1. No Significant Regulatory Reform in Alabama.

Unlike many states in recent years, Alabama’s Certificate of Need (CON) laws remain essentially unchanged. While it is not unusual for bills to be introduced making significant cutbacks, those attempts have not yet gained any traction in the Alabama legislature.

2. Further Consolidation of Healthcare Providers.

2023 saw USA Health’s acquisition of Providence Hospital from Ascension Health for $85 million in Mobile, Alabama.^[i] In North Alabama, Huntsville Emergency Medical Services Inc. (HEMSI) merged with the Huntsville Hospital Health System as of January 2024.^[ii]

3. Expansion of Healthcare Providers.

There were a number of investment and expansion announcements from Alabama healthcare providers in 2023. Cullman Regional Medical Center invested $30 million in capital improvements, which will include the addition of critical care and medical-surgical units.^[iii] The Chilton County Healthcare Authority broke ground on a new $6 million medical office building to attract more physicians to the area.^[iv] Huntsville Health System^[v] integrated with yet another North Alabama-based health system, DeKalb Regional Medical Center.^[vi] In Mobile, a brand new multi-million-dollar pediatric emergency center was opened in early January 2024 at the Children’s & Women’s Hospital of USA Health.^[vii]

In an effort to “get ahead of the curve,” in 2023 the City of Hoover and the Hoover Health Care Authority (HCA) created the “Hoover Health Care District” (the “District”).^[viii] To break ground on the healthcare services to be offered within the District, the HCA in January 2024 “filed a [CON] application with the State Health Planning and Development Agency (SHPDA) for an Ambulatory Surgical Center and Diagnostic Facility.”^[ix]

Set to open in Fall 2025, East Alabama Health recently announced that it had secured approval from the CON Board to construct a new mental health facility—a $30 million, 54,000 square foot freestanding psychiatric hospital.^[x]

Finally, an investment area in 2023 appears to be freestanding emergency departments (“FED”), which continue to spread throughout Alabama. The first FED to open was in Birmingham in 2015.^[xi] At the start of 2023 there were only 8 FEDs^[xii] in the state, but at least 6 have been built since then, averaging $20 to $30 million per FED.^[xiii]

4. Continued Expansion of Private Equity.

In 2023, private equity (“PE”) firms continued to expand their presence in healthcare across the nation. One 2023 report, released in January 2024, suggests that North American healthcare PE “announced deal values came in around $29 billion, with biopharma accounting for 25% of deal activity and 54% of deal value.” The same report notes that while activity in healthcare provider business slowed due to inflation and labor market pressures, PE firms nonetheless closed a number of substantial healthcare provider deals last year.^[xiv] This trend towards increased PE activity will continue in 2024. However, it is important to note that Alabama’s regulatory environment has made it challenging for some PE firms to thrive.

• Medical Properties Trust (MPT), headquartered in Birmingham, is the nation’s largest hospital leasing company with approximately $18.3 billion in total assets.^[xv] Recent reports suggest growing losses to one of its largest tenants, Steward Health Care Systems. MPT reported a 2023 fourth-quarter net loss of a staggering $664 million, “driven by $772 million of write-offs and other impairment charges mainly related to Steward, a Dallas-based hospital chain trying to stay out of bankruptcy.”^[xvi] Despite these losses, “Edward K. Aldag, Jr., Chairman, President and Chief Executive Officer, [recently] said, ‘Our primary focus is on accelerating our capital allocation strategy by pursuing transactions expected to generate at least $2 billion of incremental liquidity in 2024.’”^[xvii]
• Effective September 30, 2023, private equity-owned Help at Home, Alabama’s largest provider of home care services, abruptly left the state. With nearly 800 caregivers helping over 1,100 patients, this departure from Alabama “‘had a significant effect,’ according to Debra Davis, deputy commissioner for the Alabama Department of Senior Services.”^[xviii] Help at Home cited Alabama’s reimbursement and regulatory environment, claiming it was too difficult to recruit and retain enough caregivers.^[xix] Actions such as this may eventually lead to regulatory changes in Alabama, considering in 2023 “24 states enacted laws related to health system consolidation and competition.”^[xx]
• It was announced in January 2024 that Primordial Ventures, a medical supplies manufacturing company, plans to establish a $3.3 million high quality medical supply production hub in Birmingham. “Primordial Ventures manufactures and distributes supplies such as catheter kits, urine bags, cadaver bags and medical-grade tubing using high-density polyethylene, low-density polyethylene, and polystyrene resins.”^[xxi] After considering several cities throughout the southeast, Primordial found Birmingham to be the most strategic decision for its mission and vision.^[xxii]

