Josh Dobson, President & CEO, North Carolina Healthcare Association

Josh Dobson, president and CEO of the North Carolina Healthcare Association, spoke with Invest: about Medicaid funding, workforce challenges, and the role of hospitals as community and economic anchors. “We are in the business of making the lives of North Carolinians better,” Dobson said.

How would you describe the overall healthcare industry in North Carolina, and what trends are shaping your work?

There are challenges; there is no question about that. There is a false narrative by some that all hospitals and all providers are flush with cash, with infinite coffers. That is just inaccurate.

In rural areas, where I come from in Western North Carolina, the hospitals that I represented in the State House, and now as president of NCHA, many of the hospitals in North Carolina are on the margins, 1% or 2% every single year. Every policy decision that legislators make at the state level and the federal level has an impact on these underserved areas.

However, I am optimistic. Our members keep showing up. They have been and continue to be economic anchors in many of these communities. When the local chamber calls for a donation, or something is going on in that community, they start with the hospital.

It is not just a place you go when you get sick. It is part of that community. That is why I am optimistic, because they continue to show up for the people of North Carolina.

In 2024 alone, hospitals and health systems supported more than 464,000 jobs, nearly 7% of all employment in the state. They invested $44 billion in operations and workforce and contributed $2.8 billion in state and local taxes. I am optimistic about healthcare in North Carolina, despite the policy and budget challenges.

How are state budget questions and Medicaid shaping financial stability and long-term planning for hospitals?

At the federal level, Congress had no good options. The federal government is spending $7 trillion a year and taking in $5 trillion a year, and the national debt is right at $40 trillion.

In North Carolina alone, H.R. 1 cut $40 billion out of the state’s Medicaid program over a 10-year period. Some have said that was just waste, fraud, and abuse. That is inaccurate. This was direct funding for Medicaid and Medicaid recipients in North Carolina.

When you cut $40 billion out of the program, there are going to be consequences.

At the state level, earlier in the year, it was an open question whether Medicaid would actually get funded through the end of the year. The General Assembly stepped up, and the governor and legislative leadership came together to fully fund Medicaid through the rest of the fiscal year. That is going to be a huge win for Medicaid recipients across North Carolina.

With regard to Medicaid expansion, 700,000 people’s lives got better when the General Assembly and the governor came together to expand Medicaid in North Carolina.

What a lot of people do not know is that in the Medicaid expansion population, North Carolina hospitals pay for North Carolina’s share. It is not state dollars. Because of Medicaid expansion, people’s lives got better the day that bill was signed.

Our members are committed to making sure that Medicaid expansion stays in place. We do it because we are in the business of making the lives of North Carolinians better.

Where do you see the biggest gaps between urban and rural healthcare providers?

The urban-rural divide is real, and the challenges in rural areas versus urban areas are completely different.

Lack of providers is a real challenge. We have to create incentives to create an environment where clinicians want to practice in rural areas, through loan reimbursement, investment in community colleges, and other options.

Not just in physical health, but in behavioral health. We are seeing emergency departments stay full, particularly in rural areas, and a lot of that is behavioral health challenges. That is something we need to work through.

While there are some hospitals doing well in growing areas, many of the hospitals in North Carolina are on that 1% or 2% margin. That false narrative that all hospitals are flush with cash is inaccurate, particularly in rural areas.

How important are partnerships with small businesses and community organizations in supporting underserved communities?

If you do not have that, you cannot sustain anything, certainly not healthcare.

There is no margin for error in many of these communities. It is all hands on deck, and everybody has to step up to keep those communities solvent. It cannot be overstated how important small businesses and community partnerships are in underserved areas of our state.

What needs to change to build a stronger healthcare workforce pipeline?

There is not a switch you can flip or a silver bullet that says if we do this, we will solve the workforce challenges. It has to be a combination of things over a long period of time.

One problem I am hearing in the healthcare field is preceptor sites. It is not instructor pay or infrastructure. It is the ability for nurses to go to certain facilities to train and get the hours they need to graduate.

We have to figure out how we can open up those preceptor sites and encourage providers to welcome future nurses into their systems.

We also have to invest in instructors, particularly at the community college level. When someone can make more in a hospital role than they can as an instructor, it makes it difficult to grow programs and graduate more CNAs, LPNs, and RNs.

The General Assembly has invested in community college instructors, particularly in healthcare, and we need to continue that.

The opioid crisis is real and present. It is hard to hold any job if you are struggling with drug abuse. We need to make sure people get help in the right setting.

We also need to look at loosening requirements for jobs where we can for those who have imperfect pasts. Some people want to work and move forward, but they are locked out. More flexibility will help address workforce challenges.

How is technology helping providers improve efficiency and service?

We are trending in the right direction. Telehealth is a huge part of what our members do and will continue to do.

A challenge is making sure we have Wi-Fi universally in underserved areas of our state.

Concerning AI, physicians are using it to document and spend more time with patients. Technology needs to enhance, but not replace, clinical judgment. If we stay in that lane, it will be a positive thing.

How are patient expectations evolving?

Patients expect and deserve high-quality healthcare. That is not an unrealistic expectation.

We are always striving to improve the patient experience, and our members are focused on that. There is an expectation that there will be high-quality healthcare, and our members are going to deliver that.

What are your top priorities for the association over the next few years?

Considering the financial pressures that many hospitals are under, especially with the $40 billion cut to Medicaid, one priority is making sure hospitals stay financially viable.

We need policymakers to make decisions that make it easier for providers to provide care in underserved areas, not harder.

Behavioral health is another priority, particularly in emergency departments. We need to make sure individuals with behavioral health challenges are in the right setting for care, not just in the ED.

We also need to work with the General Assembly to make Medicaid funding sustainable. We are projected to face a $1 billion Medicaid shortfall next year, and how we address that will have long-term consequences.

What would you tell investors and business leaders about healthcare in North Carolina?

North Carolina is the ninth-largest state in the country and growing quickly. There is a reason people want to come here.

Two of those reasons are good public education and good healthcare. When you are looking to move somewhere or invest somewhere, you want both.

We have both here, and that is a reflection of the clinicians and healthcare workers across North Carolina who make that happen.