Dive Brief:

• North Carolina Attorney General Josh Stein will allow HCA Healthcare's $1.5 billion acquisition of Asheville, North Carolina-based hospital chain Mission Health to move forward without legal challenge.

• The approval comes after HCA pledged to double the period it will provide comprehensive services in rural hospitals from five to 10 years, keep all of Mission's facilities open until 2029 and follow through with expansion plans, among other commitments.

• The news advances HCA's foray into North Carolina. The for-profit health system currently doesn't operate any facilities in the state.

Dive Insight:

With this green light, the biggest regulatory hurdle for the deal is now in HCA and Mission's rearview. The deal, percolating since September, could close as early as the end of this month.

And Mission isn't HCA's only recent plotted expansion. At the end of December, the health system purchased 100 acres in west Florida for a planned 80-bed hospital facility.

HCA is one of the few health systems actually expanding, instead of contracting. The chain is coming off a strong third quarter, where the Nashville-based system beat analyst expectations with an almost 80% spike in net income spurred by an increased in admissions and utilization (in sharp contrast to its struggling competitor CHS).

Two hired experts, state consultancy Stout Risius Ross and Mission Health's Cain Brothers, concluded HCA's asking price for Mission was "fair."

The deal created an outside independent monitor to keep HCA honest as it moves forward with the nitty-gritty of the acquisition of one of the region's largest employers. HCA also agreed to build a replacement for Angel Medical Center in Franklin, along with a 120-bed inpatient behavioral health hospital in Asheville.

Dogwood Health Trust is the nonprofit corporation that will succeed previously nonprofit Mission if the transaction is finalized and oversee the spending of proceeds from the sale.

Previously, critics of the merger have said the foundation's board of directors aren't transparent or diverse enough to represent western North Carolina, either ethnically or geographically.

Under the terms of the agreement with Stein, the board must be fully representative of the population of the western part of the state by early next year, hold annual public meetings and undergo periodical reviews from the attorney general's office.

"After extensive negotiations, I am satisfied that this new agreement protects healthcare in western North Carolina, ensures that the full value of Mission's assets will continue to be used for public purposes, and requires that the Dogwood Health Trust will be independent and representative," Stein said in a statement.

HCA's fourth-quarter earnings call is set for Jan. 29.