Alabama's 2nd congressional district has tens of thousands of uninsured residents, rural hospitals that are closing crucial services, and counties with higher mortality rates than the rest of the state.
The issue of health care and health insurance remains a top concern in a South Alabama district that stretches from Mobile to Montgomery and traverses through the rural Black Belt region.
Republican Caroleene Dobson and Democrat Shomari Figures agree that there is a healthcare crisis within a congressional district that is a majority Black and has a higher-than-average poverty rate. But how to resolve it has created differences in philosophical and political viewpoints ahead of the Nov. 5 general election.
Dobson, in short, wants less government involvement in health decisions; Figures said that lawmakers need to expand federal programs like Medicaid to address the uninsured coverage gap.
"There is a healthcare crisis in the Second Congressional District, and it is impacting the ability of the elderly to access needed services, and it is preventing young people from staying, opening businesses, and putting deep roots in the area," Dobson said. "Solving the challenge is going to take innovative thought and a willingness to reach across the aisle and work with the other party, which I am fully committed to doing."
Figures calls the issue one of the single most important matters in the congressional campaign.
"For all intents and statistical purposes, when you were born in Alabama, you were born into a state with the worst life expectancy of any state in the U.S.," Figures said. "That's where this conversation has to begin. And when we talk about rural health care, those outcomes are even worse. They have fewer health practitioners, ambulances ... the life expectancies are even worse."
The Centers for Disease Control (CDC) lists Alabama as the fourth worst case for life expectancy in the United States.
The issue is also getting lumped into the increasingly bitter contest in a high stakes battle in which the outcome could help tilt the majority in the U.S. House.
Dobson, a Montgomery attorney, is accusing Figures of supporting policies of the Biden Administration which she claims have contributed to inflation and hurt the economy and the ability for rural residents to afford groceries.
Figures, a Mobile attorney, says Dobson backs extreme right-wing opinions crafted in the Heritage Foundation's Project 2025 document, and is "out-of-touch" with the poor, rural Black voters within the 2nd district. He also accuses his Republican opponent of backing policies that would lead to people losing their health insurance.
Figures said the priority and focus of the 2nd district representative should be on expanding Medicaid under the Affordable Care Act (ACA). He said the expansion will help the state reverse hospital closures, create more access to care, and increase life expectancy.
None of the 13 counties within the 2nd district has a life expectancy that is any better than the state's average of 73.7 years, let alone coming close to the national average of 76.4 years.
There is limited action a member of Congress can do on Medicaid expansion, which would need to be authorized by the state legislature and signed by Republican Gov. Kay Ivey. The governor has expressed concerns about the long-term costs of expansion.
Figures said he would support initiatives to expand the reimbursement program under the ACA. That program has since ended, and Alabama remains one of 10 states that did not expand Medicaid under ACA to assist in covering the uninsured.
"We need to open that window, first and foremost," he said. "That's the biggest thing Congress can do to incentivize Alabama to expand Medicaid. This is an issue of life or death."
Without expansion on the state level, Figures said he is a proponent of simply offering direct funding to state and local levels "to get health care services to the rural areas."
"They literally do not have options," he said. "Starting a federal program, that is what we can do at the congressional level. The State of Alabama needs to get its act together to expand health care options in this state."
Dobson said that health care is becoming out-of-reach for Americans due to "skyrocketing premiums and rising prescription costs."
She said that good health care "starts with a strong economy, where good jobs provide good health benefits," and she said the Biden administration's economic policies have failed Alabamians.
Dobson has also said she will honor the federal commitment to families and retirees who have contributed to Social Security and Medicare and protect the rights of patients with pre-existing conditions. She does not support "Medicare for All" Act, establishing a single-payer national health insurance system.
Dobson said that such a system would disallow private insurance and "turns all healthcare services and decisions over to the federal government."
Said Dobson, "It would explode our state and federal budgets and take away your ability to make the best healthcare choices for you and your family."
Figures has accused Dobson of supporting a complete repeal of the ACA, something that Republicans attempted to do in 2017. The ACA's popularity, though, has peaked in the past year and six in 10 voters surveyed by Kaiser Family Foundation (KFF) say they support the federal health law first enacted in 2010 and commonly referred to as Obamacare.
Dobson was cited in an Alabama Daily News article in December of supporting a repeal of the ACA. But her campaign spokesperson, last week, told AL.com that is not her position.
