Pardee Hospital's Buncombe County Patient Count Rose From 12,973 in 2019 to 20,981 in 2025 as HCA's Mission Heads to Trial

A County Hospital's Patient Count Jumped 62 Percent. That Number Alone Won't Tell You Why.

In 2019, UNC Health Pardee in Hendersonville treated 12,973 patients from Buncombe County, the home turf of its much bigger rival, Mission Hospital in Asheville. By 2025, that number had climbed to 20,981 — a rise of about 62 percent^[1][2]. Both figures are undisputed. What they mean is not.

Pardee is a 222-bed hospital owned by Henderson County, about 25 miles south of Asheville. UNC Health has run its daily operations since a 2011 management deal, but the hospital and the decisions about it stay with local government^[1][2]. Mission Hospital, by contrast, has been owned since 2019 by HCA Healthcare, the largest for-profit hospital company in the country^[12]. That single fact — one hospital public, one for-profit — sits underneath almost everything that follows.

The timing invites an obvious story: a for-profit buyer took over, quality slipped, and patients drove south instead. Federal regulators have cited Mission for "immediate jeopardy" four times in the five years since the sale, most recently in January 2026^[5]. But Mission is also the region's only high-level trauma center, meaning it keeps the sickest, most complicated patients that other hospitals can send elsewhere^[1]. A hospital that can't turn anyone away will look different on paper than one that can. Both things are true. They point in different directions.

What "Immediate Jeopardy" Actually Means, and Why It Cuts Two Ways

"Immediate jeopardy" is not a vague warning. It's the most severe finding the Centers for Medicare & Medicaid Services can issue, reserved for situations where a hospital's failures have caused, or are likely to cause, serious harm or death to a patient. Mission has landed there four times since HCA's 2019 purchase, most recently after a preventable death during an unannounced inspection in January 2026^[5]. Mission said it submitted correction plans and was later found in substantial compliance^[6].

For critics, that pattern is the whole story: a for-profit owner cut staffing to protect margins, and patients paid the price. Nonprofit and public-radio outlets covering the region — Asheville Watchdog, Blue Ridge Public Radio, Carolina Public Press — have built years of reporting around that frame^[2][4][5]. HCA disputes the underlying comparison. The company argues that Mission, as the region's referral hospital, absorbs transfers and trauma cases that smaller hospitals send its way, which will always produce worse-looking numbers than a hospital that can move its hardest patients elsewhere^[19]. It also points to over $40 million spent on employee tuition assistance company-wide in 2025 as evidence of investment, not neglect^[16].

Neither side disputes the CMS findings themselves. The disagreement is about what caused them.

A Contract With a Clock Attached to It, Now Headed to Trial

Underneath the quality debate sits a legal one, and it's the part with an actual court date. When HCA bought Mission Health in 2019, it signed an Asset Purchase Agreement — a contract, not a general promise — committing the company to maintain specific services, including emergency, trauma and cancer care, for a set period^[12]. That contract created an independent monitor and gave North Carolina's Attorney General and a local foundation, Dogwood Health Trust, the power to enforce it^[7][12]. In 2025, the monitor flagged two instances of potential noncompliance, which Dogwood passed along to the Attorney General's office^[7].

In December 2023, Attorney General Jeff Jackson's office sued HCA, arguing the company broke that contract^[12]. On July 27, 2026, Business Court Judge Julianna Theall Earp denied motions from both HCA and the state to resolve the case without a trial^[3][4]. That's a meaningful detail often lost in the headlines: the judge didn't just reject HCA's defense. She also ruled the state hasn't yet proven its case on paper, which means the Attorney General still has to make it in front of a jury^[3][4].

That's the only lawsuit still moving. A separate federal antitrust case, filed in 2022 by Asheville, Buncombe County and other local governments, accused HCA of using its market dominance to push insurers into "all-or-nothing" contracts — deals where an insurer had to accept every HCA facility to get any of them, alongside clauses blocking insurers from steering patients toward cheaper options^[12]. That case didn't go to trial. HCA and Mission settled it in August 2025, agreeing to fund $1 million in health-cost assistance for local families and to keep Transylvania Regional Hospital open through at least 2032, while continuing to deny the allegations^[13].

