Court Opinion

ID: 4709200
Source: CourtListenerOpinion
Date Created: 2021-08-05 00:00:36.234794+00
Date Added: 2024-06-11T08:06:54.876987
License: Public Domain

Case: 18-50722    Document: 00515965541        Page: 1   Date Filed: 08/04/2021

           United States Court of Appeals
                for the Fifth Circuit                           United States Court of Appeals
                                                                         Fifth Circuit

                                                                       FILED
                                                                  August 4, 2021
                                No. 18-50722
                                                                  Lyle W. Cayce
                                                                       Clerk
   Air Evac EMS, Incorporated,

                                                         Plaintiff—Appellee,

                                    versus

   Kent Sullivan, in his Official Capacity as Texas Commissioner of
   Insurance; Cassie Brown, in her Official Capacity as Texas Commissioner
   of Workers’ Compensation,

                                                    Defendants—Appellants,

                                    versus

   Texas Mutual Insurance Company; Liberty Mutual
   Insurance Company; Zenith Insurance Company;
   Hartford Underwriters Insurance Company; Twin City
   Fire Insurance Company; Transportation Insurance
   Company; Valley Forge Insurance Company; Truck
   Insurance Exchange,

                                                    Intervenors—Appellants.

                 Appeal from the United States District Court
                      for the Western District of Texas
                            USDC No. 1:16-CV-60
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                                    No. 18-50722

   Before Stewart, Clement, and Ho, Circuit Judges.
   James C. Ho, Circuit Judge:
          Air Evac EMS, Inc., is an air ambulance provider that offers medical
   transport services to a wide variety of patients. That includes patients who
   are injured at their workplace. The price that Air Evac may charge for such
   transportation is accordingly subject to conflicting regulatory regimes.
          The Texas Workers’ Compensation Act (“TWCA”), Tex. Lab.
   Code §§ 401.007–419.007, regulates the prices that insurers must pay to
   providers for various medical services utilized by their beneficiaries. That
   includes air transport services. But those price restrictions conflict with the
   federal Airline Deregulation Act (“ADA”), which makes clear that the states
   “may not enact or enforce a law, regulation, or other provision . . . related to
   a price, route, or service of an air carrier that may provide air transportation
   under this subpart.” 49 U.S.C. § 41713(b)(1).
          The price restrictions are not saved by the McCarran–Ferguson Act.
   That act makes clear that “[n]o Act of Congress shall be construed to
   invalidate, impair, or supersede any law enacted by any State for the purpose
   of regulating the business of insurance, or which imposes a fee or tax upon
   such business, unless such Act specifically relates to the business of
   insurance.” 15 U.S.C. § 1012(b). But the price regulations at issue here do
   not govern “the business of insurance.” The McCarran–Ferguson Act
   concerns state efforts to regulate the relationship between insurers and
   insureds—not between insurers and providers.
          We accordingly affirm. In doing so, we agree with our sister courts of
   appeals, which have unanimously held that the ADA preempts state price
   caps on air ambulance reimbursements, and that those state price caps are
   not saved by the McCarran–Ferguson Act. And we disagree with the Texas
   Supreme Court, which has reached contrary conclusions by a divided vote.

