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Wake County commissioners voted 5-2 Monday evening to approve the merger of WakeMed and Charlotte-based Atrium Health, sending the proposal to state and federal officials for approval.
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The vote was interrupted by protesters, and Chair Don Mial had the room cleared so the board could proceed. The media was allowed to remain, as chants of “Shame!” could be heard in the hallway. A majority of commissioners had already indicated in their comments they would back the merger.
WakeMed leadership has said the merger will help secure the money needed from Atrium to upgrade its hospital facilities.
Commissioners voted on amendments to two key documents that were required to be changed for the merger to move on.
The changes were to WakeMed’s articles of incorporation — giving Atrium control over WakeMed’s board of directors — and an agreement that transferred ownership of the hospital’s main campus from Wake County to the private nonprofit hospital system.
Mial and Commissioners Cheryl Stallings, Safiyah Jackson, Susan Evans and Shinica Thomas voted for the merger. Commissioners Vickie Adamson and Tara Waters voted against it. Waters’ district includes WakeMed’s main campus.
Some commissioners took issue with how fast the process had moved forward.
In May, the proposed deal was announced on a Friday, with commissioners set to vote on the changes the following Monday. They would have voted on it as a consent agenda item, which is a list of items considered noncontroversial and voted on all at once.
They ultimately delayed the May vote after concerns raised by the community and state officials, but the more recent process — months later — mirrored the May decision with a lot of new information announced Thursday night to be voted on Monday, Adamson said.
“I spoke out in May because the process felt rushed and undemocratic, and I feel the same about where we stand today,” Adamson said before the meeting.
Commissioners in favor of the agreement pointed to recent concessions made in negotiations that are now incorporated into the merger and legally enforceable.
“When local leadership joins a larger network, they can get the tools needed to focus on local values,” Jackson said.
The deal approved Monday included new pledges including that WakeMed spend 8% of its revenue, up from its current requirement of 4.8%, on indigent care, and that $150 million be paid to Wake County over 10 years to help address mental healthcare, homelessness, food insecurity and more.
The agreement also loosens control over WakeMed’s board of governors by making it harder to remove the eight board members appointed by Wake County commissioners, and it prevents the sale of WakeMed in the future without Wake County’s consent.
The newest version of the documents further clarifies the pledge for Atrium to invest $2 billion, according to the hospital’s spokesperson Kristin Kelly.
That came after questions raised by Gov. Josh Stein’s office about where the $2 billion investment — originally supposed to be made over 10 years, but now changed to 15 — would actually come from.
In a letter responding to that question, WakeMed CEO Donald Gintzig said the money might actually come from WakeMed. The pledge was merely a guarantee that the $2 billion investment would happen, and Atrium might end up covering a part of that, Gintzig said.
After concerns were raised about the fact that Atrium might not actually be putting money into WakeMed, the new language was included in the transfer agreement to address that concern.
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“Atrium Health shall make or cause to be made capital expenditures in furtherance of WakeMed’s strategic initiatives in the aggregate sum of not less than two billion dollars,” the language said.
But an analysis by researchers from the Brown University Center for Advancing Health Policy Through Research found that even with the new language, there wasn’t a guarantee that Atrium would have to invest the full $2 billion.
The language isn’t binding because it’s in a part of the transfer agreement labelled “recitals” which are like the preamble of a contract, according to the analysis. And the language didn’t specify where the money will come from, as it only says the spending “shall” occur.
However, the county attorney said on Monday that the $2 billion will be legally enforceable under the agreement.
County Attorney Roger Askew added that he was now able to disclose a provision not previously made public: Wake County’s eight appointees to WakeMed’s board will be allowed to vote independently on whether Atrium is upholding its part of the deal and potentially find Atrium in violation of the agreement.
If Atrium didn’t follow through with that money then the Wake County-appointed WakeMed board members could seek legal arbitration.
He added that in negotiations with Atrium the county has secured a pledge the money will come entirely from Atrium and not WakeMed.
Opponents of the deal rallied outside the building before the meeting Monday. They said a hospital merger would likely increase healthcare costs for patients.
Stein announced on Sunday that he wouldn’t oppose the deal because he’d managed to get a key concession from Atrium: The Charlotte-based nonprofit, part of the national nonprofit health system Advocate Health, would cap price increases at WakeMed to not more than 1.5 times the annual increase in Medicare costs for the next five years.
In a statement Monday night, Stein said he welcomed an impending review and “independent assessment” of the deal by the North Carolina Attorney General’s Office.
“Since my time as Attorney General, I have been urging the General Assembly to give the Attorney General’s Office more authority to review hospital transactions and protect North Carolinians from the increased prices and decreased quality they often bring,” he said. “Health care costs are too high, and additional oversight and authority would better protect patients.”
It was not immediately clear Monday night how the price cap will work or if there is a written agreement in place for it.
Askew said a “member addition agreement” between WakeMed and Atrium — which will ultimately govern their relationship — will include the price cap provision after lawyers add the language.
That document is not public. But Askew said the cap will be legally enforceable. County attorneys will be able to review the member addition agreement to make sure the language is satisfactory, Askew said.
Gintzig has previously said that healthcare prices are going up regardless of the merger moving forward or not.
This story was originally published September 21, 2026 at 7:32 PM.
CORRECTION: This story has been corrected to reference that Gov. Josh Stein welcomes an impending review of the merger by the attorney general’s office.
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