Key Health Care Issues to Track in 2025 in Alabama

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02.25.2025

This update examines the shifting landscape of healthcare regulation and industry developments in Alabama. It addresses key areas affecting healthcare, such as the ongoing expansion efforts by Alabama providers, significant investments in new facilities and services, and the growing role of private equity in the sector, despite potential challenges. Additionally, it provides insights into recent legal updates at both the state and federal levels, offering a comprehensive overview of Alabama's healthcare environment in 2025.

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. Deal Activity for Healthcare Providers.

In Birmingham, 2024 saw two highly valued healthcare provider deals. First, UAB Health System’s (“UAB Health”) acquisition of Ascension St. Vincent’s Health System for $450 million.[i] Second, Tenet Healthcare Corp. sold its 70% majority interest in Brookwood Baptist Health to Orlando Health for $910 million.[ii] In North Alabama, American Family Care acquired all Urgent Medcare locations.[iii]

It is important to note that there are an increasing number of states that are passing laws that restrict health system consolidation and competition. Note that “[a]t least 34 bills relating to health system consolidation and competition were enacted across 22 states in 2024.”[iv]

3. Expansion of Alabama Healthcare Providers.

There were a number of investment and expansion announcements from Alabama healthcare providers in 2024.

• In late 2024, UAB Health opened its new, state-of-the-art $400 million Medical West hospital, funded mostly through a U.S. Department of Agriculture’s loan program.[v] UAB Health also expanded its primary care clinic with the addition of a new location and opened a new oral surgery clinic.[vi] A new ambulatory care facility joined the Birmingham skyline when Cooper Green Mercy Health Services Authority, an affiliate of UAB Health, opened its new Cooper Green outpatient clinic.[vii] Looking ahead, UAB Health continues construction on a (1) $190 million facility for its medical school, (2) $156.7 million inpatient rehabilitation facility, and (3) $73 million emergency department expansion.[viii] Finally, UAB Health affiliate Southern Research’s flagship biotech center, including new wet lab space for life sciences, is expected to finish construction in the third quarter of 2025.[ix]
• Children’s of Alabama recently wrapped up a $55 million expansion[x], which included expansions for its neonatal intensive care unit (NICU) and inpatient behavioral health services unit.[xi] The expansions will help meet the rising need for neonates from referring hospitals that require specialized treatment and adolescent-focused mental health.
• Baptist Medical Center South announced a $14 million expansion of its emergency department.
• East Alabama Health continued construction on its $43 million intensive care unit (ICU) expansion.
• South Baldwin Regional Medical Center’s $200 million expansion opened at the end of 2024. Also in South Alabama, in January of 2025, Thomas Hospital broke ground on a $40 million addition to its hospital.
• Huntsville Hospital announced that its $150 million expansion plans have been green lit by the Alabama Certificate of Need Review Board.

4. Continued Expansion of Private Equity.

In 2024, private equity (“PE”) firms continued to expand their presence in healthcare across the nation and globally. One 2024 report, released in January 2025, suggests that global healthcare private equity deal value “soared in 2024 to an estimated $115 billion,” with North America continuing to be “the largest market, representing 65% of global deal value . . . .”  In North America, deal value reached an estimated $75 billion, with value of provider buyouts accounting for 34% of deal activity and Biopharma accounting for 34% of deal activity. In addition, “[a]fter declining in 2023, healthcare IT deal making rebounded in 2024 . . . .”[xii]