5. Legislative updates.

After an extensive review by the Alabama Board of Nursing in an effort to expand access to care for Alabama patients and to the rural community, “the various voices of advanced practice nursing in the state were unable to achieve consensus on [an] APRN Compact.”^[xxiii] If passed, “[t]he APRN Compact would allow advanced practice nurses in states that join the Compact to practice freely in any other APRN Compact state.”^[xxiv]

An interesting 2024 development in Alabama is the $26.4 million investment to Alabama School of Healthcare Sciences Foundation to fund a first-of-its-kind residential healthcare high school in Demopolis, Alabama.^[xxv] 

A bill recently introduced in the Alabama Senate would “prohibit an occupational licensing board from taking adverse action against a health care professional, including a physician, physician assistant, or nurse practitioner, who recommends an off-label medical treatment,” and establish a cause of action against an occupational licensing board who takes such actions in violation of the bill.^[xxvi] Under the bill, patients would also be required to provide written, informed consent to receive a recommended off-label medical treatment if the treatment is not used in a manner approved by the FDA.

A bill introduced in the Alabama House would require “health care providers in clinical settings that maintain a supply of durable medical equipment and medical supplies for potential use by a patient covered by Medicare, Medicaid, or a health benefit plan” to file a Certificate of Exemption with the Department of Revenue to be eligible for a tax exemption of these items.^[xxvii]

As reported by Maynard’s Government & Regulatory Affairs Group:

[A] bill, sponsored by Representative Chip Brown, proposes to require genetic testing companies to obtain express consent from consumers before they can retain, use, or share their genetic information with third parties. In addition, the bill imposes civil penalties for genetic testing companies that violate this requirement. The Office of the Attorney General would oversee the enforcement of these provisions. This bill received a favorable report from the House Judiciary Committee this week after some amendments were made, including a carve-out for requesting law enforcement agencies with a valid subpoena.^[xxviii]

6. 340B Litigation.

In February 2024, Baptist Health in Montgomery was the first reported Alabama health system to have sued to recoup Medicare Advantage payments under the 340B Drug Pricing Program that were unlawfully cut in 2018 by the Department of Health and Human Services (HHS).^[xxix]

7. Alabama Supreme Court IVF Ruling.

On February 16, 2024, the Alabama Supreme Court issued a ruling significantly impacting in vitro fertilization (“IVF”) clinics. Essentially, the Court “characterized frozen embryos [from IVF] as people, indicating that any destruction of these frozen embryos could be considered a crime.”[xxx] “The justices wrote, ‘the text of the Wrongful Death of a Minor Act is sweeping and unqualified. It applies to all children, born and unborn, without limitation.’”^[xxxi] As a result of the ruling, three (3) IVF clinics have already closed in Alabama as they evaluate the risk of criminal prosecution or “punitive damages for following the standard of care for IVF treatments[.]”^[xxxii]

In an effort to resolve the concerns of IVF clinics and patients, both the Alabama House and Senate have passed legislation. As reported by Maynard’s Government & Regulatory Affairs Group:

The legislation would provide civil and criminal immunity to persons providing goods and services related to IVF, except acts or omissions that are intentional and not arising from or related to IVF services. While the legislation passed in both the House and Senate, there was a serious debate on the best way to address this issue in both chambers, and some members raised the point that a long-term solution addressing the concerns of IVF clinics could require a constitutional amendment. The Governor is expected to have an IVF bill to sign on her desk next week.^[xxxiii]

These bills continue to be discussed and debated by the Alabama legislature.

