Rural health care — and what to do about it — has emerged as a political issue during this election year.

The topic has gained traction in the wake of four rural Georgia hospitals closing in the past two years over financial difficulties. Many others have severe cash flow problems, and rural counties have an extreme shortage of primary care physicians. A large percentage of residents have chronic health conditions.

Michelle Nunn and David Perdue, in a tight race for the U.S. Senate seat left open by Republican Saxby Chambliss, who is not seeking re-election, have widely differing solutions to this crisis.

In an updated election guide, produced by Healthcare Georgia Foundation, the two candidates answer a new question about rural health care.

In her response, Nunn, a Democrat, calls for expansion of the Medicaid program in the state, as outlined by the Affordable Care Act.

Expansion "would enable over 600,000 low-income Georgians to sign up for Medicaid and allow rural hospitals to receive payments for services to people who were previously uninsured,'' Nunn says. "By not expanding Medicaid, Georgia will lose $33.7 billion in federal funding from 2013 to 2022, while our tax dollars are spent in other states."

Perdue, rather than implement more of the Affordable Care Act, would go in the opposite direction. The Republican candidate supports a plan by U.S. Rep. Tom Price, R-Ga., to repeal the health law and embrace free-market solutions to the problems of health care.

He blasts the law, often known as Obamacare, for ending government payments to hospitals that treat a large share of low-income patients, and for "driving insurance companies out of many underserved areas, and causing health care premiums to spike on the remaining plans."

Earlier this year, the closures of rural hospitals drove political leaders to act. Gov. Nathan Deal, a Republican, established the Rural Hospital Stabilization Committee, created to identify needs of rural facilities and offer potential solutions. He also proposed a regulatory change that would allow a rural hospital to downsize its services.

No hospital has yet applied to do this, the state Department of Community Health said recently.

Meanwhile, more than 40 hospitals in rural areas in Georgia have given up baby deliveries, according to Jimmy Lewis of HomeTown Health, an association of rural hospitals in the state.

"Rural hospitals and rural physicians are in a cash crisis,'' Lewis says. "It's going to mean restricted access to care for patients. It will lead to rationed health care."

The election guide from Healthcare Georgia Foundation is "designed to inform Georgia voters (and) provides an insight into the leadership values and principles that will guide our U.S. senator's approach to a healthier Georgia,'' said the foundation's executive director, Gary Nelson.

In her response on rural health care, Nunn, like Perdue, criticizes the Affordable Care Act's cuts to hospitals that serve a "disproportionate share'' of poor patients.

"Too many communities already lack access to prompt emergency care, and if these cuts are allowed to continue, the effect on Georgia's rural communities will be devastating,'' says Nunn.

She also supports creating "a new tier of lower-cost health care plans for places like southwest Georgia, which still faces some of the highest premiums in the nation."

And Nunn emphasizes investment in preventive care as part of the solution to rural health issues.

Perdue backs "harnessing technology, financial incentives, and the free market in creating a sufficient market for hospitals, medical practitioners, and other parties to invest in rural America."

He also calls for a reduction in the regulatory burden for health-care providers.

The election in November puts Nunn and Democratic gubernatorial candidate Jason Carter on one side of the Medicaid expansion issue, and Perdue and Deal on the other.

But the Affordable Care Act is not as sharp an issue as it was four years ago, says Charles Bullock, an expert in Southern politics at the University of Georgia. (In 2010, the law was newly passed, and though still largely unimplemented, it continued to spark national debate.)

A George Washington University poll released this month found that of the 70 percent who said the country was off on the wrong track, just 5 percent offered a reason having to do with the Affordable Care Act, The Washington Post reported.

"It's yesterday's news,'' Bullock said. "And there are elements that people like'' about the health law, he said, such as allowing children to stay on their parents' policies until age 26 and banning insurance discrimination based on pre-existing health conditions.

While there's not as much bashing of ht law by Republicans, Bullock said, they will try to tie Nunn — and Carter — to President Barack Obama because of his overall unpopularity.

The Affordable Care Act would be mentioned in that effort, Bullock said.