Key Health Care Issues to Track in 2025 in the Carolinas

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04.08.2025

Following a year of significant regulatory changes and market realignments, the health care landscape in North and South Carolina continues to undergo significant transformation driven by federal policy shifts, state legislative developments, and evolving industry trends. Health care stakeholders across both states must remain attentive to these developments as they will likely shape strategic planning and service delivery in 2025 and beyond. While not an exhaustive list, these are some of the key issues that we are currently monitoring this year.

1. Federal Deregulation and Its Impact on the Carolinas

According to the White House, the first Trump Administration eliminated five and a half regulations for every new regulation put into place.^[1] Upon taking office this year, President Trump has initiated a more aggressive deregulatory agenda, which has included blocking “costly Biden” proposed rules, such as new Medicare and Medicaid and Children’s Health Insurance Program (CHIP) mandates,^[2] and launching a “10-to-1” deregulation initiative, which requires the repeal of ten existing rules, regulations, or guidance documents for every new rule, regulation, or guidance issued.^[3] Such federal deregulation could reshape the current health care regulatory framework by streamlining administrative requirements and reducing compliance costs for providers across the Carolinas.^[4] While reduced administrative burdens may free up resources for patient services, the resulting regulatory regime may also alter current oversight and quality control mechanisms and cause long-term effects on health care costs, access, and quality of care. It is not easy to predict whether the federal deregulation efforts will spur the growth in the health care industry that the Carolinas has enjoyed over the last several years.

2. Federal Funding Cuts and Their Impact on the Life Sciences Industry in the Carolinas

The National Institutes of Health (NIH) awards grants that provide substantial federal funding for research, with a significant portion covering indirect costs (facilities and administration) based on rates negotiated by designated federal agencies.[5] In fact, NIH funds most medical research in the U.S.^[6] For 2024, through “mid-August 2024, funding from the [NIH] into the life science and healthcare sector ha[d] reached $26.4 billion[.]”^[7]

But on February 7, 2025, NIH issued supplemental guidance that capped the indirect cost rate at 15 percent,^[8] which is “far below what many institutions have been getting to maintain buildings and equipment and pay support staff and other overhead expenses.”^[9] To illustrate this point, the negotiated indirect cost rate was 55.5% at the University of North Carolina; 61.5% at Duke University;^[10] 51% at the Medical University of South Carolina (MUSC); 49% at the University of South Carolina Columbia campus; and 52.5% at Clemson University.^[11]

With respect to these NIH cuts, the Association of American Medical Colleges warns, “Americans will have to wait longer for cures and our country will cede scientific breakthroughs to foreign competitors.”^[12] These cuts would mean “less research. Lights in labs nationwide will literally go out. Researchers and staff will lose their jobs.”^[13] According to United for Medical Research, NIH funding supports 21,769 jobs in North Carolina and 3,650 jobs in South Carolina.^[14]

On March 5, 2025, a federal district court granted a nationwide preliminary injunction enjoining the NIH from taking any steps to implement, apply, or enforce the new indirect cost rates. The court’s decision offers a temporary reprieve, but the future of NIH funding and its impact on the life sciences industry remains a critical issue. Life science has been a high-growth industry in the Carolinas in recent years, so if the NIH cuts ultimately do go through, this will have a potentially negative impact on the life sciences industry.

3. Medicaid Funding and Reimbursement Challenges

Medicaid, which is jointly funded by federal and state governments, provides health coverage to millions of Carolinians and is administered by the states under federal guidelines, such as federal guidelines outlining, among other things, Medicaid funding and reimbursement methodologies. For instance, both North and South Carolina make Disproportionate Share Hospital (DSH) payments to hospitals serving Medicaid and uninsured patients, with federal funding limits based on state allotments and hospital costs. On March 15, 2025, President Trump signed H.R. 1968, the Full-Year Continuing Appropriations and Extensions Act, 2025,^[15] which delays billions of dollars in DSH cuts. ^[16] These cuts, originally set to begin on April 1, 2025, will now start Fiscal Year 2026,^[17] thus providing additional time for hospitals to prepare for these significant cuts.