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                                        I.
          Under the TWCA, employees in Texas receive guaranteed medical
   care paid for by employer-funded insurance policies, in exchange for
   relinquishing their common-law workplace injury claims. As part of this
   regulatory scheme, the TWCA strictly regulates the prices that private
   insurers must pay health care providers for treating workers injured on the
   job. See Tex. Lab. Code § 413.011; 28 Tex. Admin. Code §§ 134.1,
   134.203. The TWCA also prohibits providers from engaging in “balance-
   billing”—that is, they cannot collect any remaining balance from either the
   employer or employee after an insurer has reimbursed the provider less than
   the full amount for the services rendered.        See Tex. Lab. Code
   § 413.042(a).
          Air Evac contends that these price caps are preempted by the ADA.
   So it sued various Texas state officials, seeking a declaration that the ADA
   preempts the TWCA and its regulations, and an injunction barring
   enforcement of the price caps.      Alternatively, Air Evac requested an
   injunction barring enforcement of the TWCA’s balance-billing prohibition.
          Eight insurance companies joined the Texas officials as intervenors to
   defend Texas law. Together they moved to dismiss the case on various
   jurisdictional grounds.   The district court granted the motion, but we
   subsequently reversed. See Air Evac EMS, Inc. v. Tex., Dep’t of Ins., Div. of
   Workers’ Comp., 851 F.3d 507, 510 (5th Cir. 2017).
          On remand, the district court granted Air Evac’s motion for summary
   judgment on its claim that the Texas price caps were preempted by the ADA
   and not saved by the McCarran–Ferguson Act. See Air Evac EMS, Inc. v.
   Sullivan, 331 F. Supp. 3d 650, 667 (W.D. Tex. 2018). Consequently, it did
   not address Air Evac’s alternative balance-billing claim. Id. at 656 n.4. The
   district court enjoined enforcement of Texas Labor Code § 413.011 and

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   Texas Administrative Code §§ 134.1 and 134.203 as applied to Air Evac. Id.
   at 664.
             Both the State and the eight insurance companies appealed.
   Following oral argument in this case, the Supreme Court of Texas decided a
   similar case addressing the same issues. See Tex. Mut. Ins. Co. v. PHI Air
   Med., LLC, 610 S.W.3d 839 (Tex. 2020), cert. denied, _ S. Ct. _, 2021 WL
   1602647 (Apr. 26, 2021) (mem.). Contrary to the district court here and our
   sister courts of appeals that have examined these issues, the Texas Supreme
   Court held that the TWCA price caps on air ambulance providers are not
   preempted by federal law. But it did so over a thorough dissent supported by
   two members of the court. Id. at 865 (Green, J., joined by Hecht, C.J.). Seven
   members sided with the majority, but for differing reasons—six concluded
   that the ADA does not preempt the TWCA price caps, id. at 843, while four
   concluded that the TWCA price caps are saved by the McCarran–Ferguson
   Act, id. at 856.
             We review summary judgment rulings de novo.            IberiaBank v.
   Boussard, 907 F.3d 826, 842 (5th Cir. 2018).
                                         II.
             Congress enacted the ADA in 1978, introducing free-market
   principles to a heavily regulated and stagnating aviation industry.        To
   streamline regulations, avoid a patchwork of state protocols, and “ensure
   that the States would not undo federal deregulation with regulation of their
   own,” Congress included an express preemption provision. Morales v. Trans
   World Airlines, Inc., 504 U.S. 374, 378 (1992).
             Under the express preemption provision, “[a] State[] . . . may not
   enact or enforce a law, regulation, or other provision having the force and
   effect of law related to a price, route, or service of an air carrier that may
   provide air transportation under this subpart.” 49 U.S.C. § 41713(b)(1). The

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   Supreme Court has made clear that this express preemption provision “has
   a ‘broad scope’” and “an ‘expansive sweep,’” and that the “ordinary
   meaning of these words . . . express a broad pre-emptive purpose.” Morales,
   504 U.S. at 383–84 (citations omitted).
            Two of our sister circuits have unanimously held that the ADA
   preempts price controls on air ambulance services set by state workers’
   compensation regulations. See Air Evac EMS, Inc. v. Cheatham, 910 F.3d 751
   (4th Cir. 2018); EagleMed LLC v. Cox, 868 F.3d 893 (10th Cir. 2017). We
   agree.
            As a threshold matter, Texas and the insurers urge that we adopt a
   presumption against preemption when it comes to issues of traditional state
   law such as workers’ compensation. We need not address that contention
   here, however, because we do not regard this as a close call—the text of the
   ADA plainly governs this case. See, e.g., Cheatham, 910 F.3d at 762 n.1
   (“[W]e need not enter the great preemption presumption wars here because
   the text of the preemption provision . . . governs the disposition of this
   case.”).
            Under the ADA, a state may not enforce any law or regulation that is
   (1) “related to a price” of (2) an “air carrier” that (3) may provide air
   transportation “under this subpart.” 49 U.S.C. § 41713(b)(1). Each of those
   elements is satisfied here. We address each in turn.
                                         A.
            The TWCA regulations in question plainly involve the “price” of air
   transport services. The ADA defines “price” as “a rate, fare, or charge.”
   49 U.S.C. § 40102(a)(39). We see no reason to depart from the ordinary
   meaning of these terms. The term “price” simply means the “sum of money
   . . . asked or given for something” in return. American Heritage
   Dictionary of the English Language 1038 (1979). See also id. at

