North Carolina was ranked by Forbes as the most expensive state for health care, but a new analysis challenges this, citing flawed methodology. Forbes weighted 85% of costs on employee-sponsored insurance premiums, which only covers less than half of North Carolinians. Using broader data, North Carolina ranks 10th lowest in per capita health spending and 13th lowest in hospital prices. The key issue Forbes highlighted is cost-shifting: NC employers pay less, while employees shoulder higher insurance costs. Employees pay the 14th-highest premiums nationally, while employers pay among the lowest. This suggests policy discussions should focus on who pays, not overall costs.
by Jane Winik Sartwell, Carolina Public Press July 9, 2025
North Carolina is the most expensive state in the nation for health care, according to a highly cited claim made by Forbes magazine, at least. But how true are those claims about costs?
Not very, according to a new analysis that challenges both the methodology and conclusions of the Forbes ranking. The reality, researchers from Ascendient Healthcare say, is much more nuanced.
But Forbes did get something right about health care costs — just not exactly what they set out to prove. In doing so, the publication revealed an under-researched issue in North Carolina health care policy.
Dubious methodology to judge costs
Which state has the most expensive health care? The answer depends on how you measure “expensive.”
That’s where things get complex. And those complexities have important implications.
The Forbes ranking relies on a weighting system devised by the authors of the study. The system puts 85% of the weight on what folks with employee-sponsored health insurance pay in premiums and deductibles each year.
Here’s one problem: less than half of North Carolinians have employee-sponsored health care.
“Somebody made some determination about the relative importance of each of these elements to be able to spit out an overall metric,” Brad Wright, former UNC Sheps Center researcher who now works at University of South Carolina, told Carolina Public Press.
“Without seeing a justification for how they did that, that’s concerning. If you gave me the same data set and I just changed those weight percentages, I’d get a different answer, and would be writing a different story.”
Forbes’s method addresses insurance shopping concerns rather than health care system performance, according to Dawn Carter, a North Carolina health care consultant who co-wrote the Ascendient analysis of health care costs in the state.
The methodology results in some interesting aberrations. Some of the least-expensive states for health care, according to Forbes, are Hawaii, California, and Massachusetts.
“Those cheapest states are states I don’t think of as being least expensive in anything,” State Treasurer Brad Briner told CPP. “Once you see that, you have to ask yourself the questions: What is the methodology here? What is the ulterior motive here?”
Briner’s skepticism of the Forbes costs ranking is a break from his predecessor.
Former State Treasurer Dale Folwell, a Republican like Briner,frequently cited North Carolina’s ranking to argue against North Carolina’s Certificate of Need laws, which regulate hospital construction.
The politicization of the Forbes data shows how powerful — and potentially arbitrary — statistics can be.
“The issue, of course, is that every data set is filtered through whatever lens the authors choose: pro-insurance, pro-state regulations, etc.,” UNC law professor Joan Krause told CPP.
Forbes defended its approach when CPP pressed about the methodology.
Forbes Advisor Editor Michelle Megna wrote: “We felt access and outcomes were most important, so gave them the most weight in our scoring.”
Other ways to measure health care costs
Ascendient’s chosen data points paint a very different picture.
“When I saw those headlines, I just thought: ‘Wait a minute. This is just not this is not consistent with what I know to be true,’” Carter told CPP.
“Let’s check their data and understand where this is coming from. And then let’s check back with the other data points that we are more familiar with.”
A common way of measuring health care costs, according to Carter, is to aggregate all health care spending — think hospitals, nursing homes, doctors — within the state and divide by total population.
Using this method, which accounts for people on all kinds of health care plans, North Carolina has the 10th-lowest health care costs in the nation.
North Carolina health care spending per capita comes out at $8,917 annually, while nationally, the average is $10,191.
Another way to rank costs is to measure hospital prices, since hospitals tend to be the most expensive option for health care. According to Ascendient, North Carolina had the 13th-lowest net price per inpatient discharge nationally.
Plus, when one looks at total insurance premiums rather than employee contributions, North Carolina drops from second to 45th-most expensive, according to Wright.
But all this does not mean that Forbes didn’t point out something true.
What Forbes got right
What Forbes proved is this: more than in any other state, NC employers shift higher portions of insurance costs onto employees.
This is a real data point, proven out by Forbes.
