By Lucas Thomae
In 2022, North Carolina’s Department of Health and Human Services approved new hospital beds to be built in Western North Carolina for the first time in more than a decade.
According to the formula the state uses annually to determine which areas require expanded medical services, Buncombe and its neighboring counties were due for 67 more acute care beds. That determination kicked off a competitive application process to determine which health system was best positioned to receive the certificate of need required for them to build and operate those beds.
In the end, DHHS chose to approve Florida-based AdventHealth’s application for a brand-new hospital in Weaverville, a small town in the northern part of Buncombe. The decision was welcome news for residents of nearby Madison County, who sometimes faced commutes longer than an hour to reach needed medical care.
Not everyone was pleased with the decision to build a new hospital, though. Mission Health, with its flagship in Asheville, controlled a near-monopoly in the region, but calls for greater patient choice had grown louder since its 2018 sale to Tennessee-based corporation HCA.
A competing hospital so close to Mission’s flagship Asheville facility could threaten HCA’s hold over the region. So, the hospital system behemoth took legal action against DHHS and AdventHealth in an attempt to prevent the Weaverville hospital from being built.
In a sense, the HCA’s strategy worked by significantly delaying the project. Construction on the planned Weaverville facility is still underway. For now, Mission continues to operate the only hospital in Buncombe County, which is the most populous in the state’s mountain region.
It’s a story that has been playing out in much the same way with different players in the healthcare industry across different parts of North Carolina.
This is the first article in Battling for Beds, a three-part investigative series from Carolina Public Press, examining how certificate-of-need disputes between competing health systems have hampered the state’s ability to meet healthcare needs in its fastest-growing communities.
This story examines the scope of the problem and its implications for North Carolina in the near future. Upcoming installments will examine how North Carolina’s stringent certificate-of-need process has enabled these delays and the debates over how to address the issue.
Appeals leave needed hospital beds unbuilt
The mechanism which allowed HCA to delay the development of AdventHealth’s Weaverville hospital is North Carolina’s certificate-of-need law.
A certificate of need is a government-mandated document which allows a healthcare provider to expand or develop new services.
Under this centralized system, a hospital can’t simply decide to build a new facility, nor can it purchase new equipment like an MRI machine or PET scanner, without first receiving a certificate of need. Every year, DHHS determines which parts of the state require expanded medical services and holds a competitive review process for each available certificate of need.
Certificate-of-need programs have long been touted as a way to control healthcare costs by preventing unnecessary expansions and duplications of services. However, they have also been criticized for being anti-competitive, limiting patient choice and actually driving up healthcare prices by artificially restricting supply.
While the fight over beds in Buncombe County is among North Carolina’s longest-lasting and highest-profile legal disputes regarding certificates of need, it is far from the only one.
CPP’s statewide analysis of certificate of need applications, decisions and appeals revealed that since 2020 DHHS approved more than 1,100 acute care beds which are still undeveloped and stuck in legal limbo because of competitors’ appeals.
That means new hospital beds are not matching the pace at which the state’s population is growing, and the numbers show it. Since 2020, statewide hospital occupancy rates have steadily crept up from 56% to 67%, and the state’s busiest hospitals — like Mission in Asheville — are consistently operating well above that benchmark.
Statewide, at least six planned hospitals and 13 expansion projects at existing hospitals are currently prohibited from beginning construction because of competitors’ appeals, despite winning DHHS approval.
Most economists would agree that competition is a good thing for consumers. Generally, it gives them more choices and drives down prices. But under North Carolina’s certificate-of-need process, that competition has incentivized hospital systems to use the legal challenges to stall their competitors’ approved projects for as long as they are able, even if that comes at the expense of the timely deployment of new hospital beds and medical equipment to the communities they serve.
Those delays are problematic because the state approves these projects with the intent of meeting projected future needs based on a mathematical formula.