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   1082 (defining “rate” as “a charge or payment calculated in relation to any
   particular sum or quantity”); id. at 476 (defining “fare” as a “transportation
   charge”); id. at 226 (defining “charge” as “to set or ask (a given amount) as
   a price”).
          The TWCA regulations plainly govern “price”—namely, the price
   that Air Evac is allowed to charge Texas workers’ compensation insurers for
   air ambulance services.
          For their part, Texas and the insurers contend that the term “price”
   applies only to competitive markets—and that “air ambulances do not
   operate in a market that would dictate the price or rate charged in the absence
   of government interference.”        Under that view, any amount that is
   determined by a regulator for a particular good or service would not
   constitute a “price.” That would make terms like “price controls” an
   oxymoron. Yet the term is ubiquitous in our law. “Consistent usage, as
   reflected in numerous judicial opinions, can be an authoritative source of
   common parlance.” Frederking v. Cincinnati Ins. Co., 929 F.3d 195, 198 (5th
   Cir. 2019) (citing New Prime Inc. v. Oliveira, 139 S. Ct. 532, 540 (2019)). See,
   e.g., Yakus v. United States, 321 U.S. 414, 418 (1944) (concerning the
   constitutionality of the Emergency Price Control Act of January 30, 1942, 56
   Stat. 23); United States v. Uni Oil, Inc., 710 F.2d 1078, 1080 (5th Cir. 1983)
   (concerning federal “price controls” on oil). See also Address to the Nation
   Outlining a New Economic Policy: “The Challenge of Peace”, Public
   Papers of President Richard M. Nixon 888 (Aug. 15, 1971) (“I
   am today ordering a freeze on all prices and wages throughout the United
   States for a period of 90 days. In addition, I call upon corporations to extend
   the wage-price freeze to all dividends.”); Exec. Order No. 11,615—Providing
   for Stabilization of Prices, Rents, Wages, and Salaries, 36 Fed. Reg. 15,727
   (Aug. 15, 1971). In response, Texas and the insurers rely on Hodges v. Delta

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   Airlines, Inc., 44 F.3d 334, 336 (5th Cir. 1995) (en banc). But in Hodges we
   construed the term “service,” not “price,” under the ADA.
          In sum, the amount that TWCA rules would allow Air Evac to receive
   for its air ambulance services falls well within the term “price” under the
   ADA. Accordingly, those TWCA rules plainly “relate to” price.
          As the Supreme Court has observed, the term “related to” under the
   ADA is broad and indeed “much more broadly worded” than other
   preemption provisions. Northwest, Inc. v. Ginsberg, 572 U.S. 273, 283 (2014).
   See also Morales, 504 U.S. at 383–85. A law “relate[s] to” price under the
   ADA so long as it has a “connection with or reference to” price or presents
   a “significant effect” on the price of air services. Morales, 504 U.S. at 384,
   388. See also Buck v. Am. Airlines, Inc., 476 F.3d 29, 34–35 (1st Cir. 2007)
   (“[T]he ADA preempts both laws that explicitly refer to an airline’s prices
   and those that have a significant effect upon prices.”); Travel All Over the
   World, Inc. v. Saudi Arabia, 73 F.3d 1423, 1433 (7th Cir. 1996) (declining to
   find preemption when plaintiffs’ tort claims neither “expressly refer to
   airline rates, routes, or services,” nor have a “‘forbidden significant
   [economic] effect’ on airline rates, routes, or services”) (alteration in
   original).
          The TWCA regulations challenged here obviously have a “significant
   effect” on Air Evac’s prices—they effectively forbid Air Evac from
   recovering from workers’ compensation insurers the price that they would
   otherwise charge for air ambulance services. As we have previously noted,
   the “TWCA’s provisions effectively set a reimbursement rate” on air
   ambulance services by restricting the amount insurers pay them. Air Evac,
   851 F.3d at 514. See also PHI Air Med., 610 S.W.3d at 866 (Green, J.,
   dissenting) (“The TWCA’s reimbursement scheme is related to an air
   ambulance’s prices because it indirectly limits the amount than an air carrier