This trend towards increased PE activity will continue in 2025, especially if interest rates continue to decrease. 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 landlord with approximately $15.23 billion in total assets ($18.3 billion this time last year^[xiii]).[xiv] Despite a difficult year, posting a net loss of $801 million in the third quarter of 2024, MPT removed seventeen Steward Health Care System hospitals, which sought Chapter 11 protection May 6, from its portfolio.[xv] As a result of this and other recent deals, Edward K. Aldag, Jr., Chairman, President and Chief Executive Officer, recently said, “we look forward to demonstrating the strength and resilience of our diversified portfolio of hospital real estate and the importance of our business model to an industry in desperate need for more capital solutions.”[xvi]
• An affiliate of US Radiology Specialists, American Health Imaging, announced its expansion into the new market of the greater Huntsville, Alabama area, by opening two new multimodality imaging centers.[xvii]
• It was announced in January of 2025 that The Ensign Group, Inc., whose independent subsidiaries provide a broad spectrum of skilled nursing and senior living services, physical, occupational and speech therapies and other rehabilitative and healthcare services at 333 healthcare facilities in 17 states, has expanded its footprint into Alabama.[xviii] As part of the deal, The Ensign Group will operate nine skilled nursing facilitates – eight in Tennessee and one in Alabama.[xix]
• Headquartered in Huntsville, Alabama, Lakeland Industries, Inc., a leading global manufacturer of protective clothing for industry, healthcare, and first responders, acquired the fire and rescue business of LHD Group Deutschland GmbH in Hong Kong and Australia for $16.3 million.[xx]
• Ampersand Capital Partners, a private equity firm specializing in growth equity investments in the life sciences and healthcare sectors, closed on the acquisition of Nektar Therapeutics’ PEGylation reagent business, manufacturing critical components in advanced biopharmaceutical and therapeutic products.[xxi] The new Ampersand portfolio company will be branded Gannet BioChem and will continue to operate out of its state-of-the-art facility in Huntsville, Alabama.
• Birmingham-based The Sanders Trust, which develops and acquires medical office buildings and healthcare facilities nationwide, has acquired a Tulsa, Oklahoma rehabilitation hospital for $34.2 million.[xxii]
• Proactive MD, a national leader in value-based care, recently announced an expansion in Alabama through the acquisition of healthcare organizations.[xxiii]

5. Legal Updates.

(a) Alabama.

• What is A Woman? Act. On February 11, 2025, the Alabama Legislature passed the “What is a Woman?” Act. This legislation, sponsored by Senator April Weaver and Representative Susan DuBose, adds definitions for terms such as “man,” “woman,” “boy,” “girl,” “father,” “mother,” “male,” “female,” and “sex” to the state code. The bill’s sponsors said that it provides definitional clarity to the state code. This legislation has been signed into law by Governor Kay Ivey, a vocal proponent of the legislation.[xxiv]
• Presumptive Medicaid Eligibility for Pregnant Women. The House has passed a bill that would provide presumptive Medicaid coverage for pregnant women until sunsetting in 2028, when adequate data will have been collected. Specifically, the bill aims to ensure immediate prenatal care by extending Medicaid eligibility for up to 60 days while applications are processed. The bill unanimously passed the House and now moves to the Senate for consideration.[xxv]
• Pharmacy Benefit Managers. Two pieces of legislation concerning Pharmacy Benefit Managers (PBMs) were introduced in the first week of the legislative session but did not advance. The fragmented pharmacist groups advocating for these bills are currently working to unify their support behind a single piece of legislation.SB 93 would require PBMs and private health plans to reimburse pharmacies using the Medicaid Agency’s pricing index with a $10.64 dispensing fee per prescription, while SB 99 would mandate reimbursement using the NADAC index plus 2% or $25, whichever is less, in addition to a $10.64 dispensing fee. There will be public hearings held on both bills in the Senate Banking and Insurance Committee meeting.[xxvi]
• Rural Hospital Tax Credit.Legislation sponsored by Representative Terri Collins that would incentivize donations to rural hospitals was reintroduced after failing to advance in previous legislative sessions. This legislation would provide tax credits against income tax liability for individuals and businesses.[xxvii]
• Rural Physician Income Tax Credit. This bill would loosen the requirements for rural physicians to qualify for a special tax credit and increase the tax credit from $5,000 to $10,000.
• Consent to Medical Treatment: Changing Age from 14 to 18. This bill would change the age a minor may consent to medical treatment from the age of 14 to 18.[xxviii]
• Parental Consent for Minor to Receive Vaccine. This legislation requires written consent from a parent or legal guardian for an unemancipated minor to be administered a vaccine.
• Prohibit Enforcement of Contractual Terms that Restrict Sharing Cost Information to Patients and Consumers. Amongst other things, this bill would prohibit health insurance companies from regulating what physicians, other health care providers, and pharmacists may tell patients about the cost of the treatment or medication they are receiving, or from informing patients about alternative treatments or medications that may be lower in cost.
• Medical Cannabis: Senator Tim Melson has filedlegislation which would amend the licensing process for medical cannabis facilities. The bill would, among other things, remove the requirement for an investigatory hearing for challenges made by an applicant denied a license.[xxix]
• Controlled Substances: Psychoactive Derivatives of Hemp Added as Schedule I Drug. This bill would close the loophole that currently exempts hemp-derived Delta-8 THC, Delta-9 THC, and Delta-10 THC from the Schedule I controlled substance list. As a result, these derivatives would be considered “psychoactive cannabinoids,” meaning only non-psychoactive cannabinoids would be exempt.[xxx]

