Tennessee has already decided to end the regulatory agreement that allowed Ballad Health’s hospital merger. The next governor will inherit the transition. Green explicitly wants the state-sanctioned monopoly ended. Pinkston emphasizes competition and independent hospitals. Blackburn has a rural-health record but has not yet published a Ballad-specific plan.
East Tenn. – Ballad Health is not simply another hospital company in Tennessee.
It exists under an unusual bargain between government and health care.
In 2018, Tennessee allowed Mountain States Health Alliance and Wellmont Health System to merge into Ballad Health through a Certificate of Public Advantage, or COPA. The arrangement permitted consolidation that might otherwise have raised federal antitrust problems, while placing the resulting system under active supervision by the Tennessee Department of Health. That oversight covers issues including quality, access, pricing and patient experience.
Now that arrangement has an expiration date.
Gov. Bill Lee signed legislation in May requiring Tennessee’s active COPA to expire June 30, 2028. Pricing restrictions are scheduled to remain temporarily under supervision of the attorney general, while a new acute-care hospital entering the former COPA territory would no longer need a Certificate of Need.
The next governor therefore will not decide whether Tennessee begins reconsidering Ballad’s protected structure.
Tennessee already has.
She will help decide what comes next.
Green: End the monopoly
Jerri Green has made Ballad part of her written gubernatorial agenda.
Her Day One plan says she would notify Ballad Health of her administration’s intent to end what the campaign calls the “state-sanctioned monopoly” in East Tennessee. Her broader health-care platform also calls for Medicaid expansion and policies intended to keep rural hospitals open.
The first promise now intersects with legislation already enacted.
By the time the next governor takes office, the COPA will already be scheduled to disappear in 2028.
That means the harder Green question is no longer whether she favors ending the arrangement.
It is what she would put around Ballad after the COPA disappears.
A governor cannot simply divide Ballad Health back into its former systems. Nor can she order another hospital company to build in the Tri-Cities.
Green could appoint the health commissioner, propose new oversight laws, use the budget and executive agencies to support rural providers and ask lawmakers for additional competition or accountability measures. But restructuring the hospital market itself would require more than an executive order.
Pinkston: Make room for competition
Lauren Pinkston’s published platform approaches the issue through independent hospitals and barriers to market entry.
She says Tennessee should protect independent health systems and proposes tying federal rural-health grants to eliminating Certificate-of-Need requirements. Her platform argues that consolidation has made it harder for independent providers, particularly in rural communities, to survive.
That philosophy overlaps with part of the law Tennessee just enacted.
When Ballad’s COPA expires, the new statute removes the Certificate-of-Need requirement for an acute-care hospital opening in the same geographic area.
But eliminating a regulatory barrier does not guarantee a competitor will arrive.
Hospitals require capital, physicians, nurses, patients and a financial model capable of surviving in rural Appalachia.
Pinkston’s proposal creates a path toward competition.
The market still has to walk through it.
Blackburn: A rural-health record, but no Ballad plan yet
Marsha Blackburn’s current gubernatorial platform does not contain a specific Ballad Health or COPA proposal. That absence should not be filled with an assumption.
Her Senate record does provide evidence of how she approaches rural health care.
In March, Blackburn and U.S. Rep. David Kustoff announced a bipartisan rural-health package addressing Medicare reimbursement, urgent and emergency stabilization services and clinician recruitment. Ballad Health endorsed one of the bills in that package, the Save Struggling Hospitals Act.
That endorsement establishes Ballad’s support for a specific Blackburn-backed federal proposal.
It does not establish what Blackburn would do with Ballad’s Tennessee regulatory structure as governor.
That remains a question her campaign should answer.
The Ballad record itself is complicated
The latest state COPA monitor report does not support a simple description of Ballad as either an unquestioned success or complete failure.
For fiscal 2025, the monitor reported improvement over baseline in 18 of 28 access measures. Ten of 18 reported quality measures improved over baseline, while seven were worse. The monitor ultimately found evidence that continued public advantage existed, while also identifying areas of concern.
Meanwhile, Federal Trade Commission staff warned lawmakers that ending the COPA before meaningful competition exists could create another risk: leaving a consolidated health system without the same state supervision that was used to justify the merger in the first place.
That warning does not prove the Legislature’s decision was wrong.
It identifies the tradeoff.
And that is why Ballad belongs in a governor’s race.
The next governor cannot personally break up the system.
She also cannot direct Tennessee’s attorney general, who is appointed by the state Supreme Court rather than the governor.
But she can decide what Tennessee asks of Ballad, what competition it encourages, what rural-health infrastructure it supports and whether lawmakers need to build a new accountability structure before the old one disappears.
The real question is no longer whether the Ballad arrangement changes.
It will.
The question is whether Tennessee has something better ready when it does.
I am a retired detective and criminal justice / government educator based in Tennessee. I founded The Redemption Project, as a place to focus on civics, rebuild non-partisan trust, and provide educational and emotional grace while learning about the news. I also have a column in Knox TN Today. My reporting and commentary have also appeared in other outlets including; Governing, The Arizona Capitol Times, South Florida Sun Sentinel, Police1, among other state and regional outlets.
