As we continue this series on the five geographic and economic regions that define the governing coalitions that control Georgia politics, it’s time that we consider the politics of health care delivery in the state.  The Affordable Care Act nationalized the health care debate.  And yet, our politics – and healthcare – is local.

Healthcare is the one policy issue that could unite the entire state against the almost majority of Georgians that live in the Atlanta suburbs.  Rural Georgians, both in the Mountains and in South Georgia, are watching their hospitals shut their doors. 

Arlington, Folkston, Hartwell, Glenwood, Ellijay, and Richland have all seen their hospitals close.  Just this month, a last minute sale has saved Millen’s hospital from shutting down.

Atlanta’s Urban Core has seen hospitals experience financial issues as well.  Southern Regional Medical Center in Riverdale was bankrupt and on the verge of closure in 2015 before being rescued. 

Even on Georgia’s coast, there have been challenges.  The future of Chatham County’s Memorial Hospital was up in the air until an April deal was made with Hospital Corporation of America to retire debt and invest $280 million for capital improvements. 

With the known problems across the state, it would seem that there would be a majority coalition of voters demanding long term solutions.  Thus far, there is not.

The first barrier to finding workable solutions has been mentioned.  As long as there is a national debate over the future of our healthcare system, state and local solutions take a back seat.  This is partially due to an electorate that has their focus on Washington, but state lawmakers are reluctant to spend the political capital necessary to fix this very complex problem if Washington is just going to change the rules on them.

While many are quick to make this debate about an expansion of Medicaid, there’s more to it than that.  Georgia currently underfunds the existing, non-expanded Medicaid program.   Healthcare providers’ estimates on how much they lose per Medicaid patient to be between thirteen and seventeen cents on the dollar. 

For every dollar Georgia doesn’t fund into Medicaid, two dollars from the Federal Government are not sent to providers as reimbursement.  Thus, closing the gap and ending the reliance on doctors and hospitals to subsidize indigent care would require Georgia to come up with one third of the money, with the federal government providing the additional two-thirds.

In rural Georgia, it is estimated that 80 percent of patients are on Medicaid, Medicare, or are uninsured.  A doctor or hospital can expect to lose money treating a patient in any of these groups. 

This directly contributes to a shortage of physicians.  No one graduating medical school would want to start a practice in an area where they will lose money on almost every patient they see. 

Adding to the challenge of fixing the problems is that those in Suburban Atlanta don’t have these issues. In politics, when the majority of the voters that comprise the votes in primaries for the majority party don’t see a problem, those problems are often going to be ignored.

In Atlanta suburbs, there are several thriving and competing hospital systems.  They continue to grow larger, adding new and impressive facilities across Atlanta’s suburbs – areas that have relatively few Medicaid recipients, and plenty of customers carrying employer sponsored health insurance who are able to meet their co-pays and deductibles.

Adding additional voter antipathy toward hard or expensive solutions is that Georgians over the age of 65 receive Medicare coverage from the federal government.  There’s little appetite of these Georgians to pay more in state taxes to fix a problem that most of them don’t have. 

There is one way to get many suburbanites to begin paying attention to the Medicaid system.  Medicaid is now paying for 60% of long term nursing home stays because of the cost, according to AARP.  As baby boomers are now in an age range where long term care becomes a need and concern, a stable and healthy Medicaid system will become increasingly more desirable across a larger pool of voters.

Politics, however, is often an exercise in self-interest.  Until those who have decent healthcare access and coverage have a reason to invest in solutions, the problems will likely remain identified but unsolved.

Charlie Harper is the publisher of GeorgiaPol.com and the Executive Director of PolicyBEST, which focuses on policy issues of Business Climate, Education, Science & Medicine, and Transportation.