By Michelle Crouch
Co-published with The Charlotte Ledger
Key Takeaways:
- North Carolina’s biggest hospital systems are expanding, fueled by population growth, financial pressures and competition for patients.
- Hospitals are spending billions on new facilities and partnerships as they’re fighting over state permission to add beds.
- The growth could bring patients more choices and better access to care. Research also suggests hospital consolidation typically leads to higher prices.
Maybe you’ve noticed: North Carolina hospitals have been making a lot of headlines lately:
- Durham-based Duke Health is trying to move into Charlotte through a partnership with Gastonia-based CaroMont Health.
- Charlotte-based Atrium Health wants to expand into Raleigh by combining with WakeMed.
- And Winston-Salem-based Novant Health has won approval to build new hospitals in Denver and Asheville, markets long dominated by Atrium and Mission Health, respectively.
Traditional regional boundaries are blurring as hospital systems scramble to expand and stake out claims in each other’s territories. They’re forming unconventional partnerships, filing lawsuits and battling each other for state permission to build new beds.
What’s going on?
Experts say it’s an arms race of sorts, fueled by North Carolina’s population growth, a more competitive health care landscape and a belief among hospital executives that the only way to survive in the current marketplace is to grow.
“It’s a land grab. If those beds aren’t my beds, they’re going to be somebody else’s beds,” said Matthew Hanis, a Charlotte-based health care consultant and co-founder of Goldie Health.
Getting bigger can save health care systems money. By operating more hospitals, they can share the costs of technology, supplies and administration. Of equal — if not greater — importance, they gain bargaining power to negotiate higher rates from health insurance companies.
High-growth urban areas like Charlotte and the Triangle are attractive targets for growth because many people move there for high-wage jobs that come with private insurance, said Ann Kempski, an independent health policy analyst. Private insurance typically pays hospitals more for the same care compared with Medicaid or Medicare.
Hospitals “really want to be geographically positioned,” she said. “It’s a lot like when you see the gas stations on every corner at certain intersections.”
Money to spend
The competition is generating billions of dollars in hospital construction in North Carolina’s major metro areas and their suburbs, including Charlotte, the Triangle, Asheville, Wilmington and Winston-Salem.
So far in 2026, 10 of the 11 proposals for new acute-care hospitals submitted for state approval were in those urban markets. The only exception, a $116 million CaroMont hospital in Cleveland County, is in an area increasingly affected by Charlotte’s suburban growth.
In the Charlotte region, the building boom is unmistakable. Novant, CaroMont and Atrium have all opened new hospitals in recent years. Last year, Duke entered the market, buying and rebranding an existing hospital in Mooresville. And more expansion is on the way:
- Duke and CaroMont Health recently announced a plan to build two hospitals in the Mecklenburg County suburbs. According to documents filed this week, the total cost will be nearly $1.2 billion.
- Novant has filed a competing proposal for a $364 million hospital it wants to build north of the city, near Mountain Island Lake. Novant already has approval to build two other hospitals in the Charlotte suburbs.
- Atrium recently announced a $450 million hospital in Fort Mill, South Carolina, just south of Charlotte, as well as a new behavioral health hospital in north Charlotte.
Hospitals are also renovating and expanding existing facilities, opening a slew of freestanding emergency departments and buying or partnering with physician practices.
All that growth takes money, and many of North Carolina’s biggest health care systems have plenty of it, Kempski said. Their finances have been boosted by billions in Medicaid payments they began receiving in 2023 as part of the state’s Medicaid expansion deal.
“They have really strong balance sheets right now,” she said.
But, Kempski noted, cuts are coming due to federal policy changes. The One Big Beautiful Bill Act, the 2025 federal budget bill often referred to as H.R. 1, is slated to slash hundreds of billions from Medicaid funding across the country.
Meanwhile, enhanced federal subsidies for Affordable Care Act plans have expired, making insurance more expensive and prompting many people to drop their coverage. That could lead to hospitals having to treat more patients who don’t have insurance.
Strange bedfellows
As hospitals seek to grow, they are forging some unlikely alliances. In addition to the Duke-CaroMont partnership, Duke and Novant previously joined forces to propose a hospital in Mebane in the central part of the state, but it failed to get state approval. Longtime rivals Duke and UNC Health are teaming up to build a $3 billion children’s hospital in the Triangle.
Those types of joint ventures can be easier for hospital systems to pull off than acquisitions or mergers because they are less likely to trigger regulatory review, Hanis said.
