Mission Health’s approach to Dogwood Health Trust worries local nonprofits

For Western North Carolina’s nonprofit community, the Dogwood Health Trust is the proverbial 800-pound gorilla. To be formed from the proceeds of Mission Health’s sale to for-profit, Nashville-based HCA Healthcare, the estimated $1.5 billion foundation would be among the richest per person served anywhere on Earth. Its mission, “to dramatically improve the health and well-being of all people and communities in Western North Carolina,” could bring unprecedented resources to bear on social determinants of health such as education, food security and employment opportunities.

But while local nonprofit leaders are excited by DHT’s potential, some have misgivings about the way it’s being put together — and they worry that airing those reservations could damage their hopes for future funding. In a Nov. 15 letter from the WNC Coalition for Health Equity to Janice Brumit, the chair of the trust, Asheville-Buncombe NAACP President Carmen Ramos-Kennedy called for DHT to adopt a nonretaliation policy toward those who have criticized aspects of its formation and purpose.

“There’s real fear among nonprofit organizations that not supporting the current iteration of the board could mean retaliation in the form of being cut from the $1.5 billion that DHT will control once the sale is final,” Ramos-Kennedy wrote. “In order to truly build trust, citizens and organizations must feel free to speak their hearts and minds without fear.”

Differences of perspective

A top concern for the WNC Coalition for Health Equity, a group of more than 15 nonprofits and community organizations including the Asheville Buncombe Institute of Parity Achievement, Just Economics of WNC and YWCA of Asheville and WNC, is making the DHT board more representative of the region’s racial, gender and geographic diversity. At the time of the coalition’s Nov. 15 letter, the DHT board’s nine members included six white men and no people of color from Buncombe County, which historically has contained the region’s largest minority populations.

While the makeup of the board shifted somewhat with the addition of two women of color from Henderson and Buncombe counties on Dec. 5, Ramos-Kennedy says her group initially got plenty of pushback in response to its request. When coalition members met with Brumit in October, she recalls, they were told that all of Buncombe County’s slots on the board were taken and the group should stop pushing for representation by people of color from the county.

“We were all stunned,” Ramos-Kennedy says. “We left that meeting saying, ‘No, we think some people need to resign if that’s the case.’”

The group is also concerned about the board’s independence; eight of its members have been affiliated with the Mission Health board or those of the system’s regional hospitals. The DHT will also be tasked with holding HCA accountable for the terms of the sale, a responsibility Ramos-Kennedy worries might be undermined by board members’ close ties to those currently negotiating the agreement.

“The way they’ve presented themselves is as people who have exceptional and unique skills to do this work, and I say that they are not exceptional or unique,” she says. “What seems to be the prerequisite is having known each other from their previous work on the Mission board, or just in their social circle.”

Ramos-Kennedy reports that Brumit responded to the Nov. 15 letter but did not formally commit to the proposed nonretaliation policy. Brumit did claim, Ramos-Kennedy says, that the DHT “will not make any grant or other decisions based upon either comments or the failure to comment” and that the board was in the process of adding new members, although “it takes time and deliberate thought to create an enduring structure for this transformational work.”

Mission has previously commented about the board’s independence through its Mission Health Forward site, which contains responses to community questions about the sale to HCA. Addressing a call from SEARCH, a community group of Mitchell and Yancey residents, to dissolve the current DHT board and reconstitute it under oversight from N.C. Attorney General Josh Stein, the health system said there was no reason to do so.

“We appreciate your perspective, but strongly disagree,” wrote Mission representatives. “Not only is there no ‘conflict’ with respect to the current Dogwood Health Trust Board, there is a direct benefit from those directors’ familiarity with Mission Health as the region’s largest health care provider, and each director selected for the Dogwood Health Trust Board has impeccable experience and credentials to serve in such capacity.”

In response to an Xpress interview request, Mission spokesperson Rowena Buffett Timms provided a statement downplaying the “organized, self-interested opposition and inaccurate publicity” surrounding the transaction. “We all know that a small group of loud voices can create an illusion of broader views,” she wrote.

Whisper network

Ramos-Kennedy says the WNC Coalition for Health Equity felt compelled to ask for the nonretaliation policy after hearing from a number of nonprofits that they’d received direct requests from Mission Health to support the sale and the resulting formation of the trust. “Whispers are swirling around the community,” she wrote in the coalition’s Nov. 15 letter, “that nonprofits are feeling pressured by Mission to send letters to the AG stating their support of the current board of DHT.”

While Ramos-Kennedy declined to name specific nonprofits, Xpress spoke with several nonprofit leaders who had received phone calls and emails from Mission staff. Only one of these directors, who spoke on the condition of anonymity due to fear of reprisal, was willing to talk on the record. She says she was surprised at Mission’s insistence about receiving her support.

“My board and my staff don’t nearly have enough expertise to evaluate whether or not this is going to be beneficial for the community,” says the nonprofit director, whose organization is not directly involved with health care. “When I repeatedly said I didn’t think I was going to able to help, [a Mission representative] said how important it was and that she planned to be following up with me.”

While the director says she’s been asked to write letters of support for other community groups before, she was taken aback by the expectation of reporting back to Mission about her nonprofit’s action. “If the request had been open-ended, I wouldn’t have felt pressured. But it sounds like there’s some type of tallying of whether or not organizations are being supportive,” she explains.

