By Michelle Crouch

For almost four months, supporters and critics of Atrium Health’s proposed combination with Raleigh-based WakeMed Health and Hospitals have filled meeting rooms, fired off emails to elected officials, carried signs and bought radio ads as they argued over what the deal would mean for Wake County.

Wake County commissioners are expected to decide in the coming weeks whether to sign off on the deal, although they haven’t scheduled a vote. Because WakeMed was once a county-owned hospital, the transaction cannot move forward unless the commissioners approve changes to the hospital’s articles of incorporation and a transfer agreement with the county. 

Yet after months of hearings and debate, some of the most important questions about the combination still don’t have easy answers. What would the combination do to health care prices in the two systems? Who would actually control WakeMed? Would the hospitals’ promises of charity care, capital investment and community programs be enforceable? And can WakeMed survive financially without the deal? 

Gov. Josh Stein’s office sent some of those same questions to WakeMed in an Aug.17 letter, noting that the proposed combination “deserves close scrutiny and careful consideration.” On Friday afternoon, a WakeMed spokeswoman said the hospital was still working on its response. 

In a quest for more clarity, North Carolina Health News interviewed experts, examined public documents, reviewed hospital and county presentations and dug into research on hospital consolidation to provide context and answers to some of the biggest questions about the deal.

1. Does WakeMed need Atrium to finance its growth plans?

What they said: WakeMed President and CEO Donald Gintzig has acknowledged that WakeMed isn’t in danger of failing, but he said it doesn’t have enough borrowing capacity to make investments — particularly for construction upgrades — that he said will be needed in the next decade to keep up with Wake County’s growth. 

“Do I think WakeMed will survive in the future? Yes. But I can see a world in which they don’t thrive, and that’s really what this is about,” he said.

As part of the deal, Atrium has pledged to invest $2 billion in capital investments over 10 years. Gintzig said WakeMed needs that money to rebuild the hospital’s aging flagship campus on New Bern Avenue, expand emergency and surgical services, and provide the facilities and equipment needed to recruit top doctors and staff. 

“The money’s not going to be there, even as strong as WakeMed is, to do all that we need to do,” he said. 

Gintzig also argued that WakeMed’s relatively small size puts it at a disadvantage. Larger hospital systems can borrow more easily and buy drugs, equipment and other supplies at a discount, he said, freeing up more money for patient care and expansion. 

A closer look: WakeMed has nearly $1 billion in cash and investments and appears capable of borrowing and investing on its own, according to two independent experts who analyzed WakeMed’s financial documents for NC Health News.

In 2025, the system reported $2.6 billion in revenue and $177 million in revenues-over-expenses, which a for-profit hospital would label as profit. The system also has strong investment-grade credit ratings, Fitch Ratings gave WakeMed an A+ rating in 2025.

Its financial performance has strengthened since then. For the first nine months of fiscal 2026, hospital finance expert Nancy Kane calculated that WakeMed had a total margin of 15 percent (or 17 percent including unrealized investment gains) — far higher than the 3 percent to 5 percent hospital margins she typically sees.

“Fifteen to 17 percent is, like, wow,” said Kane, a professor emerita of health policy and management at the Harvard T.H. Chan School of Public Health, who also is on the board of UMass Memorial Health in Massachusetts. “If 2026 is any indication of their capacity to generate cash, they may not need Atrium to invest $2 billion over the next 10 years. They could do these things on their own.” 

WakeMed is already moving forward with near-term expansion plans. In August, the system filed four applications with the state for a total of $919 million in new projects, including plans to build hospitals in Wendell and Rolesville, two Wake County suburbs.

WakeMed told WRAL that its combination with Atrium would accelerate those projects, but if the deal didn’t go through, “WakeMed remains fully capable of executing each project independently.”

Kane did identify some financial weaknesses. WakeMed’s debt burden is “at the upper range” of what’s considered healthy, she said, and its spending on its buildings has not kept pace with depreciation. But she said the hospital also has strong cash reserves, healthy debt-service coverage, and more cash and investments than long-term debt. 

“This is not a financial problem deal,” she said. “This is a financial opportunity deal.”

Ann Kempski, an independent health policy consultant, agreed that WakeMed appears to be able to finance its current expansion plans on its own. The question, then, is not if the hospital can afford to grow, she said, but if pursuing Gintzig’s more ambitious vision is worth giving up control to a larger hospital system.

“What he’s talking about are grandiose plans,” she said. “He wants WakeMed to have all the fancy stuff and be in on that game.”

2. Who would control WakeMed?

What they said: Atrium and WakeMed describe the deal not as a sale or takeover, but rather as “a strategic combination.”

