The level of health care in Western North Carlina is troubling, state Attorney General Josh Stein told Asheville’s Council of Independent Business Owners during an Aug. 26 virtual address.

Specifically, Stein reviewed the recent purchase of the nonprofit Mission Health by the for-profit HCA Healthcare, which has triggered a flood of consumer complaints and his office’s recommendation that a state certificate of need not be granted to Mission/HCA, in a quest to open the door to health care competition in the region by either of the two other health care systems interested in providing a new 67-bed acute care hospital in the Asheville area. (The two other prospects are AdventHealth and Novant Health.)

CIBO President Buzzy Cannady, serving as meeting moderator, introduced Stein, who then spoke for 25 minutes and then fielded questions from Cannady — submitted by CIBO members — for five minutes. 

“I am pleased to be able to talk to you all about the work we are doing at the (state) Department of Justice to improve the delivery of health care in North Carolina,” Stein said, in opening his address.

“I know that it’s an issue of great importance to you all, both as residents of Western North Carolina and many of you, I know, are businesspeople — and want to make sure your businesses can continue to thrive long into the future.

“Protecting people’s access to affordable quality health care isn’t just about protecting people’s quality of life. It also means protecting the economic health of our communities.”

In specifically targeting his message to the CIBO members, Stein added, “As a business-owner, you all can’t maintain or grow a business in an area that doesn’t have a decent hospital, or well-trained and talented doctors. Your managers, your employees — they won’t stand for it.

“So as your attorney general, one of my top priorities is protecting health care for people across the state. And so I’m excited to be able to share with you all some of the work we’ve been up to on this important issue.

“Now I understand that a conversation about health care in Western North Carolina has to start with the Mission-HCA combination. Now many of you know this, but I’ll go back over it...

“My office played a role in reviewing the transaction between HCA and Mission back in 2018. And in 2019, we announced that we did not object to the deal. I know that many folks in Western North Carolina are not happy that that decision by the Mission board to sell the hospital system to HCA was made.

“But that was a decision that was made by the board and management of the nonprofit, that it negotiated for itself, to sell to HCA. It was not an idea that originated in my office — but my office had to conduct the review. And when we have these types of transactions, my authority, under state law, is somewhat limited.”

Further, the attorney general said, “I had to review whether HCA was paying a fair-market price for Mission’s nonprofit assets, whether the proceeds from the sale would be used for a public purpose, and that the newly created Dogwood Health Trust — would it be independent of HCA and fully representative of the community that it serves?

“So there were some changes that my office negotiated — and once that happened, the deal met those requirements. So I made sure that there was full market value that the public received for its investments in the nonprofit over decades. 

“I worked to make sure the Dogwood Health Trust’s directors represented the full diversity of Western North Carolina — that includes geographic, racial, ethnic and gender … and that it was independent of HCA.

“Now, additionally, through intensive negotiations, we were able to secure a number of forward-looking health care commitments from HCA — probably the most important of which is that HCA essentially doubled the number of years that they were committing to keep its rural assets open... from five to 10 years.

“We also got them to agree to have an agreement to have a monitor oversee the transaction on a going-forth basis to ensure that it lived up to its commitments.

“And I am certain that this deal was better for the people of Western North Carolina due to my office’s involvement, than had we not been involved at all.

“Since the transaction went through, I, like many of you, have had real concerns about what the impact of this transaction has meant to Western North Carolina. 

“We’ve received a lot of complaints — about 350 complaints from consumers about either the quality of care they’ve received, or billing and payment issues, among others. And when we get those complaints, we reach out to HCA to seek resolution for those complaints.”

To that, Stein added, “If they have to do with quality of care issues, we refer them to the Department of Health and Human Services, which oversees the operations and quality of hospitals and health care systems in North Carolina.

“If they have to do with HCA’s commitments under the asset purchase agreement, we refer those to the monitor that is responsible for ensuring compliance under that regard.”