Despite the significant role Medicaid plays in providing health coverage to one in five Americans, the program itself is seemingly facing significant cuts.^[18] The concurrent resolution on the budget for Fiscal Year 2025, which has been agreed to in the U.S. House of Representatives and amended in the U.S. Senate, requires the Committee on Energy and Commerce to propose changes to laws within its jurisdiction to reduce the deficit by at least $880 billion dollars for the period of Fiscal Years 2025 through 2034.^[19] The committee’s jurisdiction includes laws pertaining to Medicare, Medicaid, and CHIP. According to the Congressional Budget Office, federal outlays for programs other than these three federal health care programs will total $381 billion over the next decade.^[20] Meaning, Medicare, Medicaid, or CHIP are likely to face cuts because the Committee on Energy and Commerce can only cut $381 billion otherwise, though the U.S. Senate’s amended version of the budget creates a potential safeguard through a deficit-neutral reserve fund that would allow for budget adjustments to protect and potentially strengthen Medicare and Medicaid.[21]

One proposal set forth for cutting Medicaid spending is “scal[ing] back a 90% federal matching rate for Medicaid recipients covered through the Affordable Care Act to medical assistance rates available to traditional Medicaid beneficiaries, which vary between 50% and 77%.”^[22] But implementation of such a proposal would automatically roll back North Carolina’s recently implemented Medicaid expansion (as of March 7, 2025, North Carolina’s Medicaid expansion program has enrolled 640,297 individuals^[23]), since reducing the share of federal funding would require termination of the expansion.^[24] Ultimately, these potential Medicaid cuts signal a challenging road ahead for Medicaid’s ability to sustainably serve millions of Carolinians.

South Carolina and North Carolina both have directed payment programs in place with the Centers for Medicare & Medicaid Services (CMS) that pay hospitals additional money for treating Medicaid patients: South Carolina’s program is known as the Health Access, Workforce and Quality (HAWQ) Program; and North Carolina’s program is known as the Healthcare Access and Stabilization Program (HASP). These directed payment programs have to be approved by CMS every year, so it remains to be seen as to how these existing directed payment programs will be impacted by reductions in Medicaid reimbursement.

Medical providers are lobbying Congress to reduce the proposed Medicaid cuts because of the negative impact these cuts will cause. While state appropriators in both North and South Carolina face the unenviable task of potentially having to stretch smaller federal Medicaid allocations across growing health care needs. We will be watching how this unfolds later in 2025 because if the proposed cuts do go through, there will likely be material negative impacts to hospitals, health care systems, and state budgets alike.

4. Certificate of Need (CON): Differing Reform Trajectories = Growth in Health Care Facilities?

CON reform differs materially between the Carolinas:

North Carolina

Last year, we described how North Carolina has chosen to reform its CON law in phases.^[25] For instance, effective November 21, 2025, Ambulatory Surgical Facilities (“ASFs”) that: (a) are licensed by the North Carolina Department of Health and Human Services; (b) have a single-specialty or multi-specialty ambulatory surgical program; and (c) are located in a county with a population over 125,000 according to the most recent the federal decennial census will be deemed “Qualified Urban Ambulatory Surgical Facilities” and no longer subject to CON review (note, Qualified Urban Ambulatory Surgical Facilities must commit 4% of their total earned revenue to charity care.)^[26] Notwithstanding this reform, North Carolina’s CON law continues to apply to numerous health care facilities including hospitals, ambulatory surgical facilities, inpatient rehabilitation facilities, nursing homes, adult care homes, home health agencies, hospice home care agencies, hospice facilities (residential and inpatient), kidney disease treatment centers, Intermediate Care Facilities for Individuals with Intellectual Disabilities, and diagnostic centers.[27]

But North Carolina’s CON law is currently facing multiple challenges, including litigation and proposed legislation that either seek to limit its scope or threaten its complete elimination:

• Legislation pending in both chambers of the North Carolina General Assembly would repeal CON review requirements.^[28]
• Legislation pending in the North Carolina Senate would (i) eliminate the CON law in all counties except those counties that have a population of less than 100,000 and at least one functioning hospital,^[29] or (ii) eliminate CON review for inpatient rehabilitation services, rehabilitation facilities, and rehabilitation beds.^[30]
• Legislation pending in the North Carolina House of Representatives would eliminate positron emission tomography (PET) scanners from CON review.^[31]
• A pending legal challenge, if successful, would render the CON law unconstitutional in all its applications,^[32] which would result in significant changes to the state’s CON program. This case involves a constitutional challenge filed in 2020 by a New Bern ophthalmologist to North Carolina’s CON law, alleging violations of the Monopolies Clause, Exclusive Emoluments Clause, and Law of the Land Clause of the North Carolina Constitution, which was remanded to the trial court in October 2024 by the state Supreme Court after its dismissal by a unanimous N.C. Court of Appeals three-judge panel.^[33]

South Carolina

As South Carolina has repealed CON requirements for most health care facilities in 2023, we anticipate an upward trend this year in the development of ASFs, opioid treatment programs, freestanding emergency departments, hospice facilities, residential treatment facilities for children and adolescents, cardiovascular care services, and radiation therapy facilities. This growth is expected particularly from providers in nearby states with more restrictive CON requirements and for-profit entities previously discouraged from entering the market due to onerous CON requirements. However, we foresee measured growth due to the ongoing legal, administrative, and financial challenges associated with maintaining licensure in the state.

