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Letter to Senate HELP Committee Leadership on Provider-Type Equity

Written by AAA Staff on . Posted in Emergency Preparedness, Legislative.

The Honorable Patty Murray
Chair, United States Senate Committee on Health, Education, Labor and Pensions

The Honorable Richard Burr
Ranking Member
United States Senate Committee on Health, Education, Labor and Pensions

Dear Chairwoman Murray and Ranking Member Burr:

The American Ambulance Association (AAA) appreciates the opportunity to provide suggestions for bipartisan legislation to improve medical preparedness and response programs. The AAA is the primary association for ground ambulance service suppliers/providers, including governmental entities, volunteer services, private for-profit, private not-for-profit, and hospital-based ambulance services. Our members provide emergency and non-emergency medical transportation services to more than 75 percent of the U.S. population. AAA members serve patients in all 50 states and provide services in urban, rural, and super-rural areas. As the National Highway Transportation Safety Administration identified in its 2013 report on emergency services, EMS-only systems – such as our members – provide the vast majority of emergency ambulance services throughout America.

Our members are often the first health care teams to encounter patients who are sick and/or suspect they might have COVID-19. In addition to responding to 911 emergencies and transporting patients to appropriate destinations, they are also being asked to provide health care services within their existing State-defined scope of practice without transporting patients to help reduce hospital surge, as well as to protect high-risk patients from potential exposure to COVID-19. State and Local governments and public health authorities are also enlisting ground ambulance organizations to assist with testing suspected COVID-19 patients. In addition, ground ambulances provide important medical transitional care for patients moving between facilities in both emergency and non-emergency situations.

During this pandemic, our members have experienced first-hand the gaps in the public health infrastructure and the medical preparedness and response systems and programs. One of the most frustrating aspects of the current system has been the lack of recognition and support for communities that contract with non-governmental ground ambulance providers/suppliers in everything from federal grant programs to the distribution of personal protective equipment for EMTs and paramedics.

Many of the federal grant programs triggered during the pandemic have fallen short of their promise because the statutes and regulations governing them do not recognize non-governmental ground ambulance providers/suppliers as eligible entities. This distinction remains confusing because in other areas of health care, federal grant programs are accessible by private, for-profit health care providers and suppliers.

Outdated statutes and regulations often assume that first responders are governmental or not-for-profit entities and ignore the decisions of State and Local governments to contract with private ground ambulance providers/suppliers to provide 911 or equivalent services. As others have recognized, “State and Local officials know what works best in their communities – what works best in New York City may be much different than what works in rural Tennessee.”1 The federal government should respect these local decisions and support all first responders.

An example of this problem arose early during the COVID-19 pandemic. The FEMA public assistance grant program reimburses first responders for PPE and other expenses related to the response to COVID-19. When public and private non-profit emergency ambulance providers/suppliers sought direct reimbursement under the program, they were turned away. Private emergency ambulance providers/suppliers were required to have a State or Local government agency apply on their behalf. As State and Local governments responded to the public health emergency, it was understandably difficult for them to allocate resources to work through the application process on behalf of their contractors.

This differential treatment impacts communities across the United States, including those in Arkansas, California, Colorado, Florida, Georgia, Indiana, Louisiana, Massachusetts, Mississippi, Nevada, New York, Oregon, Texas, and Wisconsin, among others.

In contrast to statutes like the one government FEMA allocations, the Homeland Security Act of 2002 (6 U.S.C. § 101) includes language that recognizes the decision of State and Local governments to contract with private not-for-profit and for-profit ground ambulance providers/suppliers within the definition of “emergency response providers.”

The AAA urges the Congress to adopt the Homeland Security Act definition of “emergency response providers” throughout the U.S. Code as applicable. Such language will help to make sure that when funding is available to help State and Local governments prepare and respond, the allocation mechanisms governing the funding permit all types of first responders, including non-governmental ground ambulance providers/suppliers, to access the dollars quickly and with minimal burden.

Recommendation

The Committee should carefully review federal public health programs and revise them as necessary to ensure that the funds may be used to support both non-governmental and governmental ground ambulance providers/suppliers to ensure that all communities, regardless of their individual decisions related to the entities operating their EMS systems, have federal funds to support their response efforts during public health emergencies.