(b) Federal.

• Rural Obstetrics Readiness Act. “At the federal level, Alabama Senator Katie Britt (R) along with Maggie Hassan (D-N.H.), Susan Collins (R-Maine), and Tina Smith (D-Minn.) are reintroducing the “Rural Obstetrics Readiness Act”. Alarmingly, Senator Britt recently said, “We have about 30% of women who are more than 30 minutes away from a labor and delivery site . . .” and “over a third of our state is actually a maternal care desert, this is clearly something that we have to hit head on.”[xxxi]
• The COVER Now Act. The Cover Outstanding Vulnerable Expansion-Eligible Residents Now Act (“COVER Now Act”), co-sponsored by U.S. Reps. Shomari Figures, Mobile, and Terri Sewell, Birmingham, aims to expand Medicaid by giving local governments in states without Medicaid expansion an option to provide health care coverage to those who would qualify under an expansion. In other words, the COVER Now Act provides another option for states, like Alabama, that have refused Medicaid expansion.
• Telehealth Services. The American Relief Act of 2025 only ensures the continuation of essential healthcare programs, including access to telehealth for Medicare patients, through March 31, 2025. As a result, it is essential that Congress passes legislation before this deadline to prevent a significant disruption in medical services to Medicare patients.
• HIPAA. In January of 2025, an update to the HIPAA Security Rule was proposed. However, President Trump issued an Executive Order two weeks later, requiring a “Regulatory Freeze Pending Review.” Despite the freeze, HHS has moved forward with inviting interested parties to submit comments by March 7, 2025. In addition, HHS delayed the effective date of a separate HIPAA final rule implementing the modified National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Standards and the Medicaid Pharmacy Subrogation Standard.
• Tariffs. The American Hospital Association and other health care organizations have urged the Trump Administration to grant exceptions for tariffs for medications and medical supplies, especially items that are in short supply.[xxxii]
• FTC’s Non-Compete Rule. Efforts continue in federal court to vacate nationwide the Federal Trade Commission’s non-compete rule.[xxxiii]
• $880 Billion in Federal Spending Cuts. On February 12, 2025, U.S. House Republicans releaseda budget blueprint, ordering the Energy and Commerce Committee, which oversees Medicare and Medicaid, to find $880 billion in savings from fiscal years 2025 through 2034.[xxxiv]
• Federal Pharmacy Benefit Manager Reform. The U.S. House Energy and Commerce Committee’s health subcommittee “will hold a hearing on so-called ‘PBM reform’ for Feb. 26, although that date could change.”[xxxv] Speaker Johnson has been urged to include bipartisan PBM reform in any upcoming spending bill.[xxxvi]
• Telemedicine Final Rules. On Friday, February 14, 2025, the Drug Enforcement Administration (“DEA”) and the U.S. Department of Health and Human Services (“HHS”) announcedthat the effective dates for two recently published final rules involving telemedicine prescribing of controlled substances – the final rule titled “Expansion of Buprenorphine Treatment via Telemedicine Encounter” and the final rule titled “Continuity of Care via Telemedicine for Veterans Affairs Patients” – are delayed from February 18, 2025, until at least March 21, 2025.
• Republicans on Energy and Commerce Committee Announce Data Privacy Working Group.The group aims to explore a legislative framework on data privacy.
• Federal Fraud Recoupment. The year 2024 saw continued efforts by the federal government to recoup money procured through fraud. For example, more than $2.9 billion was collected as a result of False Claims Act (“FCA”) settlements and judgments.[xxxvii] Notably, over $250 million was collected from COVID-19 related fraud. In addition, 2024 saw a record-breaking number of whistleblower (qui tam) lawsuits related to Stark law violations. Seven major Stark law indictments contributed to a record-breaking 979 qui tam[xxxviii] As a result, 2024’s $2.9 billion is the highest enforcement total since 2021’s $5.69 billion.
