What CON Laws Actually Do
The Federal Trade Commission and the Department of Justice have found no reliable evidence that CON programs achieve any public benefits. They have found clear evidence that the laws grant anticompetitive benefits to protected business interests.
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.
How We Got Here
The story of CON laws begins in 1959 with a UCLA health researcher named Milton Roemer. His study found a correlation between the number of available hospital beds and the number of hospital days used. The hospital industry twisted this finding into a justification for limiting competition: if more beds mean more utilization, then we must restrict the supply of beds.
What Roemer actually proved was that ,e.jsxDEV( supply and demand work . What the cartel claimed was that markets are wasteful and competition must be limited.
The federal government's entry into CON was the ,e.jsxDEV( National Health Planning and Resources Development Act of 1974 (Public Law 93-641), sponsored by Senator Edward M. Kennedy. The law effectively federalized the CON concept, threatening to withhold federal funds from states that did not adopt CON programs. By the early 1980s, nearly every state had one.
The mandate was repealed in 1987 after the policy was deemed ineffective. But 35 jurisdictions kept their laws on the books
They didn't prove waste. They proved access.
— The Rojas Report, on Roemer's Law
What the Studies Show
CON states have fewer hospitals per capita, especially in rural areas.
Mercatus Center
CON laws are associated with higher mortality rates for certain conditions.
NBER Working Paper
Repealing CON laws does not lead to a decrease in charity care.
Journal of Health Economics
CON laws pose serious anticompetitive risks. The agencies recommend repeal.
FTC & DOJ Joint Statement, 2004
States that repeal CON see 44-47% more ASCs per capita.
Mercatus Center
Rural areas see 92-112% increase in ASCs after CON repeal.
Journal of Health Economics
Deep-Dive State Profiles
These states have been fully investigated by The Rojas Report.
Kentucky
Three systems control 100% of Louisville's inpatient market. Prices reach 354% of Medicare. A Nepali immigrant was blocked from serving refugees.
Virginia
Sentara's $4.79B empire. Five systems control $16B+ in revenue. The 4th Circuit acknowledged the harm but refused to act.
Massachusetts
8 ASCs per million vs. 16+ national average. Mass General Brigham's $18.5B empire. A 15-year regulatory stranglehold on surgical competition.
Georgia
Piedmont's $5.6B system. HB 1339 began reform in 2024. Centene controls 38% of the insurer market.
North Carolina
Two systems control nearly 100% of Charlotte's inpatient market. BCBS NC holds 62% of the insurer market.
New York
Northwell's $17.6B empire. 26 regulated services. The state that started it all in 1964.