Gintzig said WakeMed would stay a separate nonprofit, keep its assets and licenses, and manage its own day-to-day operations. “Daily operating decisions would be made locally,” the hospital says on its website. 

“WakeMed stays WakeMed,” Gintzig told a crowd in July. 

Asked by reporters whether WakeMed was, in fact, becoming part of Atrium, Gintzig said yes: “When you join a family, you do things together, you become part of them,” he said. “At the same time, it’s not a sale.” 

He has also described the combination as a “marriage.” 

At another meeting, WakeMed board member Margaret Bratton described the arrangement this way: “We recognize we would lose full governance autonomy while retaining local control.”

A closer look: While WakeMed would still have local leadership, it would no longer be free to make all of its own decisions. Under the proposed articles of incorporation, WakeMed would go from being an independent nonprofit with no corporate member to having one: Atrium Health. 

That would give Atrium substantial control over WakeMed’s finances and operations and tie it to the larger Advocate Health system — the nation’s third largest nonprofit health care system — according to a county presentation. 

Atrium would also generally be able to amend the hospital’s governing documents without county approval, except in a few limited instances. 

Hayden Rooke-Ley, an assistant professor of health law at Brown University who studied the proposed transaction, said those changes amount to a significant shift in authority from the county to Atrium. “The essence of this transaction is to transfer that control over to Atrium,” he argued. “That is the transaction.”

3. Would the county’s power to appoint hospital board members change?

What they said: Gintzig has stressed that WakeMed would still have a local governing board, and that the county would still appoint eight of the hospital board’s 14 directors. Atrium would appoint only six. 

In its public materials about the combination, WakeMed says, “The county’s role in appointing board members isn’t changing.”

A closer look: Instead of appointing directors outright, Wake County’s eight appointees would have to come from nominees approved by two-thirds of the WakeMed board — a change that Gov. Stein’s office highlighted in its letter:  “Why did WakeMed agree to a governance structure that limits the Wake County Board of Commissioners’ role in selecting the WakeMed Board of Directors to merely vetoing the WakeMed Board of Directors’ nominees?”

Also, under the proposed articles of incorporation, Atrium could remove community directors for reasons including being “disruptive” and failing “to work reasonably, respectfully or collegially,” 

Rooke-Ley cautioned that the existence of a local board doesn’t always mean local control: “Many hospital systems have local boards. Oftentimes that doesn’t mean much if the larger system controls the board.”

A recent dispute involving Atrium in Mecklenburg County illustrates his point. There, Mark Jerrell, the chair of the board of county commissioners, is supposed to approve Atrium board nominees. When he refused this year — asking for the hospital to nominate someone with stronger community ties — Atrium declined and elected instead to continue with its existing members. 

4. Did WakeMed leaders do enough due diligence?

What they said: Gintzig said WakeMed has been approached by many large hospital systems over the years, but only Atrium aligned with its culture and its mission, while also bringing expertise and financial capacity.

“There was only one partner worth talking to,” he told commissioners in June.

WakeMed Board Chair Thad McDonald said the board spent two years studying Atrium and bringing in outside consultants to analyze the deal.

“We did a thorough evaluation of them, and in this evaluation, we found out just how similar to WakeMed they were,” he said. “Both organizations have cultures rooted in service and compassion. Both have a long-standing focus on community, and, most importantly, both have a commitment to delivering leading-edge care for everyone.” 

Gintzig said WakeMed didn’t have a competitive open bidding process because the system wasn’t for sale.

A closer look: It’s not clear how deeply the WakeMed board explored other potential partners or financing options. Stein’s office asked whether WakeMed is confident that it couldn’t have secured a larger investment from Atrium or another partner, and if so, how it reached that conclusion. 

The governor’s letter also questioned how much of Atrium’s $2 billion capital investment would actually come from Atrium and how much could be financed with revenue generated by WakeMed itself. 

A competing offer for WakeMed did emerge after the Atrium deal was announced: UNC offered $5 billion in investments in and around Wake County, but WakeMed leaders rejected it. They said their signed agreement with Atrium prevented them from considering other offers, and that much of UNC’s promised investment would have happened regardless because UNC already planned to expand in the Triangle. 

They also said a merger with UNC would reduce competition in Wake County. The two systems would have controlled 80 percent of the market, a level of concentration that likely would have raised antitrust concerns, Kempski said.

5. Why isn’t Wake County getting an endowment or community foundation?

What they said: Although two other recent hospital transactions in North Carolina led to the creation of community foundations, WakeMed leaders said those deals were different. 

When HCA Healthcare purchased Asheville-based Mission Health for $1.5 billion, it converted the hospital from a nonprofit to a for-profit, which, by state law, required the creation of a community endowment, the Dogwood Health Trust, which is also the independent monitor of the terms of HCA’s purchase agreement. When Novant Health purchased New Hanover Regional Medical Center in Wilmington, the hospital was still owned by the county, so the county set up a foundation to distribute money from the sale. 

