Health care has been a minor part of the U.S. Senate race in Alabama dominated in large part by President Donald Trump. But the person who takes the oath of office next January will represent a state with many challenges on that front.

The endemic poverty that has gripped the state since its founding drives most of Alabama's health challenges. According to the Kaiser Family Foundation, a Washington D.C.-based nonprofit that studies health care issues, life expectancy in Alabama is 75.5 years, compared to 78.7 for the United States as a whole. The state's rate of death from cancer (170 per 100,000) is higher than the national average (152.5 per 100,000), as is the rate of death from heart disease (223.2 per 100,000 deaths in Alabama in 2017 v. 165 per 100,000 nationwide).

Despite some recent improvements, the state’s infant mortality rate of 7 deaths per 1,000 births remains higher than national averages. The infant mortality rate for African-Americans — 11 per 1,000 — is more than twice the rate for whites (5.1 per 1,000).

“I see it as a symptom of the underlying problem, why we have such disproportionately high poverty,” said U.S. Rep. Bradley Byrne, R-Mobile, running for the Republican nomination for U.S. Senate. “Some of that goes back to issues with the education system. Some of that goes to losing manufacturing jobs in Alabama that hasn’t come back.”

Over 1 million Alabamians – about 21% of the state population -- received insurance through Medicaid or the Children's Health Insurance Program (CHIP) in 2017, according to the Alabama Medicaid Agency. That’s despite strict eligibility requirements that make it next to impossible for able-bodied, childless adults to qualify. The program chiefly serves children, the elderly, and the disabled.

About 148,000 Alabamians receive health insurance through the Affordable Care Act (ACA). The Trump administration is pursuing a lawsuit to repeal the ACA, including requirements for insurers to cover people with pre-existing conditions. In late January, the administration unveiled a proposal to allow states to apply for block grants for Medicaid funding, though the current proposal appears targeted at populations that are a small part of Alabama’s current Medicaid population.

Democratic U.S. Sen. Doug Jones plans to put health care at the forefront of his general election campaign. In a recent interview, Jones criticized the Trump administration’s lawsuit to overturn the ACA, saying it would create “chaos in the marketplace,” and criticized Republicans for what he called a lack of serious ideas about a potential ACA replacement.

“They have talked a good game,” he said. “This goes back to purely a political issue. No one on the other side has really cared about the health care of the citizens of Alabama.”

Jones also called block grant proposals “the first step in getting rid” of Medicaid. The senator said he does not support Medicare for All, a proposed single-payer health care system, saying “it’s too expensive and I think there are other ways we could do it.” He said a public option – a government-operated plan that would compete with private insurers – would be “an opportunity and a way to go.” Jones also said he would like to give Medicare the ability to negotiate for “at least some prescription drugs” as a way to control prescription drug prices.

The GOP candidates broadly support fewer restrictions on private insurance companies and what they call “free market” solutions, though their opinions run on a spectrum. Byrne said in an interview he supports the lawsuit to overturn the ACA but says he would support preserve some of the more popular features in anything that might succeed the law.

“You have to have protections for pre-existing conditions,” he said. “And then what I would like to do is give maximum flexibility to consumers to buy the type of policy a consumer wants that suits them.”

Attempts to get comment from former U.S. Sen. Jeff Sessions’ campaign were unsuccessful. As U.S. attorney general, Sessions in 2018 oversaw the U.S. Justice Department’s decision to stop defending major parts of the ACA, including the pre-existing conditions coverage. (Trump later claimed that Sessions did this without notifying him; Sessions said Trump agreed to the move.) The former senator has not addressed his approach to health care on his website.

The Tommy Tuberville campaign did not respond to emails for comment. Tuberville’s website says the former Auburn head football coach supports the repeal of the Affordable Care Act and called for a free market-driven health care model “where companies compete for your business while ensuring that pre-existing conditions are not a deterrent to obtaining quality insurance and care.” Tuberville does not appear to have a specific plan that he favors.

In a recent interview, Tuberville said he would oppose cuts to Medicare and Medicaid.

Former Alabama Chief Justice Roy Moore said in an interview he believed there was “no provision for the federal government to be involved in health care.” Moore sounded supportive of Medicare but said “we should cut down on the Medicaid.”

“I'm simply saying that whatever is done is done, perhaps, but we should be less involved with health care at federal government (level), because there's no provision for the federal government to be involved in health care in the United States Constitution,” he said.

There are a few areas of agreement. Jones and Byrne, for example, both supported recent efforts to raise the Medicare Area Wage Index, which provides more funding for the state’s struggling rural hospitals. Byrne says he supports the expansion of community health centers to address the crisis in rural health care, which he said provide a “more cost-effective way to provide outpatient care to people.” But Byrne said he does not believe they are “substitutes for quality hospitals at all” and says he will work to ensure rural hospitals get federal funds.

Jones says he believes expansion of Medicaid could help address many issues in state health care. Jones has pushed a bill that would give Alabama the same 100 percent match over three years that the first states to adopt expansion got it. Jones is also sponsoring a bill called the Healthy Maternal and Obstetric Medicine Act, which would extend Medicaid eligibility for postpartum women for a year after birth.

“That would be a huge deal,” Jones said. “It gives better health care outcomes for a long time. We’ve got a real problem with infant mortality and maternal mortality, which is especially high for women of color.”

The primary for Senate is March 3.

USA Today congressional reporter Christal Hayes contributed to this report.

Contact Montgomery Advertiser reporter Brian Lyman at 334-240-0185 or blyman@gannett.com.