The decision to sell nonprofit Mission Health to for-profit HCA Healthcare was made behind closed doors, without public review, and, contrary to promises made by Mission’s leadership at the time of the 2019 sale, did not lead to lasting improvements at Mission Hospital, according to the final two installments of an academic study of the merger.
Though HCA made improvements to the western North Carolina health care system, according to the Wake Forest University report, many were already planned or required by then-Attorney General Josh Stein as part of the terms of the sale.
“[I]t is difficult to point to any concrete lasting improvements that HCA has brought to Mission Hospital,” the report states. “It is telling that, even under the most favorable viewpoints, there is no credible voice openly claiming that Asheville and western North Carolina are actually better off now with HCA at the helm of Mission.”
Other states could give their attorneys general more power over sales and strengthen or modify certificate-of-need laws that are supposed to regulate health care facility competition, according to the report, which was written by professor Mark Hall, a leading scholar on health care law, public policy, and bioethics.
They could consider requiring promises of quality of care in sale agreements or push for public review of mergers instead of letting the decision be made behind closed boardroom doors, the report states.
Read Asheville Watchdog’s coverage of Hall’s work:
Asked if Mission or HCA wanted to comment on the final installments of the report, Mission Health spokesperson Nancy Lindell said, “I do not have any comment for you on this.” Lindell has previously criticized the study because it is financed by a group that is also partially funding a law firm representing plaintiffs in a case against HCA.
At the time of the sale, Stein demanded 15 conditions be added to the deal’s asset purchase agreement (APA), several of which required HCA and Mission to maintain levels of service for 10 years following the sale. But the APA did not contain stipulations about quality of care.
Stein sued HCA and Mission in late 2023, alleging they violated the APA regarding cancer care and emergency services at Mission Hospital. HCA countered that it never committed to provide quality care, noting the APA is “silent as to the quantity or quality of services required” at Mission Hospital.
Proposed legislation in the General Assembly has called for better regulation of hospital sales and more oversight power for the attorney general and a longer list of items to vet for the attorney general’s office during such a review process, the report notes. And though that bill may undergo significant alteration, it could garner bipartisan support, it added.
Shortly after Stein’s suit, the federal Centers for Medicare & Medicaid Services found Mission Hospital to be in immediate jeopardy, the toughest sanction a hospital can face, related to multiple deficiencies in care. The federal government eventually lifted the sanction.
A previous installment of Hall’s study, as well as extensive reporting from Asheville Watchdog since 2020, found that Mission Health board members, who voted unanimously to approve the sale, were blindsided by HCA’s decision to aggressively cut patient care staff in order to save money.
The decision to sell the non-profit system to the largest for-profit hospital owner in the U.S. was based on the belief HCA would create efficiency while maintaining quality and would establish a massive health foundation, Dogwood Health Trust, to improve health and well-being throughout western North Carolina.
“[T]his study’s extensive interviews with former leaders at Mission uncovered virtually no one who felt that the sale was the right thing to do, knowing what we know now,” the report says. “Still, several leaders genuinely feel that the decision made was the right one at the time, based on what was known then.”
An examination of potential positive outcomes
The report also examines potential positive outcomes from the sale and tries to determine if the backlash against HCA and Mission is justified.
While Hall’s study describes many negative consequences of the sale, it says some of the harshest public criticism that has been leveled at HCA and Mission may be overstated.
“On balance, there are various bases on which to conclude that the picture that HCA’s harshest critics paint, or even that this study’s Executive Summary shows, is not as bad as it’s made out to be,” the report says. “There are some positive aspects to Mission’s conversion to a for-profit hospital, and to HCA’s substantial resources. Also, the problems that have arisen at Mission are not unique to it or to HCA.”
Dogwood, according to the report, could be seen as such a positive. A charitable foundation now valued close to $2 billion, Dogwood was created to improve health, social justice and community welfare in western North Carolina. The report issues a caveat, however, noting that Dogwood’s long-term impact may become clearer in coming years.
