Bileca, the board member who is also an executive with a healthcare company, said Jackson has to make the UM relationship work. He notes that both the UM Hospital and Jackson have been losing market share to the powerful Baptist Health system which has four hospitals in South Miami-Dade. “I think we can be stronger together.”

Barbera, the former hospital administrator, thinks Jackson needs to explore other options. “This will not be an easy fix but Jackson has no choice and must aggressively pursue and develop new relationships with FIU, [Florida Atlantic University], Nova Southeastern, and even the University of Florida.”

Bileca notes that in January net patient revenue reversed a long-standing trend, and was up $10 million from a year ago, although admissions were still below January 2012, a disparity caused by Jackson being more aggressive in collecting from insurers and doing better in enrolling the uninsured in Medicaid.

Like his three CEO predecessors, Migoya has been trying to recruit more doctors to Jackson, either as employees or as community physicians who admit patients to Jackson facilities so that there is not much reliance on UM doctors. One issue has been lack of medical office space. Jackson is now converting part of an underused building on the central campus for doctors’ use.

But Migoya admits that many doctors will be hard to attract as long as the facilities, some of them now a half-century old, don’t get brought up to modern standards. He has built into the present budget a surplus of $35 million, hoping to use the money for capital improvements.

That would be just the start. Migoya projects that Jackson needs $600 million in capital improvements. “And $120 million of that is in stuff you’d never see — elevators, electrical wiring.”

Some board members have tentatively started talking about asking voters to approve a $300-million plus bond issue. Lapciuc could envision that as happening as early as next fall’s election, but Bileca believes that Jackson first needs to show a longer record of surpluses before it asks voters for support.

“We need hundreds of millions to compete effectively,” Bileca said. “We can’t succeed unless we can get significant capital.”

Before Jackson gets that capital, it will have to adjust to Medicaid reform, which could start next year, forcing almost all of the three million recipients statewide into managed care organizations. That is likely to mean considerably lower reimbursement rates, a crucial issue for Jackson since Medicaid is its dominant insurer. Jackson will be setting up a provider service network to compete with health maintenance organizations for patients.

Bileca thinks it can be done. Costs at Jackson have come down in the past two years, he said, which means “we’re in a position in which we can be competitive for those contracts.”

Medicaid expansion — extending coverage to about a million more Floridians, as provided in the federal Affordable Care Act — could also be a big help to Jackson. But Bileca doubts that it’s going to happen. Though Governor Scott and Senate leaders have endorsed expansion, Bileca, a Republican representing Kendall, said on Monday “I do think it’s a long shot for the House to go along with Medicaid expansion.”

Next year, when millions more Americans get insurance through federal healthcare reform, the issue is whether the newly insured will keep going to Jackson. “Many of those indigents are going to have a choice in the future,” Migoya said. “So if you mistreat them at Jackson, they’re not going to come to Jackson.”

Fitch, the unions’ consultant, noted that federal reforms emphasize primary care, an area in which “Jackson has been far behind the curve.” He said the system has had some recent improvements in primary care clinics, but needs to do a lot more. “Jackson will need to very quickly reengineer its patient-delivery model to focus on primary care services.”

Lapciuc has another concern. If Jackson’s trajectory toward prosperity continues, its $1.7 billion in annual revenue is likely to grow, attract new contractors and raise new dangers of corruption. “The vultures will be circling,” he warned.

“Jackson’s future is critical to the community, not only to the consumers,” said Fitch, the unions’ hospital consultant, “in terms of availability and cost and access, but it also plays a significant role as an employer and contributor to the local economy.”