Duke’s move into Charlotte, he said, is likely an effort to hold onto the patients who drive to Durham for specialized care, especially now that Atrium has opened a Wake Forest University School of Medicine campus in Charlotte.
“Why don’t I plant my flag down there to make sure I keep that locked in?” he said, imagining Duke’s thinking. “The medical school in five, 10 or 15 years will be super competitive with Duke.”
Battles for beds
Even with money to spend, hospitals in North Carolina can’t just build anywhere they want. Under North Carolina’s “certificate of need” law, they must get permission from state regulators before they can open or expand hospitals, open other types of facilities or purchase expensive medical equipment.
Every year, the state determines how many more hospital beds are needed in each area, pitting hospital systems against each other in the fight over who gets permission to build them.
The latest applications illustrate how fierce that competition can be: Atrium Health, Novant Health and Duke-CaroMont are seeking approval for a combined 686 additional hospital beds in Mecklenburg County — nearly 300 more than the 389 the state has determined are needed.
The proposals include three new hospitals: the two Duke-CaroMont facilities and a new 200,000-square-foot Novant hospital in the Mountain Island Lake area. Novant and Atrium also want to expand some of their existing hospitals.
The competition is also intense in Wilmington, where three hospital systems are fighting over 225 additional beds the state is allowing in New Hanover County, which has become a retirement destination. UNC Health wants to build a new 150-bed hospital, Atrium is proposing a 42-bed hospital and Novant wants to add 225 beds to its existing hospital. Together, they’re seeking 417 beds — nearly twice the number the state has determined is needed.
Even after a project wins state approval, that doesn’t mean it can get built right away. A September 2026 investigation by Carolina Public Press found that more than 1,100 approved acute-care beds statewide are being delayed by competitors’ appeals. At least six proposed hospitals and 13 expansion projects are stalled.
Kempski said the certificate of need process is expensive and complicated, which gives large hospital systems an advantage over smaller competitors who might offer lower prices. She pointed to an independent Wilmington medical group that recently lost to Novant Health in a bid to buy cardiac equipment.
“You need to lawyer up for this stuff,” she said.
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What about rural hospitals?
Urban and suburban areas are attractive targets for expansion and investment “because that’s largely where the money is,” said Professor Mark Holmes, who researches health care policy at the UNC Gillings School of Global Public Health.
But he worries that the building boom could make things even harder for rural hospitals.
Adding a new hospital in a suburban area may attract patients who otherwise would have received care closer to their rural homes, he said. So the expansion of large hospital systems in populated areas could further drain patients from smaller rural hospitals that have already seen admissions decline and need a certain volume of patients to stay afloat.
“I worry that as we’re seeing these actions in more urbanized areas, what does that mean for access to people who live in the generally lower-income, lower-volume parts of the state?” he said. “I think that’s something we have to monitor across the country.”
What will all this growth mean for ordinary North Carolinians?
For people across the state, hospital system expansion could bring more sophisticated technology, more modern facilities, easier access to specialists and cutting-edge treatments, and a shorter drive to the hospital.
It could also mean more jobs. Employment at hospitals in North Carolina has already surged by 48 percent in the past decade, compared with 17 percent employment growth across all industries during that time, according to federal statistics.
But there are tradeoffs. Bigger health care systems typically come with more complexity and a less personal experience, Hanis said.
When you call your doctor’s office, you might end up talking to someone in a centralized call center hundreds of miles away instead of someone at the front desk. You might see a different medical provider at every appointment or struggle to get a question answered without being transferred from office to office.
Will more competition lower prices?
And what about the cost of care?
Hospitals in competitive markets generally charge lower prices, Holmes said. But bigger health systems also have more leverage when negotiating payments with insurance companies. “The larger your health system is, the more negotiating power you have,” he said.
Research shows that hospital mergers and acquisitions — even when the merging hospitals are in different markets — typically drive up prices without improving quality. And when hospitals add more beds, they tend to get filled, leading to higher overall health care spending, Hanis said.
Close to half of all health care spending in the U.S. comes from government payers. When there’s more spending overall, there are more taxpayer dollars going to support it.
Even in markets where hospitals are competing, Kempski said she doubts the new projects will do much to lower prices.
Most people don’t shop for health care like they shop for a new car or refrigerator. They often don’t even know the cost of a procedure until the bill arrives.
Instead of competing on price, Kempski expects the hospitals to compete on amenities and high-tech care: “I think you’re going to have more gleaming glass towers and cancer centers and fancy VIP parking.”
This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting. You can support this effort with a tax-deductible donation.
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