Give me liberty or give me death” may have been a great rallying cry in 1776; it’s less persuasive as a public health policy.

Lately, some Alabama conservatives sound more like the John Birch Society members than the Republican Party of just a few years ago.

“In the name of fighting the coronavirus, more and more state governors are ruling by decree, curtailing freedoms and ordering residents to stay at home,” says the Birch website.

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The Republican Party in the 1960s deemed Birchers dangerous and severed ties with the group. But like 60s racism, Red-baiting and a fear that socialist are lurking behind every corner, all that’s old is new again.

Not surprisingly, former Alabama Supreme Court Chief Justice Roy Moore is one of the leading voices in the fight to discredit the Ivey administration’s COVID orders.

Senate President Pro Tem Republican Del Marsh is part of the anti-masker movement and has suggested he’d like to see more people become infected to build the state’s overall immunity to the virus.

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Marsh is certainly not alone; there is a motivated mop of miscreants who sees any restriction as an affront to them doing anything they please. Perhaps they can refuse to wear a seatbelt or maybe light up a cigar the next time they are dinning at the county club and show some real radical resistance.

The truth is many of those who condemn masks as an intrusion on personal freedom would happily compel their fellow citizens to pray at school and stand for the national anthem. They are more than willing to regulate liberties when it contradicts their opinion of what is good and wholesome. But heaven forbid they wear a mask to protect others—that is one regulation too far.

Like a pubescent boy, they live in a fantasy world; without consequences.

Anti-maskers are given to a form of herd mentality, which is part of a broader movement to discredit science for political purposes.

Perhaps the most critical job of a governor or lawmaker is the heath and safety of the public.

Masks protect others more than the wearer, and where the “Golden rule” should apply, it is trampled on just like Jesus’ admonition to love our neighbors as ourselves.

But I suspect that many of those who continuously espouse conspiracies, apocalyptic nightmares, and end time prophecies actually don’t like themselves very much and therefore don’t really care about the shared responsibilities we have toward others.

Writing for Business Insider, George Pearkes explains the four different types of liberty, according to David Hackett Fischer’s Albion’s Seed to explain mandatory mask orders.

“Efforts to require masks are a straightforward expression of ordered liberty,” writes Pearkes. “The concept of ordered liberty argues that without structure and a set of rules which are enforced for the common good, society would devolve into chaos.” He further concludes that “Mask orders are quite literally saving society from itself, so that we can be more free than we would if COVID spread even further and faster.”

Ordered liberty can be seen at the heart of Ivey’s policies during the coronavirus plague.

But for anti-maskers, “Live Free or Die” means they are free to do what they want, even if it kills you.

Ivey is putting people ahead of politics. We should wish more would follow her example.

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