In this case, there would be no money to place in an endowment because the combination would not be a sale, Gintzig said. Atrium’s $2 billion commitment is not a sale price, but a promise to spend that much on capital investments over the next decade. 

A closer look: While the current proposal includes no money for the county, that doesn’t mean Wake County couldn’t ask for money. They could request annual payments or a one-time lump sum that could be put into an endowment to serve the county, Rooke-Ley and Kempski said.

“I think the real crime here is that they are paying nothing,” Kempski said. “Atrium is getting this incredibly valuable asset for nothing.”

State Treasurer Brad Briner has called for Atrium to contribute at least $1.5 billion to an endowment focused on keeping health care accessible and affordable in Wake County.

Gene Woods, CEO of Atrium parent Advocate Health, told the Wake County commissioners this summer that large health systems create efficiencies when ordering supplies, drugs and equipment, helping offset what he described as thin hospital operating margins. “After we take care of paying teammates and debt and supplies, we have four cents to reinvest in the community,” he said, in response to a question about the system’s margin.

When investment and other nonoperating income are included, Advocate’s overall margin was 11 percent in 2025, according to financial disclosures. That amounted to about $4.6 billion in revenues-over-expenses — what a for-profit hospital would call profit. 

6. Will prices rise if the deal goes through?

What they said: WakeMed and Atrium say in public materials that their combination “won’t drive up your health care costs.” They say insurance companies largely determine what patients pay by setting premiums and deductibles and deciding what they will cover.

The hospitals write, “If we could put a freeze on healthcare costs we would,” adding that the cost of labor, supplies and medication affect the cost of health care. 

Gintzig has said WakeMed would continue to negotiate its own rates with health insurers rather than automatically adopting Atrium’s, which tend to be higher. The State Health Plan already pays Atrium 15 percent to 40 percent more than WakeMed for the same services, according to plan officials.

But Gintzig also said he believes WakeMed is underpaid.

“We don’t go to Atrium rates,” he told a crowd in Southeast Raleigh in July. Then he added: “Lord, as the CEO, I wish we would, because we’re paid so much less.”

A closer look: WakeMed has not publicly or formally agreed to keep its prices from rising. When Wake County Commissioner Cheryl Stallings asked in June if WakeMed would commit to capping reimbursement increases for 5 or 10 years, Gintzig did not directly answer. 

A robust — and growing — body of evidence links hospital consolidation to higher prices for patients. 

A Brown University analysis looked specifically at Atrium and its 2020 combination with Wake Forest Baptist in Winston-Salem. Researcher Dan Arnold said it offers insight into what might happen to prices after a WakeMed-Atrium deal because it was the same health system expanding into another North Carolina market.

The study found average inpatient prices rose 28 percent at Baptist from 2020 to 2024, compared with a 20 percent increase at other N.C. hospitals. 

7. Would it change WakeMed’s charity care and community commitments?

What they said: Gintzig has said WakeMed’s commitment to the community and charity care won’t change under Atrium and would expand to match Atrium’s broader policy. Both systems now provide free care to families that earn 300 percent of the federal poverty level, but Atrium offers additional partial assistance up to 400 percent.

Gintzig has also stressed that the proposed agreement continues an existing requirement that WakeMed spend at least 4.8 percent of its adjusted revenue each year on indigent care, or uncompensated and Medicaid care. 

WakeMed spends about 12 percent of its revenue on indigent care, hospital board members said.  

A closer look: Despite Atrium’s broader eligibility, WakeMed devotes a much larger share of its net patient revenue to charity care than Atrium, according to the National Academy for State Health Policy’s hospital cost tool. In 2024, WakeMed’s net charity care costs were about 4 percent of patient revenue, compared with 1 percent across Atrium’s North Carolina hospitals, the tool shows.

The NASHP figures may be different from numbers reported by hospitals because it uses hospitals’ Medicare cost reports to estimate the actual costs of providing the care, rather than hospital sticker prices, which can inflate the numbers.

WakeMed also scores high in community responsibility. The Lown Institute, a health care think tank, ranked WakeMed’s Raleigh campus No. 35 out of 2,689 acute care hospitals nationally in 2026 for social responsibility, and ranked it the top hospital for social responsibility in North Carolina. The ranking considers more than 50 variables, including racial inclusivity, patient safety, pay equity, avoiding unnecessary procedures, and patient satisfaction. 

Atrium Health University City in the Charlotte area was Atrium’s highest hospital on the list, at No. 115 nationally. Atrium’s flagship hospital in Charlotte, Carolinas Medical Center, was No. 714, although it still received an “A” grade for social responsibility. It received a “D” in pay equity, which measures the difference in compensation of hospital CEOs compared to housekeeping staff. 