• New Stark Law Non-Monetary Compensation Limits for 2025. ASCs, physician groups, and hospitals can provide non-monetary compensation to physicians up to an amount of $519 for the calendar year 2025. This cap applies to gifts, meals and other non-cash benefits provided to physicians by ASCs, hospitals, and groups.
• New U.S. Immigration and Customs Enforcement’s Policy. While there have been guidelines in the past that limited ICE enforcement actions at “sensitive locations,” such as at healthcare facilities and religious institutions, these have been rescinded by the Trump Administration. As such, it would appear that any enforcement by ICE would be handled in the same way as other law enforcement actions, and existing policies would control, with warrants, subpoenas, and other correspondence being reviewed for compliance with the exception set out in 45 CFR 164.512(f).
• Federal Funding Freeze for Transgender Care Executive Order. President Trump’s executive order targeting federal funding for transgender care for young people has been blocked by a federal judge, ruling that Trump’s order “was an unconstitutional overreach because it discriminated against people based on sex or transgender status and also proclaimed that Trump has authority over Congress’ exclusive spending power.”[xxxix] Judge King pointed out in her opinion that, “the Executive Order prevents transgender youth from obtaining necessary medical treatments that are completely unrelated to their gender identity. For example, a cisgender teen could obtain puberty blockers from a federally funded medical provider as a component of cancer treatment, but a transgender teen with the same cancer care plan could not.” As a result, “[t]he executive order thus amounts to an end-run around the separation of powers.” Another federal judge has also blocked President Trump’s executive order requiring the administration to keep in place federal funding for healthcare providers that provide transgender care.[xl] Lawsuits against Trump’s orders will likely be settled at the U.S. Supreme Court, which is set to review Tennessee’s 2023 gender-affirming care ban blocking minors from hormone therapy and puberty-blocking medications.[xli]
• In Vitro Fertilization (“IVF”) Executive Order. On February 18, 2025, President Donald Trump signed an executive order directing his administration to develop policy recommendations designed to protect access to IVF and sharply reduce out-of-pocket costs for IVF treatment. The order fails to outline any specific ideas but calls broadly for removing any legal or regulatory burdens that impair access to IVF or make it more expensive.

6. NIH Grant Cuts for “Indirect Costs”.

On February 7, 2025, the NIH announced that it would make immediate cuts to the “indirect costs” awardees receive from federal research grants. “In 2023 NIH grants in Alabama supported 4,769 jobs for an economic impact of $909 million . . . . They impact almost 13,000 jobs at more than 1,200 businesses . . . .”[xlii] Currently, UAB Health—the state of Alabama’s largest employer—has a negotiated maximum indirect cost rate of 48.5% but averages about 33% across all NIH grants. Under the new rule, all grant recipients would receive a maximum indirect cost rate of 15%, meaning UAB Health would lose approximately $70 million in annual funding. Officials with the University of Alabama at Birmingham made the following statement:

“Drastically lowering NIH indirect cost recovery jeopardizes life-saving research, and it would also result in job and economic loss in Birmingham and Alabama . . . . If the reduction remains in place, advancements in virtually all areas of research would slow, including those addressing the leading causes of death in the United States, from cancer to Alzheimer’s, stroke, Parkinson’s, heart disease and diabetes, among other diseases and disorders that devastate lives and families.”[xliii]

A lawsuit has been filed by 22 state attorneys general—not including Alabama—seeking to prevent implementation of the cuts. The Federal judge in the case has granted a temporary restraining order, temporarily blocking the rule from implementation and setting a hearing for later this month to settle whether the cuts are legal and should proceed.

