What to know about WakeMed’s deal with Atrium as NC officials raise alarms

A plan to let Charlotte-based Atrium Health take over Raleigh-based WakeMed has generated skepticism and opposition from state and local officials on both sides of the aisle.

State lawmakers, the Raleigh mayor, a group that represents state employees and the state’s elected attorney general, auditor and treasurer are among those weighing in on the deal, which would give one of the nation’s biggest hospital chains a foothold in the Triangle.

A vote by Wake County officials that would enable the deal was initially scheduled for Monday. That vote was delayed after pressure from state officials.

Here’s what you need to know about the proposed transaction.

What's the deal? WakeMed would be taken over by Atrium, which promises to create new jobs and invest more money into the Triangle health care market. Atrium already owns hospitals in the Charlotte and Triad regions, and it has a partnership with Wake Forest University’s medical school. Under the agreement, WakeMed would keep its name but be run by Atrium. WakeMed would continue as the same legal entity without dissolving or reincorporating, according to a summary of the proposed transaction provided to county officials. Wake County commissioners would retain the power to appoint eight of the WakeMed board’s 14 members. Atrium would be allowed to appoint the remaining six members. WakeMed’s existing leadership team is expected to stay in place after the transaction closes, a person with direct knowledge of the transaction told WRAL.

What is Atrium? Atrium is part of a larger hospital chain that’s one of the biggest in the nation. It already had hospitals throughout the Southeast even before it combined in 2022 with a Midwestern hospital chain called Advocate Aurora. That new company, Advocate Health, is based in Charlotte. Hospitals in its markets continue to go by their old names, so the company is still known as Atrium in North Carolina. The combined Advocate Health group is the nation’s fourth-biggest hospital chain measured by total revenue, according to Definitive Healthcare, an industry analysis group. The company brought in $22.5 billion last year — almost 10 times the revenue reported by WakeMed.

Why do the companies say this is a good idea? WakeMed is feeling the crunch of competition from UNC Health and Duke Health, each of which also operate hospitals and doctor’s offices throughout the Triangle. A booming and aging population has driven up the demand for more hospital space — more surgical centers, more urgent care offices, more mental health care and more overall hospital beds — and building all that supply takes quite a bit of money. Becoming part of the bigger, wealthier Atrium group could help WakeMed keep up with UNC and Duke. Meanwhile, Atrium gets access to a new market in the lucrative Triangle region — specifically Wake County — which is the biggest and wealthiest county in the state. State officials such as State Treasurer Brad Briner have questioned whether the combination with Atrium is needed for WakeMed to finance its expansion. 

What could this deal mean for the Triangle? Atrium says the deal will create more than 3,000 new jobs. Local leaders are skeptical. WakeMed is already the largest private employer in Wake County, with nearly 13,000 employees. Raleigh Mayor Janet Cowell, a Democrat, told WRAL on Monday she doesn’t buy the promise of more job creation. “There’s no community benefit at all,” Cowell said. “There’s a promise of jobs, but we already have growth and jobs in this hospital without this transaction. So it really seems like we’re getting absolutely nothing.” As part of the deal, Atrium has promised to invest about $2 billion to help expand WakeMed’s footprint, including redevelopment and expansion of the flagship Raleigh campus with additional inpatient beds and modern infrastructure. The investment would also help expand hospitals in Cary and North Raleigh and continue development of inpatient and outpatient services in Garner. Briner, Republican, and other officials have also said the promised investment by Atrium would be achieved regardless of a deal due to population growth. 

What about the cost of care? In a statement, Atrium and WakeMed said the deal would “improve affordability and remove cost-related barriers for vulnerable members of our communities by expanding financial assistance” for low-income patients. But Cowell, Briner and others predict it will lead to more expensive health care. “They're just going to raise prices, expand operating margin,” Briner told WRAL in an interview Monday. “And ultimately, the patients will feel the brunt of that through higher prices.” The State Employees Association of North Carolina also said it fears the deal could raise costs, and therefore lead to state employees and others having to pay more for health insurance and medical care. “SEANC has long opposed the trend of hospital consolidation in North Carolina, and for good reason: the evidence is clear that when large health systems absorb independent or community hospitals, prices rise and competition disappears,” the group wrote in a letter to Wake commissioners Friday. SEANC also represents employees of UNC Health, one of WakeMed’s main competitors.

What evidence is there to suspect price hikes? Atrium has a history of using its large market share in Charlotte to inflate health care prices in that market, according to state and federal regulators. The company was forced to abandon those practices after North Carolina and the U.S. government sued. That lawsuit, brought by then-Attorney General Roy Cooper in 2016 and resolved by then-Attorney General Josh Stein in 2018, ended in a settlement that allowed Atrium to avoid any admission of wrongdoing if it promised to stop forcing insurance companies to steer patients to high-priced treatments. “Atrium Health did not violate the law,” the company said in a statement at the time. “... Atrium Health has always been a champion for patient choice, and believes its unparalleled quality, value and world-class services are the reason why more people continue to choose Atrium Health.”

