Certificate of Need Laws:
The Architecture of a Healthcare Monopoly
In 35 jurisdictions, it is illegal to open a hospital, surgery center, or imaging facility without government permission. Your competitors sit on the board that decides. This is how the monopoly was built.
How Certificate of Need Works
A four-step process designed so that your competitors decide whether you are allowed to exist.
You want to build a surgery center
You apply to the state board
Your competitors sit on that board
Your competitors vote on whether you exist
It's like asking McDonald's for permission to open a Burger King.
What CON Laws Actually Do
The FTC and DOJ have found no reliable evidence that CON programs achieve any public benefits.
Higher Healthcare Costs
In CON states compared to free market states.
Mercatus Center
More ASCs After Repeal
Increase in ambulatory surgery centers per capita.
FTC/DOJ Joint Statement
Rural ASC Growth
Increase in rural surgery centers after CON repeal.
Journal of Health Economics
Every State, Ranked
Darker orange means more restrictive. Click any state with a CON law to view its full intelligence dossier.
Start With the Worst Offenders
Four states where the monopoly is most entrenched. The data below is the rest of the map.
Most Restrictive
Kentucky
Three systems control 100% of Louisville. Tiwari v. Meier failed at SCOTUS.
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Most Restrictive
Virginia
Sentara's $13B empire. 19 services regulated. Five systems, $16B+ combined.
View Dossier →
Most Restrictive
Georgia
FTC v. Phoebe Putney went to the Supreme Court. Albany HHI: 7,453.
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Most Restrictive
West Virginia
HB 2013 CON repeal died by one vote (13-12). Closest any state has come.
View Dossier →
All 36 States
Sorted by restrictiveness (most to least)
Nevada
Most Restrictive
Sunrise (HCA) + Dignity. 100% score. No reform efforts since 1971.
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New Jersey
Most Restrictive
RWJBarnabas $7.5B. 25+ regulated services. The Garden State cartel.
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North Carolina
Most Restrictive
Two systems control nearly 100% of Charlotte. BCBS NC holds 62%.
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Vermont
Most Restrictive
Green Mountain Care legacy. UVMHN dominates the state.
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Washington
Most Restrictive
Providence Swedish + MultiCare + Virginia Mason Franciscan. 100% score.
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Maryland
Most Restrictive
Johns Hopkins $9B. University of Maryland $8.7B. All-payer rates.
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Connecticut
Highly Restrictive
Yale New Haven Health $6.1B. 40+ years of hospital mergers.
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Iowa
Highly Restrictive
Entrenched hospital lobby. No reform efforts in recent years.
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Massachusetts
Highly Restrictive
Mass General Brigham $18.5B. 15-year stranglehold on surgical competition.
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Mississippi
Highly Restrictive
40-year moratorium on home health, lifted only by federal court order.
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Washington, D.C.
Highly Restrictive
MedStar dominates tertiary care. George Washington + Children's.
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Tennessee
Highly Restrictive
HCA + Ascension + Ballad. Governor Lee has not pushed reform.
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Alabama
Highly Restrictive
Decatur monopoly (HHI 10,000). BCBS controls 84% of the market.
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Missouri
Highly Restrictive
SB 1268 partial repeal pending. BJC + SSM + Mercy dominate.
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Rhode Island
Highly Restrictive
Amended 25+ times, never repealed. 2026 repeal bill introduced.
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Hawaii
Restrictive
Queen's Health System: $1.7B. Last fully-regulated Pacific state.
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Illinois
Restrictive
BCBS controls 97% of the HMO market. CON sunsets in 2029.
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Maine
Restrictive
MaineHealth + Northern Light. Repeal efforts consistently fail.
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Michigan
Restrictive
Bureaucratic MDHHS process. Corewell + Henry Ford + Trinity dominance.
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New York
Restrictive
Northwell $17.6B. 26 regulated services. Started it all in 1964.
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Oregon
Restrictive
ASC exemption 2009. Providence + Legacy core-state control.
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Alaska
Restrictive
Premera BCBS owns 79% of the insurer market. HHI 2,785.
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Louisiana
Restrictive
Ochsner dominates New Orleans. 2024 reform entrenched FNR process.
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Delaware
Moderate
ChristianaCare $2.5B. 45% restrictiveness. One-system state.
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Nebraska
Moderate
Narrow CON, primarily a moratorium on new long-term care beds.
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Minnesota
Moderate
CON repealed 1984, replaced with hospital construction moratorium.
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Oklahoma
Mostly Free
Saint Francis: $2.04B revenue. INTEGRIS $1.84B. OU Health $1.64B.
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Arkansas
Mostly Free
Transitioned to Permit of Approval system. 2 services regulated.
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Florida
Mostly Free
Mostly repealed in 2019. AdventHealth still pulls in $17B.
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Montana
Mostly Free
Mostly repealed in 2021. Limited CON scope remains.
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North Dakota
Mostly Free
Effectively repealed. Sanford + CHI St. Alexius dominate.
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Wisconsin
Mostly Free
CON repealed post-1987. Only nursing home bed moratorium remains.
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