Advocate Health CEO Gene Woods reported compensation of $25.8 million in 2024; Atrium has not responded to requests for more recent compensation numbers.

8. What could the deal mean for WakeMed workers and staffing?

What they said: Gintzig said WakeMed workers would benefit from higher pay, more resources and improved technologies. He also said the transaction would not lead to layoffs, and the combination would create more than 3,300 jobs over five years. 

“There are some combinations that result in mass layoffs and eliminations of jobs and those sorts of things. This is about growing and adding jobs and growing and improving health,” he said. 

A closer look: The public documents have no guarantees about retaining staffing levels or nurse-to-patient ratios. 

However, the full, detailed agreement between Atrium and WakeMed has not been made public. Hospital leaders said it contains confidential proprietary information. They have allowed Wake County commissioners to review it privately in small groups. 

Gintzig told NC Health News he would receive no personal payout from the deal. “Not a penny,” he said. “I get nothing out of it.”

Since the proposed partnership was made public, two of WakeMed’s top leaders have announced their departures. Chief Operating Officer Tom Gough was named chief operating officer of Baptist Health in Jacksonville, Florida, and Chief Medical Officer Seth Brody left WakeMed after 30 years to join UNC Health. A WakeMed spokeswoman said their departures were unrelated to the combination. 

At Wake Forest Baptist, which combined with Atrium in 2020, some current and former employees described tighter staffing, reduced incentive pay and greater pressure to cut costs in the years after Baptist joined Atrium. In response, an Atrium spokesman said nursing staffing plans were not reduced and budgeted nursing hours per patient day increased after the combination. (Read our full report on what changed after Baptist joined Atrium.)

9. What promises is Atrium making? Are they enforceable?

What they said: Atrium and WakeMed leaders have promised at least $2 billion in local investment over 10 years and 3,300 new jobs. They said the combination would help rebuild WakeMed’s aging Raleigh campus, expand specialty care and clinical trials, add behavioral health services and expand community partnerships.

At a June meeting, Gintzig and board vice chair Bratton told commissioners the combination would bring Atrium’s school-based virtual care model to Wake County. Bratton called it “one of the gains we are most excited about.”

Atrium leaders also described other programs they run, including mobile health services, “street medicine” programs, food distribution and millions invested in affordable housing. Asked whether Atrium would make a similar housing commitment in Wake, Woods said “we have discussed exactly that.” 

He added, “We know affordable housing is an issue here … So, we’d like to discuss opportunities and find out what the needs are here, so we can support them.”

In response to another question, Gintzig said parking at WakeMed would remain free. 

A closer look: The public transfer agreement requires WakeMed to continue operating its main New Bern Avenue hospital as a community general hospital and spells out the 4.8 percent indigent care requirement, but other specific benefits hospital leaders discussed are not included. 

Instead of guaranteeing $2 billion in investment over 10 years, the document says Atrium “intends to make or cause to be made” capital expenditures of at least that amount. 

At a June meeting, Wake County Commissioner Vickie Adamson said she “would be a lot more comfortable if some of these community benefits were in writing and in an enforceable agreement.”

In response, Woods pointed to the charity care requirement. When Adamson clarified that she meant other benefits such as mobile health services, hospital leaders did not commit to putting them in the agreement.

10. Could commissioners ask for more before approving the deal?

What they said: Wake County initially framed its role in approving the deal as narrow. The vote  was placed on the commissioners’ May 4 consent agenda, where items are typically voted on without discussion. After public pushback, the commissioners delayed their decision to allow more time for public input.

The board’s May agenda described the commissioners as having a “limited” role in WakeMed, and a news release after the board delayed the vote said the board “does not have the legal authority to approve the joining of WakeMed and Atrium Health.” 

A closer look: Rooke-Ley said the county’s descriptions understate the commissioners’  leverage. Atrium and WakeMed are asking the county to permanently give up significant authority over WakeMed, he said — including most of its rights to approve changes to the hospital’s governing documents — and nothing requires the board to accept the deal as currently proposed. 

“There’s not much they couldn’t ask for here,” he said. 

At public hearings, patient advocates and community members have encouraged the commissioners to ask Atrium and WakeMed for more protections, such as direct county control over board appointments, limits on price increases, requirements to maintain essential services and staffing ratios, and stronger accountability measures.  

Conditions have been placed on hospital mergers elsewhere, said Brianna Miller, state advocacy manager of the United States of Care, a health policy nonprofit. For example, in Indiana, two hospitals agreed to more than 45 conditions to receive state approval for their merger, including price caps and nurse and staff protections.

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