After noting that lawsuits against Mission/HCA have been filed by the Town of Brevard, the City of Asheville and Buncombe County, he pointed out that they have been combined into one, with support from his office.

“Allegations of monopoly pricing are always serious — and that’s especially true in health care. Health care systems cannot be allowed to use their size or market dominance to harm North Carolinians, who need accessible, affordable health care.

“Recently, my office wrote to the Department of Health and Human Services, asking it not to grant a certificate of need to Mission Hospital that would allow Mission to build a 67-bed acute care facility in Buncombe. 

“I know that Buncombe is growing and needs that additional capacity, but we need competition. We need competition from other health care providers in Western North Carolina. And I think that if Mission were given the certificate, it would represent a real missed opportunity to introduce some needed competition into the region.

“So we did not take a position on which of the other two applicants (AdventHealth and Novant Health) should get the certificate of need. But we did argue that it should not be Mission. We’re going to keep an eye on these issues and continue to advocate for the interests of Western North Carolinians as it relates to health care….”

Stein also said that the lack of health care competition is a problem in many other areas of the state and that, “many people have been frustrated with this and other (legal) cases in the state... Since I’ve been serving as AG for the last six years, we’ve had a number of mergers come before my office, with some that went through and some that didn’t.

“This is important because when hospitals get swallowed up (by for-profit health care conglomerates), patients often are left with higher costs and lower-quality care.

“I have worked with other legislators and used Tennessee law as a model, expanding the DHHS and my office to work together with the public more closely.”

Under a regulation he is considering, “it would penalize health care systems when they violate the terms of the transaction... I want to ensure that patient service comes first... Patients are forced to navigate a system that has a lack of transparence by hospitals... Our review showed that most hospitals are in compliance with federal rules. When hospitals are transparent, patients can make decisions in their best interest.”

Besides encouraging competition among health care providers in the state, Stein, a Democrat, said, “The math is clear and simple — expanding Medicaid” would be the next best way to help those needing health care services.

“I’m so glad the Republicans in the legislature are saying they finally are in favor” of expanding Medicaid. “No decision yet. I urge them to strike while the iron is hot.”

What’s more, the attorney general said, “Nearly 40 percent of the (people in the) state have a pre-existing condition. For an insurance company to discriminate against you is against the law under the Affordable Care Act.

“Finally, I’d like to report on the opioid

epidemic. It’s the deadliest moment in the deadliest epidemic — 2021 was the worst year in history. It’s a record (in opioid-related deaths) we hope won’t be broken again.

To fight the opioid epidemic, “We’re going to get our full $750 million allotment,” Stein said, adding, “and we’ve got another $8 million in the hopper.

“I’ve been traveling around the state to see what programs will benefit” the most people for the dollars spent.

To that end, Stein said, “The population at greatest level of overdose threat is those who are incarcerated.”

The attorney general added, “The death rate of people leaving incarceration in Buncombe Couny with opioid problems is below that of what other localities (in the state) are experienceing  — and much credit should be given to Buncombe County Sheriff (Quentin) Miller. I know there will be people alive and healthy thanks to these efforts.” (Miller is a Democrat.)

“Finally,” Stein said, “I want to speak about how freedoms of women’s reproductive rights are under attack. It’s important for women here in North Carolina to know, that even with the (U.S.) Surpeme Court decision, North Carolina protects their rights to have an abortion. We’re seeing state after state banning abortion, even in cases of rape, incest, or if the woman’s life is at risk.” 

“I’ve filed two friend-of-the-court briefs this week to defend women’s right to an abortion, especially if a woman’s life is at risk,” Stein asserted. “I believe that the decision on abortion should be made by the woman – and not by the politicians. There are those who want to take that right away from North Carolina women.”

In concluding his address, Stein said, “I am excited and so thrilled to have this job so that I can help build a North Carolina that is safer and stronger for all.”