Wake County commissioners vote to back WakeMed-Atrium merger

• Several political leaders in the state, including State Treasurer Brad Briner, State Auditor Dave Boliek and Gov. Josh Stein, have publicly questioned it, citing research that consolidation of hospital ownership leads to higher prices.

State of play: Behind the scenes, the governor's office had been pushing for an improved offer from Atrium, which is headquartered in Charlotte.

• Over the weekend, Stein said that Atrium had improved its bid by adding more language around its promised $2 billion investment into WakeMed, making sure the money comes entirely from Atrium funds.
• It added an agreement to cap price increases at no more than 1.5 times the annual increase in Medicare costs for the next five years and increase the minimum amount of charity care from 4.8% to 8% of adjusted revenues.

• It also offered to create a $150 million fund that the Wake County Commissioners can deploy to support nonprofit organizations working to improve health outcomes.
• Stein said the revised offer was sufficient for him not to oppose the deal moving forward.

Driving the news: The Wake County Board of Commissioners voted 5-2 in front of a packed meeting room to change WakeMed's articles of incorporation to allow the merger. The vote was momentarily interrupted by protesters. Commissioners Vickie Adamson and Tara Waters voted against the deal.

• Before the vote, a majority of speakers came forward to ask the commissioners to reject the deal during the public comment period, citing concerns over rising costs, a lack of transparency around the deal and a loss of local control.
• While Atrium would be the sole corporate member of WakeMed, the agreement is amending a provision that would give Atrium the ability to dismiss any board member for "cause," which included a list of reasons many considered overly broad. Wake County will still appoint eight of the hospital's 14 board members.

Between the lines: WakeMed and Atrium needed the Wake County Commissioners to approve a change to its articles of incorporation to officially file for the merger.

• WakeMed and Atrium can now file for regulatory approval from the Federal Trade Commission and Department of Justice.
• WakeMed has served Wake County since 1961 and was originally built with taxpayer money. The county owned the hospital network until 1997 when it became a nonprofit.

Zoom in: WakeMed has made the case that a capital infusion from Atrium is needed to keep the hospital network in good health a decade from now due to rising consolidation in the health care industry and competition locally.

• One of WakeMed's concerns has been that its main campus on New Bern Avenue, originally built in the 1960s, needs at least $1 billion worth of renovations, according to WakeMed's CEO Donald Gintzig. A majority of Atrium's planned investments would go toward that redevelopment.
• WakeMed is also one of the largest sources of charity care in Wake County. As part of its offer, Atrium said it will provide financial assistance to patients with household incomes up to 400% of the federal poverty level.

What they're saying: Don Mial, chair of the Wake County Commissioners, called the vote one of the most important decisions it will make.

• "This will shape what health care will look like for years to come," he said. WakeMed "needs to keep up, especially for our most vulnerable in Wake County. I believe this action will make WakeMed stronger in the face of growing demands."

Commissioner Adamson voted against the deal, saying she didn't believe enough due diligence was done to consider other offers.

• "If I could wave a magic wand, we would vote no today, send it back to WakeMed and get a new board that's willing to do the hard work and do due diligence … so you know that we're getting the best deal for your hospital."