8. Federal Government Clawbacks of Covid-19 Provider Relief Fund Payments.

On September 21, 2023, the U.S. Government Accountability Office (“GAO”) released a report suggesting that the Health Resources and Services Administration (“HRSA”) was still attempting to clawback $1.36 billion of the $2.62 billion in Provider Relief Payments that were previously identified for recovery.^[xxxiv] According to the GAO’s report, recoverable funds include overpayments, unused payments, and payments received during the distribution period by providers who failed to comply with the reporting requirement.^[xxxv] In August 2023, HRSA established a timeframe to distribute final repayment notices to providers, announcing that all identified providers should receive a notice by April 2024.^[xxxvi] Once HRSA issues a final repayment notice to a provider, the provider has 60 days to return payment to HRSA or request a decision review to appeal HRSA’s request.^[xxxvii] In the first few months of 2024, providers in Alabama should be on the lookout for these final repayment notices and act quickly to provide a response to the HRSA. Providers who do not take action within 60 days are referred to debt collection services within the Department of Health and Human Services (HHS), which may result in a lengthy resolution process or higher payments in the form of penalties and fees.

In addition to HRSA clawbacks from providers who received Provider Relief Fund payments, the DOJ is also continuing to audit and investigate recipients of PPP loans and other CARES Act funding, bringing fraud allegations on those who have abused those programs.

9. Rapid Development in Artificial Intelligence (AI). 

Over the past couple of years, generative AI has revealed a promising transformative potential that transcends nearly every industry. As lawmakers scramble to develop an adequate regulatory and policy framework, perhaps all that can be said for certain about the future of AI in healthcare is that it’s here to stay. Recent AI investment in Alabama has included the following:

• In October 2023, the White House designated Birmingham, Alabama as one of 31 “Tech Hubs” across the nation.^[xxxviii] The Birmingham Biotechnology Hub (the “Hub”) aims “to become a global leader in drug, vaccine and diagnostics development” by utilizing AI-driven biotechnology to increase representation in clinical genomic data and clinical trials. ^[xxxix] Through the increased use of AI-trained with inclusive patient data, the Hub seeks to “shorten the drug development pipeline and deliver affordable drugs, vaccines and diagnostics that treat a diverse global patient population.” ^[xl]
• HData, a regulatory technology company based in Birmingham, announced they will be working with Southern Company to launch a pilot program that uses AI to manage regulatory data at electric and gas utilities. This pilot program aims to explore the potential benefits of regulatory AI across key subject areas. [xli]

• In March 2023, an Auburn-based public-private partnership established the Alabama Artificial Intelligence Center of Excellence (AAICE) “to improve the development and understanding of artificial intelligence and machine learning.”^[xlii] AAICE’s central focus is workforce development, and the organization provides educational programs designed “to help meet the high demand for data science, medical informatics, cybersecurity, and AI professionals.” ^[xliii] The AAICE discusses the potential for AI in the healthcare industry, noting that AI’s ability to analyze vast amounts of patient data can improve the accuracy of diagnoses and aid in developing more personalized medicine and treatment plans. Additionally, the AAICE aims to promote the use of AI-powered chatbots and virtual assistants to increase patient accessibility to medical advice and assistance. ^[xliv]

• Also in 2023, the University of Alabama in Huntsville (UAH) announced that researchers at UAH had teamed up with Little Orange Fish, a non-profit local to Huntsville, “to pioneer the use of artificial intelligence to enhance the lives of autistic and neurodiverse individuals in North Alabama.” ^[xlv] The project aims to use AI and geographic information systems (GIS) “to map the autism and neurodiversity ‘ecosystem’ in North Alabama” in order to increase accessibility to mental healthcare and treatment for neurodiverse persons and their families in the region. ^[xlvi]

• Finally, in April 2023, Digital Diagnostics announced that it would be expanding its AI-diagnostic system, LumineticsCore, into nine Labcorp patient service centers across Alabama, increasing access to diabetic care throughout the state. LumineticsCore uses AI to detect diabetic retinopathy in patients “by analyzing retinal images for signs of disease without the need for a specialist to interpret the images.” ^[xlvii]

Legislators have yet to promulgate a comprehensive legislative or regulatory scheme governing the use and creation of AI, but that is not to say there are no laws currently restricting its use.  However, even in the absence of a comprehensive regulatory scheme governing the use and creation of AI there are some existing regulations that should be considered when using or creating AI.

