Small-business owners in North Carolina are reaching out to legislators for help, citing hospital mergers as one reason their health-care costs are soaring.

The fusion of former hospital competitors has left employers in the state with fewer options for services, as well as higher expenses for both companies and workers, which could ultimately hinder business expansion.

State Treasurer Dale Folwell revealed that even at the top levels, they're grappling with challenges such as cost transparency.

"The fact," he said, "is that this is the only product in your life that you don't know the value and the price of it, even after you have consumed it."

In a recent national poll, 45% of entrepreneurs said soaring health-insurance costs have forced them to hit the brakes on expanding their businesses. The majority of companies in North Carolina are small businesses, but together they employ more than 1.7 million people. So, Folwell said, the higher rates could signal lasting economic impact.

Greater NC Black Chamber of Commerce regional president Valerie Benton Smith stressed the urgent need for affordable, quality health care for businesses to stay competitive. She emphasized that without regulations on hospital consolidation and pricing, small companies in particular will keep facing obstacles.

"Small-business owners struggling with the expense of providing health-care benefits to their employees face a stark choice when costs rise," she said, "drop or cut health-care benefits, making it hard to attract quality candidates or divert funds to health care."

She said addressing the growing burden of escalating health-insurance costs is essential to ensure the growth and stability of small businesses. In the survey by the group Small Business for America's Future, 86% of business owners said they believe federal and state governments should actively intervene in health-system consolidations.

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Health-care workers in Oregon have authorized a potential strike that includes nurses at Providence Women's Clinic and doctors at Providence Saint Vincent. If it happens, it would be the first time doctors have held a strike in Oregon history.

Jeremiah Wright, a nurse practitioner at Saint Vincent, said it took a long time for the doctors and other hospitalists there to reach the point where they felt comfortable with a strike. He said doctors' first priority is "do no harm," but they have struggled to provide care because of understaffing.

"Realizing that it is beholden on the corporations and the health-care systems to ensure that we are providing the best health care for our patients," he said. "If it comes to a point where a strike is necessary for us to achieve that, then it's up to Providence to make sure that the hospital's staffed when we're on strike."

Workers represented by the Oregon Nurses Association have said they've reached an impasse with Providence over concerns about staffing and retention. Federal mediators have been called into negotiations at Saint Vincent, which started in January. Providence did not respond before the deadline for this story.

Christina Malango is a clinic nurse with Providence Women's Clinic. Negotiations at her clinic began in November 2023, and there have been 36 bargaining sessions so far. She described nurses as "burnt out" and the clinic as short-staffed since the pandemic. She added that Providence hasn't moved on the issues most important to her and her coworkers.

"Work-life balance, competitive wages and benefits, health benefits, retirement that rewards loyalty and ensures the dignity of people as they move into retirement," she said. "Those are areas [where] we have been really stuck."

Malango said many nurses don't feel like they're being listened to - and so, a strike authorization felt like a necessary step.

"As someone who is at the bargaining table myself," she said, "I feel like the strike authorization is another tool to convey the seriousness and the unity among our union members."

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By Taylor Sisk for KFF Health News.
Broadcast version by Shanteya Hudson for North Carolina News Service reporting for the KFF Health News-Public News Service Collaboration

On a mid-August morning, Christopher Harrison stood in front of the shuttered Martin General Hospital recalling the day a year earlier when he snapped pictures as workers covered the facility’s sign.

“Yes, sir. It was a sad day,” Harrison said of the financial collapse of the small rural hospital, where all four of his children were born.

Quorum Health operated the 49-bed facility in this rural eastern North Carolina town of about 5,000 residents until it closed. The hospital had been losing money for some time. The county’s population has slightly declined and is aging; it has experienced incremental economic downturns. Like many rural hospitals, those headwinds drove managers to discontinue labor and delivery services and halt intensive care during the past five years.

Prospects for reopening seemed dim.

But a new hospital designation by the Centers for Medicare & Medicaid Services that took effect last year offered hope. As of August, hospitals in 32 communities around the country have converted to the rural emergency hospital designation to prevent closure. The new program provides a federal financial boost for struggling hospitals that keep offering emergency and outpatient services but halt inpatient care.

The REH model “is not designed to replace existing, well-functioning rural hospitals,” said George Pink, a senior research fellow at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which has documented 149 rural hospitals that have either closed or no longer provide inpatient care since 2010. “It really is targeted at small rural communities that are at imminent risk of a hospital closing.”

The program hasn’t yet been used to reopen a closed hospital.

With guidance from health consultants, Martin County officials asked federal regulators to explore the possibility of adopting the REH model and were ultimately given the go-ahead.

If successful, Martin County could become one of the first in the nation to convert a shuttered hospital to this new model.

Ask members of a community that has lost its hospital what they miss most, Pink said, and it’s almost invariably emergency services. Count Harrison among them, especially after a medical crisis nearly killed him.

Harrison, who lives in a smaller crossroads community a few miles south of Williamston, began experiencing leg pain in February. Under normal circumstances, Harrison said, he would have gone to his primary care doctor if his leg began to hurt. This time he couldn’t, because the practice closed when the hospital folded months earlier.

Then, one morning he awoke to find his foot turning black. It took him 45 minutes to drive to the closest hospital, in the town of Washington. There, doctors found blood clots and he was flown by helicopter to East Carolina University Health Medical Center. A doctor there told him that he’d probably had the blood clots for close to a year and that he was lucky to be alive. The medical team was able to save his foot from amputation.

