Healthcare has been top-of-mind for voters, politicians in election cycle

Nov. 03--U.S. Rep. Mike Rogers, R-Saks, predicts his fellow Republicans will try once more to repeal and replace the Affordable Care Act if the GOP does well on Nov. 6.

His opponent, Democrat Mallory Hagan, wants to set up birthing centers to serve expectant mothers in counties where hospitals have vanished.

And just about everyone running for office has a theory about how the closure of Jacksonville's hospital could have been avoided.

In the months leading up to Tuesday's election, candidates have argued about everything from a Space Force to whether to hold a televised debate. But one theme has remained constant: rural health care and how to fix it.

"Virtually every Democrat running is talking about expanding Medicaid, and Republicans have been talking about issues like rising health care costs," said David Hughes, a political science professor at Auburn University Montgomery.

In a survey released earlier this year by the Public Affairs Research Council of Alabama, 65 percent of respondents said they were "very concerned" about health care, with the issue ranking second only to education in voters' top policy priorities. According to Google Trends, health care has been the top policy issue searched for by Alabamians on the Web for most of the past year, coming in second only on two brief occasions when immigration searches spiked.

For much of the campaign, health care was a ten-thousand-foot policy issue, with candidates sometimes struggling to connect stories of personal hardship to policy decisions about insurance.

Then RMC Jacksonville closed.

Closing, and expanding

In May, Regional Medical Center's board of directors announced it would shutter its facility in Jacksonville, a 104-bed hospital once owned by the city.Board members cited low patient volume, poor federal reimbursements for services and the rising cost of providing care.

For many Democrats, the closure was a sign of a larger problem. The state's failure to expand Medicaid under the Affordable Care Act was causing rural hospitals to go under, some argued.

"Problems seem to be far away until they're in your own home," Hagan said in a meeting with Star editors earlier this year. "Right now, in the state of Alabama, health care is a problem in every home. Every person has been negatively impacted by our lack of expansion of Medicaid."

Republican incumbents sometimes bristle at the idea that the hospital's closure could be laid at their feet. State Sen. Del Marsh, R-Anniston, and state Rep. Koven L. Brown, R-Jacksonville, told The Star earlier this month that they worked with RMC to try to avoid the closure -- and tried to recruit other hospital chains to come to town and take over the facility.

"We had our hands full," said Loy Howard, CEO of the Georgia-based hospital chain Tanner Health. "We wanted to live up to our current commitments."

Tanner in 2016 opened a hospital in rural Randolph County, to replace Wedowee's closed local hospital. Howard said the county voters' decision to build a new hospital building, which required a one-cent sales tax, was crucial to Tanner's decision to move in.

The hospital is still operating in the red, Howard said. Until the Wedowee facility becomes profitable, the chain's Georgia hospitals can cover for it.

Reimbursement debate

The Wedowee hospital isn't alone. Three-fourths of the state's hospitals are also operating at a loss, said Danne Howard, executive director of the Alabama Hospital Association.

Covering uninsured patients is part of the problem, she said. But it's difficult to say whether Medicaid expansion alone would have saved any single hospital from closure.

"We know that Medicaid expansion is the one biggest thing the state can do to help the survival of our hospitals," she said.

Howard identified another problem facing those hospitals: the Medicare Wage Index, a formula which determines how much the federal government reimburses hospitals for care for patients covered by federal programs. The formula -- intended to reflect the higher cost-of-living in major cities -- now pays urban hospitals much more for performing the same procedures, she said.

"It's piling on and piling on to a fragile system," she said.

The wage index may be one reason Tanner can afford a hospital in Wedowee. Hospital officials said most of the hospitals in the chain are in the Atlanta metro area for purposes of the formula.

Fixing the wage index problem may be the one health care issue candidates agree on across party lines. In a speech in Anniston last week, U.S. Sen. Doug Jones, D-Birmingham, said he was working with Republican Sen. Richard Shelby to get the formula changed.

"These are not other states' dollars," Jones said. "These are your dollars."

Jones said he and other lawmakers were in talks with Seema Verma, director of the Center for Medicare and Medicaid Services, on a change to the formula.

"That is the number one thing," said incumbent U.S. Rep. Mike Rogers, R-Saks, "To get us some relief."

Rogers said he believed the formula could be changed administratively, without legislation being passed.

In an interview last month, Rogers said a fix to the problem would take legislation at the national level. In remarks after the Jones speech last week, Rogers said he believed the wage index could be changed by administrative action.

Not waiting for answers

Even if rural health care's financial problems get fixed, no one on the ballot is arguing that RMC Jacksonville or any of the state's other closed hospitals will be reopened. Candidates on both sides say they'd like to see some sort of clinic open on the hospital site.

Some candidates are looking for new policies to fill the gaps in a world with fewer hospitals. Democratic state Senate candidate Jim Williams wants lawmakers to meet with the operators of air ambulances to negotiate better prices for helicopter airlifts to large-city hospitals, something he believes will become more common with the closure of Jacksonville's hospital.

Hagan, the Democratic Congressional candidate, has advocated for more federal support for birthing centers -- lower-cost maternity clinics where women are attended mostly by midwives -- to better serve women who otherwise have a long drive to an obstetrician.

There are no such birthing centers in Alabama now, said Kate Bauer, director of the American Association of Birth Centers. Most that do exist are in larger cities, where there's a larger volume of patients.

"Right now, about a third of birth centers serve a rural population," Bauer said. "It is an option to fill a gap."

There are plenty of unknowns that could make the health care conversation still more complicated. Hospitals for years have been bracing for the end of Disproportionate Share Hospital payments, a type of federal funding that goes to hospitals that serve large numbers of low-income patients. So far, plans to eliminate those payments have been postponed again and again, but Howard, the hospital association director, said another deadline will likely come up in a few years.

There's also the chance that the Affordable Care Act could be repealed, though what would replace it is still unclear. Attempts to repeal and replace have failed in recent years, even with Republicans in control of both houses of Congress and the White House. Rogers, the incumbent Congressman, said on the campaign trail earlier this year that GOP lawmakers would likely try repeal again if they keep the majority after Nov. 6.

Polls open at 7 a.m. Tuesday.

Capitol & statewide reporter Tim Lockette: 256-294-4193. On Twitter @TLockette_Star.

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