With respect to the use of AI technology in the delivery of care, the FDA oversees the use of AI technology in medical devices and, in fact, in January, accepted the first AI-powered clinical outcome assessment tool into their Innovative and Technology Approaches for New Drugs (Istand) pilot program.^[xlviii]

10. Medicare & Medicaid in Alabama.

Medicaid expansion is intended to extend health care coverage to more low-income Americans. Under Medicaid expansion guidelines within the Affordable Care Act (“ACA”), eligibility is extended to “adults under the age of 65 with incomes up to 138% of the federal poverty level/FPL (133% plus a 5% income disregard).”^[xlix]

(a) Alabama Medicaid Expansion.

So far, Alabama has resisted Medicaid expansion under the ACA, but recent developments suggest growing support for expanding coverage for lower-income individuals and families.

• In February 2024, a group of Alabama lawmakers heard a presentation on a proposed, Alabama-specific plan for Medicaid expansion through a public-private partnership which would use “Medicaid expansion dollars to offer private health insurance through Blue Cross or another qualified insurer to low-income families.” This proposed plan could provide health care coverage to almost 260,000 uninsured Alabamians.[l]
• Another opportunity for Medicaid expansion presented itself in a bill to expand gambling in the state. In February 2024, two bills were introduced to the Alabama House which proposed to expand gambling and create a state-regulated gambling industry within the state. House Bill 152 provides that net proceeds collected from an all-state gaming tax and other revenues collected under this bill may be appropriated for “the purchase of qualified health benefit plans for adults with income below 138 percent of the federal poverty level and parents or other caretaker relatives of dependent children with income between 14 and 138 percent of the federal poverty level to ensure residents have adequate health care services and ambulatory care.”^[li] Under its current wording, the bill would allow—but not require—lawmakers to fund “qualified health benefit plans”.

(b) Continued Growth of Medicare Advantage.

A 2023 report concluded that more than half of all eligible Medicare beneficiaries are enrolled in Medicare Advantage (MA) and that MA accounts for over half of federal Medicare spending. Notably, despite its massive scope, enrollment in MA is highly concentrated among a handful of companies, with UnitedHealthcare and Humana accounting for nearly half of all MA enrollees in the nation. Alabama has some of the highest MA enrollment rates in the country, with 57 percent of those eligible for benefits currently enrolled in MA Plans. [lii] These rates will likely continue to increase in 2024.^[liii]  

11. Life Sciences Continue to Grow Rapidly in Alabama.

It appears that the life sciences industry in Alabama will continue to expand in 2024. The “traditional tech epicenters like California and New York” continue to see substantial declines in startup funding, while “emerging startup hubs like Alabama [have seen] growth.”^[liv] “Growth projects valued at almost $200 million are under way in Alabama’s bioscience sector, setting the stage for robust new research grants and the recruitment of additional scientists to conduct cutting-edge projects.”^[lv]

Already, “Alabama is home to 780 bioscience establishments employing nearly 18,000 people earning average annual salaries exceeding $67,000, according to an analysis produced for BioAlabama.”^[lvi] The state has announced a number of key investments that will impact the industry throughout 2024 and beyond:

• The “[University of Alabama at Birmingham (“UAB”)] research awards break another record, reaching $774.5 million for fiscal year 2023.”^[lvii]
• 2023 saw a multimillion-dollar cancer research laboratory in Birmingham. “The lab is IN8bio’s new research and development facility” that adds 6,000 square feet of wet lab space to its footprint.^[lviii] “IN8bio is a biotechnology company focused on developing novel cellular therapies for cancer, with deep roots in cutting-edge cancer research developed at the [UAB] and other prominent institutes in the southern United States.”^[lix]
• BioCryst Pharmaceuticals, which has a large Birmingham presence, cut research and development (R&D) jobs at the beginning of 2024 amid big plans for one of its clinical programs.^[lx] “The company is anticipating peak sales from this drug could eventually reach $1 billion.”^[lxi]
• Alabama-based digital health company Acclinate was engaged by global biopharmaceutical company Merck & Co. at the end of 2023 to increase participation of communities of color in oncology clinical studies.^[lxii] Acclinate also recently announced the expansion of its Birmingham operations with the addition of 25 new full-time jobs.^[lxiii]
• “BIO Alabama, a leading advocate for Alabama’s bioeconomy, is teaming with AIDT, Alabama’s workforce training agency, to introduce a comprehensive Bioscience Technician Program.”^[lxiv]
• Southern Research’s new $150 million biotech center is set to open in 2024, featuring new commercial wet labs, A/BSL-3 space, data science facilities, vivarium space, and a new clinical diagnostics lab.[lxv]
• The biotech company, BioCryst Pharmaceuticals, that was born in Birmingham, but had its U.S. headquarters moved to Durham, North Carolina, has recently committed to a $22 million expansion of its Discovery Center of Excellence in Hoover, Alabama.^[lxvi] “The project is not the only ‘Discovery’ happening in Alabama’s biosciences sector. In October 2023, Discovery Life Sciences opened the doors to its new global headquarters at the HudsonAlpha Biotech Campus in Huntsville.”^[lxvii]
• “[I]n Birmingham, UAB is constructing the Altec/Styslinger Genomic Medicine and Data Sciences Building — to advance its leadership in precision medicine, genomic science and biomedical research.”^[lxviii] Finally, “[i]n Huntsville, the HudsonAlpha Institute for Biotechnology is also growing in new and exciting directions.”^[lxix]

