Rural Healthcare at a Crossroads: Hospital Dispute Highlights Flaws in north Carolina’s Certificate of Need Law
North Carolina’s rural communities are facing a critical healthcare access crisis, exemplified by a stalled hospital project in madison County and a broader debate over the state’s certificate of need (CON) law.
Madison County, nestled in the mountains of western North Carolina, currently operates without a hospital, relying on just three ambulances to serve its roughly 22,000 residents.These ambulances frequently make lengthy trips – sometimes exceeding two hours – to Mission Hospital in Asheville, the region’s largest medical center, according to Mark Snelson, director of Madison medics EMS. “When we get busy and all three of them are gone, we have no ambulances in our county,” Snelson stated.
Residents aren’t seeking more ambulances; they desire a closer hospital, a sentiment echoed by state officials. The North carolina Department of Health and Human Services initially identified a need for 67 additional acute care hospital beds in Madison and three other mountain counties in 2022.This figure was subsequently increased to 93 beds in 2024 and further escalated to 222 by October 15th.
though, the only visible sign of progress is a 25-acre graded field marked with a sign proclaiming “FUTURE HOME OF AdventHealth Weaverville.” For the past three years, Mission hospital’s owner has actively contested AdventHealth’s attempt to construct a hospital on a $7.5 million plot of land in rural Weaverville,just south of Madison County. The project, initially slated to open this year, would have bucked the national trend of rural hospital closures.
Ironically, the state’s certificate of need law – the very legislation intended to authorize the new hospital – is being used to impede its construction. These laws, designed to curb unchecked healthcare expansion by requiring documentation of need for new facilities, have become a source of legal battles. Similar disputes have stalled projects in Tigard, Oregon; Connecticut; and Fort Mill, South Carolina.
All states onc had certificate of need laws, but a federal mandate requiring them was repealed in 1987.Today, North Carolina is among 35 states that still maintain these regulations.Twelve states have either repealed or allowed their laws to expire, while others, like Montana and South Carolina, have significantly weakened them due to concerns about limiting access and increasing costs.Even the Federal Trade Commission and Department of Justice under President Donald Trump have questioned the necessity of these laws.
Opposition to North Carolina’s certificate of need law is gaining momentum, surfacing in the General Assembly – where a repeal bill has remained stalled as april – and, more prominently, in state Superior Court.
However, some within the hospital industry, healthcare economists, and legal professionals specializing in certificate of need regulations argue that, while the laws can create bureaucratic delays, they are not justification for complete abolition.
Proponents of the certificate of need process maintain that it prevents unnecessary expansion and price inflation driven by a free market,ultimately making healthcare more expensive for everyone.”If the principle is worth preserving, don’t abandon the principle,” asserted Mark J.Silverman, a healthcare attorney with the Benesch law firm and former counsel for Illinois’ certificate of need board. “Improve the process to allow the principle to flourish.”
Who Should Fill the Need?
Mission Health, the largest healthcare network and employer in the North Carolina Appalachian region, was acquired by Nashville-based HCA Healthcare in 2019 for $1.5 billion,transitioning from a nonprofit to a for-profit operation serving an 18-county area. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund coverage of this issue.)
While AdventHealth alr