Although CON requirements applicable to hospitals will sunset on January 1, 2027, entities are continuing to submit CON applications to establish new hospitals, recognizing that competitors are unlikely to oppose such applications given the approaching end date of these requirements and the significant investment of time and resources needed for the objection process. The following entities have recently submitted CON applications to establish a new hospital:

• Prisma Health-Upstate d/b/a Prisma Behavioral Health Hospital[34]
• Novant Health Hilton Head Medical Center d/b/a Novant Health Bluffton Medical Center[35]
• South of Broad Healthcare d/b/a Bluffton Community Hospital[36]
• Novant Health Greenville Hospital, LLC d/b/a Novant Health Greenville Hospital[37]

The University of South Carolina School of Medicine has announced its plans to develop a hospital that will focus on the integrated care of patients with brain and nervous system illnesses.[38]

We expect to see additional CON applications for new hospitals in the next 18 months or so leading up to the sunset date.

5. Tort Reform in South Carolina

On March 27, 2025, the South Carolina Senate passed and sent to the South Carolina House of Representatives tort reform legislation that modifies South Carolina’s approach to tort liability by revising joint and several liability rules, establishing how fault is allocated among plaintiffs, defendants, and non-parties whose actions contributed to damages; requires certain alcohol server training for alcohol servers and managers; clarifies liquor liability insurance obligations; increases minimum automobile insurance coverage limits; and extends the time limit for construction defect claims.[39]

As of the writing of this article, this bill increases governmental liability caps under the South Carolina Tort Claims Act for licensed physicians and dentists from $1.2 million to $2 million per occurrence, while also raising general governmental liability limits from $300,000 to $500,000 per person and from $600,000 to $1 million total per occurrence.[40] Importantly, this bill clarifies that an “occurrence” encompasses not only a single act of negligence but also multiple acts of negligence occurring without a break in the causal chain that result in substantially the same damages, as well as continuous or repeated exposure to substantially the same harmful conditions.[41]

Additionally, this bill revises South Carolina’s noneconomic damages liability framework for health care providers and health care institutions by restructuring when damage caps don’t apply.[42] It narrows exceptions to three specific scenarios: willful or wanton or reckless conduct, related felony convictions, or actions impaired by drugs or alcohol.[43] Importantly, even when these exceptions apply, the bill limits total liability to ten times the noneconomic damages cap, regardless of the number of claims or causes of action.[44]

While the outcome of this legislation remains uncertain, this is the most substantial tort reform legislation proposed in South Carolina in recent years, and we’re closely monitoring its progress.

6. Mid-Level Provider Scope of Practice Expansion and Health Care Access Reform

Mid-Levels

Proposed legislation in South Carolina would grant greater practice autonomy to advanced practice registered nurses (APRNs), physician assistants (PAs), and Certified Registered Nurse Anesthetists (CRNAs):

• House Bill No. 3580 / Senate Bill No. 45: This South Carolina legislation would grant APRNs (other than CRNAs) “full practice authority” as defined in the legislation,  enabling them to perform certain medical acts and nonmedical acts independently without a practice agreement with a physician. To attain this authority, APRNs would need to complete 2,000 clinical hours after initial licensure as an APRN, possess malpractice insurance, and provide attestation and documentation of their compliance to the Board of Nursing. Once granted full practice authority, APRNs could then independently order and interpret diagnostic data, prescribe medications and treatments, perform acts approved by national nursing organizations, and perform nonmedical acts such as population health management and quality improvement projects.
• House Bill No. 3579 / Senate Bill No. 44: This South Carolina legislation would allow PAs with over 2,000 hours of postgraduate clinical experience, and additional experience if changing to a new specialty, to practice independently without physician supervision. The PA must submit an attestation statement to the SC Board of Medical Examiners, which is a document confirming their qualifications and commitment to appropriate collaboration without transferring supervisory or legal responsibility to a physician. Qualified PAs may perform comprehensive medical services, including examinations, diagnoses, treatments, prescribing, and writing orders across various health care settings.
• House Bill No. 4044 / Senate Bill No. 360: This South Carolina legislation would grant CRNAs independent practice authority by removing requirements for physician or dentist supervision. The bill also creates a pathway for CRNAs to obtain prescriptive authority by completing education requirements in pharmacology and controlled substances.

None of these bills appears likely to pass during this first regular session, though they will likely be brought up again next session, as it would be the second year of the two-year legislative cycle.