Maynard Nexsen will be following these and other key health care and life sciences issues in Alabama throughout 2024.

_{[i] Andrea Ramey, University of South Alabama Votes to Purchase Ascension Providence Hospital for $85m, NBC 15 News (Apr. 17, 2023), https://mynbc15.com/news/local/university-of-south-alabama-to-announce-consideration-of-a-strategic-transaction.}

_{[ii] Megan Plotka, HEMSI Merges with Huntsville Hospital Health System to Streamline Services, Help Neighboring Counties, WAFF 48 (Jan. 3, 2024), https://www.waff.com/2024/01/04/hemsi-merges-with-huntsville-hospital-health-system-streamline-services-help-neighboring-counties/.} 

_{[iii] Madeline Ashley, 7 Hospital Expansions in 6 Days, Becker’s Healthcare (Jan. 8, 2024), https://www.beckershospitalreview.com/capital/7-hospital-expansions-in-6-days.html.} 

_{[iv] Claire Wallace, Alabama Medical Office Building Breaks Ground Near Ascension, Becker’s Healthcare (Jan. 9, 2024), https://www.beckersasc.com/new-asc-development/alabama-medical-office-building-breaks-ground-near-ascension.html.} 

_{[v] “The current 11-hospital system includes the Madison Hospital, Athens-Limestone Hospital, the Decatur Morgan Hospital, the Highlands Medical Center, and the Marshall Medical Centers, among others.” Gus Wintzell, Huntsville Health System Expands Alabama Footprint with Latest Acquisition, Huntsville Bus. J. (Jan. 9, 2024), https://huntsvillebusinessjournal.com/news/2024/01/09/huntsville-health-system-expands-alabama-footprint-with-newest-acquisition/.}

_{[vi] Id.} 

_{[vii] Stephen Moody, Ribbon Cutting Held for Brand New Pediatric Emergency Center at Children’s & Women’s Hospital, Fox 10 News (Jan. 10, 2024), https://www.fox10tv.com/2024/01/10/ribbon-cutting-held-brand-new-pediatric-emergency-center-childrens-womens-hospital/.} 

_{[viii] Laurel Thrailkill, ‘Getting Ahead of the Curve’: Hoover Takes Next Step Toward Health Care District, Birmingham Bus. J. (Jan. 14, 2024), https://www.bizjournals.com/birmingham/news/2024/01/14/hoover-takes-next-step-toward-health-care-district.html/.}

_{[ix] Ashley Shipley, Hoover Seeks Approval for State-of-the-Art Medical Facility, Yellow Hammer News (Jan. 16, 2024), https://yellowhammernews.com/hoover-seeks-approval-for-state-of-the-art-medical-facility/.}

_{[x] East Alabama Groundbreaking for New Psychiatric Hospital, Birmingham Med. News, https://www.birminghammedicalnews.com/article/8946/east-alabama-groundbreaking-for-new-psychiatric-hospital (last visited Feb. 29, 2024); Elizabeth White, East Alabama Health Expanding with New Mental Health Facility, News 3 (Jan. 25, 2024), https://www.wrbl.com/news/east-alabama-health-expanding-with-new-mental-health-facility/.}

_{[xi] Amy Yurkanin, Freestanding Emergency Departments Spread in Alabama as Rural Hospitals Struggle, Advanced Local Media (Mar. 9, 2023), https://www.al.com/news/2023/03/freestanding-emergency-departments-spread-in-alabama-as-rural-hospitals-struggle.html.}

