“They’re kind of providing less services with the same amount of county money,” said Fitch. “At some point, that equation has to be addressed.” That discussion could lead in a direction that Gov. Rick Scott has urged: tax dollars following the poor and uninsured patients, flowing to whatever facility they use, rather than going solely to government hospitals.

Michael Bileca, a state representative and Jackson board member, said he disagrees with Fitch. He believes county leaders will be happy that “Jackson is no longer a ticking time bomb,” which could overwhelm county finances if it couldn’t meet payroll. “I think they would take that trade-off — lower services for same taxes — all day long.”

Bileca and many others believe that Jackson’s main problem is reversing the trend of declining admissions. Jackson’s patient numbers have been steadily declining since 2007, the year that UM bought Cedars Medical Center, just across Northwest 12th Avenue from Jackson Memorial.

Since UM doctors represent more than 90 percent of the staff at Jackson Memorial, some believe that the timing of Jackson’s patient decline and UM’s purchase was not coincidental. Lapciuc said Jackson has an “almost unsustainable relationship with the university.” He listed several service areas — including urology, oncology, pulmonology, cardiology and orthopedics that “the University of Miami has basically plundered those lines out of Jackson … and taken them across the street.” Lapciuc has urged Jackson’s leadership to consider other academic alternatives to UM.

UM Dean Pascal Goldschmidt responded: “We are disappointed that Mr. Lapciuc does not realize the extraordinary opportunity that Jackson and the University of Miami bring to the community in all disciplines of medicine. … Together we have created lines of service second to none, and together we have trained legions of outstanding physicians who are caring for hundreds of thousands of patients in South Florida and beyond. We intend to continue our partnership of excellence in the decades to come.”

CEO Migoya, speaking recently to The Miami Herald editorial board, praised UM doctors working at Jackson, “It’s great to have some of the best doctors in the country,” but it’s hard “when the guy that owns a Burger King is running a McDonald’s across the street.”

Last year, Migoya sought a clear split to define doctors’ loyalties, so that some UM faculty would either be hired or leased by Jackson and owe all their loyalty to Jackson Memorial. That idea has gone nowhere, and Migoya is now establishing programs that UM and Jackson can work on together, such as organ transplants.

Fitch, the union consultant, believes Jackson has to find a way to work with UM. “The relationship with UM is probably the most complex and potentially concerning long-term issue facing Jackson.” FIU’s medical school is too young to offer a real alternative to UM’s depth of faculty specialists, Fitch said.

“It is critical that Jackson and UM find a pathway to work together to meet the community’s needs. … There are no viable alternatives for Jackson,” Fitch said.