Proposed legislation in North Carolina would grant greater practice autonomy to APRNs and PAs:

• House Bill No. 514 / Senate Bill No. 537: The North Carolina legislation would update and clarify definitions related to APRNs across various roles including Nurse Practitioners (NPs), Certified Nurse Midwives (CNMs), Clinical Nurse Specialists (CNSs), and CRNAs. The legislation would allow APRNs to practice to the full extent of their education and training, enabling them to care for patients in the capacity they are trained for without physician supervision, similar to laws already enacted in 27 other states.^[45]
• House Bill No. 672 / Senate Bill No. 345: This North Carolina legislation would adjust the supervision arrangements for PAs by creating a new “team-based practice” framework that would allow experienced PAs to practice with greater autonomy in qualifying health care settings. To qualify, PAs would need over 4,000 hours of clinical practice experience as a licensed PA and more than 1,000 hours of clinical practice experience within the specific medical specialty of practice with a physician in that specialty. This legislation would reduce direct physician supervision requirements while maintaining appropriate collaboration based on patient needs.

These North Carolina bills are currently in the early stages of the legislative process.

Although there seems to be a national trend towards increasing mid-level provider autonomy, medical associations have generally expressed concerns about expanding the scope of practice of mid-level providers, emphasizing that patients deserve care from the most highly educated, trained, and skilled health care professionals, which necessitates physician involvement and supervision.[46]

Other Health Care Professionals

Pending legislation in the Carolinas seeks to expand the scopes of practice for several other health care professionals, including pharmacists (SC: would gain authority to prescribe for conditions not requiring new diagnoses, minor self-limiting issues, or patient emergencies; NC: would be permitted to perform CLIA-waived tests with treatment capabilities),^[47] optometrists (SC: would receive authorization to perform certain surgical procedures),^[48] and dental hygienists (SC: would be allowed to provide expanded services without direct supervision).^[49]

Pharmacy Benefit Manager (PBM) and Prior Authorization Legislation

Both North and South Carolina have legislation pending that would regulate PBMs.^[50] Despite taking different approaches, both states’ bills aim to curb PBM practices that increase costs for patients and create unfair conditions for pharmacies.

Both North and South Carolina have legislation pending that would address prior authorizations. South Carolina’s bill includes provisions that would establish provider exemptions from authorization requirements when they maintain high prior authorization approval rates; set timelines for prior authorization determinations; and prohibit ongoing authorization requirements for chronic health conditions.^[51] North Carolina’s bills would require insurers to honor prior authorizations for 90 days after patients switch plans (six months for chronic conditions) and prohibit using artificial intelligence (AI) alone for utilization review determinations.^[52]

7. State Regulation of Private Equity

In 2024, private equity (“PE”) firms continued to expand their presence in health care across the nation. According to the Global Healthcare Private Equity Report 2025, deal activity surged in 2024, resulting in “the second-highest year on record in North America.”^[53] The report also notes, “While historically more concentrated in provider assets, mid-market PE firms have expanded their focus in healthcare IT and provider services while maintaining a strong presence in biopharma and medtech.”^[54] This trend towards increased PE activity will continue in 2025. In the Carolinas:

• Last September, San Francisco-based PE firm TPG obtained a stake in the business side of Tryon Medical Partners, Charlotte’s largest independent physician practice.^[55]
• In February of this year, PT Solutions Physical Therapy, an Atlanta-based company backed by private equity,^[56] announced its acquisition of the physical therapy branch of OrthoCarolina,^[57] which was already one of the nation’s largest independently owned orthopedic practices.^[58]

We are aware of several other PE-backed transactions in the Carolinas that are being negotiated but have not been finalized.

In recent years, lawmakers across the nation have been exploring options for increasing oversight of health care transactions,^[59] such as requiring notice to regulators or pre-closing approval.^[60] But recent efforts by lawmakers in the Carolinas to impose such requirements have not yet borne fruit. For instance, in North Carolina, a 2023 bill that would have required hospital entities (i.e., any corporation or governmental entity licensed as a hospital under the Hospital Licensure Act, including any entity affiliated through ownership, governance, or membership, such as a holding company or subsidiary) to provide written notice and receive approval for certain proposed transactions failed to gain traction in the general assembly,^[61] and two 2025 bills that would codify the corporate practice of medicine doctrine, address management services organizations, subject nonclinical services to consumer protection laws, and address certain physician noncompetes, all of which could create barriers to private equity ownership of health care entities, are pending in the legislature.^[62] Similarly, a 2025 bill in South Carolina addressing physician noncompetes, which includes corporate practice of medicine provisions that could potentially create additional barriers to private equity ownership of medical practices, is pending in the legislature.^[63]

As private equity activity in health care continues, we expect to see additional attempts at state level regulation of their activities.