“There’s two different things going on here. One is ‘How much does health care cost?,’ and then the other is ‘Who pays?’” Treasurer Briner said.
“If the question is: ‘Who pays?,’ that is a very different discussion. In North Carolina, we have made the choice to have the individual pay more than the companies. In Massachusetts, for example, they’ve had the state pay a lot more than the individual.”
Though this doesn’t necessarily equate to NC’s overall health care costs being the highest, it is a salient point.
North Carolina employees contributed $1,806 for single coverage, the 14th-highest in the nation, while employers paid $5,937, the 10th-lowest.
If the issue is cost-shifting rather than expensive health care delivery, the potential policy solutions are different.
“If you don’t really look at what your data point is and what it’s measuring, then you’re going to look for policy solutions that don’t fix the root cause of the problem,” Carter said. “To generalize that one correct data point to make a claim about health care costs doesn’t paint a clear picture.”
But why do North Carolina employers do this? The answer isn’t entirely clear, even to experts who study the state’s health care system.
Carter guesses it might have something to do with North Carolina’s “business-friendly” stance.
Briner views it as a necessary balance to the low taxes and low cost-of-living North Carolina provides to its residents.
More research is needed to understand why companies shift more insurance costs onto their employees in North Carolina than in any other state. It is likely a combination of state policy decisions, labor market dynamics and regulatory choices.
Once that is understood, the real conversation begins.
Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.
Political Bias Rating: Centrist
This content presents a balanced, fact-based analysis of health care cost rankings in North Carolina without evident partisan rhetoric. It critiques the methodology of a Forbes study while providing alternative data and viewpoints from experts and officials across the political spectrum, including both current and former state treasurers from the Republican Party. The article acknowledges complexities in health care costs and cost-shifting between employers and employees, avoiding advocacy for any particular policy or ideological agenda. Overall, it aims to inform readers by dissecting data and interpretations fairly, reflecting a centrist perspective.
Florida-based nonprofit AdventHealth is seeking public support to expand its new hospital in Weaverville, North Carolina, from 93 to 222 acute-care beds. This would make it the second-largest hospital in western North Carolina and a major competitor to HCA Healthcare’s Mission Health, which currently holds a near-monopoly in Buncombe County. AdventHealth has started site work but cannot apply for the additional beds until October. The project faces legal challenges from Mission Health, which has appealed previous approvals. The expansion aims to improve access to specialty care and create jobs, but state certificate of need (CON) laws complicate the process.
Months before it can get official permission from the state, Florida-based nonprofit AdventHealth is seeking public support for a 129-bed expansion of its already approved 93-bed new hospital under construction in northern Buncombe County.
Coupled with an earlier, pending certificate of need (CON) request to the state for 26 additional beds, AdventHealth will be proposing a total of 222 acute care beds for the new facility in Weaverville, making it — if approved by state regulators, and if it withstands possible challenges from Nashville-based for-profit HCA Healthcare — the second-largest hospital in western North Carolina and the first major competitor to HCA Mission Health’s near-monopoly on hospital services in Buncombe County.
Mission Hospital in Asheville has 682 licensed acute-care beds. UNC Health Pardee in Henderson County has 201. The Charles George VA Medical Center in Buncombe County has 119. AdventHealth already operates a 62-bed hospital in Henderson County, according to the Proposed 2026 State Medical Facilities Plan.
AdventHealth in Hendersonville has 62 acute-care beds, according to the latest State Medical Facilities plan. The Florida-based nonprofit wants to expand its footprint in western North Carolina to a Weaverville hospital with 222 beds. // Watchdog photo by Katie Linsky Shaw
For months, AdventHealth, a Seventh-day Adventist nonprofit that is the largest Christian-based nonprofit hospital system in the United States, quietly has been pitching a proposal for the additional 129 beds to local leaders across the region. But this week’s public announcement of plans marks the first significant indication of AdventHealth’s vision for a much larger facility.
The announcement, however, comes months before any possible official action.
Applications for the additional 129 beds cannot be submitted to the state until Oct. 15, according to the 2025 State Medical Facilities Plan. AdventHealth, which owns more than 50 hospitals across the nation, has been gathering letters of support from town councils, health departments and residents in preparation for its application.
It’s already started grading work at the 30-plus acre site and is planning a groundbreaking ceremony later this year. When AdventHealth first applied for the project, the nonprofit told the North Carolina Department of Health and Human Services’ Division of Health Service Regulation (DHSR) it would cost $254 million. Plans to expand the hospital will inflate the price, AdventHealth spokesperson Victoria Dunkle said.