7. 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:

• On February 8, 2024, Governor Kay Ivey issued Executive Order 738, establishing a Generative Artificial Intelligence (GenAI) Task Force. “The purpose of the GenAI Task Force is to understand current uses of GenAI in state executive-branch agencies, encourage the responsible and effective use of GenAI in executive-branch agencies, and recommend policies and procedures related to the use of GenAI in state executive-branch agencies going forward.”[xliv]
• During the 2024 legislative session, Alabama passed two laws concerning AI. HB172 prohibits the distribution of materially deceptive media in an attempt to influence an upcoming election, while HB168 prohibits artificially-generated child pornography.
• The University of Alabama announced in 2024 that it plans to move forward with a $100 million facility that will scale up the university’s computing capacity and will be a “gateway to a new era of computing at UA . . . .”
• In May of 2024, Meta announced that it is building an $800 million data center in Montgomery, Alabama.
• On January 14, 2025, federal officials announced that a group of biotechnology research companies based in Birmingham, including the Birmingham Biotechnology Hub, which is led by Southern Research, will received $44 million in federal funding to research AI to shorten drug development to provide affordable drugs, vaccines and diagnostics.
• Core Scientific announced a $400 million expansion into Auburn, Alabama, with a new high-performance computing facility.
• “A collaboration between East Alabama Medical Center, Inflo Health and the American College of Radiology Learning Network began using machine language models and advanced natural language processions to extract data from radiology reports to improve its follow-up with pulmonary patients . . . .”[xlv]
• President Trump signed an executive order on AI on January 23, 2025, which, among other things, rescinded President Biden’s AI executive order of 2023 and directs the development of an AI Action Plan and the revision and reissuance of the Office of Management and Budget AI memorandum (M-24-18).
• In October of 2024, although likely rescinded by the Trump Administration, the U.S. Department of Labor released a guide, “Artificial Intelligence and Worker Well-being: Principles and Best Practices for Developers and Employers,” on AI best practices for developers and employers.
• In February of 2025, the FDA released updated guidance on AI titled “Artificial Intelligence and Medical Products: How CBER, CDER, CDRH, and OCP are Working Together.” In addition, the FDA proposed a risk-based credibility assessment framework that it outlined in draft guidance, Considerations for the Use of Artificial Intelligence to Support Regulatory Decision-Making for Drug and Biological Products, that was published on January 7, 2025, with comments due by April 7, 2025.
• On January 7, 2025, the FDA issued draft guidance, titled “Artificial Intelligence-Enabled Device Software Functions: Lifecycle Management and Marketing Submission Recommendations” that addresses management of cybersecurity risks affecting AI-enabled devices. The new guidance supplements the FDA’s more general 2023 guidance, “Cybersecurity in Medical Devices: Quality System Considerations and Content of Premarket Submissions,” which contained recommendations for medical device makers with respect to designing and maintaining cybersecurity, and providing cyber details to the FDA in premarket submissions. The guidance is open for public commentuntil April 7, 2025.[xlvi]

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.

8. Medicare and 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).”[xlvii]

(a) Alabama Medicaid Expansion.