8. State Regulation of Health System Consolidation

The health care industry has witnessed a steady and substantial pattern of consolidation throughout the United States over the last thirty years,[64] which has prompted lawmakers in several states to investigate how such consolidation affects health care prices and service quality.[65] According to a National Conference of State Legislatures (NCSL) Brief, “At least 34 bills relating to health system consolidation and competition were enacted across 22 states in 2024.” On March 25, 2025, a revised version of the 2023 bill discussed in the previous section was filed in the North Carolina Senate and is aimed at preserving competition in health care by regulating the consolidation and conveyance of hospitals.[66]

As health care consolidation continues nationwide, lawmakers in both North and South Carolina are monitoring these market developments, with North Carolina’s March 2025 bill illustrating how some state legislatures are responding to changes in the health care landscape.

9. New Medical School Developments in the Carolinas

The medical school landscape in the Carolinas is evolving with three notable projects in distinct phases. The Wake Forest University School of Medicine in Charlotte will welcome its first four-year class in July.^[67] The University of South Carolina’s new School of Medicine Columbia facility in Columbia’s BullStreet District, which broke ground in February 2025, is projected to be completed by August 2027.^[68] The Methodist University Cape Fear Valley Health School of Medicine in Fayetteville is in its construction phase after breaking ground in September 2024, with plans to open in fall 2026.^[69] These developments come as the United States faces a projected physician shortage of up to 86,000 by 2036, according to the AAMC.^[70]

Beyond just adding educational capacity, these developments reflect a growing desire to create integrated health care ecosystems. The Pearl Innovation District, which houses Wake Forest’s Charlotte campus, represents this new approach.^[71] The 20-acre site includes not only the medical school but also research facilities, spaces for biotech startups, and health care technology companies.^[72] This model aims to create collaborative environments where medical education, research, and entrepreneurship can thrive together.

10. Increase in Use and Possible Regulation of AI

AI use is increasing and transforming health care across the Carolinas, with providers deploying AI solutions to enhance care while addressing staffing shortages and clinician burnout:

• Atrium Health utilizes AI to help physicians assess lung cancer risk from scans and to draft patient portal responses.^[73]
• OrthoCarolina’s AI digital assistant monitors post-surgical recovery, reducing follow-up messages and calls by 70%.^[74]
• Novant Health employs AI algorithms to scan X-rays for prioritizing critical cases and to analyze patient data for flagging suicide risks. ^[75]
• Duke Health utilizes AI for sepsis detection (reducing mortality by 31%), identifying patients overdue for follow-ups, and operating room scheduling (13% more accurate than human schedulers). ^[76]
• Wake Forest’s AI-based electronic Cognitive Health Index screens for cognitive impairment. ^[77]
• UNC Health’s AI chatbot helps providers navigate resources to reduce administrative time. ^[78]
• MUSC Health leverages Nuance Dragon Ambient eXperience (DAX) Copilot’s AI technology to automatically draft clinical summaries, reducing documentation time by 20% while enhancing patient engagement.^[79]
• Prisma Health has implemented Amazon’s AI-powered “Just Walk Out” technology at its Richland Hospital campus, offering convenient no-checkout food options.^[80]

With the increasing adoption of AI technologies across sectors, legislators in the Carolinas have introduced bills to regulate insurers’ use of automated systems. Both North and South Carolina have pending legislation that prevents insurance utilization reviews and coverage determinations from being made solely by automated decision-making tools or AI algorithms, requiring licensed health care professionals to maintain oversight of these critical decisions.^[81]

Maynard Nexsen will be following these and other key health care and life sciences issues in the Carolinas throughout 2025.

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_{[1] Fact Sheet: President Donald J. Trump Launches Massive 10-to-1 Deregulation Initiative, The White House (Jan. 31, 2025), https://www.whitehouse.gov/fact-sheets/2025/01/fact-sheet-president-donald-j-trump-launches-massive-10-to-1-deregulation-initiative/.}

_{[2] President Trump’s Deregulation Effort Has Already Saved Families Thousands of Dollars, The White House (Mar. 6, 2025), https://www.whitehouse.gov/articles/2025/03/president-trumps-deregulation-effort-has-already-saved-families-thousands-of-dollars/.}

_{[3] The White House, supra note 1.}

_{[4] See id.}

_{[5] Supplemental Guidance to the 2024 NIH Grants Policy Statement: Indirect Cost Rates, NIH (Feb. 7, 2025) https://grants.nih.gov/grants/guide/notice-files/NOT-OD-25-068.html.}