On behalf of the AAA, I want to thank you for your ongoing support of EMS and ground ambulance providers/suppliers, as well as the leadership demonstrated by your work to prepare for the next pandemic. Over the years, the Congress has consistently recognized the vital and unique role that ground ambulance providers/suppliers play in protecting their communities and providing mobile health care services. In light of the lessons learned during this pandemic, we encourage you and your colleagues to revise antiquated language that no longer represents the innovations and progress that have led to State and Local governments to rely upon ground ambulance providers/suppliers, including non-governmental organizations.

The AAA and its volunteer leaders would welcome the chance to discuss this recommendation. We would also be pleased to participate in any fact-finding discussion or hearing that the Congress plans to host to better understand how the problems experienced during the current pandemic can be avoided in the future. Please do not hesitate to reach out to Tristan North at (202) 486-4888 or tnorth@ambulance.org, or Kathy Lester at (202) 534-1773 or klester@lesterhealthlaw.com to schedule a time for further discussion.

Sincerely,

Shawn Baird
President, American Ambulance Association
Vice President of Rural Services, Metro West Ambulance

1The Honorable Lamar Alexander, “Preparing for the Next Pandemic” White Paper” 4 (June 9, 2020).

CMS Addresses Substance Use, Mental Health Crisis Care for Those with Medicaid

Written by AAA Staff on . Posted in Executive, Finance.

CMS Addresses Substance Use, Mental Health Crisis Care for Those with Medicaid

$15 Million Funding Opportunity for State Planning Grants to Bolster Mobile Crisis Intervention Services

The Centers for Medicare & Medicaid Services (CMS) announced a funding opportunity made possible by the American Rescue Plan (ARP) to help states strengthen system capacity to provide community-based mobile crisis intervention services for those with Medicaid. The $15 million funding opportunity is available to state Medicaid agencies for planning grants to support developing these programs.

This funding opportunity provides financial resources for state Medicaid agencies to assess community needs and develop programs to bring crisis intervention services directly to individuals experiencing a mental health or substance use related crisis outside a hospital or facility setting. These services may include screening and assessment, stabilization and de-escalation, and coordination of referrals after the initial treatment.

“Investing in crisis intervention services ensures Americans experiencing a mental health or substance use disorder crisis get the care and treatment they need,” said Secretary Becerra. “These grants will help states build these critical services to help communities send a responder who is trained and ready to assist people in crisis.”

“It is vital that we can meet people where they are, especially when those individuals are in crisis,” said CMS Administrator Chiquita Brooks-LaSure. “This funding will help state Medicaid agencies plan innovative ways to provide and better mobilize these essential intervention services to their communities.”

The planning grants provide funding to develop, prepare for, and implement qualifying community-based mobile crisis intervention services under the Medicaid program. Grant funds can be used to support states’ assessments of their current services, strengthen capacity and information systems, ensure that services can be accessed 24 hours a day/365 days a year, provide behavioral health care training for multi-disciplinary teams, or to seek technical assistance to develop State Plan Amendment (SPAs), demonstration applications, and waiver program requests under the Medicaid program.

Letters of Intent to apply from states and territories are due July 23, 2021. Final applications must be submitted by August 13, 2021, 3:00 pm ET. The period of performance for this grant will be from September 30, 2021, through September 29, 2022. The Notice of Funding Opportunity (NOFO) provides additional details regarding eligibility and program requirements, as well as key deadline and application submission information.

To view the NOFO, visit Grants.gov and search for the announcement by CFDA# 93.639.

EMS.gov | New Resources Help EMS Clinicians and Agencies Navigate HIPAA

Written by AAA Staff on . Posted in Operations, Patient Care, Regulatory.

Nationwide, EMS agencies regularly report that hospitals and other healthcare workers refuse to share patient information with them, citing Health Insurance Portability and Accountability Act (HIPAA) concerns. Misconceptions about HIPAA can create artificial barriers to the legitimate, approved exchange of data between EMS and other providers, resulting in missed opportunities to improve patient outcomes and advance evidence-based practices in prehospital care.

To address this issue, the NEMSIS Technical Assistance Center collaborated with the law firm Page, Wolfberg & Wirth to provide helpful resources explaining the sharing of patient information between EMS and other healthcare professionals:

While obstacles may remain for the appropriate sharing of patient information, HIPAA is not one of them. Sharing patient information benefits EMS agencies and improves prehospital patient care by revealing evidence-based practices that make a difference for patients in the field.