“There’s a power dynamic here — this wasn’t a passive request,” the nonprofit leader continues. “[Speaking out] could have a negative impact on our funding and ability to advance some of our agenda through the organization.”

Not all nonprofits share these concerns about the Mission ask, however. “While I was surprised to get the email [requesting a letter of support], I didn’t feel like I was being forced to do one thing or another,” says Miriam Schwarz, CEO and executive director of the Western Carolina Medical Society. “I don’t feel compelled to reply.”

Charlie Jackson, executive director of the Appalachian Sustainable Agriculture Project, says he also found Mission’s request to be in line with others his nonprofit has received. But he notes that his letter only supported the creation of the DHT, as he felt insufficiently knowledgeable to support the sale as a whole.

Mission did not acknowledge repeated requests for a phone interview about its outreach to the nonprofit community. In an emailed statement, Timms wrote, “Knowing that so many others share our feelings of hope about having more than $1.5 billion to invest in the social determinants of health to dramatically improve the health and well-being of all people and communities in Western North Carolina, we were encouraged by our friends to ask close community partners to write the Attorney General if and only if they are comfortable and agreeable with doing so.”

War of the words

In a Nov. 11 op-ed published in the Citizen Times, Mission representatives suggested that they have been keeping tabs on the nonprofit world’s response. Members of the Mission Health Board Foundation Planning Committee referenced “more than 30 nonprofit organizations across the region” that had written to Stein’s office “to express support of the transaction and/or Dogwood Health Trust and its board.”

David Heinen, vice president for public policy and advocacy at the N.C. Center for Nonprofits, notes that nonprofits generally solicit public comments to demonstrate broad-based support for a given issue. “The impact of submitting a lot of comments is to show the regulatory body, but also the press and public, that there are lots of organizations that feel strongly all in the same direction on an issue to sway public opinion,” he says.

Heinen adds that such campaigns are usually conducted for broader regulatory changes, not the government approval of a particular transaction between two entities. “Reviewing deals is a pretty standard job of the AG’s office and one that traditionally has not been politicized,” he explains. “It’s not the type of transaction where comments are posted to the public.”

But comments on the sale are considered public record. In response to an Xpress request, Stein’s office had made 110 comments available as of publication time. Of those comments, roughly half criticize the deal or the DHT board, while the remainder are in favor of or neutral about the transaction.

The majority of supportive comments come from nonprofits that have received funding from Mission, such as Homeward Bound WNC and MANNA FoodBank, or from individuals currently or formerly affiliated with the health system. Most deal primarily with the formation of the DHT, including 11 comments submitted July 25-27 that appear to have been modified from the same form letter.

“Their message is personal and theirs to share; we are not sending out ‘template letters’ to sign and send,” Timms wrote about these public comments. However, she acknowledged that Mission had sent nonprofits an “advocacy packet” containing key points about the “real, tangible benefits” to come from its sale to HCA.  

Those comments in opposition to the deal mainly come from unaffiliated WNC residents or members of SEARCH. Their range of concerns is also broader than those of Mission’s supporters, with points raised about “sweetheart deal” compensation for company executives, HCA’s for-profit orientation and the fate of Mission’s existing municipal debt.

The waiting game

Stein recognized the ongoing debate through a Dec. 4 press release, in which he mentioned “nearly 200 letters and emails from people in Western North Carolina.” The AG also shared his three primary points of concern about the deal: guarantees of continued service at Mission’s rural hospitals, diverse representation on the DHT board and sufficient funding of the trust through a fair sale price.

And the debate is indeed ongoing — Laura Brewer, Stein’s communications director, confirmed that his office is still gathering information and has not yet started its official 60-day review of the deal. Interested parties can submit public comment by telephone at 1-877-5NOSCAM or online at ncdoj.gov/complaint.

While the DHT has not responded directly to Stein’s comments, it did announce two women of color as new board members on Dec. 5: Vivian Bolanos of Henderson County, the vice president and business development officer for First Bank, and Jackie Shropshire Simms of Buncombe County, the vice president of the Ethical Humanist Society of Asheville’s board of directors. Simms’ inclusion suggests that the DHT changed its previous stance on adding new Buncombe County representatives.

“From the beginning, Dogwood Health Trust made an intentional pledge to the entire 18-county region of Western North Carolina, and we have continued to evolve to more closely reflect, fully understand and meaningfully serve the region,” Brumit wrote in a press release announcing the new board members. “We are honored to add Jackie and Vivian and to now have a group of 11 extraordinary leaders, all of whom have demonstrated their commitment to serve as an engaged, thoughtful and strategic board that will lead Dogwood Health Trust in its important work.”

The region’s residents continue to await the final outcome of the AG’s review with a mixture of hope and trepidation, as summarized by SEARCH member Risa Larsen. “If [the DHT] can do what they wrote in their articles of incorporation, in their bylaws, about dramatically improving health across this region, then I am all for it,” she says. “But their tactics so far make us nervous.

“We’re not necessarily trying to just ruffle feathers for the purpose of ruffling feathers,” Larsen continues. “We are trying to be proactively, positively taking a stand on what we need in our community.”