Harrison, like many other community members, now had firsthand experience with the consequences of a shuttered hospital.

The state legislature’s decision last year to expand Medicaid has meant fewer North Carolinians are uninsured, which means fewer hospital bills go unpaid. But health care is evolving: Many procedures that once required inpatient care are now performed as outpatient services. Dawn Carter, the founder and a senior partner of Ascendient, a health care consulting firm working with the county, said the inpatient census at Martin General in its last few years ranged from five or six a day to a dozen.

“So you’re talking about a lot of cost, a lot of infrastructure to support that,” she said.

With no emergency care within a half-hour radius, Martin County administrators believe a rural emergency hospital would be a good fit and a viable option. REH status allows a hospital to collect enhanced Medicare payments, an annual facility payment, and technical assistance.

Carter said the team will present to the state Department of Health and Human Services a set of drawings of the portion of the building they intend to use to see if it meets REH regulations.

“I’m hoping that process is happening in the next several weeks,” she said, “and that will give us a better idea of whether we have a handful of really quick and easy things to do or if it’s going to take a little more effort to reopen.”

Officials then will take proposals from companies interested in running the hospital.

Carter said the expectation is that, initially, the facility will be strictly the emergency room and imaging department, “and then I think the question is, over time, where do you build beyond that?”

And the rebuilding could prove a challenge from the start. Many former staff members have taken positions at nearby health care facilities or left the area. The effects of that exodus will be compounded by the widespread difficulty in recruiting health workers to rural areas.

It’s early yet, Pink said, to assess the success of the rural emergency hospital model. “All we have are armchair anecdotes.” It seems to be working well in some communities, while others “are struggling a little to make it work.”

Pink has a list of questions to assess how an emergency hospital is faring in the long run:

• Is it at least breaking even? And if not, do administrators foresee a solution?


• How is the community responding? If someone believes they have an issue that might require inpatient care, Pink suggested, perhaps they’ll bypass the REH for a hospital that can admit them. And to what extent does bypassing their doors carry over to all services?


• Are patients happy with the care they’re receiving? Are the clinical outcomes good?

The rate of rural hospital closures rose through 2020, then dropped considerably in 2021. Congress had passed the CARES Act, and the Provider Relief Fund offered a financial lifeline, Pink said. That money has now been distributed, and the concern is that “many rural hospitals are returning to pre-covid financial stresses and unprofitability.”


If the trend continues, he said, more rural hospitals may turn to the REH model.


Ben Eisner serves as Martin County’s attorney and interim manager. He acknowledges that the health and well-being of this community require a lot more than a hospital. He cites, for example, a new nonprofit with a mission to address the social determinants of health.


Advancing Community Health Together was created in response to the hospital closure. Composed of community members, its focus is addressing inadequate health care access and poor health outcomes as a consequence of generational poverty, said Vickey Manning, director of Martin-Tyrrell-Washington District Health.


“We can’t address rural health care in a vacuum,” Carter said. Her organization, Ascendient, is part of the Rural Healthcare Initiative, a nonprofit commissioned by the North Carolina General Assembly to study sustainable models of health care for rural communities.


Like most of rural eastern North Carolina, Martin County is in transition, Eisner said. Diminishing family farms, less industry. “And so the question becomes,” he said, “‘What happens for all these communities? What happens next?’ And it’s an answer that is not yet fully written.”


Harrison, still relying on crutches to get around, recently drove 45 minutes north on U.S. 13 to the town of Ahoskie to have a doctor examine his foot. He said a hospital that offers basic emergency care isn’t a perfect solution, but he’ll have some peace of mind once the cover is peeled from that sign and his local hospital reopens.




Taylor Sisk wrote this story for KFF Health News.


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October marks Spina Bifida Awareness Month, a time dedicated to raising awareness about a birth defect that affects one in 2,000 births in the United States, every year. Ohioans, like the Badenhop family, have faced this medical challenge head-on when their daughter Lexi was diagnosed with spina bifida in the womb, during a 20-week ultrasound. For Brittany, Lexi's mom, the journey from diagnosis to surgery was filled with anxiety, but it also led to life-saving interventions at Nationwide Children's Hospital in Columbus, one of only a handful of hospitals equipped to offer fetal surgery for spina bifida.

"When people meet or see someone with spina bifida, that knowing how to ask questions about it, knowing how to approach the subject in a way that's informational then it's going to be easier to understand and sympathize with that person," she said.

Spina bifida occurs when the spine and spinal cord don't form properly. Though outcomes vary, access to advanced medical care can improve the quality of life for those affected. Still, not all families are able to pursue fetal surgery, and many rely on lifelong care for complications that can affect the brain, bladder and mobility.

Nationwide Children's Hospital is at the forefront of addressing this condition. Fetal and Neonatal Surgeon Dr. Oluyinka Olutoye stresses the importance of early intervention and the role of advanced surgical techniques in improving outcomes for spina bifida patients.

"There is hope. In the past, when the diagnosis of spina bifida was made before birth, most families were devastated and with fetal surgery there isn't a guarantee that everything's going to be perfect and okay. But now, we can improve the outcomes for those families and for those children at birth," Olutoye explained.

Spina Bifida Awareness Month is a reminder of the strides in medical research and treatment that offer hope to families.


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