Since the sale, HCA built several new facilities including a new behavioral health facility and a new emergency department. All five regional Mission hospitals remain open as well, part of the 10-year commitment HCA made to Stein’s office. The report notes that staffing has dropped in some of these hospitals.
HCA’s position as the largest hospital chain in the U.S. makes it more able to respond to crises with money and resources, according to the report. It cites Mission’s performance during two significant crises in the past five years: the COVID-19 pandemic and Tropical Storm Helene.
“HCA Mission appeared able to access critical supplies and equipment early in the [COVID-19] crisis more quickly or effectively than some or many other hospitals,” the report says. “More recently, when hurricane Helene devastated the region, shutting down the water supply for weeks or months, HCA Mission was able to maintain or restore operations by bringing in 20 tanker trucks of water a day, along with fuel, food, and other essentials.”
But Mission has suffered supply shortages as well, the report notes.
Hall conducted extensive interviews with unidentified sources in direct care and management, according to the report, and some said HCA was using its “superior data analytics and supply-chain management more to reduce costs than to ensure superior performance.”
Mark Hall is a member of the National Academy of Medicine and the author or editor of 20 books. // Photo credit: Wake Forest University
In a section titled “Unduly Critical Reactions?” Hall notes that Mission was also criticized before the HCA purchase, and some current criticism may be born out of idealism.
“Many people tend to base their impressions on the level of performance they feel should be expected rather than a more realistic level that reflects the true difficulties that all hospitals face in current and changing economic, political, and public health spheres,” the report says. “In brief, as one former leader put it, the tendency is to measure Mission ‘against what is perfect, but not what is possible’ considering various realities.”
Final installments are part of 178-page study
The entries on positive aspects of the sale and regulatory paths forward are the last pieces of Hall’s eight-part, 178-page study titled “Lessons Learned from HCA’s purchase of Mission Hospital in Asheville, North Carolina.”
Mission has proven a unique case study, Hall told TheWatchdog.
“I cannot think of another instance where the sale of a hospital has generated this much controversy, and so I have to think that the experience in Asheville is rare,” he said. “I believe the main reason that’s the case is that HCA has rarely, if ever, taken over a hospital with the quality and stature that Mission Hospital previously had, and so Mission had a lot more to lose in being brought to HCA’s standard operating level than most of its other hospitals, many of which were struggling to stay afloat when HCA assumed control.”
Despite the uniqueness of what has happened to Mission, laws and policies to prevent what happened in Asheville are applicable nationwide, Hall said.
“The North Carolina regulatory environment is fairly standard, and so reforms that might be (or might have been) helpful here could also be considered in other states,” he told The Watchdog. “One especially important feature of the North Carolina regulatory setting is the state’s decision in 2015 to terminate its financial oversight of Mission Hospital, despite having permitted Mission to acquire monopoly status on condition of subjecting itself to this oversight. Given what has transpired, that history raises the question of whether the state should revisit reimposing monopoly oversight.”
Hall’s work is funded through an Arnold Ventures grant to Wake Forest.
Arnold Ventures is a philanthropic group headquartered in Houston “working to improve the lives of all Americans by pursuing evidence-based solutions to our nation’s most pressing problems,” according to its website. “We fund research to better understand the root causes of broken systems that limit opportunity and create injustice.”
Arnold Ventures is helping fund Fairmark Partners — a group pursuing antitrust lawsuits against “hospital behemoths in Wisconsin, Connecticut, and North Carolina,” according to the group’s website. Fairmark attorneys are representing plaintiffs in a western North Carolina antitrust lawsuit against HCA and Mission Hospital.
Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s local reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.
www.thecentersquare.com – By Alan Wooten | The Center Square – (The Center Square – ) 2025-04-05 08:13:00
(The Center Square) – Hugo and Helene are rare, as is the ever-dangerous tornado outbreaks that sometimes plague the South. Charlotte, regardless of frequency, remains in a dangerous gap every day.
U.S. Rep. Tim Moore, R-N.C.
