At Cooper Green, Jefferson County delivers a different quality of health care than the other 66 counties, which don’t operate their own hospitals.

When it comes to how it spends money, what makes Jefferson County so different from the 66 other counties in Alabama?

That question used to be easy to answer. It was people like Larry Langford and Jack Swann. It was miles of sewer “rehab work” in areas such as the Cahaba River watershed where there had been no sewer before. It was checks hand delivered to Computer Help for Kids and then spent in casinos by former Commissioner John Katopodis. It was hundreds of thousands of dollars spent on accounting software that couldn’t muster basic arithmetic. It was a sheriff’s office flying a helicopter to special events, but never so much for fighting crime. It was commissioners traveling to New York for hard nosed negotiations with Wall Street, who spent their nights sleeping at the Plaza and their days in spas and high-end clothing stores.

But all of that has changed. The money is gone, and the people who burned through it are gone too, many of them to prison. The county has cut its general fund spending nearly in half. The current commission is honest and hard working.

So why is Jefferson County still so screwed up?

Obviously the problems created by former officials would never disappear overnight, but some of them are more contained that you might suspect. The sewer debacle is, at least for the moment, quarantined. Under the bond indentures — the county’s contracts with Wall Street for this debt — in the event of a default, the creditors are entitled only to net sewer revenues. They can’t touch any of the other taxes we pay. So let’s set the sewer mess aside for a moment and look at the rest of the budget.

For the last 15 years Jefferson County has wrestled with the legality of its occupational tax. While cities such as Birmingham can levy an occupational tax with no problem, the county’s tax has been wildly unpopular, and Alabama lawmakers, who have a bad habit of meddling with the county, have alternately tried to kill the tax and reinstate it. For Jefferson County, dealing with Montgomery has been like negotiating with a dangerous person with multiple personality disorder. Goat Hill giveth and Goat Hill taketh away.

The county is again going back to the legislature this spring to seek a new occupational tax to replace the one that was thrown out by the courts that replaced the previous one that was ruled by the courts to have been repealed by the legislature, even though a lower court had said the repeal was illegal and the tax was fine. Got all that? Don’t worry. It doesn’t matter nearly so much as why the county needs this money to begin with. Again, what makes Jefferson County different than all the other counties that don’t have or need an occupational tax?

There are lots of things that make Jefferson County different from its peers, but one stands out: Cooper Green Mercy Hospital.

Jefferson County has two percent sales tax. The rest of the sales tax you pay when you buy something here either goes to the state or the city where you make your purchase. Of those two pennies on the dollar you pay to the county, one goes to pay school construction debt.

Of the other penny, nearly two thirds of it is earmarked by the Legislature for things other than the general fund — Cooper Green, the Jefferson County Health Department and the BJCC. Of those three Cooper Green receives the bulk of the earmark — about $40 million.

Additionally, until last year, the county supplemented Cooper Green with up to $9 million a year out of its general fund.

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That’s almost $50 million per year Jefferson County spends on indigent health care. The next county after Jefferson, Tuscaloosa, spends about $7 million per year on indigent health care, according to county officials.

At Cooper Green, no matter what people think about it, Jefferson County delivers a different quality of health care than the other 66 counties, which don’t operate their own hospitals. And mind you, this is a service that is mandated by state law. And mind you, it’s expensive.

It takes a lot of figuring to get to the answer, but this is what makes Jefferson County different than the 66 other counties in the state.

The next questions are obvious: Do Jefferson County citizens want to continue offering indigent health care? And if so, are they willing to pay for it?

These are questions that need answers soon, and it will likely fall to Alabama lawmakers to answer them for their constituents.

Last year, the county commission cut off Cooper Green’s subsidies from its general fund, about $9 million per year. Now the hospital is beginning to fall behind on its bills. Last week the Birmingham News reported that Cooper Green has at least $1 million of unpaid invoices. When the commission cut the hospital off from the general fund, county officials figured it was only a matter of time before Cooper Green hit a wall. It looks like that time is come.

Un-earmarking the money for Cooper Green won’t be enough, says County Commission President David Carrington.

“The fact of the matter is, we have a hospital, and just because you un-earmark it doesn’t mean that hospital or the indigent go away,” Carrington says.

Carrington says he is not afraid of a debate on the role of government in health care, but the county can’t wait on that debate before a budget fix. The county needs revenue first. Eventually, though that debate needs to happen.

“Until this community is willing to gather together — black and white, rich and poor, young and old, Republican and Democrat — and actually have a meaningful conversation on what is cost effective quality care for the indigent mean, and how we implement it, we’re always going to have problems,” he said.