Justice took office as a U.S. Senator in January 2025, so his record is evaluated over his first-term votes. His signature health-care legislative action was voting Yea on H.R. 1, the One Big Beautiful Bill Act (Senate Roll Call Vote #372, July 1, 2025, passed 50-50 with the VP tie-break), which enacted the largest Medicaid cuts in the program's history and let enhanced ACA premium tax credits lapse. He also voted for the March 2025 budget resolution enabling large Medicaid reductions and voted against a spending measure that would have extended ACA premium subsidies, changes projected to raise insurance premiums and cause roughly 60,000 West Virginians to lose affordable Marketplace coverage. These outcomes run directly opposite to the promise's aims of lowering insurance costs, improving care, and protecting access. Mitigating actions keep this short of HOSTILE: he voted NO on the Rick Scott amendment that would have deepened Medicaid cuts, publicly warned Medicaid cuts could close WV rural hospitals, and advocated for rural-health funding. But those steps did not offset the net direction of his decisive votes, which increase costs and reduce coverage/access. Statutory ACA pre-existing-condition protections were not repealed, yet affordability and access were undermined. On balance his actual record acts against the promise, warranting MISALIGNED rather than PARTIAL or HOSTILE.