_{[6] Taylor Haney, What National Institutes of Health funding cuts could mean for U.S. universities, NPR (Feb. 12, 2025), https://www.npr.org/2025/02/12/nx-s1-5292359/what-cuts-to-nih-funding-could-mean-for-american-universities.}

_{[7] NIH funding into U.S. life science sector on pace for another record-setting year, Avison Young (Sept. 5, 2024), https://www.avisonyoung.us/w/nih-funding-into-us-life-science-sector-on-pace-for-another-record-setting-year}

_{[8] NIH, supra note 5.}

_{[9] Rob Stein, A federal judge temporarily blocks Trump administration’s new NIH funding policy, NPR (Feb. 11, 2025), https://www.npr.org/sections/shots-health-news/2025/02/08/g-s1-47383/nih-announces-new-funding-policy-that-rattles-medical-researchers.}

_{[10] Michael Perchick, Proposed NIH funding cuts would greatly impact NC universities and research centers, WTVD-TV (Feb. 11, 2025), https://abc11.com/post/medical-research-north-carolina-limbo-trumps-executive-order-could-cut-national-institutes-health-funding/15894625/.}

_{[11] Tom Corwin, Ian Grenier, & Caitlin Herrington, SC research universities could lose tens of millions under Trump’s federal funds cut, The Post and Courier (Feb. 15, 2025), https://www.postandcourier.com/education-lab/sc-nih-funding-cuts-musc-usc-clemson/article_16ea6cae-ea3a-11ef-b241-b3c71ab1c595.html.}

_{[12] AAMC Statement on Drastic Cuts to NIH-Funded Research, AAMC (Feb. 8, 2025), https://www.aamc.org/news/press-releases/aamc-statement-drastic-cuts-nih-funded-research.}

_{[13] Id.}

_{[14] NIH in your State, UMR, https://www.unitedformedicalresearch.org/nih-in-your-state/ (last visited Mar. 18, 2025).}

_{[15] H.R. 1968, 119th Cong. (2025), https://www.congress.gov/bill/119th-congress/house-bill/1968.}

_{[16] See id. at § 2401.}

_{[17] See id.}

_{[18] Nina Lakhani, GOP budget goals impossible without Medicare and Medicaid cuts, budget office says, The Guardian (Mar. 6, 2025), https://www.theguardian.com/us-news/2025/mar/06/gop-budget-medicare-medicaid-cuts.}

_{[19] H.R. Con. Res. 14, 119th Cong. § 2001 (2025), https://www.congress.gov/bill/119th-congress/house-concurrent-resolution/14/text.}

_{[20] Letter from Phillip L. Swagel, Director, CBO, to Brendan F. Boyle, Ranking Member, Comm. on the Budget & Frank Pallone, Jr., Ranking Member, Comm. on Energy and Commerce (Mar. 5, 2025), https://www.cbo.gov/system/files/2025-03/61235-Boyle-Pallone.pdf.}

_{[21] H.R. Con. Res. 14, 119th Cong. § 3005 (2025), https://www.congress.gov/119/bills/hconres14/BILLS-119hconres14eas.pdf#page=51.}

_{[22] David Morgan, Republicans split on spending cuts, Medicaid as they seek path forward on Trump tax cuts, Reuters (Mar. 16, 2025), https://www.reuters.com/world/us/republicans-split-spending-cuts-medicaid-they-seek-path-forward-trump-tax-cuts-2025-03-16/.}

_{[23] Medicaid Expansion Dashboard, NCDHHS, https://medicaid.ncdhhs.gov/reports/medicaid-expansion-dashboard (last visited Apr. 3, 2025).}

_{[24] Luciana Perez Uribe Guinassi, NC Medicaid Could Face Risk from Congressional GOP Ideas to Fund Tax Cuts, Immigration, The News & Observer (Jan. 28, 2025), https://www.newsobserver.com/news/politics-government/article299257104.html; see N.C.G.S. § 108A-54.3C.}

_{[25] See Access to Healthcare Options, S.L. 2023-7 (H.B. 76), Part III, https://www.ncleg.gov/Sessions/2023/Bills/House/PDF/H76v4.pdf.}

_{[26] See id.; N.C.G.S. §§ 131E-147.5, -176(16) & (21a), -178.}

_{[27] See Overview of Certificate of Need (CON), NC DHSR HPCON (Dec. 17, 2024), https://info.ncdhhs.gov/dhsr/coneed/overview.html.}

_{[28] See Repeal Certificate of Need Laws, H.B. 455 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/House/PDF/H455v1.pdf; Repeal Certificate of Need Laws, S.B. 370 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S370v1.pdf.}

_{[29] See Limit the Scope of Certificate of Need Laws, S.B. 494 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S494v1.pdf.}