If a county is projected to need hundreds of new hospital beds within the next two years, but the projects to add those beds lag behind by several years, hospitals in that area could become overcrowded and patients less safe.
“It seems to be a regular occurrence that these things end up in court and end up delaying these projects, which is not good for health policy,” Mark Hall, a professor of health policy at Wake Forest Law School, told CPP.
“If (DHHS) is defining a need and there’s a legal delay in the plans to meet that need, by definition you’re leaving people without the capacity to meet their needs,” he added.
NC turf wars over hospital beds
Right now, there are three distinct hot spots when it comes to multi-system fights over hospital beds and equipment.
- The Research Triangle is controlled by a triumvirate of rival systems: WakeMed in Raleigh, Duke Health in Durham and UNC Health in Chapel Hill.
- The area around Charlotte is in Mecklenburg County and bordered by suburban counties including Cabarrus, Union, and Lincoln. In this area, Atrium Health — the state’s largest hospital system — routinely goes head-to-head with Novant in competitive reviews for acute care beds.
- The area around Asheville historically has been dominated by Mission Health but now includes AdventHealth and Novant. UNC Health is also seeking to build a new hospital there and has joined in on the ongoing appeals battles.
Each 19 of the state’s delayed hospital projects are concentrated in those three clusters, but more turf wars seem primed to break out soon enough.
DHHS is currently considering applications for 225 new acute care beds in New Hanover — North Carolina’s most populous coastal county and home to Wilmington. Novant is the dominant player in that region and is seeking to keep it that way, but UNC Health and Atrium have launched bids to build competing hospitals there.
In the Piedmont Triad region, Forsyth County is set to be awarded 276 new beds over the next two years. Novant and Atrium, which both have strong presences there, are competing for those beds alongside Greensboro-based Cone Health.
A three-way battle in the Research Triangle
The three-system rivalry between UNC Health, Duke Health and WakeMed is exemplary of the issues caused by delayed hospital projects.
Currently, 337 acute care beds approved to be built in Wake County are held up in the appeals process. Another 82 beds approved for Durham county are languishing without a certificate of need for the same reason.
Each of the three systems have been awarded some amount of those beds by DHHS, but none have begun work on their respective projects because they’re caught up in legal fights with each other.
In one notable case, Duke Health delayed construction of a new hospital in southern Durham County for more than four years before reaching a settlement with UNC Health, finally allowing DHHS to issue the certificate of need required to begin work.
That hospital, which is being built near Research Triangle Park, won’t open until 2032. DHHS originally awarded UNC Health the beds in 2021 with an expectation for the new hospital to begin operating in July 2026.
Certificate of need battles aren’t limited to hospital beds either. In 2023, DHHS awarded a linear accelerator — a device used in radiation therapy for cancer patients — to WakeMed, which previously had none.
Duke Health, which already owned four linear accelerators, appealed DHHS’ decision and held up the certificate of need for more than two years before finally resolving the dispute.
In court filings responding to the appeal, WakeMed characterized Duke’s behavior as anti-competitive.
“Duke directly benefits from WakeMed’s inability to offer radiation oncology in the form of a steady stream of WakeMed patient referrals and tens of millions in revenue annually,” WakeMed’s attorneys wrote.
The two systems eventually reached a settlement and DHHS issued the certificate of need to WakeMed in February.
Similar episodes have played out between the three competitors over PET scanners, and more appeals are on the horizon. This year, all three are competing for 233 acute care beds and a PET scanner. DHHS has not yet made any decisions regarding those applications.
Atrium-Novant feud spills into the Charlotte suburbs
Atrium Health and Novant Health, the two largest hospital systems in the state, have a similar tit-for-tat dynamic in the Charlotte metropolitan area.
DHHS often chooses to divide its bed allocations between the two rivals, and for a while both Atrium and Novant appeared content with that relationship. However, appeals between the two have become more common as both systems seek to expand their reach in Charlotte and beyond. The deployment of new hospital beds have lagged in response.
