Classification Framework
How we score, classify, and track Certificate of Need laws across 51 jurisdictions. Transparent methodology. Reproducible results.
Six Tiers of Restrictiveness
Free Market
Score: 0 · 12 jurisdictions
No Certificate of Need law. Healthcare providers can open facilities, expand services, and purchase equipment without government permission.
Texas, Idaho, New Hampshire, California, Colorado, Kansas, New Mexico, Pennsylvania, South Dakota, Utah, Wyoming, Arizona
Mostly Free
Score: 5-20 · 6 jurisdictions
CON has been largely repealed or reduced to a narrow scope. Minimal services still regulated, typically limited to nursing homes or specific equipment.
Florida, Montana, North Dakota, Wisconsin, Arkansas, Oklahoma
Moderate
Score: 30-45 · 4 jurisdictions
CON law exists with meaningful scope but contains significant exemptions or has been partially reformed. Some services are deregulated.
Minnesota, South Carolina, Delaware, Nebraska
Restrictive
Score: 55-65 · 8 jurisdictions
Broad CON law covering most major healthcare services. Application process creates significant barriers to entry. Incumbent providers can intervene.
Alaska, Louisiana, Hawaii, Maine, Michigan, Illinois, Oregon, New York
Highly Restrictive
Score: 80-90 · 9 jurisdictions
Extensive CON law covering numerous services. High fees, long timelines, and aggressive incumbent intervention. Reform efforts have repeatedly failed.
Missouri, Alabama, Rhode Island, Tennessee, Mississippi, Connecticut, Iowa, Massachusetts, District of Columbia
Most Restrictive
Score: 95-100 · 10 jurisdictions
Maximum CON restrictiveness. Nearly every healthcare service requires permission. Markets are highly concentrated. Reform is politically blocked.
Georgia, Maryland, Kentucky, Nevada, New Jersey, North Carolina, Vermont, Virginia, Washington, West Virginia
Cicero Institute Scoring (0-100)
Scores reflect the statutory and regulatory burden of the CON program. A score of 0 means no CON law exists. A score of 100 means maximum restrictiveness across all dimensions.
Scoring Dimensions
- 1Number of regulated service categories
- 2Breadth of regulated activities (new construction, expansion, equipment, relocation)
- 3Financial thresholds triggering review
- 4Competitor intervention mechanisms
- 5Appeal and judicial review processes
Source: Cicero Institute. Scale: 0-100.
5-Point Momentum Scoring
Each CON state is evaluated on five binary dimensions. A state earns 1 point for each dimension it satisfies, producing a score from 0 to 5.
Bill Introduced
A reform or repeal bill was introduced in the current or most recent legislative session.
Committee Assignment
The bill received a committee assignment, indicating it was taken seriously by leadership.
Hearing Held
The bill received a hearing, markup session, or floor vote.
Governor Support
The sitting governor has publicly supported CON reform or repeal.
Prior Reform
The state has previously reformed its CON law through partial repeal, exemptions, or scope reduction.
Signal Thresholds
| Score | Signal | Meaning |
|---|---|---|
| 4-5 | Green | Reform likely |
| 2-3 | Yellow | Reform possible |
| 0-1 | Red | Reform stalled |
Where the Data Comes From
- Cicero Institute: State CON restrictiveness scores and tier classifications
- National Academy for State Health Policy (NASHP): CON program scope and facility type classifications
- Federal Trade Commission (FTC): Anticompetitive findings and joint policy statements
- Department of Justice (DOJ): Competition advocacy and CON policy recommendations
- Centers for Medicare & Medicaid Services (CMS): CMS data files, facility counts, utilization data
- Institute for Justice: CON litigation and constitutional challenges
- Mercatus Center at George Mason University: Economic research on CON impacts
- National Bureau of Economic Research (NBER): Academic working papers on CON and health outcomes
- State health departments: Individual state CON program rules, fee schedules, and application data
- The Rojas Report: Original analysis, market concentration data, and editorial content