Madison County, tucked in the mountains of western North Carolina, has no hospital and just three ambulances serving its roughly 22,000 people.

The ambulances frequently travel back and forth to Mission Hospital in Asheville, the largest and most central hospital in the region. Trips can take more than two hours, according to Mark Snelson, director of Madison Medics EMS, the local emergency medical service.

“When we get busy and all three of them are gone, we have no ambulances in our county,” he said.

Snelson and others in Madison County aren’t seeking more ambulances. They want a hospital closer than Mission. And the state agrees. In 2022, North Carolina Department of Health and Human Services officials said Madison and three other mountain counties needed 67 more acute care hospital beds. The state raised that to 93 beds in 2024, then to 222 by Oct. 15.

But the only indication of a new hospital thus far is a 25-acre field of graded dirt with a sign planted beside the highway reading “FUTURE HOME OF AdventHealth Weaverville.”

For the past three years, Mission Hospital’s owner has contested Florida-headquartered AdventHealth’s attempt to build the hospital on land bought for $7.5 million in rural Weaverville, just minutes south of Madison County. It was supposed to open this year, an event that would have defied the national trend of rural hospital closures.

The irony is that the very law that calls for the new hospital — the state’s certificate of need, or CON, law — has been used to prevent further construction. Such laws are intended to cap unfettered health care expansion by allowing new hospitals and expansions only when a state can document a need for them. But the legal process has tied up the proposed Weaverville hospital in court, just as other such laws have done with projects in Tigard, Oregon; Connecticut; and Fort Mill, South Carolina.

All states had certificate of need laws until 1987, when the federal government repealed a mandate requiring them. Today, North Carolina is one of 35 states with the laws still on the books. Twelve others have repealed them or let them expire, and some, such as Montana and South Carolina, have significantly weakened theirs amid concerns they limit health care access and boost costs. President Donald Trump’s Federal Trade Commission and Department of Justice are among those questioning the need for the laws.

In North Carolina, too, opposition to the state’s certificate of need law has surfaced in both the General Assembly, where a bill to repeal the law has been dormant since April, and more prominently in the state Superior Court.

But some hospital industry organizations, health care economists, and certificate of need lawyers argue that, though the laws create bureaucracy that can delay projects, that’s not justification to do away with them.

The principle behind certificates of need is to hold at bay what supporters say is unnecessary expansion and price inflation brought on by a free market, which makes health care more expensive for everyone.

“If the principle is worth preserving, don’t abandon the principle,” said Mark J. Silberman, a health care attorney with the Benesch law firm and former counsel for Illinois’ certificate of need board. “Improve the process to allow the principle to flourish.”

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Who Should Fill the Need?

Mission Health is the largest health care network and the largest employer in the Tar Heel State’s share of the Appalachians. Nashville-based HCA Healthcare bought the century-old, nonprofit, six-hospital system for $1.5 billion in 2019, converting it to a for-profit operation that serves an 18-county region. (The Dogwood Health Trust, a nonprofit established as part of HCA’s purchase of Mission Health, helps fund KFF Health News’ coverage.)

Though AdventHealth already owns one hospital in the North Carolina mountains about a 30-minute drive from the Weaverville site, its bid to build a new one represents a threat to HCA’s stronghold. Mission argues it is best positioned to meet the needs the state says exist in the Madison County region.

“Not all acute care beds are the same,” Mission Health spokesperson Nancy Lindell said. “Instead of adding more beds at facilities that are unable to provide the complex medical and surgical care needed, the region would be better served by expanding bed capacity at Mission Hospital.”

An eastern North Carolina eye surgeon’s lawsuit filed in 2020 against the state’s health agency and top state officials alleged the state’s certificate of need law “has nothing to do with protecting the health or safety of real patients.” The ophthalmologist, Jay Singleton, has argued the law prevented him from performing surgeries at his own center because the state didn’t see a need to duplicate services already provided at the local hospital, where he was obligated to operate.

In early November, Republican state Treasurer Brad Briner, the State Employees Association of North Carolina, and several academics who study such laws nationally filed amicus briefs supporting Singleton’s case and urging a judge to reject the state’s attempt to dismiss it.

“I’ve characterized CON law as a permission slip to compete,” said Thomas Stratmann, a George Mason University economics and law professor who co-authored the brief. “It’s as if, when a McDonald’s wanted to open up a shop next to Burger King, they have to go to the state regulator to ask if that’s OK.”

Stratmann argued that, instead of raising prices, more competition would give hospitals and providers greater leverage in negotiating with insurance companies.

That view aligns with a stance the federal government has held for almost 40 years. With varying degrees of fervor under Democratic and Republican leadership, the Federal Trade Commission and Department of Justice have argued that the laws are anticompetitive and bad for consumers. The Justice Department did not respond to questions about its current position, and the FTC declined to comment on the record.

“CON laws create barriers to entry and expansion, limit consumer choice, and stifle innovation,” the Federal Trade Commission wrote in an April letter to Rhode Island Gov. Dan McKee, a Democrat, as the state’s legislature considered, but ultimately abandoned, amendments to its certificate of need law. “For these reasons, the Agencies have consistently suggested that states repeal or retrench their CON laws.”

‘It’s Personal’

In a June letter to Trump and congressional leaders, Senate Democrats named five North Carolina hospitals on a list of rural hospitals in danger of closing if the president’s then-pending spending and tax-cut legislation, called the One Big Beautiful Bill, became law, citing research from the University of North Carolina Sheps Center.

Two of the five North Carolina hospitals on that list, Angel Medical Center and Blue Ridge Regional Hospital, are part of the Mission Health system. Both had three consecutive years of negative profit margins, like hundreds of others on the list. Lindell, the Mission Health spokesperson, said HCA is committed to keeping those two facilities open.

Even so, Madison County Health Department Director Tammy Cody said the needs in the region remain and the certificate of need appeals process has slowed down getting help.

“This isn’t theoretical — it’s personal," she said. "Every delay means a mother in labor risks a longer ride, an elder with chest pain waits longer for help, or a worker injured on the job faces unnecessary complications.”

AdventHealth spokesperson Victoria Dunkle said the hospital system supports the state’s law partly because it “protects rural access to health care and ensures the community has a voice in the process.” The legal process has kept families waiting, she said, but AdventHealth plans to move forward with the Weaverville hospital “as soon as possible.”

Snelson, the ambulance service director, voiced a question many in the region have asked since the hope of a new rural hospital surfaced.

“Why is it a bad thing for another hospital to come in here to take some of the stress off of Mission?” he asked. “Within a day of it opening, it’s going to be full.”