EMS Balance Billing Quick Take—July 7, 2021

Written by Kathy Lester on . Posted in Advocacy Priorities, Balance Billing, Executive, Legislative, Regulatory.

Webinar July 7, 2021 | 13:00–13:30 ET | Free to AAA Members
Speakers: Kathy Lester, Esq. & Asbel Montes

On July 1, CMS issued a proposed rule on Surprise Billing which applies to those providers and physicians identified in the No Surprises Act. This statute subjected ground ambulance suppliers to an HHS Advisory Committee process prior to any rulemaking addressing these services.

The consultants and staff of the American Ambulance Association are doing a deep dive into the 400+ page rule and evaluating its nuances. We continue to understand from our conversations that ground ambulances are not included and instead are subjected to the Advisory Committee.

The American Ambulance Association will soon provide a summary to members, and will address any confusion with the Administration. Join AAA for a quick take live webinar on July 7 at 13:00 ET to learn more!

Register Now

 

CMS | New Medicaid and CHIP Enrollment Snapshot

Written by AAA Staff on . Posted in Executive, Medicaid, Regulatory.

FOR IMMEDIATE RELEASE
June 21, 2021

Contact: CMS Media Relations
CMS Media Inquiries

New Medicaid and CHIP Enrollment Snapshot Shows Almost 10 million Americans Enrolled in Coverage During the COVID-19 Public Health Emergency

Report Shows Record Medicaid Enrollment and Highlights the Program’s Importance in Preserving Coverage for Millions of Children and Adults Throughout the United States

The Centers for Medicare & Medicaid Services (CMS) released a new Enrollment Trends Snapshot report today showing a record high, over 80 million individuals have health coverage through Medicaid and the Children’s Health Insurance Program (CHIP).  Nearly 9.9 million individuals, a 13.9% increase, enrolled in coverage between February 2020, the month before the public health emergency (PHE) was declared, and January 2021.

Among the 50 states and the District of Columbia, a total of 80,543,351 people were enrolled and receiving full benefits from the Medicaid and CHIP programs by the end of January 2021. In the 50 states that reported total Medicaid child and CHIP enrollment data for January 2021, over 38.3 million children were enrolled in Medicaid and CHIP combined, approximately 50% of the total Medicaid and CHIP enrollment. These numbers highlight the essential role the Medicaid and CHIP programs play in providing quality and needed coverage for millions of vulnerable children and adults. In fact, both programs serve as the largest single source of health coverage in the country.

“The Biden-Harris administration is using every lever to ensure any American needing access to quality health coverage receives it. Now more than ever, people need the peace of mind of knowing that they have health coverage,” said HHS Secretary Xavier Becerra. “This report reminds us what a critical program and rock Medicaid continues to be in giving tens of millions of children and adults access to care. This pandemic taught us that now more than ever, we must work to strengthen Medicaid and make it available whenever and wherever it’s needed using the unprecedented investments Congress provided.”

The increase in total Medicaid and CHIP enrollment is largely attributed to the impact of the COVID-19 PHE, in particular, enactment of section 6008 of the Families First Coronavirus Response Act (FFCRA). FFCRA provides states with a temporary 6.2% payment increase in Federal Medical Assistance Percentage (FMAP) funding.  States qualify for this enhanced funding by adhering to the Maintenance of Effort requirement, which ensures eligible people enrolled in Medicaid stay enrolled and covered during the PHE.

“Medicaid and CHIP serve as a much-needed lifeline for millions of people throughout this country. The increase we are seeing is exactly how Medicaid works: the program steps in to support people and their families when times are tough,” said CMS Administrator Chiquita Brooks-LaSure. “For the parents that may have lost a job or had another life change during the pandemic, having access to coverage for themselves and their kids is life-changing. CMS is committed to ensuring our nation’s marginalized communities and low-income families have the coverage they need.”

To assist states and territories in their response to the COVID-19 PHE, CMS developed numerous strategies to support Medicaid and CHIP programs in times of crisis, including granting states more flexibility in their Medicaid and CHIP operations. Today’s data release also reflects a range of indicators related to key application, eligibility, and enrollment processes from within state Medicaid and CHIP agencies.

