Before we sign away WakeMed to Atrium, these questions need answers | Opinion
Ask any North Carolina family about health care, and the conversation often doesn’t start with policy — it starts with a bill. The $4,000 surprise bill after a child’s emergency room visit. The employer who dropped coverage because premiums jumped 20 percent in a single year. The NC Medicaid program is struggling, like all other states, to rein in costs while providing a lifeline to millions of North Carolinians. Across our state, families, businesses, and government are all struggling with the same crisis: the cost of health care is simply too high.
This is the backdrop against which Wake County commissioners are now weighing a consequential decision — how to approach a transaction that would transfer control of WakeMed to Atrium Health, part of Advocate Health, the nation’s third-largest nonprofit health system. We are glad commissioners are taking the time to scrutinize this transaction carefully.
WakeMed is a lifeline for our community. Founded in 1961 as a county hospital, it is the dominant inpatient provider in Wake County with a 46 percent market share — home to the county’s only Level I trauma center and only pediatric intensive care unit. It is a safety net institution for some of the most vulnerable people in our region.
Atrium/Advocate operates large hospital systems in Charlotte, Winston-Salem and in several other states. Economists and researchers have documented that hospital mergers, particularly cross-market mergers in which a dominant system absorbs an independent in a new geography, drive up prices for patients. Forty-two percent of every health care dollar spent on privately insured Americans goes to hospital care, and since 2000, hospital prices have risen faster than virtually any other sector of the economy. The primary driver: two decades of mergers.
We recognize that WakeMed faces real pressures. Federal Medicaid and Affordable Care Act cuts in the recently enacted law passed by Congress will hit smaller systems hardest. The $2 billion investment Atrium has pledged is significant. And WakeMed has operated for 65 years as a beacon of community health in this region. The leaders at both institutions are people of good faith.
But good faith is not a substitute for binding commitments and deeper public engagement. Before any vote proceeds, commissioners and other state officials should demand clear answers, on behalf of North Carolinians, to the following questions:
On affordability: What contractual guarantees will prevent Atrium from leveraging its expanded statewide dominance in negotiations with Medicaid, the state employee health plan, and commercial insurers? What price controls — enforceable, not aspirational — will be written into this agreement?
On access and safety net services: WakeMed currently provides obstetrics, psychiatric care, pediatric services, and trauma care to uninsured and Medicaid patients. Will those services be contractually required to continue — at current volumes and locations? Specifically, will the New Bern Avenue campus continue to operate its Level I trauma center and children’s hospital, will new construction increase access in low and middle-income communities, and will WakeMed continue to grow mental health care?
On governance: Under the proposed structure, Atrium would become the sole corporate member of WakeMed’s nonprofit, with authority to appoint six of fourteen board seats. County commissioners retain eight seats, but what does “control” mean when the parent organization sets system objectives? What decisions are made at the local hospital level, and which can Atrium make unilaterally?
On community benefit: Should this transaction require the creation of an independently governed community health foundation with a mandate to invest in the social drivers of health – food, transportation, and housing – across Wake County? Other hospital mergers in North Carolina have created such trusts. What will be the charity care standards and will systems remain in place so that it’s the hospital’s responsibility to automatically enroll all eligible individuals?
On transparency: The transaction was announced on a Friday afternoon and originally slated for a Monday vote. The people of Wake County deserve a full public process before any land rights or governance authority changes hands.
We are not arguing this merger cannot or should not happen. We are arguing that the bar for approval must be high, the commitments must be legally binding, and the process must be transparent.
The healthcare affordability crisis will not be solved by yet another mega-merger that promises transformation but delivers consolidation. It will be solved when our health systems are rewarded for keeping people healthy and accountable for the costs they impose on our communities. The time to build that accountability is now — before the ink dries.
Mandy Cohen, MD, MPH, and Kody Kinsley, MPP are both residents of Wake County and served as Secretary of North Carolina’s Department of Health and Human Services.