On Thursday of last week, the “news” was focused on melting snow in Georgia and the lingering problems of power outages from south metro Atlanta to Augusta.  During a briefing on the matter from Governor Nathan Deal, the AJC’s Jim Galloway managed to slip in a question about a problem that will linger long after the lights were turned back on.

The Governor was asked about a move within the legislature to require their authorization before committing the state to Medicaid expansion (and the long term funding commitment that comes with it).  The Governor replied “I’m fine with that”.

Instantly, the answer was crystalized as a campaign issue.  Democratic presumptive nominee Jason Carter charged the Governor with passing the buck.  Governor Deal’s campaign responded with a suggestion that Carter would prefer a backroom Deal with President Obama rather than to give the representatives of the people a say in how their tax dollars are spent.

Lost in the fray was the announcement that Lower Oconee Community Hospital in the Wheeler County town of Glenwood was closing its doors.  It is the fourth rural Georgia hospital to close its doors in two years.  There will likely be more.  Wheeler County residents will now face a 30-plus minute trip to Dublin, Vidalia, or Eastman for their medical care.

“Medicaid expansion” will likely remain the political question of the day.  It gives Democrats the opportunity to say that Georgia is turning down “free money” from Uncle Sam.  It gives Republicans the opportunity to demonstrate that they are actively fighting Obamacare at the state level along with future unfunded liabilities.

It gives both sides the opportunity to demonstrate they’re fighting for something, without having to examine critical structural issues facing rural healthcare delivery in Georgia.   It is yet another example demonstrating that campaigning is easy, but governing is hard.

The economics of Wheeler County resemble that of much of rural Georgia.  According to Georgia Health News, “The Wheeler County area had a 23 percent uninsured rate, and 10 percent of citizens are unemployed…Forty-one percent of the county’s children live in poverty.”  That indicates much of the population is likely already eligible for Medicaid.  Add in that 26.5% of the county’s residents are over 65 and you’ll see that Medicare is also a huge factor in health care delivery for the area.

The problem – with or without the expansion of Medicaid – becomes one of costs versus revenue.  According to one Georgia hospital executive, Medicaid reimburses roughly 87% of costs to his hospital.  Medicare is slightly better, but still less than actual delivery costs of services.  A “Critical Access Hospital” – one such as Lower Oconee that agrees to limit its size to no more than 25 beds – is eligible to receive up to 100% reimbursement on Medicare patients.

In much of rural Georgia, there are barely enough patients to keep a facility operating to begin with.  Add in a population base served by government backed insurance programs that have “bent the cost curve” by reimbursing at or less than the costs of services provided, and it becomes obvious of the cause and effect.

The problem for rural health care is only exacerbated when you consider that area hospitals often are the backbone for local physicians.  Georgia now has roughly one third of its counties without a general practitioner.  Roughly half lack a pediatrician.  Doctors face the same problems that hospitals do.  After a decade of expensive school and residency training, they’re unlikely to re-locate to an area where they will lose money on almost every patient they see.

It’s easy to make expanding Medicaid a fix-all boogeyman.  But even if expanded to cover a relatively small portion of those who don’t already qualify, the hospital and other health care professionals are left with the same problem:  The vast majority of the patients they see will never cover their basic operating costs, must less yield a profit.  And without profits, there is a systemic disincentive to deliver services.

That part of the problem is very real. But it’s not something that fits very well on a bumper sticker.

Fixing it will require more than a sound bite.  Instead, we’re likely to see short term political battles continue to cloud the long term problem.  And even more importantly, potential solutions.