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The term “nonprofit hospital” evokes a specific image in North Carolina — one of charity, and community stewardship. The reality, however, is that these institutions have grown into something more like monopolistic holding companies than local caregivers.
And for the state’s middle class, the consequences are increasingly inescapable.
Four hospital systems: Atrium Health, Duke Health, UNC Health, and Novant Health dominate the state’s healthcare ecosystem. Each claims nonprofit status. Each operates under a vast tax shield. And each pulls in billions in revenue annually while behaving less like high-performing, tax-advantaged corporations.
The contradiction is no longer just a technicality. It’s a structural injustice, and voters are beginning to notice.
The Numbers Behind the Tax Halo
Atrium Health, the largest among the four, brought in over $12 billion [ [link removed] ]in revenue last year. Its CEO, Eugene Woods, was paid more than $14 million. Atrium simultaneously enjoyed massive tax exemptions (property, income, and sales) while reportedly suing patients over unpaid medical bills.
Duke Health, tied to one of the wealthiest private universities in the country, earned $6.8 billion [ [link removed] ]in 2024. Its facilities benefit from Duke University’s endowment infrastructure and tax-exempt status. Novant Health reported $10.17 billion [ [link removed] ]in revenue that same year and declared over $1.6 billion [ [link removed] ]in “community benefit,” which can include unpaid Medicare reimbursements rather than direct charity.
Even UNC Health [ [link removed] ], the state-run system often described as the most civic-minded of the group, benefits from opacity around what exactly qualifies as “charitable” care. Like the others, it sits on valuable, tax-exempt real estate and receives billions in federal and state funds.
These organizations do not pay the taxes other businesses do. Yet they compete in the same marketplace, sell services at market rates, and shield their executive compensation behind complex nonprofit governance structures.
This is a golden arrangement.
The Middle-Class Price Tag
For North Carolina’s working and middle-class families, the cost of this arrangement is both direct and diffuse.
The most obvious impact is the inflated cost of care. Despite their tax benefits, nonprofit hospitals routinely charge commercial insurance plans, and their patients, the same, if not higher, prices than for-profit competitors. This drives up premiums and out-of-pocket costs, especially for families whose income disqualifies them from subsidies but cannot absorb $1,500 ER bills without financial strain.
The indirect burden is equally damaging.
Every dollar these hospitals avoid in taxes is a dollar unavailable to counties and municipalities who maintain roads, fund schools, and staff police departments. When a hospital system sits tax-free on hundreds of millions in prime downtown property, the rest of the tax base picks up the slack.
In theory, the trade-off is justified: nonprofit hospitals are expected to provide charity care — free or reduced-cost services for those who can’t pay. In practice, many spend far less on such care than they receive in tax breaks.
The result is a net outflow of public wealth into privately governed institutions with little oversight.
The Charade of Charity
The issue is not that these hospital systems make money. Healthcare is expensive, and stability requires reserves. The issue is what they do with their profits, and what they claim in return.
According to a recent City Journal analysis [ [link removed] ], these systems fund real estate expansion, executive bonuses, and administrative growth at scales that dwarf most public institutions. They also invest heavily in public relations, lobbying, and legislative obstruction.
Atrium, for instance, has lobbied aggressively against price transparency laws that would force it to disclose what it charges insurers, patients, and government programs.
None of this is illegal. But all of it undermines the core assumption that nonprofit hospitals exist primarily to serve the public.
As access shrinks and costs rise, the spectacle of billion‑dollar “nonprofits” paying hedge‑fund salaries reads not as reform failure, but institutional contempt.
Accountability on the Table
The political winds are shifting. Lawmakers in Washington and Raleigh have begun floating reforms that would pressure nonprofit hospitals to justify their status.
Among the proposals:
Requiring minimum levels of charity care as a condition of tax exemption
Enforcing price transparency and penalizing noncompliance
Mandating disclosure of executive compensation and property holdings
Revisiting what counts as a “community benefit” under IRS rules
Allowing state lawsuits against systems that behave like for-profits while claiming public subsidies
If enacted, these measures would force systems like Atrium and Duke to demonstrate that their nonprofit status reflects actual public service, not just legal classification.
Not a Political Issue — A Moral One
This is not a partisan issue. Conservatives bristle at the distortion of free markets. Progressives point to economic justice. Centrists are left wondering why public funds subsidize private accumulation.
In the middle of it all is a vanishingly small group of families who can afford both good care and its rising cost. Everyone else lives under the dual pressure of medical inflation and civic underinvestment.
These are the same people whose neighborhoods lie near gleaming hospital campuses but whose children lack a reliable pediatrician. They are the ones who fund the tax base while nonprofit giants operate tax-free across the street.
A Reckoning Long Overdue
Hospitals save lives. No serious person disputes that. North Carolina’s nonprofit systems have pioneered research, trained generations of doctors, and treated millions.
But good deeds do not excuse structural privilege, especially when that privilege contributes to rigging.
The proposed reforms do not seek to punish hospitals. Rather, they seek to recalibrate a balance that has tipped too far toward corporate behavior and away from public trust.
If these systems wish to retain their status, they should meet the standards they invoke.
The middle class in North Carolina doesn’t want a fight. It wants fairness. And for the first time in decades, it might get it.

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