Do hospital combinations typically increase prices for consumers? Academic research, including papers from 2012, 2015 and 2025, indicate mergers and acquisitions between hospital groups tend to raise prices for consumers. It’s also what politicians say. In 2021, when he was attorney general, Stein — now the governor — singled out several examples, including Atrium’s acquisition of Wake Forest Baptist in Winston-Salem. “Recently in North Carolina, there has been a wave of hospital consolidations — HCA and Mission, Novant and New Hanover, Wake Forest and Atrium — and I have real concerns about this trend,” Stein wrote in 2021. “Bigger doesn’t always mean better. In fact, it often means worse and more expensive.” On Monday, Briner added that it’s just simple economics: The bigger a company becomes, the higher it can drive prices. “That's what we've seen in every other merger,” Briner said. “So I don't know why we wouldn't see it here.” 

What needs to happen for the deal to go through?  The WakeMed board of trustees has already approved the deal, but that’s only the first step. Next, the Wake County Board of Commissioners needs to approve changes to the articles of incorporation that govern WakeMed. The county still has power over board seats and interests in the hospital system's real estate, and therefore need to approve language in corporate documents that would allow for the Atrium transaction. That was scheduled for Monday but was delayed after state and local officials asked commissioners to pump the brakes. Even if the Wake County commissioners ultimately agree to advance the transaction, it’s possible state or federal regulators — the Federal Trade Commission, the U.S. Department of Justice or North Carolina Attorney General Jeff Jackson — could seek to block the deal. However, the bar for doing so is high and comes with substantial legal roadblocks. According to the Kaiser Family Foundation, a health care research group, as of 2023 “cross-market mergers have never been fully litigated by a federal or state antitrust agency, and doing so in the short term may be difficult.” Stein's office said Monday that the state legislature needs to give the attorney general’s office more legal power to put pressure on deals like this. “The Department of Justice needs more tools in the toolbox to ensure these types of transactions are transparent and actually benefit the public,” a Stein spokesperson said in a statement.

Why the call for a delay?  Many of the officials are opposed to the deal. But even if it does go through, they said, it shouldn’t be rushed through without debate. That’s how the county commissioners had originally planned to do it, by putting the vote on what’s called a “consent agenda” — a list of items that are voted on in a group, without debate, typically used for low-level or clerical issues. State Auditor Dave Boliek is among those who called for a delay to let the public find out what’s going on. “It's not an accident that the county commissioners are required to promote and pass approval on the change in ownership,” Boliek told WRAL in an interview Monday. “Because ultimately this is a public asset. … It's not something that should be done quickly, and it's not something that can be done without stakeholders involved.” On Monday, after the county commissioners voted to pull the hospital overhaul off their consent agenda, chairman Don Mial acknowledged the outcry that led them to delay the vote. “The board made this decision to provide time for the hospitals to engage with the community,” he said. “… While the joining of these hospitals may be positive for Wake County, we want to be fully open and transparent about the process.”

What are local leaders saying? In addition to Cowell’s opposition, Wake County lawmakers are also raising concerns. Republican state Rep. Erin Pare and Democratic state Sen. Jay Chaudhuri are among a bipartisan group expressing concerns. “This deal should receive appropriate scrutiny, and it seemed like there was an attempt to avoid that,” Pare wrote on social media. Chaudhuri added in an interview: “There's got to be a public hearing. We have to understand what the details are of such a merger. And I think there have to be real questions asked about whether a merger leads to increasing health care premiums.”

Have there been other examples of deals like this in the past? As Stein alluded to in his 2021 statement warning about the dangers of hospital mergers and consolidations, there have been several in recent North Carolina history. One deal he initially approved as attorney general, before later reversing course and attempting unsuccessfully to stop, was the takeover of Asheville-based Mission Health by Tennessee-based HCA Healthcare. HCA has since shut down what North Carolina Health News reported was the only only-term care hospital in western North Carolina. It has also been flagged multiple times for violations that placed patients at risk, while reporting rising income and stock prices, according to the Asheville Watchdog news organization. Briner referenced the Mission sale, as well as the same takeover Stein had also mentioned of the New Hanover Regional Medical Center by Novant Health. According to the Wilmington Star News, locals are organizing a protest against the merged hospital, over its poor safety ratings. “Call someone in Asheville or in Wilmington and ask them how it's gone there,” Briner said. “Because it'll be the same here.”

What happens for WakeMed if this deal doesn't go through? If the deal doesn’t go through, WakeMed would continue to operate as normal. What that means in the long run is up for debate. Briner said that should be good enough, even without Atrium taking over. Briner, who was a Wall Street investor before becoming the state’s treasurer, said he has a high opinion of its current business. “WakeMed is a very well managed company,” said Briner, who as treasurer also serves as head of the Local Government Commission, which approves bonds for counties and municipalities. “It's very profitable. They have the capability and the debt capacity to build. … The bond market will finance things that are attractive. And WakeMed operates well in an attractive geography, with an attractive payer mix, so there's no practical limit on the amount of financing that will be available to them to expand.” WakeMed Chief Executive Don Gintzig appears to disagree. He told Wake County commissioners Monday that his hospital is facing an existential crisis. Unless the deal goes through, he told commissioners at the meeting, WakeMed could cease to exist within just a few years, leaving UNC and Duke the only options in the Triangle. “This new partnership will mean Wake County will still be served by three strong systems,” Gintzig said. “There will be more competition not less.”

WRAL reporter Carly Haynes contributed to this article.