North Carolina Hospital Systems Enjoyed Record Profits During Pandemic

The North Carolina State Health Plan and the National Academy for State Health Policy find that North Carolina’s seven largest hospital systems reaped billions of dollars in profits and growth in cash and investments

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An analysis by the North Carolina State Health Plan and the National Academy for State Health Policy found that taxpayer-funded COVID relief gave a huge wealth transfer to North Carolina’s seven dominant hospital systems. While patients and rural hospitals suffered, wealthy hospital systems enjoyed record profits and a $7.1 billion growth in cash and investments during the pandemic. 

State Treasurer Dale R. Folwell, CPA, invited National Academy of State Health Policy researchers to analyze the audited financial reports of Atrium, Novant, UNC, Duke, Vidant, Cone and WakeMed Health. The study was peer reviewed by Dr. Ge Bai, Professor of Health Policy & Management at the Johns Hopkins Bloomberg School of Public Health and Professor of Accounting at the Carey Business School.

After taking the lion’s share of the COVID relief dollars, the wealthy hospital systems recorded such a massive growth in cash and investments that it rivaled the state’s 2020 appropriations for K-12 classroom instruction. Duke Health even exceeded the average net profit margins of tobacco and investment banking in 2021. The increase in their charity care spending in 2020 equaled only a fraction of their windfall.

Interactive charts of hospital profit margins and their growth in cash and investments and an interactive map are below. Hover over each graphic for more detailed information.




  • After taking taxpayer-funded COVID relief dollars, North Carolina’s seven large hospital systems reaped $7.1 billion growth in cash and financial investments from 2019 to 2021. 
    • They recorded $5.2 billion in net profits in 2021, when six hospital systems made higher net profits than in the years before the pandemic.
      • Duke Health scored a 41% net profit margin of $1.8 billion in 2021. Its net profit margin was 11% in 2019. 
      • Atrium Health took the most taxpayer relief dollars, collecting $589 million in COVID relief and another $438 million in Medicare advance payments. Atrium Health then made a $1.7 billion net profit after its merger with Wake Forest Baptist Health in 2021.  
  • Seven systems took $1.5 billion in taxpayer-funded coronavirus relief meant for struggling hospitals, as well as another $1.6 billion in Medicare Accelerated and Advance Payments from 2020-2021.
    • These systems had vast resources compared to rural hospitals and independent physicians. Most had enough cash on hand to operate for more than half a year without any incoming revenue, as well as billions of dollars in cash and financial investments.  
    • In contrast, many rural hospitals lacked the cash on hand to operate for a month before shutting their doors.
  • The dominant hospital systems did not share their profits with disadvantaged patients.
    • Charity care spending fell across a third of 104 hospitals in 2020.
    • Across 104 hospitals, charity care spending rose only $246.5 million from 2019 to 2020 — an increase that equals less than 8% of the seven systems’ $3.1 billion growth in cash and investments that year.
    • Some hospitals increased billing poor patients eligible for charity care, while Atrium Health sued hundreds of patients. 
  • There is little accountability at the state or federal level for nonprofit hospitals’ tax exemptions or community benefits.
    • North Carolina does not require a minimum threshold for charity care spending. 
    • The Internal Revenue Service cannot prove that it is consistently reviewing hospitals’ community benefits. 
    • Unless state lawmakers take action, the profits gained from the misdirection of taxpayer dollars are expected to fuel record levels of consolidation and price increases.