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

• As mentioned above under the Alabama Legislative Updates section, the Alabama House has passed a bill that would provide presumptive Medicaid coverage for pregnant women.
• On the heels of Jackson Hospital’s bankruptcy filing in early February, Alabama lawmakers briefly discussed Medicaid expansion. However, concerns that it will result in a financial deficit for the state of Alabama and “not be enough . . . to really make a huge difference,” have stalled such discussions.[xlviii]
• In response to the Trump Administration’s push to cut federal Medicaid funding, “[t]he leader of the Alabama House of Representatives said [February 13, 2025] that Medicaid expansion will not be one of the chamber’s priorities for the 2025 legislative session . . . .”[xlix]

(b) Continued Growth of Medicare Advantage.

A 2024 report concluded that more than half (54%) of all eligible Medicare beneficiaries are enrolled in Medicare Advantage (MA) and that MA accounts for over half (54%) 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 (47%) of all MA enrollees in the nation. Alabama has some of the highest MA enrollment rates in the country, with 51 percent of those eligible for benefits currently enrolled in MA Plans.[l]  These rates will likely continue to increase in 2025.

9. Life Sciences Continue to Grow Rapidly in Alabama.

It appears that the life sciences industry in Alabama will continue to expand in 2025. The traditional tech epicenters like California and New York continue to see declines in startup funding, while emerging startup hubs like Alabama have seen growth.[li] In 2022, bioscience-related academic research and development expenditures in the state reached $866 million and continue to grow. Already, Alabama is home to 780 bioscience establishments employing nearly 18,000 people, with an annual economic impact of approximately $7.3 billion.[lii]

The state has announced a number of key investments that will impact the industry throughout 2025 and beyond:

• Alabama is home to the Birmingham Biotechnology Tech Hub, which is 1 of the 15 bioscience-related economic development administration’s regional technology hubs and strategy development grant recipients in the nation. The hub is 1 of only 4 health technology hubs. Alabama is also a partner to the Southeast Biotech Collaborative (SEBC) Strategy Development Consortium. In addition, Cummings Research Park, in Huntsville, is the 2nd largest research park in the U.S. and fourth largest globally.
• Alabama saw job growth in (i) agricultural feed-stock and industrial bioscience, (ii) bioscience-related distribution, (iii) medical devices and equipment, (iv) pharmaceuticals, and (v) research, testing, and medical laboratories.
• “The Global Business team from the Alabama Department of Commerce [led] a delegation of Alabama small and mid-sized businesses at MEDICA 2024, the world’s largest event for the medical industry, held in Germany. Following MEDICA, the Alabama team will extend its bioscience-focused mission in Europe with a visit to The Netherlands, which has a flourishing life sciences environment.”[liii]
• In August of 2024, TriAltus Bioscience announced that it, in partnership with UAB, had obtained a patent for its innovative CLiM protein purification technology.
• In June of 2024, Southern Researchawarded more than $2.7 million to eight biotech companies through its new Therapeutics Development Fund.
• Southern Research’s biotech incubator, Station 41, which has 12 private leasable wet labs and 13 private offices, has filled up with tenants and now has plans to expand. 
• In 2024, Hudson Alpha Institute for Biotechnology produced over 85 publications and secured 26 new grants, totaling over $10 million in grant funding.
• In August of 2024, Hudson Alpha opened a new shared lab space on its biotechnology campus in Huntsville, Alabama, to meet a critical gap in early start-ups’ need for spaces to perform research and development.

Maynard Nexsen will be following these and other key health care and life sciences issues in Alabama throughout 2025.

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_{[i] Ron Southwick, Alabama health system completes $450M deal to acquire 5 hospitals, ChiefHealthcareExecutive.com (November 2, 2024), link.}

_{[ii] Ron Southwick, Five Alabama hospitals to be sold in $910M deal, ChiefHealthcareExecutive.com (August 6, 2024), link.}

_{[iii] American Family Care Acquires Urgent Medcare, PR Newswire (Oct. 16, 2024), link.}

_{[iv] Sarah Jaromin, 2024 Legislative Recap: Health Care Consolidation and Competition, National Conference of State Legislatures, (Updated November 15, 2024), link.}

_{[v] Molly Gamble, UAB ready to open $400 million hospital, Becker’s Hospital Review, (August 1, 2024), link.}