The Snapshot is a product of the Centers for Medicare and Medicaid CHIP Services (CMCS) Medicaid and CHIP Coverage Learning Collaborative (MACLC), which monitors Medicaid and CHIP enrollment trends, primarily using the CMS Performance Indicator (PI) data reported to CMS by state Medicaid and CHIP agencies. PI data reflects key Medicaid and CHIP business processes- including applications, renewals, eligibility determinations, and enrollment.

The Enrollment Trends Snapshot, which is released monthly, is available here:  https://www.medicaid.gov/medicaid/program-information/medicaid-chip-enrollment-data/medicaid-and-chip-enrollment-trend-snapshot/index.html

The complete dataset, including data from January 2021, is available on data.Medicaid.gov.

HHS ASPR Project ECHO COVID-19 Clinical Rounds

Written by AAA Staff on . Posted in Operations, Patient Care, Regulatory.

HHS Office of the Assistant Secretary for Preparedness and Response

  • Peer to Peer Sharing : HHS ASPR, Project ECHO, and the National Emerging Special Pathogens Training and Education Centers (NETEC) together support the COVID-19 Clinical Rounds, peer to peer real-time knowledge sharing sessions among front line clinicians on challenges and successes encountered treating COVID-19.
  • Audience of Multidisciplinary Clinicians: Physicians, nurses, and EMS clinicians participate in the Rounds, which continue to focus on critical care, emergency departments, and EMS.
  • Format of Sessions: Each Clinical Rounds session includes brief presentations from experienced expert clinicians complemented by discussion among expert panelists in response to Q&A from participants.
  • Sharing of Experience, Not Official Guidance: Rounds are intended to be the sharing of clinical experience rather than formal recommendations or guidance.
  • Evolving Clinical Round Topics: Topics of Clinical Rounds evolve to address the dynamic COVID-19 medical response.
  • Continuing Medical Education (CME) Credit: Participants can fill out a short survey and receive 1 hour of Continuing Medical Education credit instantly for each session.

Watch On-Demand Sessions

Register for Future Rounds

Medicare Ambulance Relief Bill introduced in Senate

Written by AAA Staff on . Posted in Advocacy Priorities, Government Affairs, Legislative, Medicare.

Yesterday, Senators Catherine Cortez Masto (D-NV) and Susan Collins (R-ME) introduced the Protecting Access to Ground Ambulance Medical Services Act of 2021 (S. 2037). Senators Cortez Masto and Collins were joined by Senators Debbie Stabenow (D-MI), Bill Cassidy (R-LA), Patrick Leahy (D-VT) and Bernie Sanders (D-VT) as primary cosponsors and leads on the legislation.

S. 2037 is identical to H.R. 2454 by Representatives Terri Sewell (D-AL), Devin Nunes (R-CA), Peter Welch (D-VT) and Markwayne Mullin (R-OK) and would extend the temporary Medicare ground ambulance increases of 2% urban, 3% rural and the super rural bonus payment for five years. The increases are currently scheduled to expire on December 31, 2022. The five-year extension would allow for the increases to remain in place during the two-year delay on ambulance data collection due to the COVID-19 public health emergency, an analysis of the data by MedPAC and subsequent action by the Congress to reform the Medicare ambulance fee schedule.

The legislation would also help ensure that rural zip codes in large urban counties remain rural following geographical changes under the fee schedule as a result of the 2020 census data. The current definition using rural urban commuting areas (RUCA) in Goldsmith Modification areas would be modified for zip codes with 1,000 people or less per square mile would also be rural. Ground ambulance service providers and suppliers could also petition the Centers for Medicare and Medicaid Services (CMS) to make the argument that a specific zip code should be rural. It is vital that this provision be implemented before CMS makes changes from the 2020 census data which will likely occur in 2023.

The AAA has been leading the effort on the legislation with the support of the International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs, National Rural Health Association and the National Volunteer Fire Council.

The AAA will be launching a Call to Action shortly requesting AAA members to ask their Senators to cosponsor S. 2037, and reach out to their Representatives to cosponsor H.R. 2454 if they have not already done so.

We greatly appreciate the leadership of Senators Cortez Masto, Collins, Stabenow, Cassidy, Leahy, and Sanders on this vitally important legislation.

