NASHVILLE, Tn. (WCYB) — There are two bills making their way through the Tennessee General Assembly that have the potential of drastically changing the healthcare landscape of our region.

One bill, SB 2414/HB 2278, would dissolve the Certificate of Public Advantage (COPA) between the state of Tennessee and Ballad Health by June 30, 2028. It would also remove the Tennessee Department of Health’s oversight of Ballad while still retaining pricing restrictions to be supervised by the attorney general.

The other, HB 819/SB 1369, would exempt any acute care hospitals from being required to obtain a certificate of need (CON) in order to establish a facility in the state; essentially removing regulatory barriers for groups interested in providing healthcare in the state.

What does all this mean? East Tennessee lawmakers that News 5 spoke with, believe if passed, these two pieces of legislation would open the door for increased competition with Ballad Health.

The merger

In 2018, when the merger was made, Wellmont Health Systems was on the market to be sold. Risking the loss of local control over the hospital system, Wellmont merged with Mountain States to become the largest state-sanctioned hospital monopoly in the U.S., forming Ballad Health.

In order for the merger to form into Ballad Health and to avoid a Federal Trade Commission (FTC) block, both states – Tennessee and Virginia – had to enter into an agreement governing the formation of the new healthcare group.

In Tennessee, the agreement is known as the Certificate of Public Advantage (COPA). In Virginia, the document is known as the cooperative agreement. These agreements were made under the assumption that the likely benefits from Ballad’s formation would outweigh the likely disadvantages that would result from the loss of competition.

These agreements also granted the states limited oversight over Ballad Health through both the Tennessee and Virginia Departments of Health. Still, Ballad Health is a private entity. These agreements do, though, force Ballad Health to limit price increases, maintain quality, and provide charitable donations.

2026 Tennessee General Assembly

A main focus among Tennessee lawmakers during the 2026 Tennessee General Assembly has been on healthcare, with these two bills (SB 2414/HB 2278 & HB 819/SB 1369) at the forefront. Northeast Tennessee lawmakers tell News 5; the combination of these bills is the first step at establishing regional healthcare competition with Ballad Health.

The exemptions within HB 819/SB 1369 have also been a nation-wide push. According to Sen. Bobby Harshbarger of Sullivan County, Certificate of Need (CON) repeal has been an initiative outlined by the Trump Administration in an effort to incentivize more competition.

As of now, each bill has a different timeline of rollout: HB 819/SB 1369 would repeal CON requirements beginning Jul 1, 2030. SB 2414/HB 2278 would expire Ballad’s COPA agreement on June 30, 2028.

The two year “gap” that would result from the current language is something lawmakers from our region are trying to eliminate. Rep. Timothy Hill is expected to propose an amendment this week that would rollout both pieces of legislation in 2028 for our region.

Sen. Harshbarger says, even if this “gap” is left in place, Ballad would still face regulatory oversight through agencies like the Centers for Medicare & Medicaid Services (CMS); the same as other hospitals throughout the nation.

“”I think the biggest thing is making sure everyone back home understands that [Ballad] has the same oversight that any other hospital system across the state, across the country. They’re held under the same statues,” Harshbarger said.

As a result of the COPA, Ballad Health is required to submit a yearly report to the Tennessee Department of Health (TDH) detailing their work throughout the region. This annual report also contains a “COPA Compliance Complaints Report,” which outlines how Ballad’s past year aligned with the requirements within the COPA.

While TDH and the attorney general’s office have direct authority over Ballad under the COPA agreement, some lawmakers like longtime Ballad critic Rep. David Hawk say, it hasn’t been enough.

“I’ve been very frustrated with the Tennessee Department of Health and even the Tennessee Attorney General’s office in terms of what limited oversight they have given to start with,” Hawk said. “As far as how much oversight the Department of Health has had over Ballad to start with – it hasn’t been much.”

What happens to Ballad Health?

According to Sen. Harshbarger, if the COPA is dissolved, Ballad Health would have no protection from the FTC.

While Harshbarger says it is unlikely that Ballad, a private company, would be broken up by the FTC since it has already been established, he did say if Ballad were to violate the standards established, there would be consequences.

“Once that COPA dissolves, it’s game on,” Harshbarger said. “Any kind of violation that occurs, it’s going to be handled.”

As it is written now, the COPA would terminate on June 30, 2028 but it would require pricing restrictions to remain in place for an additional 5 years or until a new inpatient acute care hospital is opened. These pricing restrictions would be supervised and/or changed by the attorney general.

Still, if these bills pass and are both implemented by 2028, Harshbarger does not expect competition overnight.

“This will take months, if not years, and that’s just the nature of the beast,” he said.

Ballad Health sent the following statement in response to News 5’s request:

Ten years ago, as rural hospitals throughout the nation, including in our region, were closing, the Legislature developed a framework by which competing hospital systems could collaborate to save hospitals, sustain access to care, and meet the needs of their communities. The two local health systems prioritized collaboration over seeing more hospitals close, and followed the law to apply for, and be granted, a Certificate of Public Advantage. Each year since, the State of Tennessee has, independently and transparently, affirmed the public advantage of this policy decision.Since the legislature originally created the COPA law, it is appropriate for the legislature to determine the policy going forward. Ballad Health has – and will continue to – advocate for improved access to health care for everyone in our region. We thank our lawmakers for their work on this important healthcare access issue.Regardless of the COPA, the oversight of anti-trust in Tennessee lies with the Attorney General, who acts independently. As it has for the duration of the COPA, Ballad Health will continue to comply with state and federal anti-trust law and would expect swift and serious action by the Attorney General if it were to violate such law.

Senator Rusty Crowe has also supported both pieces of legislation. He sent the following statement to News 5:

The people I serve were very adamant that they wanted me to vote to do away with Certificate of Need as well as change the COPA to give more force and protection to patients and constituents who use the hospital system. I voted to do both, as well as to protect Karing Hearts cardiology.This change in the COPA actually is a change that affords more protection for the people who are served by Ballad it gives more force from an antitrust, anti-monopoly perspective, by shifting everything to the state’s Attorney General who has the ability to enforce state and federal antitrust, anti-monopoly laws..protects the pricing provisions and still takes care of oversight of quality type metrics through the Health Facilities Commission, CMS, Joint commission etc. like it did before the change, making complaints and actions taken open to the public.