Restrictiveness Score
90/100
Highly RestrictiveDistrict of Columbia
Certificate of Need Investigation
Governor
Muriel Bowser
Democrat
CON Law Enacted
1996
Dominant System
MedStar Health
Reform Status
No Meaningful Reform
Scope of Regulation
What requires a permission slip?
Regulated Services
- Hospitals & Major Expansions
- Ambulatory Surgery Centers (ASCs)
- Diagnostic Imaging Facilities (MRI, CT, PET)
- Nursing Homes & Long-Term Care
- Home Health Agencies
- Hospice Providers
- Major Medical Equipment Purchases
The Application Gauntlet
| Review Authority | D.C. Dept. of Health (SHPDA) |
| Application Fee | $5,000 - $250,000 |
| Review Timeline | 6-12 months (in practice) |
| Competitor Veto | Yes, incumbents can intervene |
Market Concentration
Who benefits from the lack of competition?
Dominant Health Systems
1. MedStar Health
Controls a dominant share of tertiary care via Washington Hospital Center & Georgetown University Hospital.
2. George Washington University Hospital (UHS)
Major academic center owned by for-profit giant Universal Health Services.
3. Children's National Hospital
Dominant pediatric academic system.
Top Insurers
- CareFirst BlueCross BlueShield
- UnitedHealthcare
- Kaiser Permanente
The Human Cost
How CON laws impact patient care.
Notable Disputes & Delays
Howard University Hospital (2013-2014): A major modernization project was significantly delayed by the CON review process, which cited financial viability concerns and slowed critical infrastructure upgrades at a historic institution.
Specialty Hospital of Washington (2009-2010): A proposed expansion faced stiff opposition from incumbent hospitals, triggering a prolonged and costly review before a limited expansion was finally approved. This is a classic case of the competitor's veto in action.
Reform Status
Where does D.C. stand on CON reform?
The District of Columbia has undertaken no significant reforms to its CON program. The framework established in 1996 remains largely intact, preserving a high-barrier, anti-competitive environment that favors established players.
The Rojas Report Take
Washington, D.C.'s healthcare market is a textbook example of regulatory capture. With a CON score of 90 out of 100, the District operates one of the most restrictive systems in the nation. This isn't about planning; it's about protectionism. The law grants incumbent giants like MedStar Health a de facto veto over any potential competitor, strangling innovation and choice before they can even take root.
The application process itself is a financial and bureaucratic gauntlet, with fees reaching up to $250,000 and timelines stretching over a year. This system doesn't serve patients; it serves the boardroom. By limiting the supply of everything from hospital beds to surgical centers, D.C.'s CON program ensures the dominant players face minimal competitive pressure, leading to higher prices and less accountability for the city's residents.
It's a closed loop where the powerful stay powerful, and patients pay the price.
Dive Deeper
Data sourced from state regulatory filings, public records, and independent analysis by The Rojas Report.