_{[xii] Id.}

_{[xiii] Ascension St. Vincent’s adds FED in Pelham, Alabama. Kyra Purvis, Ascension St. Vincent’s Moves Forward with Freestanding Emergency Department in Pelham, ABC3340 News (Jun. 12, 2023), https://abc3340.com/news/local/ascension-st-vincents-moves-forward-with-freestanding-emergency-department-in-pelham. Crestwood adds first FED in North Alabama (in the Harvest community). Crestwood Announces First Freestanding Emergency Room in North Alabama, Huntsville Bus. J. (Jan. 5, 2023), https://huntsvillebusinessjournal.com/lead/2023/01/05/crestwood-medical-center-announces-new-freestanding-emergency-room/. Ascension St. Vincent’s adds FED in Trussville, Alabama. Freestanding ER Opens in Trussville, Bus. Ala. (Feb. 19, 2024), https://businessalabama.com/freestanding-er-opens-in-trussville/.  Grandview Medical Center opens FED in Trussville, Alabama. Gregg Garrison, Grandview Medical Center Opens Freestanding ER with Helipad in Trussville, Advanced Local Media (May 3, 2023), https://www.al.com/news/2023/05/grandview-medical-center-opens-freestanding-er-with-helipad-in-trussville.html.  Cullman Regional to build FED in Hartselle, Alabama. Carson Burns, Freestanding ER ‘Officially’ Coming to Hartselle, News19 (Apr. 20, 2023), https://whnt.com/community/freestanding-er-officially-coming-to-hartselle/. Grandview Medical Center to add FED in Hoover, Alabama.  Aajene Robinson, Proposed Freestanding Emergency Department Coming to Hoover, WBRC (Jun. 5. 2023), https://www.wbrc.com/2023/06/05/proposed-freestanding-emergency-department-coming-hoover/.}

_{[xiv] Nirad Jain, et al., Healthcare Private Equity Market 2023: Year in Review and Outlook, Bain & Co. (Jan. 3, 2024), https://www.bain.com/insights/year-in-review-global-healthcare-private-equity-report-2024/.}

_{[xv] Drew Babin, Medical Properties Trust, Inc. Reports Fourth Quarter and Full-Year Results, Bus. Wire (Feb. 21, 2024), https://www.businesswire.com/news/home/20240220394795/en/Medical-Properties-Trust-Inc.-Reports-Fourth-Quarter-and-Full-Year-Results.}

_{[xvi] Jonathan Weil, Stock Medical Properties Trust Reports Bigger Loss Related to Largest Tenant, The Wall Street J. (Feb. 21, 2024), https://www.wsj.com/livecoverage/stock-market-today-dow-jones-earnings-02-21-2024/card/medical-properties-trust-reports-bigger-loss-related-to-largest-tenant-vG1zAVPQWTmMDJC5eeas.}

_{[xvii] Babin, supra note 14.}

_{[xviii] Anna C. Vollers, Private Equity’s Growing Footprint in Home Health Care Draws Scrutiny, Ala. Reflector (Jan. 31, 2024),  https://alabamareflector.com/2024/01/31/private-equitys-growing-footprint-in-home-health-care-draws-scrutiny/.}

_{[xix] Id.}

_{[xx] Id.}  

_{[xxi] Primordial Ventures Plans Birmingham, Alabama Operations, Area Dev. (Jan. 10, 2024), https://www.areadevelopment.com/newsitems/1-10-2024/primordial-ventures-birmingham-alabama.shtml.}

_{[xxii] Primordial Ventures Will Put Its Production Hub in Birmingham, Bus. Ala. (Jan. 10, 2024), https://businessalabama.com/primordial-ventures-will-put-its-production-hub-in-birmingham/.}

_{[xxiii]  Ala. Bd. of Nurses, The Alabama Board of Nursing Insights, Ala. Bd. of Nurses, Spring 2024, at 3, https://www.abn.alabama.gov/wp-content/uploads/2024/02/Spring-2024.pdf.}

_{[xxiv] Id. at 2.}

_{[xxv] Andrea Burroughs, Healthcare High School Receives $26.4 Million Investment, Demopolis Times (Jan. 23, 2024), https://www.demopolistimes.com/2024/01/23/healthcare-high-school-receives-26-4-million-investment/.}

