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.
- Charlotte-based Atrium Health wants to expand into Raleigh.
- 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 healthcare landscape and a belief among hospital executives that the only way to survive 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 healthcare consultant and co-founder of Goldie Health.
Getting bigger can save healthcare systems money. By operating more hospitals, they can share the costs of technology, supplies and administration. They also gain bargaining power to negotiate higher rates from health insurance companies.
High-growth urban areas like Charlotte and the Triangle are particularly attractive because so 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 to Medicaid or Medicare.
“They 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.”
Employment at hospitals in North Carolina has surged by 48% in the last decade, compared with 17% employment growth across all industries during that time, according to federal statistics. Healthcare and social assistance is North Carolina's largest employment sector, accounting for about one in seven jobs statewide, and it is expected to drive nearly a third of the state's job growth over the next decade, according to the N.C. Department of Commerce.
Money to spend
In the Charlotte region, hospital construction seems to be everywhere. Novant opened a new hospital in Ballantyne in 2023, Gastonia-based CaroMont Health opened one in Belmont in 2025 and Atrium opened a new facility in Lake Norman that summer. Duke also entered the market, buying and rebranding an existing hospital in Mooresville.
More expansion is on the way:
- Novant has won approval for hospitals in Kannapolis and Union County and wants to build a $364M hospital in the Mountain Island Lake area.
- Duke and CaroMont Health have teamed up to propose two in Mecklenburg County, at a total cost of nearly $1.2B.
- And Atrium recently announced a $450M hospital in Fort Mill and a new behavioral health hospital in north Charlotte.
Hospitals are also renovating and expanding their 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 healthcare systems have plenty of it, Kempski said. Their finances have been boosted by billions in additional 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 she noted that cuts are coming in the next few years because of federal policy changes expected to reduce those payments and leave more people uninsured.
Strange bedfellows
The growth is creating 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. And longtime rivals Duke and UNC Health are teaming up to build a $3B children’s hospital in the Triangle.
Those types of joint ventures can be easier for hospital systems to pull off compared to acquisitions or mergers because they are less likely to trigger regulatory review, Hanis said.
He said Duke’s move into Charlotte 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 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.”
Fighting for the right to grow
Even with money to spend, hospitals in North Carolina can’t just build anywhere they want. Under North Carolina’s so-called “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 as they 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.
What does the growth mean for patients?
For patients in urban areas, the hospital growth could mean more sophisticated technology, easier access to specialists and a shorter drive to the hospital.
But there are trade-offs. Bigger healthcare 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.
And what about the cost of care?
Hospitals in competitive markets generally charge lower prices, said Mark Holmes, a professor at UNC Chapel Hill’s Gillings School of Global Public Health who researches healthcare policy.
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 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 healthcare spending, Hanis said.
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 healthcare as they shop for a new car or refrigerators. They often don’t even know the cost of a procedure until the bill arrives.
Instead of competing on price, Kempski said she 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,” she said.