“We will be sharing the updated scope, scale and costs in the final application,” she said.
Though AdventHealth originally said the hospital would open by 2027, expansion and a complex application process make that aspiration unlikely.
Weaverville Mayor Patrick Fitzsimmons said that although the delays are frustrating, the prospect of a large new hospital is welcome in this town of about 4,500.
“This is a positive development for our town,” Fitzsimmons said. “We’re talking about the addition of maybe as many as a couple thousand jobs as these new hospital beds are allotted, the kind we’re trying to attract to Weaverville.”
Service area: Buncombe, Graham, Madison and Yancey
Meant to serve patients in Buncombe, Graham, Madison and Yancey counties, the facility originally was slated for only 67 beds, according to the certificate of need application AdventHealth filed in 2022, which was approved by the state months later, despite competition and opposition from other big health care systems, including the HCA Healthcare-owned Mission Health system.
North Carolina’s CON law forces medical facilities to compete when they want to expand, add services, or buy expensive equipment. Organizations apply for projects and the state decides whether they are necessary.
In 2024 Advent added an application for 26 more beds to its original bid, bringing the total it was asking to 93. The extra 129 beds proposed this week would more than double the total bed count at the proposed Weaverville hospital.
“With 222 beds, the community will have more access to higher-level emergency and specialty care and more choices for how and where to receive this advanced care,” the release said, touting “not-for-profit, whole-person care” and “the growing needs of our region.”
An artist’s rendering shows what AdventHealth’s planned 222-acute-care-bed hospital in north Buncombe could look like when it opens in the coming years. // Photo credit: AdventHealth
Though a thumbs-up from the DHSR, the entity responsible for approving applications, is the first step to getting those beds, it’s hardly the last. CON law allows other hospitals to appeal the DHSR decision repeatedly, which Mission Health has done with all of AdventHealth’s previous approvals for the hospital. Last month an appellate court judge ruled against HCA-Mission’s most recent challenge to the 67-bed bid, which the DHSR approved more than three years ago.
Mission Health spokesperson Katie Czerwinski declined comment on Mission’s appeals. She did not respond to a question about whether Mission would also apply for the 129 beds come October.
HCA also challenges 26-bed AdventHealth award
AdventHealth’s announcement Monday highlighted the North Carolina Court of Appeals decision to finally greenlight the 67 beds, opposing Mission Health’s contention since 2022 that it didn’t get a fair shake in the CON process. Both Mission and Novant Health tried to win the beds that year.
“AdventHealth is grateful for the North Carolina Court of Appeals’ decision to uphold the State’s approval of our CON application for a 67-bed hospital in Buncombe County,” the news release said.
Because of CON laws and Mission’s legal contentions, AdventHealth is far from clear to finalize its vision of opening what would be one of the region’s largest hospitals by acute-care-bed count. Although the battle over the 67 beds is over now, another one is waiting on an Office of Administrative Hearings judge’s decision. Mission Health filed an appeal Dec. 20, 2024, stating that AdventHealth’s 26-bed application was erroneously granted to AdventHealth.
“By denying Mission a CON for the Mission Application, the Agency’s Decision prevents Mission from expanding Mission Hospital to meet the needs of Mission’s existing and future patients and therefore directly limits Mission’s ability to engage in its lawful business,” the appeal said.
AdventHealth did not mention the 26 beds in its release.
“The 26-bed approval is currently under appeal by a competitor,” AdventHealth spokesperson Victoria Dunkle said Tuesday. “That appeal is being reviewed through the Office of Administrative Hearings. Despite this delay, we remain steadfast in our commitment to bring these 93 beds — and the whole-person care they represent — to the people of Western North Carolina. We are confident that the State’s original decision will be upheld, and we continue to prepare to deliver on that promise.”
An effort to repeal CON laws, Senate Bill 370, made headway in the General Assembly this April. But that effort may be overshadowed by a 2020 lawsuit brought by a New Bern vision physician, Jay Singleton, in the state’s Supreme Court, arguing the multilayered application process “has nothing to do with protecting the health or safety of real patients.”