_{[30] See Lower Healthcare Costs, S.B. 316 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S316v4.pdf.}

_{[31] See Eliminate PET Scanners from CON Review, H.B. 664 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/House/PDF/H664v1.pdf.}

_{[32] Anne Blythe, Doctor’s lawsuit tests constitutionality of how NC regulates health care facilities, NC Health News (Oct. 23, 2024), https://www.northcarolinahealthnews.org/2024/10/23/lawsuit-tests-nc-certificate-of-need-law/; Singleton v. N.C. Dep’t of Health & Hum. Servs., No. 260PA22, 3 (N.C. Oct. 18, 2024) (Published), https://appellate.nccourts.org/opinions/?c=1&pdf=44132.}

_{[33] Id.}

_{[34] Certificate of Need Update, S.C. Dept. of Public Health 1 (Nov. 2024), https://dph.sc.gov/sites/scdph/files/2024-12/2024_November_CON_Updates.pdf; see also Archived C.O.N. Applications, S.C. Dept. of Public Health 98 (Feb. 28, 2025), https://dph.sc.gov/sites/scdph/files/2025-02/2025_February_Archived_CON_Applications.pdf.}

_{[35] Certificate of Need Update, S.C. Dept. of Public Health 1 (Feb. 2025), https://dph.sc.gov/sites/scdph/files/2025-02/2025_February_CON_Updates.pdf.}

_{[36] Id. at 2.}

_{[37] Id.}

_{[38] Jeff Stensland, USC planning SC’s first clinical neurological and rehabilitation center, Univ. of S.C. (Mar. 14, 2025), https://sc.edu/uofsc/posts/2024/10/usc-plans-hospital-specializing-in-neurological-care.php.}

_{[39] S.B. 244, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/244.htm.}

_{[40] Id.}

_{[41] Id.}

_{[42] Id.}

_{[43] Id.}

_{[44] Id.}

_{[45] See Gary Brode, NC House bill would give nurses more authority over patient care, WCCB Charlotte’s CW (Mar. 28, 2025), https://www.wccbcharlotte.com/2025/03/28/nc-house-bill-would-give-nurses-more-authority-over-patient-care/.}

_{[46] See AMA successfully fights scope of practice expansions that threaten patient safety, AMA (May 15, 2023), https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten.}

_{[47] See S.B. 378, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/378.htm; Pharmacists/Test and Treat/Influenza & Strep, S.B. 335 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S335v2.pdf; Pharmacists/Test and Treat, S.B. 414 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S414v1.pdf; Pharmacists/Test and Treat, H.B. 736 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/House/PDF/H736v1.pdf.}

_{[48] See S.B. 393, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/393.htm; H.B. 4103, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/4103.htm.}

_{[49] See H.B. 4169, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/4169.htm.}

_{[50] See S.B. 342, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/342.htm; H.B. 3934, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/3934.htm; S.B. 330, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/330.htm; H.B. 3575, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/3575.htm; S.B. 100, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/100.htm.}

_{[51]  See S.B. 531, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/531.htm.}

_{[52] See More Transparency/Efficiency in Utiliz. Rev., S.B. 315 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S315v1.pdf; Lower Healthcare Costs, S.B. 316 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S316v4.pdf.}  

_{[53] Global Healthcare Private Equity Report 2025, Bain & Company 2 (January 9, 2025), https://www.bain.com/globalassets/noindex/2025/bain_report_global_healthcare_private_equity_2025.pdf.}

_{[54] Id.}

_{[55] Michelle Crouch & Charlotte Ledger, Docs who ditched Atrium now partnering with private equity, NC Health News (Oct. 9, 2024), https://www.northcarolinahealthnews.org/2024/10/09/tryon-medical-partnering-with-private-equity/.}

_{[56] Michelle Crouch & Charlotte Ledger, OrthoCarolina plans to sell its physical therapy business to a private-equity backed firm, NC Health News (Jan. 17, 2025), https://www.northcarolinahealthnews.org/2025/01/17/orthocarolina-to-sell-its-physical-therapy-business-to-a-private-equity-backed-firm/.}

_{[57] PT Solutions Acquires OrthoCarolina Physical Therapy, Teams Up with Novant Health to Expand Access to Premier Physical Therapy Services in the Southeast, Business Wire (Feb. 3, 2025), https://www.businesswire.com/news/home/20250113218116/en/PT-Solutions-Acquires-OrthoCarolina-Physical-Therapy-Teams-Up-with-Novant-Health-to-Expand-Access-to-Premier-Physical-Therapy-Services-in-the-Southeast.}