Moore.House.gov
U.S. Rep. Tim Moore, R-N.C., has introduced the Radar Gap Elimination Act as a vehicle to close it. Bipartisan support includes Reps. Deborah Ross, D-N.C., and Pat Harrigan, R-N.C.
Charlotte is among the nation’s 15 largest cities by population. Moore’s proposal would bring modernization to the National Weather Service, he says, and “close dangerous gaps in high-risk areas like Charlotte.”
“The devastation of Hurricane Helene showed us just how important accurate weather data is to saving lives and hardening communities to minimize damage from upcoming storms and natural disasters,” Moore said. “Charlotte is one of the most populated regions in the country without full radar coverage, creating a blind spot that puts families at risk and hampers emergency response. I’m proud to lead the Radar Gap Elimination Act to close these critical gaps by prioritizing new radar in underserved areas and transitioning to new technology that can better detect severe weather.”
In a release, Moore said House Resolution 2646 “directs the National Weather Service to replace aging NEXRAD radar infrastructure and prioritize the deployment of Phased Array Radar in locations that are more than 75 miles from existing radar coverage. These upgrades will allow meteorologists to detect severe weather closer to the ground, particularly in areas where traditional radar fails to capture low-level storm activity.”
The National Weather Service is in evaluation of a new radar system replacing the Next-Generation Radar system, colloquially called NEXRAD. Moore said it is estimated PAR stations could be built by the end of the decade.
NEXRAD gets blind spots from the curvature of the Earth. For example, a distant NEXRAD station will have trouble on flash flood-causing storms, and F0 and F1 tornadoes at lower altitudes, a release says. That delays warnings and jeopardizes life, Moore said.
Ross said, “Every second counts when severe weather strikes, and this legislation will close the dangerous radar gap in our state and modernize our radar systems, ensuring our communities aren’t left in the dark when extreme weather hits.”
by Sarah Michels, Carolina Public Press April 5, 2025
More than 61,000 voters challenged by NC Supreme Court candidate Jefferson Griffin have 15 business days to prove their eligibility, or have their ballots removed from the count in Griffin’s 2024 bid to unseat Justice Allison Riggs, according to a Friday ruling from a three-judge panel of the NC Court of Appeals.
After all votes were tallied in November, the contest came down to 734 votes, with incumbent Riggs, a Democrat, in the lead. Soon thereafter, Griffin, a Republican Court of Appeals judge, asked for recounts and filed election protests.
The recounts maintained Rigg’s lead, while the State Board of Elections dismissed the protests.
Since then, Griffin’s legal challenges and countering lawsuits from Riggs have made their way through state and federal courts on their path to a delayed resolution while Riggs retains her seat.
Friday, the most significant decision in the case came down from two Republican justices on the North Carolina Court of Appeals. In a 2-1 decision from the panel, the court declared that Griffin’s protests were valid.
Incomplete voter registrations
The panel majority ruled that the largest portion of challenged voters, those who have “incomplete voter registrations” without a driver’s license or Social Security number included in their elections records, are ineligible to vote because they were not registered to vote correctly.
The blame lies squarely on the State Boards of Elections, which did not update voter registration form to make that information required in accordance with the federal Help America Vote Act, the panel majority opinion states.
Once the issue was identified in 2023, the State Board issued a new registration form, but didn’t go back and contact registrants who didn’t list a driver’s license or Social Security number, or check a box saying they had neither to be assigned a unique identification number.
Now, the appellate court panel says those voters are ineligible. The majority emphasized that the court has the right to remove ballots cast by these voters from the count, but is choosing not to do so immediately.
Instead, they are returning the case to the Wake County Superior Court, and instructing them to tell the State Board to contact impacted voters to provide them an opportunity to fill in the missing information. If voters do so within 15 business days of notification, their votes will count. If not, they will be removed from the count for the Supreme Court race, but not other races.
Overseas and military photo ID
The court panel ruled similarly on Griffin’s second protest, which challenged overseas and military voters who did not provide photo identification with their absentee ballots.
During legal proceedings, the State Board has argued that under the state’s Uniform Military and Overseas Voters Act, overseas and military voters are exempt from the voter ID requirement. UMOVA is contained in a separate statute from the one including photo ID requirements, and the Board argued that was intentional.
