With repeal of the Affordable Care Act looming, the health care world is buffeted by an unusual level of uncertainty.

Advocates of the repeal plan say it will be an improvement over the ACA, while defenders of the 2010 health law paint a dire picture of what could come next. Health organizations large and small are feeling apprehensive, wondering what will happen in Washington.

Georgia’s rural hospitals, already in precarious financial situations, are feeling the anxiety acutely. And lawmakers in the General Assembly are looking at different financial tools to ease this pressure on rural medical providers.

“There is more uncertainty now than there has ever been,’’ Jimmy Lewis, CEO of HomeTown Health, an organization of rural hospitals in Georgia, said Monday.

That uncertainty is about more than just Obamacare, as the ACA is commonly known. Rural health care in Georgia has been in a state of crisis for some time, with five hospitals having closed since the beginning of 2013.

Some of the rural hospitals that have hung on are in a daunting financial predicament. Georgia has the third-highest rate of uninsured people, who often cannot pay for the hospitals’ services. Many other patients have high deductibles and, after getting the hospital services, wind up as bad debt.

Georgia has opted not to expand its Medicaid program under the ACA, which would have extended coverage to many of these uninsured people. Now, with Congress moving toward repealing the ACA, expansion is off the table here, at least for now. So the state is not likely see an increase in its insured patient rate any time soon.

Some hospitals, meanwhile, are asking their counties to raise funds to keep them operational. These include Monroe County Hospital in Forsyth.

This March, Monroe County voters will decide whether to approve a 1-mill property tax increase that would go to the hospital. The increase, if approved, would generate about $1.2 million in revenue, while bonds may be issued to cover remaining expenses to keep the hospital’s doors open, the Macon Telegraph reported recently.

“Not only do we need more patients, we need more patients that are paying,” said Tony Ussery, chairman of the Monroe Hospital Authority, according to the newspaper.

Jefferson Hospital in Louisville is asking for 3 mills of temporary taxes to help support operations, a proposal also heading for a March referendum.

About half of rural hospitals are getting a subsidies from their counties to stay afloat, said Lewis of HomeTown Health. Many county governments realize that a hospital is not only a major employer, but also a vital component for economic development. An area with no hospital is unlikely to attract potential employers.

In some places, even though hospitals remain, cutbacks in services are considered. The emergency department at Cook Medical Center in Adel in South Georgia is closing. Ironically, that ER just treated more than a dozen victims of the deadly tornado that ripped through the area this month.

For rural hospitals and physicians, “the core issue is resources,’’ says Chris Kane, a consultant with DHG Healthcare. “They lack the people and money to monitor and adapt to the endless shifts in federal regulations and incentives.”

Many health care leaders are adopting a “wait and see’’ posture on potential ACA changes, Kane said.

Hospitals and the provider fee

In recent years, Gov. Nathan Deal and state lawmakers have taken steps to respond to the rural medical crisis.  Deal has created a rural hospital stabilization project, which now involves extra support and funding for seven facilities.

The Georgia Legislature last year took action to create a tax credit program for individual and corporate donors to rural hospitals. The main sponsor of the initiative, Rep. Geoff Duncan, a Cumming Republican, now is trying to raise the level of the tax credit to increase the number of potential donors.

Duncan told GHN on Monday that he’s also introducing a bill that would help fund up to 100 additional community health centers in Georgia. These federally qualified health centers could increase access to rural health services, he said, for all kinds of patients, including veterans.

Meanwhile, the hospital industry is united in its support for Georgia renewing the hospital provider fee, which would raise an additional $600 million in federal funding for the state’s Medicaid program. Passage of the fee by the General Assembly is expected, and hospital industry officials say it’s critical to stave off Medicaid reimbursement cuts.

Monty Veazey, president of the Georgia Alliance of Community Hospitals, said that “as the impending closure of Cook Medical Center’s emergency room shows, too many communities in Georgia have either been left without access to health care or on the brink of losing it. We are glad to see the legislature moving so quickly to renew the hospital provider fee.”

The Senate Finance Committee passed the provider fee legislation Monday.

Meanwhile, with ACA repeal imminent, GOP lawmakers in Washington have discussed turning Medicaid into a block grant program, capping the amount a state could get from the federal government. This would allow states to make their own rules on eligibility and benefits.

Depending on how it’s constructed, a block grant “could be good or could be devastating.” Lewis said.

Greg Charleston, an Atlanta-based consultant and a senior managing director at Conway MacKenzie, says rural hospital leaders are almost accustomed to such wholesale changes.

“Rural hospitals have been dealing with a great deal of uncertainty for many years,’’ he said. “The Affordable Care Act has been evolving. Parts of it have been delayed and parts have changed since being enacted. Therefore, this uncertainty is somewhat more of the same for them.”