Missouri
Certificate of Need Investigation
CON Score
80/100
CON Enacted
1980
Governor
Reform Status
Partial Repeal Pending
Scope of Regulation
Regulated Services
Missouri's CON law covers a broad range of healthcare services, requiring providers to obtain state approval for significant capital expenditures. This includes:
- New or expanded hospitals
- Long-term care facilities (nursing homes, assisted living)
- Psychiatric and rehabilitation services
- Major medical equipment (MRI, CT, PET scanners)
Application Process
| Process Step | Details |
|---|---|
| Review Body | Missouri Health Facilities Review Committee |
| Application Fee | $1,000 or 0.1% of project cost |
| Review Timeline | ~71 days (full), ~41 days (expedited) |
| Competitor Intervention | Yes, "affected persons" can object and request hearings |
Market Concentration
CON laws often lead to consolidated markets, benefiting established players. In Missouri, the healthcare landscape is dominated by a few large systems, particularly in the St. Louis metropolitan area.
BJC HealthCare
37.5%
Market Share in St. Louis
Mercy Health
22.6%
Market Share in St. Louis
Top 3 Insurers
64.5%
Combined Market Share
Case Law & Disputes
Moberly Retirement Center (2018)
In a clear example of bureaucratic hurdles, the Missouri Health Facilities Review Committee unanimously denied a CON for an 18-bed residential care facility. The denial was not based on need, but on a technicality: the applicant had moved the proposed site by 1.5 miles after filing the initial letter of intent. This case highlights how CON regulations can stifle development over procedural minutiae rather than community benefit.
Reform Status
While full repeal has failed multiple times, a significant reform bill (SB 1268) was introduced in 2026 and is currently pending in the Senate Families, Seniors and Health Committee. If passed, the bill would eliminate CON review for new hospitals and major medical equipment. CON requirements would remain for other services like long-term care. The fight for a fully open market continues.
The Rojas Report Take
Missouri's score of 80 places it firmly in the "harmful" category, a direct consequence of a four-decade-old law that has stifled competition and empowered incumbent health systems. While the introduction of SB 1268 is a welcome crack in the armor, it remains pending in committee. The state's healthcare market remains an oligopoly in key regions, with BJC HealthCare (37.5%), SSM Health (26.8%), and Mercy (22.6%) commanding over 85% of the market in St. Louis. This isn't a free market; it's a state-sanctioned cartel.
The denial of the Moberly Retirement Center's application over a change of address is a textbook example of the absurdity of CON. A community's need for elder care was dismissed on a technicality, a clear signal that the system prioritizes bureaucratic process over patient access. The $12.1 billion and $10.2 billion revenues of BJC and Mercy, respectively, are not just numbers; they are a testament to the financial rewards of a protected market. Missouri is moving in the right direction with SB 1268, but the job is far from over. It's time to dismantle the rest of this anti-competitive relic.