_{[58] Michelle Crouch & Charlotte Ledger, OrthoCarolina plans to sell its physical therapy business to a private-equity backed firm, NC Health News (Jan. 17, 2025), https://www.northcarolinahealthnews.org/2025/01/17/orthocarolina-to-sell-its-physical-therapy-business-to-a-private-equity-backed-firm/.}

_{[59] Sarah Jaromin, The Evolving Landscape of State Health Care Transaction Laws, NCSL (August 19, 2024), https://www.ncsl.org/health/the-evolving-landscape-of-state-health-care-transaction-laws.}

_{[60] Ari Jonathan Markenson, Gregory W Packer Jr, & Pamela Polevoy, State Healthcare Transaction Review Laws: A New Landscape, ABA (June 25, 2024), https://www.americanbar.org/groups/business_law/resources/business-law-today/2024-june/state-healthcare-transaction-review-laws-a-new-landscape/.}

_{[61] See Preserving Competition in Health Care Act.-AB, S.B. 16 (NC 2023), https://www.ncleg.gov/Sessions/2023/Bills/Senate/PDF/S16v1.pdf.}

_{[62] See Prohibit the Corporate Practice of Medicine, S.B. 570 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S570v1.pdf; Protect Physicians Voices/Freedom of Movement, S.B. 673 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S673v1.pdf.}

_{[63] S.B. 46, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/46.htm.}

_{[64] HHS Consolidation in Health Care Markets RFI Response, U.S. Dep’t of Health & Hum. Servs. 3 (Jan. 2025), https://www.hhs.gov/sites/default/files/hhs-consolidation-health-care-markets-rfi-response-report.pdf.}

_{[65] Sarah Jaromin, 2024 Legislative Recap: Health Care Consolidation and Competition, NCSL (November 15, 2024), https://www.ncsl.org/health/2024-legislative-recap-health-care-consolidation-and-competition.}

_{[66] See Preserving Competition in Healthcare Act, S.B. 532 (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S532v0.pdf.}

_{[67] Chase Jordan,Wake Forest makes history by selecting first class for new Charlotte medical school, YAHOO!: The Charlotte Observer (Mar. 20, 2025), https://www.yahoo.com/news/wake-forest-makes-history-selecting-163219651.html.}

_{[68] Tony Santaella, USC breaks ground on new medical school at BullStreet in Columbia, WLTX-TV (Feb. 25, 2025), https://www.wltx.com/article/news/local/midlands/building-the-midlands/university-south-carolina-medical-school-groundbreaking/101-ff70405b-2352-4769-b601-a83d0bcc7450.}

_{[69] Construction begins on $60M facility to house Methodist University medical school in Fayetteville, WTVD-TV Raleigh-Durham (Sept. 10, 2024), https://abc11.com/post/groundbreaking-began-tuesday-fayetteville-methodist-university-cape-fear-valley-health-school-medicine/15287340/.}

_{[70] New AAMC Report Shows Continuing Projected Physician Shortage, AAMC (Mar. 21, 2024), https://www.aamc.org/news/press-releases/new-aamc-report-shows-continuing-projected-physician-shortage.}

_{[71] Michelle Crouch & Charlotte Ledger, More than a medical school, NC Health News (Oct. 2, 2024), https://www.northcarolinahealthnews.org/2024/10/02/the-pearl-more-than-a-medical-school/.}

_{[72] Id.}

_{[73] Emily Vespa, Michelle Crouch, & Charlotte Ledger, 10 ways North Carolina health care providers are harnessing AI, NC Health News (Jan. 7, 2025), https://www.northcarolinahealthnews.org/2025/01/07/nc-health-care-harnessing-ai/.}

_{[74] Id.}

_{[75] Id.}

_{[76] Id.}

_{[77] Id.}

_{[78] Id.}

_{[79] Celia Spell, MUSC Health finds 20% reduction on documentation following adoption of AI-driven technology, MUSC Health, https://muschealth.org/health-professionals/progressnotes/2024/summer/dax-copilot (last visited Mar. 18, 2025).}

_{[80] Prisma Health unveils new Amazon “Just Walk Out” store at Richland Hospital campus to enhance food options for team members and guests, Prisma Health (Sept. 25, 2024), https://prismahealth.org/patients-and-guests/news/richland-s-new-ai-powered-store-adds-24-7-convenience-and-healthy-food-options.}

_{[81] See S.B. 443, 126th Gen. Assemb., Reg. Sess. (SC 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/443.htm; More Transparency/Efficiency in Utiliz. Rev., S.B. 315, (NC 2025) https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S315v1.pdf; Safeguard Health Ins. Utilization Reviews, S.B. 287, (NC 2025), https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S287v1.pdf.}