6/16 | Federal Interagency Committee on EMS Virtual Meeting

Written by AAA Staff on . Posted in Executive, Regulatory, Webinars.

Federal Interagency Committee on EMS to Hold Virtual Meeting on June 16

FICEMS also recently approved a new strategic plan to guide Federal activities related to EMS through 2025
The Federal Interagency Committee on EMS, which coordinates EMS activities throughout the federal government, will hold its first virtual meeting of 2021 on June 16 at 1 pm ET. Members of the public are invited to watch the webcast. Visit the FICEMS meeting page to learn more and view the agenda, or click below to register now. Anyone wishing to provide public comment can email FICEMS@dot.gov with “FICEMS Feedback” in the subject line. There will also be opportunities to ask questions or submit comments via a chat function during the webcast.

Register Now

New FICEMS Strategic Plan

One of the items on the agenda for the next FICEMS meeting is the new FICEMS Strategic Plan, which is now available on EMS.gov. The plan will guide FICEMS and its efforts to support and advance EMS and 911 services in the Nation over the next five years. The plan outlines seven strategic goals, each with multiple objectives, that will serve as the foundation for the activities of FICEMS and its member agencies.

Read the FICEMS strategic plan and learn more about the committee’s vision for Federal support of state, local, tribal and territorial EMS.

Download

NEMSIS 2020 Public-Dataset Now Available

Written by AAA Staff on . Posted in News, Press, Regulatory.

From NEMSIS on May 28, 2021

FOR IMMEDIATE RELEASE

NEMSIS 2020 Public-Dataset Now Available

Salt Lake City, Utah, May 11, 2021 – The National Emergency Medical Services Information System Technical
Assistance Center (NEMSIS TAC) today announced the availability of the 2020 Public-Release Research Dataset,
the largest publicly available dataset of emergency medical service activations in the United States. With this
release, NEMSIS aims to improve understanding of, confidence in, and support for EMS data collection and
analysis that will lead to data being utilized more effectively to improve patient care.

“The 2020 dataset is a powerful asset for researchers looking into all manner of conditions that affect different
aspects of EMS service.,” said Dr. N. Clay Mann, Professor in the Department of Pediatrics at the University of
Utah School of Medicine and Principal Investigator for the NEMSIS Technical Assistance Center. “Hopefully, the
information gathered during the COVID-19 pandemic will help give EMS agencies valuable insight on their work
improving EMS services under all sorts of conditions.”

The 2020 Public-Release Research Dataset is a subset of the National EMS Database that is the repository for
EMS data collected from U.S. States and Territories. NEMSIS maintains the national standard for how patient
care information resulting from an emergency 9-1-1 call for medical assistance is collected. The dataset includes
43,488,767 EMS activations submitted by 12,319 EMS agencies servicing 50 states and territories.

Those interested in requesting a copy of the 2020 Public-Release Research Dataset can contact the NEMSIS TAC
and fill out a request form at their website https://nemsis.org/using-ems-data/request-research-data. A
password-protected USB drive containing the dataset, the 2020 NEMSIS Data User Manual, NEMSIS Data
Dictionary v3.4.0, Extended Data Definitions v3.4.0, and sample SAS code file will be sent via postal service.

ABOUT NEMSIS

The National Emergency Medical Services Information System (NEMSIS) is the national health information
exchange and database used to collect and store EMS data from states and territories. NEMSIS is a universal
standard for how patient care information resulting from an emergency 9-1-1 call for medical assistance is
collected. It is a collaborative system to improve patient care through the standardization, aggregation, and
utilization of point-of-care EMS data at a local, state, and national level.
NEMSIS is a program of NHTSA’s Office of EMS and is hosted at the University of Utah.

CNN | Rural ambulance crews are running out of money and volunteers

Written by AAA Staff on . Posted in Advocacy Priorities, Executive, Government Affairs, Legislative, News, Press, Regulatory.

From CNN on May 22, 2021

Rural ambulance crews are running out of money and volunteers. In some places, the fallout could be nobody responding to a 911 call

America’s rural ambulance services, often sustained by volunteers, are fighting for their survival — a crisis hastened by the impact of Covid-19.

More than one-third of all rural EMS are in danger of closing, according to Alan Morgan, CEO of the National Rural Health Association. “The pandemic has further stretched the resources of our nation’s rural EMS.”