_{[xxvi] Alabama Senate Bill 72 (2024), available at: https://legiscan.com/AL/bill/SB72/2024.}

_{[xxvii] Alabama House Bill 131 (2024), available at: https://legiscan.com/AL/bill/HB131/2024.}

_{[xxviii] 2024 Alabama Legislative Update: Regular Session - Week Three (February 23, 2024).}

_{[xxix] Dave Muoio, Alabama Health Systems Sues Humana to Recoup MA Payments After 340B Rate Revision, Fierce Healthcare (Feb. 13, 2024),   https://www.fiercehealthcare.com/payers/alabama-health-system-sues-humana-recoup-ma-payments-after-340b-rate-revision (“Baptist Health has filed a lawsuit against Humana arguing the payer’s Medicare Advantage plans had underpaid for outpatient drugs purchased through the 340B Drug Pricing Program in light of a 2022 Supreme Court decision that amended rates set by the federal government.”).}

_{[xxx] Veronica Salib, Alabama Supreme Court Ruling Compromises Access to IVF, XTelligent HealthCare Media (Feb. 21, 2024), https://lifesciencesintelligence.com/news/alabama-supreme-court-ruling-compromises-access-to-ivf.} 

_{[xxxi] Id.}  

_{[xxxii] Aria Bendix, Three Alabama Clinics Pause IVF Services After Court Rules That Embryos Are Children, NBC News (Feb. 21, 2024), https://www.nbcnews.com/health/health-news/university-alabama-pauses-ivf-services-court-rules-embryos-are-childre-rcna139846.}

_{[xxxiii] See 2024 Legislative Update: Regular Session - Week Four.}

_{[xxxiv] U.S. Government Accountability Office, COVID-19 Provider Relief Fund: HRSA Continues to Recover Remaining Payments Due from Providers, GAO (September 21, 2023), https://www.gao.gov/products/gao-23-106083.}

_{[xxxv] Id.}

_{[xxxvi] Id.}

_{[xxxvii] Health Resources & Services Administration, Repayment and Debt Collection, HRSA (November 2023), https://www.hrsa.gov/provider-relief/compliance/repayment-debt-collection.}

_{[xxxviii] White House Designates Birmingham, Alabama as One of the 31 ‘Tech Hubs’ Across the Nation, Ala. News Ctr. (Oct. 23, 2023), https://alabamanewscenter.com/2023/10/23/white-house-designates-birmingham-alabama-as-one-of-31-tech-hubs-across-the-nation/.}  

_{[xxxix] Id.}  

_{[xl] Id.} 

_{[xli] Lauren Thrailkill, Birmingham Firm to Provide AI-Based Software for Southern Co., Alabamainno (June 7, 2023),  https://www.bizjournals.com/birmingham/inno/stories/news/2023/06/07/hdata-provide-ai-based-platform-southern-co.html.}

_{[xlii] New Alabama Artificial Intelligence Center of Excellence Created to Support Education, Economic Development, Technology Parity and Access, GlobalNewswire (Mar. 22, 2023), https://www.globenewswire.com/news-release/2023/03/22/2632286/0/en/New-Alabama-Artificial-Intelligence-Center-of-Excellence-Created-to-Support-Education-Economic-Development-Technology-Parity-and-Access.html.} 

_{[xliii] Id.}

_{[xliv] AAICE, https://aaice.net/ (last visited Feb. 29, 2024).}

_{[xlv] Russ Nelson, UAH Researches Team With Mental Health Nonprofit to Pioneer Use of Artificial Intelligence to Improve Access to Care in North Alabama, Univ. Ala. Huntsville (Aug. 2, 2023), https://www.uah.edu/science/science-news/17937-uah-researchers-team-with-mental-health-nonprofit-to-pioneer-use-of-artificial-intelligence-to-improve-access-to-care-in-north-alabama.}

_{[xlvi] Id.}  

_{[xlvii] Kimberly Ballard, Healthcare AI Provider Expands Access to Diabetic Care in Alabama, 256 Today (Apr. 28, 2023), https://256today.com/healthcare-ai-provider-expands-access-to-diabetic-care-in-alabama/.} 

