This article first appeared on North Carolina Health News.
The first weekend in May, just before Wake County commissioners were initially planning to vote on a proposed combination of Atrium Health and WakeMed Health & Hospitals, Wake County Commissioner Vickie Adamson was worried.
“This feels way too rushed to me,” she wrote in a May 2 text message to fellow commissioners Susan Evans and Cheryl Stallings. “I think there’s a lot we don’t know.”
Adamson wrote that she had reached out to Wake County Board of Commissioners Chair Don Mial, telling him she felt like “it was not good government to make a decision this big with only having 72 hours to listen to constituents.” She also wrote that Mial “wanted to get it over with and he was ready to vote.”
However, after a loud public outcry that weekend, the commissioners ultimately delayed their vote to allow more time for public feedback.
Four months later, the commissioners are once again scheduled to vote on the deal, at 2 p.m. Monday.
Wake County announced the scheduled vote late Thursday. In the same announcement, the county provided a revised transfer agreement and the articles of incorporation that the board will be asked to consider.
It appears that the wait—and the intense conversations taking place out of public view—produced changes to the original proposed agreement that provide more to Wake County.
According to the two documents, the changes include:
- Cash for the county: Wake County would receive $15 million each year for a decade—or $150 million total—for the Wake County Whole Health Program, which aims to improve access to and affordability of care, expand mental health care and address social drivers of health.
- More indigent care: The previous document called for WakeMed to provide indigent care and related community services equal to at least 4.8% of total adjusted revenue each fiscal year. The revised agreement increases that to 8%.
- Board member selection and removal: Atrium Health would no longer be able to remove county-appointed board members for reasons such as being “disruptive” or “failing to work collegially.” Commissioners would still have to choose their eight appointees from a board-nominated slate of candidates. However, if commissioners reject a nominee, the WakeMed board must submit another nominee within 60 days.
- Less power to change governing documents: Certain changes to the articles of incorporation—including changes affecting community directors, county appointment authority and board member eligibility rules—would now require approval from 12 of the 14 board members as well as the Wake County commissioners. Wake County also must consent before WakeMed’s membership/equity is transferred to or replaced by a third party that is not an Atrium affiliate.
- Shall vs. intends: The new version of the transfer agreement says Atrium “shall make” at least $2 billion in capital expenditures in Wake County over 15 years; the previous document said the system “intended” to make that same investment over a shorter time period, 10 years.
5,000 newly released public records
More than 5,000 newly released public records offer a behind-the-scenes look at what has happened since the initial announcement to lead to some of those changes. The records were released this week to North Carolina Health News in response to a request filed in May. The Patients Union, a health care consumer advocacy organization, had filed a similar but unrelated open records request; a representative said it had received documents this week as well — many of which are the same.
Wake County produced the records for both organizations after an attorney representing the union sent a Sept. 14 letter demanding their release before the commissioners’ vote. The Patients Union then sent a follow-up letter saying that the records were still incomplete, lacked attachments, and contained unexplained redactions.
The records released so far capture the strong initial public reaction to the deal, with more than 3,000 emails sent to commissioners from opponents and supporters. (That includes 1,400 separate messages supporting the deal with the same subject line and nearly identical wording, mostly sent from WakeMed email addresses.)
The records also document the commissioners’ initial uneasiness about the deal, the way the county downplayed its decisive role, and the direct access to commissioners by hospital officials, who invited county commissioners to private meetings and on visits to Atrium facilities.
Commissioners told their role was “minor”
The deal would give Atrium Health, the state’s largest health care system, significant control over WakeMed, a 973-bed community-focused system based in Raleigh. Atrium, which reported $14 billion in revenue in 2025, is part of Advocate Health, a $39 billion multi-state organization that is the nation’s third largest public hospital system. WakeMed reported $2.7 billion in revenue in 2025.
Atrium said that through joining forces, it would bring $2 billion in investment to Wake County, create 3,300 jobs over five years, and allow WakeMed to update and expand its facilities. Critics say the combination would lead to higher health care prices and less local control.
Wake County must approve changes to a transfer agreement and WakeMed’s articles of incorporation before the deal can move forward because WakeMed was once county-owned.
Hospital finance experts told NC Health News that that gives commissioners significant leverage and the power to ask for changes to the deal. But early documents indicate commissioners were initially told a different story.
In talking points sent to all seven commissioners before the original May vote, Wake County Chief Communications Officer Dara Demi wrote, “Overall, our role is minor. Ours is just one of many, many steps in this process.” It advised them to “refrain from commenting extensively” and refer most questions to WakeMed.