The appellate court panel disagreed. It ruled that the two statutes were intended to be read together, and that all voters are subject to the photo ID requirement.
Again, implicated voters have 15 business days to provide photo identification or an exception form, or be removed from the count.
In his dissent, Judge Toby Hampson, the loan Democrat on the panel, said providing time to fix these issues does not make up for the fact that impacted voters followed the rules available to them at the time.
“The proposition that a significant portion of these 61,682 voters will receive notice and timely take curative measures is a fiction that does not disguise the act of mass disenfranchisement the majority’s decision represents,” Hampson wrote.
Panel nixes ‘Never Residents’
North Carolina law includes an exception to the state constitution’s residency requirement for a small subset of voters labeled “Never Residents:” overseas U.S. citizens who were born outside the country and whose parents or legal guardians’ last residence was North Carolina.
Friday, the appellate court ruled that statute ran afoul of the state Constitution, and voided the votes of Never Residents.
Panel dissent and equal protection issues
Hampson’s dissent had a few arguments that may be seen again in future litigation.
First, he questioned the timing of Griffin’s protests. The statutes and Board interpretations that are being challenged have been in existence for several election cycles.
The majority declared that eligibility is determined as of Election Day, Hampson noted.
“Despite professing this basic tenet, the majority changes the rules of the 2024 election — and only for one race — months after election day,” he wrote. “It does so even though there is no actual showing or forecast that any challenged voter was not registered or otherwise unqualified to vote.”
Second, Hampson objected to which votes are being challenged. All protests include only early and absentee voters, since that was the information Griffin had available at the time he filed them.
Additionally, the overseas and military photo ID protest only includes Guilford County ballots.
“Each of these voters is at risk of being disenfranchised while similarly-situated voters are not, simply because of the county in which they reside, when they cast their ballot, or their physical location,” Hampson wrote.
What’s next after appeals panel?
The appellate decision may be key in determining the ultimate outcome of the race.
Riggs has already declared her intention to appeal the decision to the North Carolina Supreme Court, calling it a “deeply misinformed decision that threatens to disenfranchise more than 65,000 lawful voters and sets a dangerous precedent, allowing disappointed politicians to thwart the will of the people.”
However, if the North Carolina Supreme Court comes to a very possible 3-3 tie, the appellate court’s decision would be the one that stands. Either way, if the state high court fails to take the case or acts to leave the panel’s ruling in place, Riggs’ legal team has indicated it will likely return the case to the federal courts on equal protection grounds.
The State Board also issued a statement saying that they would comply with the order, if it goes into effect.
“Regardless of the ultimate outcome of this ongoing legal dispute, any voter who is concerned that their voter registration information is incomplete or is not up to date should submit an updated voter registration form,” the statement read.
Democratic National Committee Chair Ken Martin was less neutral.
“This partisan decision has no legal basis and is an all-out assault on our democracy and the basic premise that voters decide who wins their elections, not the courts,” he said in a statement. “If upheld, this could allow politicians across the country to overturn the will of the people.”
While Griffin has stayed mum since November, North Carolina Republican Chairman Jason Simmons called the ruling a “victory for the rule of law and election integrity” in a social media post.
“This decision and order finally holds the N.C. State Board of Elections accountable for their actions and confirms every legal vote will be counted in this contest,” he wrote.
SUMMARY: Republican Judge Jefferson Griffin is contesting over 60,000 votes in his race against Democratic Supreme Court Justice Allison Riggs, claiming registration and ID deficiencies. A 2-1 NC Court of Appeals ruling, with Republican judges siding with Griffin, allows voters 15 business days to correct issues. Riggs, leading by 734 votes after two recounts, vowed to appeal, warning the ruling threatens over 65,000 lawful votes. Griffin also challenges military and overseas ballots. The GOP praised the decision; Democrats condemned it as partisan. The state Supreme Court, with a 5-2 Republican majority, will likely hear the appeal. Riggs has recused herself.