"Caroleene understands that a full repeal of the Affordable Care Act would be impossible because it has become such a foundational and intertwined part of the healthcare infrastructure, and a domino effect would result," said Drew Dickson, a spokesperson with the campaign.
Figures said it's "imperative we do everything we can to protect the Affordable Care Act," accusing Republicans of continuing to want to rescind the law.
"It would mean millions of children kicked off their parents health care," Figures said. "It would put us back in that era and in a position of significantly reducing the number of people who will be covered by health insurance and where people don't go to the doctors until they are sick and critically ill and increases the stress put on our health care providers."
The KFF polling showed that three in four adults are worried about being able to afford unexpected medical bills (74%) or the cost of health care services (73%) for themselves and their families. About half of insured adults say they are worried about being able to afford their monthly health premiums, the polling showed.
Dobson, on her campaign's website, said that if she is elected, she will fight against surprise medical billing and support initiatives to ensure fairness in healthcare pricing and ensure that "lifesaving treatments" are accessible to Alabama residents.
She told AL.com that she also believes that "addressing the flood" of undocumented immigrants into the U.S. will help resolve the healthcare crisis.
"Hospitals are required to treat (undocumented immigrants), and it is proving to be a financial burden they cannot sustain," she said.
Figures said that Dobson is a supporter of the policies within Project 2025, the controversial document that Trump has publicly disavowed. Dobson, herself, has said she hasn't read the policy proposal for a future Republican presidential administration, and believes Figures is "obsessed" with the matter.
Project 2025's authors - some of whom were staffers in the Trump administration -- propose rolling back Medicaid access and creating work requirements as a condition of coverage while instituting lifetime caps on benefits. The document also calls for rescinding the Inflation Reduction Act, which capped out-of-pocket spending on prescription drugs and insulin costs.
"I think Project 2025 would do nothing but exacerbate the issues we have in an expedited fashion," Figures said. "We cannot afford that."
Dobson said she has never read and is completely unfamiliar with the document.
"His campaign apparently believes if they repeat a lie often enough, it becomes the truth, but it doesn't - it only makes them liars," she said. "Instead of Project 2025, I am focused on 2024 and solving the runaway inflation and high prices that Shomari Figures and his D.C. insider supporters helped create. Alabamians are suffering sticker shock in the grocery aisles, and the costs of feeding the average family, even in a fast-food drive-thru, are outrageous."
The two candidates are also clashing over whose background makes them more adept at addressing health care concerns. Dobson, a rural Monroe County resident, said she is the "only candidate who has first-hand experience with the healthcare struggles and challenges of rural Alabamians."
She also said her mother helped support her family by working as a physical therapist in the rural portions of the 2nd district.
Figures said that Dobson, having grown up in Monroe County, should have "seen that level of poverty and lack of access and life opportunities in general" that permeates the 2nd district. He said that Dobson should have been more supportive of health care policies that include expanding more federal options.
"The positions of her policies are indicative to the fact she is out of touch with much of the needs in the district," he said. "Too many people live at or below the poverty line."
The concerns about rural health care in the 2nd district are likely to continue for years beyond the election. Cities are grappling with the potential of losing healthcare services - two hospitals in or near the district have shuttered labor and delivery units in the past year. The most recent one, in Clarke County, leaves mothers with the prospect of driving 80 miles to give birth at the nearest labor delivery unit or to have their child delivered in an emergency room.
Figures said he would like to see more to "leverage every resource possible," explore more public-private partnerships, and expand services at the county and local levels.
He said that in Crenshaw County, the pending closure of Physicians Choice Dialysis is creating a situation where residents in the small city of Luverne will need to drive over an hour for dialysis treatment. He said that scenario will create a likelihood of people missing their future appointments "which means having them living a shorter life has skyrocketed."
"We have to expand our healthcare networks, increase funding for community health centers and foster partnerships with reputable companies capable of delivering quality, affordable healthcare to our district so that the care we deserve is available on time, every time," Figures said.
Dobson vows to be proactive in protecting the rural healthcare and hospitals that continuing to face a stark reality: According to the Alabama Hospital Association, more than a dozen rural hospitals statewide are facing closure amid bleeding red ink.
"As a daughter of a woman who dedicated her career to helping serve the healthcare needs of rural Alabamians, I will be proactive in taking the action and crafting the legislation that will best allow rural hospitals across Alabama to grow, thrive and succeed," she said.