Western North Carolina’s healthcare system is bracing for a courtroom showdown that could reshape how the state handles hospital acquisitions going forward. A North Carolina judge has just cleared the path for the state’s lawsuit against HCA Healthcare to proceed to trial, rejecting nearly all of the company’s attempts to get the case dismissed before it ever reaches a jury.
At stake is whether HCA broke its word to an entire region when it promised to preserve emergency and cancer care after buying out a beloved nonprofit hospital system back in 2019.
How This Legal Fight Started
The origins trace back to HCA’s $1.5 billion acquisition of Mission Health, a five-hospital nonprofit system serving western North Carolina. To secure approval for that deal, HCA negotiated an agreement with then-Attorney General Josh Stein, promising to maintain comprehensive rural health services and keep all Mission facilities open through at least 2029. The contract, known as the Asset Purchase Agreement, specifically committed HCA to not discontinuing emergency, trauma, and oncology services for a full decade after the sale closed.
That agreement became the foundation for everything that followed. Stein’s office began investigating HCA’s compliance as early as February 2020, and by December 2023, he filed a formal lawsuit alleging the company had broken its commitments outright.
What the State Alleges Happened
The complaint paints a picture of steadily deteriorating care at Mission Hospital, the system’s flagship facility in Asheville. According to the attorney general’s office, HCA severely reduced emergency room and oncology services, leading to dangerously long wait times and chronic bed shortages. Some patients were reportedly treated in view of other patients due to space constraints, a detail that underscored just how strained the facility had become.
The scale of complaints reinforces those allegations. The North Carolina Department of Justice received more than 500 complaints following the acquisition, with many centered specifically on emergency, trauma, and cancer care concerns. Staff turnover compounded the problem, with medical specialties reportedly vanishing entirely as personnel left in waves.
The Judge’s Key Ruling
The case reached a pivotal moment when North Carolina Business Court Judge Julianna Earp issued a 55-page order largely denying HCA’s motion for summary judgment, a ruling that would have ended the case before trial if granted. Earp sided with the attorney general’s office on several central arguments, concluding that genuine factual disputes remain over whether HCA satisfied its contractual obligation to provide emergency and trauma services at the required level.
Notably, HCA had argued that only the complete elimination of a service, not merely a reduction in quality or access, would constitute a breach of the agreement. The state pushed back forcefully against that interpretation, and the judge’s ruling suggested that argument alone wasn’t enough to shut down the case. Earp also rejected HCA’s attempt to exclude an expert witness, Dr. Kia Parsi of Texas A&M’s Rural and Community Health Institute, finding his experience directly relevant to evaluating the hospital’s performance.
Regulatory Red Flags Along the Way
This lawsuit hasn’t unfolded in isolation. The Centers for Medicare & Medicaid Services has placed Mission Hospital under “immediate jeopardy” status multiple times since the HCA acquisition, most recently in January 2026, a designation reserved for situations regulators consider serious enough to threaten patient safety. That status was lifted in March 2026 after Mission’s leadership implemented what the hospital described as an Enhanced Plan of Correction following a follow-up survey.
Those regulatory actions have added external validation to the state’s core argument, suggesting the concerns raised in the lawsuit weren’t isolated complaints but part of a broader, recognized pattern of care quality issues.
Local Governments Are Joining the Fight
The state isn’t the only party pursuing HCA over this issue. Buncombe County filed a motion to intervene in the case, seeking to recoup more than $3 million in taxpayer costs the county says it incurred since 2020 due to long ambulance transfer wait times, which forced EMS personnel to continue caring for emergency room patients well after arriving at the hospital.
Separately, the city of Brevard sued HCA in 2022, alleging the company attempted to monopolize regional healthcare, driving up prices while lowering care quality. A judge allowed that case to continue as well, despite HCA’s attempts to have it dismissed.
HCA’s Position on the Allegations
HCA has consistently maintained that providing high-quality care to western North Carolina communities remains its foremost priority, and the company has emphasized its commitment to meeting the region’s healthcare needs. Following the summary judgment ruling, HCA has not conceded any wrongdoing, and the case will now proceed toward a trial where both sides will present evidence on whether the company’s service reductions crossed the line from operational adjustments into a genuine breach of contract.
FAQs
Q1. What happens if the court ultimately rules that HCA breached its agreement?
The attorney general’s office has asked the court to order HCA to restore emergency, trauma, and oncology services to the level Mission Hospital provided before the acquisition, along with a permanent injunction preventing further breaches. The exact remedy would depend on what the trial establishes about the extent of the violations.
Q2. Why does Buncombe County want to join the state’s lawsuit separately?
The county is seeking to recover roughly $3 million in taxpayer funds it says were spent covering extended EMS wait times caused by emergency room bed shortages at Mission Hospital, costs it argues resulted directly from HCA’s understaffing.
Q3. Does the CMS “immediate jeopardy” designation mean the hospital is currently unsafe?
No, not currently. That status was lifted in March 2026 after Mission Hospital submitted and had approved an Enhanced Plan of Correction. However, the designation having been applied multiple times since the HCA acquisition remains a significant piece of context in the ongoing lawsuit.
Q4. When is the case expected to go to trial?
A specific trial date hasn’t been publicly confirmed as of the latest rulings, though the recent decision denying HCA’s summary judgment motion clears the primary procedural hurdle standing between the case and an actual courtroom trial.