_{[vi] Brianna Hoge, UAB’s impact across the state during 2024 — and what’s next for 2025, UAB News, (Dec. 20 2024), link.}

_{[vii] Id.}

_{[viii] Id.}

_{[ix] Id.}

_{[x] Nathan Watson, Children’s of Alabama OK’d for $55M, BhamNow.com, (October 23, 2023), link.}  

_{[xi] Harper Harwell, Children’s of Alabama wraps up $6M unit expansion, Birmingham Business Journal, (February 12, 2025), link.}

_{[xii] Global Healthcare Private Equity Report 2025, Bain and Company, link.}

_{[xiii] Drew Babin, Medical Properties Trust, Inc. Reports Fourth Quarter and Full-Year Results, Bus. Wire (Feb. 21, 2024), link.}

_{[xiv] See Medical Properties Trust (MPW) - Total assets, Total assets on the balance sheet as of September 2024: $15.23 Billion USD, link (last accessed on February 17, 2025).}

_{[xv] Madeline Ashley, Medical Properties Trust cuts Steward from portfolio, hits $801M net loss in Q3, Becker’s Hospital Review (Nov. 7, 2024), link; Medical Properties Trust, Inc. Reports Third Quarter Results, Business Wire, (Nov. 7, 2024), link (last access on February 17, 2025).}

_{[xvi] Madeline Ashley, Medical Properties Trust cuts Steward from portfolio, hits $801M net loss in Q3, Becker’s Hospital Review (Nov. 7, 2024), link.}

_{[xvii] Marty Stempniak, US Radiology Specialists affiliate expands into new market, RadiologyBusiness.com, (December 23, 2024), link.}

_{[xviii] The Ensign Group Closes on Expansion in Tennessee, Adds Its First Operation in Alabama, (January 2, 2025), link.}

_{[xix] CareTrust REIT Announces Updated Investments Pipeline of $700 Million Including Agreement to Acquire $500 Million Portfolio in Southeast by Year End, (October 29, 2024), link.}

_{[xx] Lakeland Industries Completes Acquisition of LHD Group: Strategic Acquisition Enhances Lakeland's Global Presence and Fire Service Offering, ACCESS Newswire, Yahoo!Finance.com, (July 1, 2024), link.}

_{[xxi] Ampersand Capital Partners Completes Acquisition of Nektar Therapeutics' PEG Reagent Manufacturing Business, Launching Newly Branded Gannet BioChem, PR Newswire, (Dec. 2, 2024), link.}

_{[xxii] William Thornton, Birmingham company acquires $34.2 million Oklahoma hospital, AL.com (July 8, 2024), link.}

_{[xxiii] Proactive MD Expands National Footprint with New Acquisitions, EIN Presswire, wric.com, (January 14, 2025), link.}

_{[xxiv] See 2025 Alabama Legislative Update: Regular Session - Week Two, Maynard Nexsen (February 14, 2025), link.}

_{[xxv] Id.}

_{[xxvi] Id.}

_{[xxvii] Id. See also Shelby Myers, Alabama elected officials make moves to save rural healthcare, Fox 10 News, (February 11, 2025), link.}

_{[xxviii] See also Heather Gann, Alabama minors would no longer be able make medical or mental health decisions under new bill, al.com, (February 7, 2025), link (“[The] bill would require that a person must be 18 to give consent unless they are married, divorced, pregnant, emancipated, or living independently apart from their parents or legal guardian. The bill’s text specifies that these restrictions also apply to participation in school counseling services, donating bone marrow, and receipt of a vaccine. It would allow any minor to consent to services to prevent or treat pregnancy, sexually transmitted infections, and alcohol or drug dependency.”).}

_{[xxix] See 2025 Alabama Legislative Update: Regular Session - Week One, Maynard Nexsen (February 7, 2025), link.}

_{[xxx] See also Heather Gann, Delta 8 would be as illegal as heroin and LSD in Alabama under proposed law, al.com, (February 10, 2025), link.}

