New York
New York's CON program, the oldest in the nation, has been in place since 1964. It regulates a broad range of services, creating significant barriers to entry. In major markets like Long Island, incumbent systems like Northwell Health face little meaningful competition.
What CON Covers in New York
New York's CON program is administered by the Department of Health and the Public Health and Health Planning Council (PHHPC). The process is known for being lengthy and allows incumbents to object to new competition.
| Category | Services Requiring CON Approval |
|---|---|
| Facilities | Hospitals, Nursing Homes, Diagnostic and Treatment Centers, Ambulatory Surgery Centers |
| Home-Based | Home-Care and Hospice Establishment |
| Equipment | Major Medical Equipment |
| Operations | Service-Line Additions or Eliminations, Changes in Ownership |
The Application Process
| Review Detail | Value |
|---|---|
| Reviewing Agency | NY State Dept. of Health & PHHPC |
| Application Fee | $2,000 base + % of capital value |
| Review Timeline | 90-120 days (statutory), often longer |
| Can Competitors Intervene? | Yes, via public hearings and comments |
Who Benefits From New York's CON Laws
CON laws protect dominant, established hospital systems from competition, leading to highly concentrated markets and higher prices for consumers.
Northwell Health holds a dominant share, more than double its next competitor.
Kaleida Health controls nearly half of the inpatient market.
Northwell, NYU Langone, and NY-Presbyterian have combined annual revenue exceeding $46 billion.
UnitedHealth Group is the largest single insurer in a fragmented market.
New York Hospital System Revenue
Three massive non-profit systems—Northwell, NYU Langone, and NewYork-Presbyterian—dominate the state, collectively pulling in over $46 billion in annual revenue.
The Human Cost of CON
The state uses its 'public need' standard to deny new facilities, protecting incumbents and limiting patient choice.
Manhattan ASC Application
Date: 2013 | Location: Manhattan, NY
In 2013, an application was filed to establish a new multispecialty ambulatory surgery center (ASC) in Manhattan. The goal was to provide a lower-cost, more convenient option for outpatient surgical procedures.
The state's Public Health and Health Planning Council (PHHPC) committee, which reviews CON applications, proposed to disapprove the application. The official reason given was a purported "lack of public need."
This case is a clear example of how New York's CON process is used to protect existing hospitals from competition. By denying the ASC, the state ensured that patients would continue to have fewer choices and be forced to seek care in higher-cost hospital settings, benefiting the incumbent systems.
A History of Entrenchment
Despite minor tweaks, New York's fundamental CON structure has remained intact for over 50 years, making it the oldest such regime in the country.
New York (No Meaningful Reform)
- CON program in place since 1964
- 8+ service categories regulated
- Score: 65/100 (Restrictive)
- 2025 rule changes only raised cost thresholds
- Long Island market share for Northwell: 31.1%
- Erie County market share for Kaleida: 44.2%
States That Reformed
States that have repealed or significantly reformed their CON laws have seen increased competition, lower costs, and improved access to care. Evidence from these states shows that markets, not regulators, are better at determining public need.
| Metric | Impact of Reform |
|---|---|
| Hospital Beds | More beds in rural areas |
| ASC Growth | 29% more ASCs per capita |
| Healthcare Costs | Lower per-capita spending |
The Rojas Report Take
New York didn't invent the CON game by accident. They perfected it. As the nation's oldest CON regime, New York has had over half a century to fine-tune its protection racket, ensuring that incumbent systems like Northwell Health, NYU Langone, and NewYork-Presbyterian face as little competition as possible. While they call it 'planning,' it's a slow-motion cartel in action. With a 90-120 day statutory review timeline that everyone knows is a fiction, the state's Department of Health and the PHHPC hold the keys to the kingdom, and they aren't giving them away to just anyone.
Look at the numbers. Northwell Health pulls in $18.6 billion in revenue while holding a 31.1% market share on Long Island, more than double its nearest competitor. In Western New York, Kaleida Health has a staggering 44.15% of the market in Erie County. This isn't a free market; it's a series of local monopolies, all blessed by the state. And when someone tries to build something new, like the ambulatory surgery center in Manhattan, the state simply says there's no 'public need.'
The only need being served is the incumbents' need to keep their moats wide and their prices high. New York's CON law isn't about health; it's about wealth for the chosen few.
Related Content
About CON Laws
Learn about the history of Certificate of Need laws and how they create government-enforced monopolies.
Kentucky CON
With a perfect score of 100, Kentucky has one of the most restrictive CON programs in the United States.
National Analysis
A full 50-state report card and national analysis of CON laws is in development.
Data sourced from the New York State Department of Health, the PHHPC, Centers for Medicare & Medicaid Services (CMS), and the Cicero Institute.