Read Full Article

CMS | Medicare COVID-19 Data Snapshot

Written by AAA Staff on . Posted in Operations, Patient Care, Regulatory.

Today, the Centers for Medicare & Medicaid Services (CMS) released our monthly update of data that provides a snapshot of the impact of COVID-19 on the Medicare population. The updated data show over 4.1 million COVID-19 cases among the Medicare population and over 1.1 million COVID-19 hospitalizations.

The updated snapshot covers the period from January 1, 2020 to March 20, 2021. It is based on Medicare Fee-for-Service claims and Medicare Advantage encounter data CMS received by April 16, 2021.

View the Updated Snapshot

NHTSA EMS.gov | EMS Week Video

Written by AAA Staff on . Posted in Events, News, Press, Regulatory.

From NHTSA’s Office of EMS on May 17, 2021

This week, May 16-22, 2021, we once again recognize the people of EMS by celebrating National EMS Week. We hope you’ll take a minute to watch this special message from the entire team here at the National Highway Traffic Safety Administration Office of EMS.


This year’s EMS Week theme, “This is EMS: Caring for our Communities,” couldn’t be more appropriate. The past year has been a challenge, but it has also reminded people across the nation just how valuable emergency medical services systems—and most important, clinicians—are to our communities. This nation is in debt to all of the EMS clinicians and the people behind the scenes who show up every day with true professionalism and dedication.

From all of us here at the Office of EMS, NHTSA, and the Department of Transportation: Thank you.

Presidential Proclamation for EMS Week 2021

Written by AAA Staff on . Posted in Events, Executive, News, Press.

From Whitehouse.gov’s Briefing Room on Presidential Actions

A Proclamation on Emergency Medical Services Week, 2021

Every day, in communities across the country, Emergency Medical Service (EMS) providers put themselves on the line to save lives, safeguard dangerous situations, and deliver hope to families and communities in crisis.  With selflessness, professionalism, and grace under fire, they provide essential care — never more so than during our battle with COVID-19 over the past year.  This year’s Emergency Medical Services Week theme, “THIS IS EMS:  Caring for Our Communities,” honors our heroic frontline workers who provide vital emergency medical care and ease the burden of crisis for Americans in need of help.

Through service, compassion, and dedication, EMS providers represent the very best of the American spirit.  In the face of unprecedented challenges, their expertise, endurance, and hard work have been a literal lifeline for families in every community.  Whether responding to the enormous suffering caused by COVID-19, the devastation of extreme climate events, or daily medical emergencies, EMS providers — many of whom are volunteers — prepare, sacrifice, and put others ahead of themselves.  Not only do they assume the heightened risks associated with emergency care during a pandemic, but they also spend countless hours away from families and friends in order to serve their communities.

In the face of these challenges, EMS providers have not hesitated to take on new roles, including supporting COVID-19 testing, therapeutics, and vaccination sites.  To help support the women and men who do this vital work, my American Rescue Plan included $100 million to support the mental well-being — including the mental health — of our health care professionals, paraprofessionals, public safety officers, and EMS providers.  My Administration has also made it a priority to ensure that our State, local, Tribal, and territorial partners have the resources they need so that EMS providers are trained and equipped to respond to public health emergencies safely and effectively, now and in the future.

During Emergency Medical Services Week, we extend our deepest gratitude to all EMS providers.  Their courage, selflessness, and commitment are extraordinary examples of what it means to serve this great country.  We also extend our sincere condolences to the loved ones of EMS providers who have given their lives in the line of duty.  This week and every week, I urge all Americans to express their appreciation for our Nation’s EMS providers — and to bring greater safety to their lives, and to all of our lives, by getting vaccinated to help bring an end to the COVID-19 pandemic.

NOW, THEREFORE, I, JOSEPH R. BIDEN JR., President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim May 16 through May 22, 2021, as Emergency Medical Services Week.  I call upon public officials, doctors, nurses, paramedics, Emergency Medical Service providers, and all the people of the United States to observe this week with appropriate programs, ceremonies, and activities.

IN WITNESS WHEREOF, I have hereunto set my hand this fourteenth day of May, in the year of our Lord two thousand twenty-one, and of the Independence of the United States of America the two hundred and forty-fifth.

 JOSEPH R. BIDEN JR.

 

 

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