The Real Fight Might Not Be About HCA at All

While Mission's court case plays out, a separate and arguably more consequential contest is underway: a state decision on 92 new acute-care hospital beds for a five-county region that includes Buncombe. Four systems applied — Mission/HCA, UNC Health, AdventHealth and Novant Health — and all four want to put the beds in Buncombe County^[10][11]. A decision is expected around Thanksgiving 2026^[11].

This is where North Carolina's Certificate of Need law comes in, and it's worth understanding because it shapes almost everything else in this story. The law requires state permission before a hospital can add beds or build new facilities — a hospital can't simply decide to expand. The state first decides how many beds an area needs, then picks among competing applicants. Existing hospitals can formally object to a rival's application and appeal a losing decision, sometimes for years.

Free-market critics, including Carolina Journal and the John Locke Foundation, argue this is the actual villain in the story — not HCA's ownership. Their strongest example: a different North Carolina hospital, approved years ago, is still an empty dirt field because of appeals^[14]. They also note a historical irony. Mission's original dominance was built in part through a 1995 state-approved deal called a Certificate of Public Advantage, which let two competing Asheville hospitals merge by substituting state oversight for the antitrust review that would normally block two major rivals from combining. That arrangement was repealed in 2018, a year before HCA bought Mission^[12]. In this reading, government helped create the market power now being sued over — so the fix is less regulation, not more litigation.

That argument has a real cost, though, which its proponents mention less often. Certificate of Need rules also exist to protect hospitals like Mission from having their most profitable, well-insured patients siphoned off by newer competitors — the same dynamic that funds the safety-net care Mission provides to everyone else^[14].

What Pardee Actually Built, and Who Notices

Set the litigation aside, and Pardee's growth has concrete, recent causes that have nothing to do with a courtroom. In August 2026, the hospital earned Level III trauma center status, meaning it can now stabilize and treat many seriously injured patients on-site instead of transferring all of them north to Asheville^[8]. That same month, it opened a 23-bed inpatient psychiatric unit for teenagers aged 13 to 17, in a region that has long had too few beds for adolescent mental health care^[9]. Pardee has also expanded primary care as Mission scaled back some outpatient practices^[17].

For Henderson County, which owns Pardee, that growth is both a public-service win and a source of local leverage. More patients mean more revenue, easier physician recruiting and a stronger case for future state approval^[1][2]. UNC Health's own bid for the 92 disputed beds would put a new 92-bed hospital on Patton Avenue near Westgate Shopping Center — inside Mission's home county^[10][11]. Mission's competing bid asks for all 92 beds too, through a cheaper, slower $66.8 million expansion of its existing Asheville campus, finishing in January 2032^[11]. AdventHealth's rival bid, a $272.7 million new hospital in Weaverville, would finish faster, by January 2030^[11].

None of this settles whether Pardee grew because Mission got worse, or because Pardee built things the region needed regardless of who owned Mission. Coverage has split along predictable lines: nonprofit outlets frame Pardee as "emerging from Mission's shadow," a phrase that does more interpretive work than the underlying numbers do on their own^[1][2]. Carolina Journal's coverage of the same court ruling leads with the fact that the judge was retiring, a detail that adds a credibility cue without adding evidence^[15]. Trade press aimed at hospital executives gives HCA's denials unusually prominent placement^[19]. A British anti-corporate research group cites HCA's American record as ammunition in a UK policy fight over for-profit hospitals entering the National Health Service, with no independent reporting on the North Carolina facts at all^[21].

What happens next is split across three different clocks. The state's contract trial against HCA has no set date yet^[3]. The 92-bed decision lands around Thanksgiving^[11]. And Pardee's patient numbers, whatever is driving them, will keep moving before either one resolves.