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   may charge for its services.”). As the Fourth Circuit put it, “[i]f such actions
   involving an air carrier are not ‘related to price,’ it is unclear what meaning
   the phrase would have left.” Cheatham, 910 F.3d at 767–68.
                                          B.
          We likewise have little trouble concluding that Air Evac qualifies as an
   “air carrier.” The ADA defines an “air carrier” as “a citizen of the United
   States undertaking by any means, directly or indirectly, to provide air
   transportation.” 49 U.S.C. § 40102(a)(2).        Air ambulances transporting
   patients to hospitals fall squarely within that definition. Courts are agreed on
   this point. See, e.g., Cheatham, 910 F.3d at 764; Bailey v. Rocky Mountain
   Holdings, LLC, 889 F.3d 1259, 1266–68 (11th Cir. 2018); Cox, 868 F.3d at
   904; Stout v. Med-Trans Corp., 313 F. Supp. 3d 1289, 1294 (N.D. Fla. 2018);
   Schneberger v. Air Evac EMS, Inc., 2017 WL 1026012, *2 (W.D. Okla.); Valley
   Med Flight, Inc. v. Dwelle, 171 F. Supp. 3d 930, 933–34 (D.N.D. 2016); Med-
   Trans. Corp. v. Benton, 581 F. Supp. 2d 721, 732 (E.D.N.C. 2008); PHI Air
   Med., 610 S.W.3d at 843. As are federal agencies. Air Evac holds a “Part
   135” operating certificate from the Federal Aviation Administration
   (“FAA”) allowing it to “operate as an air carrier and conduct common
   carriage operations.” ROA.1235. The Department of Transportation
   (“DOT”) also recognizes Air Evac as an “air carrier” under “Part 298,”
   which grants it a license to operate as an air taxi. ROA.1239.
          Nevertheless, Texas and the insurers insist that air ambulances are not
   “air carriers” under the ADA because Congress’s purpose in enacting the
   ADA was to cover only commercial, passenger airlines. But we are governed
   by the text of the statute. See, e.g., Morales, 504 U.S. at 383 (“[W]e . . . begin
   with the language employed by Congress and the assumption that the
   ordinary meaning of that language accurately expresses the legislative
   purpose.”) (quotations and citations omitted).         Neither Texas nor the

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   insurers have “presented a single textual reason to support the argument that
   the broad language of the [ADA]’s express preemption provision should not
   include air-ambulance services.” Cox, 868 F.3d at 904.
                                            C.
          Finally, air ambulances “provide air transportation under this
   subpart”—that is, under subpart II of the amended Federal Aviation Act.
   49 U.S.C. § 41713(b)(1). Air ambulance companies hold a registration issued
   by the Secretary of Transportation and are subject to certain economic
   regulations under subpart II. 14 C.F.R. pt. 298. That is all that is required
   under the plain text of § 41713(b)(1).
          The State and the insurers argue that Air Evac is not sufficiently
   subject to subpart II because the Secretary has exempted air ambulances from
   the general requirement to hold a certificate of public convenience and
   necessity. But § 41713(b)(1) simply requires air carriers to “provide air
   transportation” under subpart II—it does not require air carriers to be
   certified under subpart II. Other courts that have examined this issue have
   reached the same conclusion. See, e.g., Cheatham, 910 F.3d at 764–65
   (agreeing “with Air Evac that the phrase ‘under this subpart’ includes all air
   carriers regulated by the Secretary of Transportation under subpart II, rather
   than those specifically certified under the subpart”); Hughes Air Corp. v. Pub.
   Utils. Comm’n, 644 F.2d 1334, 1338–39 (9th Cir. 1981) (holding that air
   carriers operating under an exemption still fell within the ADA’s preemption
   provision). We agree that air ambulance providers like Air Evac provide air
   transportation under subpart II.
                                         ***
          Accordingly, we hold that the ADA expressly preempts TWCA
   reimbursement regulations as applied to air ambulance services.