_{[xxxi] Shelby Myers, Alabama elected officials make moves to save rural healthcare, Fox 10 News, (February 11, 2025), link.}

_{[xxxii] AHA Urges Administration to Grant Exceptions for Tariffs for Medications and Medical Supplies, AHA, (February 4, 2025), link.}

_{[xxxiii] Alan Condon, Hospitals want FTC's noncompete rule vacated nationwide, Becker’s Hospital Review, (February 12, 2025), link.}

_{[xxxiv] See Alan Condon, Republicans target $880B in healthcare cuts; hospitals push back, Becker’s Hospital Review, (February 12, 2025), link.}

_{[xxxv] Ben Leonard, Key committee could advance stalled health policy overhaul, Politico, (February 12, 2025), link.}

_{[xxxvi] At Pine Plains Pharmacy, Congressman Ryan Continues Push to Bring Down Prescription Drug Costs, Demands Speaker Johnson Include Landmark Drug Pricing Reform in Next Month’s Government Funding Bill, Congressman Pat Ryan: Press Release, (February 17, 2025), link. See also Michael McAuliff, Employers, insurers press Trump and Congress to revive PBM bills, Modern Healthcare, (February 5, 2025), link.}

_{[xxxvii] Ty Howard, Brad Robertson, and Jonathan Ferry, More Whistleblower Suits Filed Than Ever Before: The False Claims Act in 2024, The National Law Review, (February 5, 2025), link.}

_{[xxxviii] Patsy Newitt, 7 Stark law indictments in record breaking year for FTC, Becker’s Physician Leadership, (February 16, 2025), link.}

_{[xxxix] Greg Lamm, Trump Trans Order Is Unconstitutional 'End-Run,' Judge Says, LAW360 (February 18, 2025), link.}

_{[xl] Mark Payne, Maryland Judge Blocks Trump's Orders On Trans Healthcare, LAW360, (February 13, 2025), link.}

_{[xli] Id.}

_{[xlii] Roy S. Johnson, NIH cut would cost UAB $70 million, threaten jobs and ‘life-saving research’ in Alabama, AL.Com, (February 11, 2025), link; see also Alaina Bookman, What would NIH funding cuts mean for Alabama? 5 things to know, AL.Com, (February 11, 2025), link.}

_{[xliii] Riley Conlon, ‘Research is stopped, lives are lost': Birmingham mayor, UAB respond to NIH’s medical research cuts, WVTM.com, (February 10, 2025), link.}

_{[xliv] Kenyatta Fishoe, Governor Ivey Establishes the Alabama Generative Artificial Intelligence Task Force, State of Alabama Office of Information Technology, (February 11, 2024), link..}

_{[xlv] Andrea Fox, Roundup: Health systems embracing AI imaging tools, HealthcareItNews.com, (October 24, 2025), link.}

_{[xlvi] See Hunton Andrews, FDA Issues Draft Guidance on Managing Cybersecurity Risks Affecting AI-Enabled Devices, The National Law Review, (February 11, 2025), link.}

_{[xlvii] Medicaid Expansion, healthinsurance.org, link  (last visited Feb. 19, 2025).}

_{[xlviii] Ryan Hall, Alabama lawmakers talk Medicaid expansion, CBS-42.com, (February 5, 205), link.}  

_{[xlix] Ralph Chapoco, Alabama House Speaker: School funding change possible; Medicaid expansion not a priority, Alabama Reflector, (January 17, 2025), link.}

_{[l] Medicare in Alabama, HealthInsurance.Org, link.}

_{[li] See VC funding in Alabama grows while other states see declines, Birmingham Business Journal (March 8, 2023), link; Don Catalano, The Rise and Fall of Tech Hubs: A Shift to America's Sunbelt Cities, iOptimizeReality.com, (April 24, 2024), link.}

_{[lii] See link.}

_{[liii] Jerry Underwood, Commerce trade team leads Alabama mission to MEDICA in Germany, Made in Alabama, (November 11, 2024), link.}