The first of these appeals came in 2024, when DHHS awarded all 89 available beds in Mecklenburg County to Atrium for an expansion of its flagship hospital, Carolinas Medical Center. Novant wanted those beds for its Charlotte hospital, Presbyterian Medical Center, but was denied by DHHS outright.
Novant sought to reverse the decision through appeal, and later that year it reached a settlement. DHHS agreed to split the need determination in half: Atrium walked away with 45, and Novant got the remaining 44.
The success of that settlement marked the start of a more aggressive approach for Novant when it came to competing with Atrium for certificates of need.
In 2025, DHHS awarded Atrium 177 beds and Novant 33. Novant also appealed that decision, and those 210 beds are still held up in the appeals process.
It’s a similar story in Cabarrus and Lincoln counties, where a total of 245 approved hospital beds are tied up by legal disputes between the two health systems.
More delays in Buncombe
Back in Buncombe County, Mission’s longstanding hospital monopoly won’t continue for much longer.
Mission owner HCA successfully held up AdventHealth’s Weaverville hospital project in court for three years. But in December 2025, the North Carolina Supreme Court declined to hear HCA’s appeal. That allowed AdventHealth to finally begin building its planned hospital.
The new opening date for AdventHealth Weaverville is February 2028, more than three years later than its original projection. A groundbreaking ceremony attended by Gov. Josh Stein took place in March.
Even so, related fights over the size of the hospital are continuing to play out.
An additional 26 acute care beds awarded to AdventHealth Weaverville in 2024 are also facing appeal by Mission, and that fight has gone on for two years without a resolution.
In March, DHHS chose to award 95 more beds to Mission and 34 to Novant Health for a new hospital in southern Buncombe County. Those beds are also stuck in legal limbo because of appeals.
In total, none of the 222 hospital beds approved for development in Buncombe County over the past four years have made significant, if any, progress toward being licensed for patient use.
Meanwhile, Mission Hospital reported to DHHS in one application for new beds that its occupancy rate had risen to potentially dangerous levels, reaching an average of 99.7% in 2025. For comparison, DHHS’ target occupancy rate for a hospital of Mission’s size is 78%.
Bigger, more costly CON battles loom
If it already seems like too many hospital projects are entrenched in legal battles, the problem is set to become much worse over the next several years.
This year’s State Medical Facilities Plan, the annual planning document which lists every need determination across the state, called for the largest batch of available acute care beds ever put forth by DHHS. That spike of needed beds was driven by both statewide population growth and a post-COVID adjustment to DHHS’ need-determination formula.
In total, North Carolina is set to approve 1,556 more acute care beds, most of them in counties like Mecklenburg, Wake and Durham that are highly contested between healthcare industry players and still haven’t begun to develop the new hospitals and expansion projects approved in last year’s cycle.
That could prove to be a major problem for the state if it fails to meet demand for hospital capacity in its growing urban centers.
At least for now, the health systems mired in appeals don’t seem to be taking issue with the certificate-of-need process itself. In fact, the major systems have consistently opposed any changes to the current certificate-of-need law through their lobbying arm, the North Carolina Healthcare Association.
They’ve decided that the benefits that come with the certificates of need, namely market stability and the ability to ward off potential competitors, outweigh the cost of extended legal battles and potential public health risks.
When asked about whether health systems were frustrated about the extent to which their projects have been delayed by legal fights, North Carolina Healthcare Association CEO Josh Dobson was hesitant to acknowledge the issue at all.
“I’m not hedging,” Dobson said, “I would just say that the challenges and competition between our members for C.O.N. beds, I typically stay out of.
“Our position is: let’s not add to the volatility of the health care market by changing the C.O.N. system that we’ve all agreed to.”
This article first appeared on Carolina Public Press and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
The post Needed hospital beds across NC delayed by industry appeals appeared first on North Carolina Health News.