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                                         III.
          The TWCA reimbursement regulations are not saved by the
   McCarran–Ferguson Act. As relevant here, the McCarran–Ferguson Act
   shields from federal preemption those state laws that are “enacted . . . for the
   purpose of regulating the business of insurance,” unless the federal statute
   “specifically relates to the business of insurance.” 15 U.S.C. § 1012(b). So
   the Act “precludes application of a federal statute in [the] face of state law
   ‘enacted . . . for the purpose of regulating the business of insurance,’ if the
   federal measure does not ‘specifically relat[e] to the business of insurance,’
   and ‘would invalidate, impair, or supersede’ the State’s law.” Humana Inc.
   v. Forsyth, 525 U.S. 299, 307 (1999) (alterations in original) (quoting U.S.
   Dep’t of Treasury v. Fabe, 508 U.S. 491, 501 (1993)).
          It is undisputed that the ADA does not “specifically relate to” the
   business of insurance. So the sole issue is whether the TWCA was enacted
   “for the purpose of regulating the business of insurance”—that is, if it has
   the “‘end, intention, or aim’ of adjusting, managing, or controlling the
   business of insurance.” Fabe, 508 U.S. at 505 (quoting Black’s Law
   Dictionary 1236, 1286 (6th ed. 1990)).
          That requires determining whether the challenged provisions of the
   TWCA regulate “the relationship between the insurance company and the
   policyholder.” Id. at 501 (quoting SEC v. Nat’l Sec., Inc., 393 U.S. 453, 460
   (1969)). The McCarran–Ferguson Act “assure[s] that the activities of
   insurance companies in dealing with their policyholders would remain subject
   to state regulation.” Nat’l Sec., 393 U.S. at 460 (emphasis added).
          The TWCA regulations at issue here deal with the relationship
   between insurers and providers—namely, the providers of air ambulance
   services—and not the relationship between insurers and their beneficiaries.

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   Accordingly, the TWCA regulations are not shielded from federal
   preemption under the McCarran–Ferguson Act.
                                          A.
          In Group Life & Health Insurance Company v. Royal Drug Company,
   440 U.S. 205 (1979), the Supreme Court made clear that the “focus” of our
   inquiry is whether the insurance practice that is the subject of state regulation
   governs “the relationship between the insurance company and the
   policyholder.” Id. at 216 (quoting Nat’l Sec., 393 U.S. at 460). That
   relationship is “the core of the ‘business of insurance.’” Id. at 215. See also
   Fabe, 508 U.S. at 493 (“We hold that the Ohio priority statute escapes pre-
   emption to the extent that it protects policyholders.”). In addition, the Court
   identified two other criteria:     “whether the practice has the effect of
   transferring or spreading a policyholder’s risk,” and “whether the practice
   is limited to entities within the insurance industry.” Union Lab. Life Ins. Co.
   v. Pireno, 458 U.S. 119, 129 (1982) (citing Royal Drug, 440 U.S. at 211–12,
   215, 231).
          The TWCA regulations fail under all three criteria. See, e.g., PHI Air
   Med., 610 S.W.3d at 876–77 (Green, J., dissenting) (concluding that the
   TWCA regulations fail under all three factors identified in Royal Drug and
   Pireno).
          To begin with, the TWCA regulations govern the relationship
   between insurers and providers, not insurers and insureds. So the regulations
   do not involve the “business of insurance” under the first criteria.
          The Court reached precisely the same conclusion under similar facts
   in Royal Drug. It held that an insurer’s agreement to reimburse pharmacies
   for the cost of prescription drugs if the pharmacies offered the drugs to the
   insurer’s policyholders for $2 did not involve the “business of insurance.”
   Royal Drug, 440 U.S. at 212–14. To conclude otherwise would “confuse the