“Proponents of CON laws contend that if excess health care service capacity exists, price inflation may occur to compensate for new, underused health care services or empty beds,” according to a summary by the National Conference of State Legislators. “Opponents believe CON laws stifle competition by protecting incumbent providers and creating a burdensome approval process for establishing new facilities and services.”
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Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s local reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/support-our-publication/.
Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.
Political Bias Rating: Centrist
This content offers a straightforward, fact-based report on AdventHealth’s hospital expansion plans and the surrounding regulatory and legal environment. It primarily focuses on healthcare infrastructure development, regulatory processes, and competition dynamics without expressing partisan opinions or ideological viewpoints. The article presents multiple perspectives, including that of AdventHealth, its competitors, local officials, and regulatory authorities, maintaining an objective tone typical of centrist reporting.
SUMMARY: Homeland Security has ended the TSA’s mandatory shoe removal rule at airport security nationwide due to advances in screening technology, increased officers, and enforcement of Real ID. This change aims to create smoother, more secure travel. Airlines support the move, noting it saves time and improves passenger experience. Homeland Security is also reviewing other screening rules, like liquid restrictions and removing belts and coats, and plans pilot programs for more efficient, less intrusive checkpoints where travelers might not need to interact with officers or remove laptops. TSA PreCheck remains beneficial for even faster screening with fewer rules to follow.
Noem said the new policy is going into effect at all airports across the country.
www.thecentersquare.com – By David Beasley | The Center Square contributor – (The Center Square – ) 2025-07-09 08:07:00
North Carolina’s $127 billion state pension plan generated $8 billion in investment profits in the first half of the fiscal year, surpassing expectations by $2.5 billion, according to State Treasurer Brad Briner. Despite this success, the plan has historically underperformed and faces a $16 billion annual deficit due to growing pension obligations and fewer contributors. The state’s contribution has increased from zero to 17% of employee salaries over 25 years, prompting calls to curb further increases. Recent legislation established a five-member North Carolina Investment Authority to modernize pension fund management, replacing the previous sole-investor model overseen by the treasurer.
(The Center Square) – In the first six months of this fiscal year, the North Carolina state pension plan investments made $8 billion and outperformed the stock market, the state’s treasurer said Tuesday.
“That number is we think the largest profit in the six-month history of our state pension system,” first-term Republican Brad Briner said at a meeting of state leaders. “But moreover, it is $2.5 billion more than we expected.”
Brad Briner, state treasurer of North Carolina
NC Department of State Treasurer | Facebook
North Carolina’s $127 billion pension plan has “underperformed for years,” according to Briner.
The plan has been running a $16 billion annual deficit based on the gains it needed to sustain pension payments without raising state contributions to the plan, Briner said.
Gains in the pension plan investments can reduce the need to increase the state contribution which has grown from zero 25 years ago to the current 17% of employee salary, Briner said.
“We can’t keep letting it go up.” Briner said told other state leaders Tuesday.
The North Carolina Retirement System serves more than 1 million people, from teachers to state employees, local governments, firefighters, police officers and other public workers. It operates at a deficit similar to Social Security, with fewer people paying in than are eligible for benefits.
Estimated market value was $89 billion when former Treasurer Dale Folwell took office in January 2017 and $127 billion on Dec. 27, 2024, in his final days of office.
This fall, the treasurer’s office will conduct studies to determine how to possibly reduce the employer match.
“All of that is getting to what we can do on the employer match side to relieve some of the pressure on our agencies and on the state budget,” the treasurer said.
Also, the Legislature this year passed and the governor signed the Investment Modernization Act which according to Briner “fundamentally” changes the way the state manages pension fund investments.
It creates a five-member North Carolina Investment Authority, chaired by the treasurer, which includes financial professionals appointed by the governor, treasure and leaders of the legislature.
The state has been one of only three in the country to give one person – the treasurer- sole power for administering pension plan investments, Briner said.
Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.
Political Bias Rating: Center-Right
This article largely reports factual information about North Carolina’s state pension plan performance and related administrative changes, quoting Republican state treasurer Brad Briner extensively. While it focuses on the treasurer’s perspective—who emphasizes financial discipline and reform—there is no overt editorializing or partisan framing beyond the presentation of his statements. The positive framing of investment gains and calls to reduce state contributions align with fiscally conservative principles, suggesting a moderate right-leaning viewpoint. However, the reporting remains largely neutral and informative, primarily conveying the actions and positions of officials rather than endorsing a specific ideological stance.
