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Ballad Health, the nation’s largest state-sanctioned hospital monopoly, has been under scrutiny for years due to poor quality of care. Tennessee is now considering changing the rules governing the monopoly to hold Ballad Health more accountable. The hospital system serves 29 counties across Tennessee, Kentucky, Virginia, and North Carolina. Following years of complaints and poor performance, there are discussions about potentially requiring Ballad Health to improve care or face the possibility of being broken up. The changes come amid a new wave of pushback and behind-the-scenes negotiations with the Tennessee government.