_{[xlviii] FDA Accepts 1st AI-Based Tool into Istand Pilot Program, LabPulse.com (Jan. 26, 2024), https://www.labpulse.com/business-insights/policy-and-regulation/regulatory-approval/article/15662961/fda-accepts-first-aibased-tool-into-istand-pilot-program.}

_{[xlix] Medicaid Expansion, healthinsurance.org, https://www.healthinsurance.org/glossary/medicaid-expansion/ (last visited Feb. 1, 2024).}

_{[l] Alexander Willis, Alabama Lawmakers Briefed on New ‘ALL Health’ Insurance Coverage Expansion Plan, Ala. Daily News (Feb. 6, 2024), https://aldailynews.com/alabama-lawmakers-briefed-on-new-all-health-insurance-coverage-expansion-plan/.}

_{[li] Alabama House Bill 152 (2024), available at: https://www.legislature.state.al.us/pdf/SearchableInstruments/2024RS/HB152-int.pdf.}

_{[lii] Medicare Advantage in Alabama, (September 24, 2023), available at: https://www.payingforseniorcare.com/medicare-advantage-plans-in-alabama#:~:text=Alabama%20has%20one%20of%20the,%2C%20compared%20to%2048%25%20nationwide.}

_{[liii] Id.}

_{[liv] VC funding in Alabama grows while other states see declines, Birmingham Business Journal (March 8, 2023), available at: https://www.bizjournals.com/birmingham/news/2023/03/08/vc-funding-fell-in-2022-except-in-these-states.html.} 

_{[lv] Alabama bioscience sector growing with major investment projects, Made in Alabama, available at:  https://www.madeinalabama.com/why-alabama/success-stories/alabama-bioscience-sector-growing-with-major-investment-projects/.}

_{[lvi] Id.} 

_{[lvii] Savannah Koplon, UAB’s research awards break another record, reaching $774.5 million for fiscal year 2023, UAB News (November 08, 2023), available at: https://www.uab.edu/news/research/item/13847-uab-s-research-awards-break-another-record-reaching-774-5-million-for-fiscal-year-2023.} 

_{[lviii] Jeff Hansen, IN8bio’s cutting-edge cancer research lab starts operations in Alabama, Alabama News Center (August 10, 2023), available at: https://www.alabamanewscenter.com/2023/08/10/in8bios-cutting-edge-cancer-research-lab-starts-operations-in-alabama/.}

_{[lix] Id.}

_{[lx]Zac Ezzone, Biotech firm with Birmingham facility cuts R&D jobs, AlabamaINNO (January 10, 2024), available at: https://www.bizjournals.com/birmingham/inno/stories/news/2024/01/10/biocryst-layoffs-research-development-orladeyo.html.}

_{[lxi] Id.}

_{[lxii] Zac Ezzone, Biotech firm with Birmingham facility cuts R&D jobs, AlabamaINNO (January 10, 2024), available at: https://www.fiercebiotech.com/biotech/merck-turns-digital-health-company-acclinate-increase-african-american-participation-cancer.} 

_{[lxiii] James Waldron, Merck turns to Acclinate to increase African American participation in cancer trials, Fierce Biotech (November 30, 2023), available at:  https://bhamnow.com/2023/11/14/3-birmingham-startups-you-need-to-know/.} 

_{[lxiv] Alabama bioscience sector growing with major investment projects, Made in Alabama, available at:  https://www.madeinalabama.com/why-alabama/success-stories/alabama-bioscience-sector-growing-with-major-investment-projects/.}

_{[lxv] Id.}

_{[lxvi] Alexis Elmore, Companies Stay Future-Focused in Alabama, Site Selection Magazine (January 2024), available at: https://siteselection.com/issues/2024/jan/companies-stay-future-focused-in-alabama.cfm.} 

_{[lxvii] Id. See also Gus Wintzell, Governor Ivey dedicates new Discovery Life Sciences global HQ, Huntsville Business Journal, (October 13, 2023), available at: https://huntsvillebusinessjournal.com/news/2023/10/13/governor-ivey-dedicates-new-discovery-life-sciences-global-hq/.} 

_{[lxviii] Alabama bioscience sector growing with major investment projects, Made in Alabama, available at:  https://www.madeinalabama.com/why-alabama/success-stories/alabama-bioscience-sector-growing-with-major-investment-projects/.}

_{[lxix] Id.}