Duke Health is suggesting it could soon drop Aetna from its list of in-network providers, saying the insurance company is unwilling to pay enough for the growing cost of health procedures.

The contract between the two companies isn’t up until late October, so there’s still time for negotiations to play out. But hanging in the balance are the thousands of Aetna customers in North Carolina who could lose coverage. Aetna is one of the biggest health insurers in the state, and Duke runs one of the largest hospital chains.

Many private companies use Aetna for their employees’ health insurance benefits. So does the State Health Plan, which provides health care for more than 700,000 teachers, state workers, state retirees and their family members.

“Unfortunately, Aetna has not agreed to updated reimbursement rates that keep pace with rising health care costs and reflect the actual cost of providing patient care,” Duke wrote on a new webpage about the contract battle. “Their current proposal would limit Duke Health’s ability to invest in technology, staffing, and essential patient services, which puts our community’s continued access to high-quality care at risk.”

If Duke doesn’t like Aetna’s terms for a new contract, the hospital webpage says, it’ll drop the insurance: “Aetna covered patients could lose in-network access to Duke Health doctors, hospitals, clinics and services on Monday, October 20, 2025, and out-of-pocket costs for most patients with Aetna insurance will increase.”

Aetna contends that Duke’s request for higher rates is unreasonable since health care is already more expensive in North Carolina than in most other states.

“We will not sacrifice affordability in our negotiations,” Aetna told WRAL in a written statement. “It is our responsibility to offer a cost effective, quality provider network for our customers. North Carolina has among the highest health care costs in the country. Those costs paid by North Carolinians are directly tied to what providers like Duke Health charge for the services they provide. Aetna is unwavering in our effort to protect our members from even higher health care costs.”

Health care providers often disclose the status of contract negotiations with insurers to give patients and employers time to adjust if changes are needed.

Those notices can also serve as a strong-arm negotiating tactic. Duke Health, for instance, is urging patients to take action by calling Aetna or their employers to advocate for continued coverage. Many companies and their employees could enter into annual open enrollment periods between now and late October, when the Duke-Aetna contract ends, potentially allowing them to add additional pressure on the negotiations.

State Health Plan leaders, meanwhile, are monitoring the situation but not taking sides.

“We are hopeful that Aetna and Duke can come to a resolution on behalf of our members that prioritizes access, rewards quality, and addresses lowering total cost of care,” Tom Friedman, the plan’s director, told WRAL. “We recognize costs are rising; our members are experiencing it both in cost-sharing increases and premium growth. We are confident that there is a solution that aligns incentives between Duke Health, Aetna, and members of the State Health Plan.”

Ripple effect of contract battle

It’s unclear if the fight could also affect state employees who don’t use Duke Health — for instance, if Aetna tried making up for any hypothetical financial losses from losing its Duke contract by increasing what it charges the State Health Plan. Those rates are negotiated separately.

Premiums are expected to go up for state workers regardless next year, due to years of losses — fueled in part by efforts to keep premiums low — that have led the State Health Plan into a roughly $500 million shortfall.

Aetna took over control of the plan this year from Blue Cross & Blue Shield, which had run the State Health Plan for the previous four decades.

Duke’s fight with Aetna for more favorable rates comes as the university faces other financial pressures, mostly from the federal government and cuts enacted by the Department of Government Efficiency, or DOGE, program under Republican President Donald Trump.

Other than Walmart, no private business in North Carolina employs more people than Duke University — in large part due to its sprawling health care system. But because of federal funding cuts, it instituted a hiring freeze earlier this spring, began offering buyouts to some employees, suspended construction and repairs in many buildings, and took other measures aimed at saving $350 million.

Duke announced Friday it would begin laying off employees in August, since not enough took the voluntary buyouts.

Amid that backdrop, the latest contract negotiations illustrate a delicate balance: Better terms from Aetna could help Duke alleviate some of its other financial pressures. But potentially losing thousands of patients, if the contract negotiations fall apart, could further stress the university’s bottom line.

For now, Duke says it can’t keep staffing at adequate levels in its hospitals and doctor’s offices if it doesn’t receive what it sees as fair compensation from its patients’ insurers.

“Our ability to maintain high quality, innovative care and attract top-tier clinicians and care teams depends on fair agreements with insurance companies,” the university wrote. “We are urging Aetna to prioritize our patients’ – their members’ – needs and allow them to keep their trusted Duke Health doctors in-network.”

Aetna said it has worked with Duke Health for decades and hopes to continue the relationship: “Our discussions are ongoing and our intent is to reach a mutually agreeable outcome with Duke.”

Contract fights not uncommon

Duke and Aetna are far from the only duo to engage in these types of negotiations — which can often involve hardball negotiating tactics, including occasionally letting contracts expire for a few months before reaching a deal. That means patients who need care during that time would either have to pay out-of-network costs or find a new provider.

UNC Health said this month it was negotiating its contract with Cigna ahead of a December deadline, recommending that patients and employers consider alternative coverage plans in case negotiations fall apart. “Unfortunately, Cigna is not willing to engage in meaningful discussion or commit to patient care that UNC Health requires,” UNC Health said in a July 1 statement.

Cigna and WakeMed also engaged in a protracted fight in 2023 that resulted in a new contract being signed just days before patients would’ve gone out-of-network.

A contract dispute in 2022 between UnitedHealthcare and WakeMed left the hospital chain out-of-network for nearly that entire year, and a separate battle between UnitedHealthCare and UNC Health in 2024 was resolved just days before that contract was set to expire.