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   obligations of [the insurer] under its insurance policies”—which involved
   the insurer–insured relationship—“and the agreements between [the
   insurer] and the participating pharmacies, which serve only to minimize the
   costs [the insurer] incurs in fulfilling its underwriting obligations.” Id. at 213.
   The defining feature of the insurer–insured relationship is the exchange of
   insurance premiums in order to obtain medical benefits. The particulars of
   any exchange between insurers and pharmacies are merely ancillary features
   that are not part of the “business of insurance.” And even though any cost
   savings might be passed on to policyholders in the form of reduced
   premiums, individual beneficiaries were “basically unconcerned” with any
   specific business arrangements between the insurer and the pharmacy, so
   long as the beneficiaries received the promised benefits. Id. at 214. As the
   Court put it, McCarran–Ferguson “exempts the ‘business of insurance’ and
   not the ‘business of insurance companies.’” Id. at 217. “It is next to
   impossible to assume that Congress could have thought that agreements
   (even by insurance companies) which provide for the purchase of goods and
   services from third parties at a set price are within the meaning of that phrase
   [i.e. ‘business of insurance’].” Id. at 230.
          By the same logic, the TWCA regulations challenged here likewise do
   not involve the relationship between the insurer and the insured. As in Royal
   Drug, the regulations help reduce costs to the workers’ compensation
   insurance carrier.       But employers and employees are “basically
   unconcerned” with how the insurer structures its payments or how much
   any single service provider is paid. Id. at 214. After all, the amount the
   insurer pays the provider is not a benefit to the insured. In sum, the focus of
   the TWCA regulations is on the relationship between insurer and provider,
   not insurer and insured.
          The insurers here try to avoid Royal Drug by contending that the
   TWCA reimbursement cap is “critical to the spreading of risk” by limiting

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   the overall liabilities of insurers. But that argument proves too much. If the
   insurers are right, then “almost every business decision” would be part of
   the “business of insurance,” because virtually every business decision has
   “some impact” on premium amounts and policy issuance. Id. at 216–17. Yet
   this is exactly the type of downstream effect that the Supreme Court has
   placed outside the “business of insurance.” After all, “[s]uch cost-savings
   arrangements may well be sound business practice, and may well inure
   ultimately to the benefit of policyholders in the form of lower premiums, but
   they are not the ‘business of insurance.’” Id. at 214.
          The TWCA regulations also fail under the two remaining criteria.
   Reimbursement arrangements between insurers and providers do not
   meaningfully affect the allocation of risk between insurer and insured. The
   arrangement may help limit the insurer’s costs, but it does not substantially
   affect the transfer of risk from the insured to the insurer. Nor is the subject
   of the regulations “limited to entities within the insurance industry.” Pireno,
   458 U.S. at 129. Air Evac is an air ambulance company, not an insurance
   company.
                                         B.
          For their part, Texas and the insurers contend that the three criteria
   set forth in Royal Drug and Pireno apply in cases involving the application of
   certain enumerated federal antitrust statutes, and have only limited
   applicability to other federal laws like the ADA. See 15 U.S.C. § 1012(b).
          But nothing in the text of the McCarran–Ferguson Act suggests that
   we should give the term “business of insurance” a different meaning when it
   comes to applying the Act to other federal statutes like the ADA. “[W]e
   ‘cannot imagine that “business of insurance” could have two different
   meanings in the same statutory subsection.’” Bailey, 889 F.3d at 1273 n.30

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   (quoting Blackfeet Nat’l Bank v. Nelson, 171 F.3d 1237, 1246 n.13 (11th Cir.
   1999)).
            Accordingly, our court has applied the Royal Drug–Pireno framework
   to federal statutes other than the enumerated antitrust provisions. See Am.
   Bankers Ins. Co. of Fla. v. Inman, 436 F.3d 490, 493–94 (5th Cir. 2006);
   Munich Am. Reinsurance Co. v. Crawford, 141 F.3d 585, 590–91 (5th Cir.
   1998).
                                       ***
            We hold that the TWCA regulations concerning the reimbursement
   of air ambulance providers like Air Evac are preempted by the ADA, and are
   not saved by the McCarran–Ferguson Act. Accordingly, we affirm.

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