Madison County, located in the mountains of western North Carolina, has no hospital and just three ambulances serving about 22,000 people.
Ambulances travel back and forth frequently. Missionary Hospital in Asheville, the region's largest and most central hospital. The trip could take more than two hours, according to Mark Snelson, the company's director. Madison Medics Ambulancelocal emergency medical service.
“When we're busy and all three of us are gone, there are no ambulances in our county,” he said.
Snelson and other Madison County residents don't need new ambulances. They want the hospital to be closer than the Mission. And the state agrees. In 2022, North Carolina Department of Health and Human Services officials said Madison and three other Mountain counties need 67 more acute-care hospital beds. The state increased that number to 93 beds in 2024 and then to 222 by Oct. 15.
But the only sign of a new hospital for now is a 25-acre field of flat land and a sign erected next to the highway that reads “FUTURE HOME OF AdventHealth Weaverville.”
For the past three years, the owner of Mission Hospital has been challenging the Florida-based court's decision. AdventHealthAn effort to build a hospital on land purchased for $7.5 million in rural Weaverville, just minutes south of Madison County. It was should open this yearan event that would challenge national trend on the closure of rural hospitals.
The irony is that the very law that requires the construction of a new hospital—the state's Certificate of Necessity, or CON, law—has been used to prevent further construction. Such laws are intended to limit the unfettered expansion of health care by allowing new hospitals to open and expand only when the state can document the need for them. But the lawsuit tied the proposed Weaverville hospital to court, as have other similar laws with projects in Tigard, Oregon; Connecticut; And Fort Mill, South Carolina.
All states had certificate of need laws until 1987, when the federal government repealed the mandate requiring them. Today North Carolina is one of the 35 states with laws still on the books. Twelve others canceled them or extended their validity, and some, for example Montana And South Carolinasignificantly weakened them amid concerns that they limited access to health care and increased costs. President Donald Trump's Federal Trade Commission and the Justice Department are among those questioning the need for the laws.
In North Carolina, opposition to the state certificate law also arose both in the General Assembly, where repeal bill Inactive since April, and more prominently on the state Supreme Court.
But some hospital industry organizationshealth economists and needs certification lawyers argue that while the laws create bureaucracy that can delay projects, that's no excuse for doing away with them.
The principle behind certificates of necessity is to contain what supporters say This is unnecessary expansion and price inflation caused by a free market that makes healthcare more expensive for everyone.
“If a principle is worth preserving, do not abandon it,” said Mark J. SilbermanBenesch Law Firm medical attorney and former counsel Illinois Board of Certificate of Need. “Improve the process to allow this principle to flourish.”
Who should fill the need?
Mission Health is the largest health care network and largest employer in the Tar Heel State of Appalachia. in Nashville HCA Healthcare bought the century-old six-hospital nonprofit system for $1.5 billion in 2019, turning it into a for-profit enterprise serving an 18-county region. (Dogwood Health Trust, a nonprofit created as part of HCA's purchase of Mission Health, helps fund KFF Health News' coverage.)
Although AdventHealth already operates one hospital in the North Carolina mountains, about 30 minutes from the Weaverville site, its proposal to build a new one poses a threat to HCA's stronghold. The mission says it is best positioned to meet the needs the state says exist in the Madison County region.
“Not all emergency beds are created equal,” said Mission Health spokeswoman Nancy Lindell. “Rather than adding more beds at facilities that are unable to provide the comprehensive medical and surgical care needed, the region would be better served by expanding the bed capacity at Mission Hospital.”
Eye surgeon in eastern North Carolina. lawsuit filed in 2020 v. state health agency, and top state officials said the state's credentialing law “has nothing to do with protecting the health or safety of actual patients.” Ophthalmologist Jay Singleton argued that the law prevented him from performing surgeries at his own center because the state saw no need to duplicate services already provided at the local hospital where he was required to operate.
In early November, Republican State Treasurer Brad Briner North Carolina State Employees Associationand several scholars who study such laws nationally have filed amicus briefs supporting Singleton's case and urging the judge to reject the state's attempt to dismiss it.
“I characterized the CON law as a license to compete,” said Thomas Stratmanprofessor of economics and law at George Mason University who co-authored the review. “It's like if McDonald's wanted to open a store next to Burger King, they'd have to go to a government regulator and ask if that's okay.”
Stratmann argued that instead price increaseincreased competition will give hospitals and health care providers more leverage in negotiations with insurance companies.
This view is consistent with the position the federal government has taken for nearly 40 years. The Federal Trade Commission and the Justice Department, led by Democrats and Republicans alike, have argued with varying degrees of enthusiasm that the laws are anticompetitive and harmful to consumers. The Justice Department did not respond to questions about its current position, and the Federal Trade Commission declined to comment for this post.
“CON laws create barriers to entry and expansion, limit consumer choice, and stifle innovation,” the Federal Trade Commission wrote in an April letter to Rhode Island Gov. Dan McKee, a Democrat, as the state Legislature considered but ultimately decided against amending its certificate of necessity law. “For these reasons, agencies routinely suggest that states repeal or reduce their CON laws.”
“It's personal”
IN June letter Senate Democrats have included five North Carolina hospitals on a list of rural hospitals that face closure if the president's pending spending and tax cut bill, dubbed the “One Big Beautiful Bill,” becomes law, according to Trump and congressional leaders, citing research conducted by University of North Carolina Sheps Center.
Two of five North Carolina hospitals on this list Angel Medical Center And Blue Ridge Regional Hospitalare part of the Mission Health system. Both companies had three years in a row of negative earnings, as did hundreds of other companies on the list. Lindell, the Mission Health spokesman, said HCA intends to keep the two facilities open.
Despite that, Madison County Health Department Director Tammy Cody said needs remain in the region and the certificate of need appeals process has slowed.
“It’s not a theory—it’s personal,” she said. “Every delay means a woman in labor faces a longer journey, an elderly person with chest pain waits longer for help, and a worker injured on the job faces unnecessary complications.”
AdventHealth spokeswoman Victoria Dunkle said the hospital system supports the state law in part because it “protects rural residents' access to health care and gives the community a voice in the process.” She said the lawsuit has kept families waiting, but AdventHealth plans to move forward with the Weaverville hospital “as soon as possible.”
Snelson, the director of emergency services, voiced a question many in the region have been asking since hopes of opening a new rural hospital began.
“Why is it bad that another hospital comes here to take some of the stress off the Mission?” he asked. “Within a day of opening it will be full.”
