In this B case, the follow-up to S-0314, Marissa Levine, the Virginia Commissioner of Health, considers reports for and against the merger of two health care entities in rural Virginia, as she decides whether to issue a waiver to allow it. This case set explores the differences in and conflicts among the interests of for-profit health care systems, of rural, low-income residents, and of federal, state, and local governments. It allows students to engage in an in-depth discussion of the sometimes emotional issue of rural healthcare. It is suitable for students in a classes spanning health care management, nonprofit management, public policy, governance, ethics, and the social sector.