The item was also placed on the consent agenda, where multiple, noncontroversial business items are typically voted on in a block without public input.
As word of the deal spread and public criticism ramped up, some commissioners were increasingly uneasy, the documents show. In one text message, Commissioner Cheryl Stallings called it “a very rushed process,” adding that she is “always supportive of allowing time for public input.” Adamson wrote at one point: “We’ve got to pull it off consent (sic).”
After commissioners delayed the vote, County Attorney Roger Askew again emphasized in a May 5 email that Wake County was not a party to the hospital agreement and had no regulatory power, “so we do not have oversight of any process to combine hospitals.”
Asked about the county’s narrow characterization of its role, Demi told NC Health News that they were trying to make clear that the county “plays a part in that process, but we are not the final decision maker.”
That narrow view was initially adopted by some of the commissioners, according to text exchanges.
On May 2, for example, Commissioner Susan Evans wrote that she would prefer the county not hold a public hearing because “this deal is not ours to approve per se,” adding that WakeMed should hold the hearings instead.
However, once the commissioners delayed the vote, their leverage became clear. The documents show hospital officials met repeatedly with them to answer questions and address concerns. On Aug. 17, the county hosted a public hearing about the deal. More than 100 people spoke, and public comments lasted four hours.
Hospital officials had extensive access
Through the summer, WakeMed and Atrium officials repeatedly offered commissioners direct access to people involved in the deal, as well as invitations to visit Atrium facilities, the documents show.
In the email and text exchanges, several commissioners reference conversations and meetings with hospital board members, and the records indicate some commissioners planned to visit Atrium facilities.
Board of Commissioners Vice Chair Safiyah Jackson asked Commissioner Tara Waters in a text message to join her on a day trip to Charlotte “to meet Atrium community partners.” In another text exchange, Commissioner Cheryl Stallings wrote that an Atrium representative was arranging an itinerary for her to visit Charlotte and Winston-Salem, where Atrium has a similar partnership with Wake Forest Baptist Medical Center.
Stallings added that the county attorney had advised her not to let Atrium pay for her lunch.
Hospital leaders and attorneys also held a series of private briefings with commissioners in groups of three to share the details of the Atrium-WakeMed contract. Holding a meeting with more than three of the commissioners would have triggered a threshold that would have meant the meetings were subject to North Carolina’s open meetings laws.
Opponents have criticized the process as one-sided.
“It is deeply concerning and anti-democratic that those who had the most access to commissioners and staff are the ones who stand to benefit from this deal, while people who stand the most to lose—patients and workers—have had the least access,” said Rob Stephens, organizing director at The Patients Union.
Asked to respond, Demi said commissioners received thousands of emails, held a public hearing, and attended community meetings organized by WakeMed where critics often spoke.
“I’m not sure how to fully measure accurately if one side’s gotten more attention or the other,” she said.
Stephens said the union and the State Employees Association of North Carolina emailed a request to the commissioners this week asking for a meeting that would allow more substantial discussion about the proposal beyond the few minutes allotted to each person in the public comment period.
“The organizations that stand to benefit from this takeover should not be the only parties afforded the opportunity to have a robust conversation about the facts and the stakes,” they wrote.
The organizations had not received a response by Thursday evening.
Mial: WakeMed did “everything that we have asked”
As time passed, county officials soon began thinking about what Wake County could seek from the hospitals, the documents show.
On May 12, county Behavioral Health Director Denise Foreman wrote that “this is not simply a hospital transaction” and urged the county to seek “clear commitments” on behavioral health services, crisis response, medical respite, youth mental health and long-term local accountability.
Deputy County Manager Duane Holder responded that county officials would develop “specific programmatic/service asks, given this potential opportunity.”
The records do not include a follow-up email spelling out the specific requests or any demands.
But on June 17, commissioners chair Mial texted Waters that WakeMed had “done everything that we have asked of them.”
“I really don’t understand what else is needed for anyone to make a decision,” Mial wrote. “It is time for us to make a decision and move on, the sooner the better.”
Stephens said the county should have given the public more than a few days to understand and scrutinize the changes in the revised agreement documents.
“It’s outrageous that the Wake County Board of Commissioners is once again planning a WakeMed vote without giving the public any time to review the substance and get answers to their questions,” he said. “This is exactly what they did in May when they put the transfer agreement on the agenda on a Friday for a Monday vote.”
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
