North Dakota
The Verdict
North Dakota maintains a very limited Certificate of Need program, creating a mostly free market for healthcare services. This minimal regulatory environment has resulted in one of the least restrictive states in the nation.
5/100
#3
780K
Limited
Governor: Kelly Armstrong (Republican)
What CON Covers
North Dakota's CON laws are narrowly focused on long-term care.
Covered Services
| Long-Term Care Facilities | Yes |
| Basic Care Facilities | Yes |
| Hospitals & Ambulatory Surgery | No |
| Advanced Imaging (MRI, CT) | No |
Application Process
The North Dakota Department of Health and Human Services administers the CON program. The process is straightforward due to its limited scope, focusing on bed capacity and need in the long-term care sector.
Who Benefits
The market is dominated by two major health systems.
Despite the lack of broad CON laws, North Dakota's healthcare market is highly concentrated. Sanford Health, which recently merged with Marshfield Clinic, is the dominant integrated system. CHI St. Alexius Health, part of CommonSpirit Health, is the other major provider, creating a duopoly in many parts of the state.
The Human Cost
With CON laws limited to long-term care, there are few high-profile public battles over new services. Market competition and disputes, when they arise, are more likely to be fought through contracting, physician recruitment, and service line development rather than regulatory CON challenges.
Reform Status
Minimal CON Remaining
North Dakota has effectively achieved full repeal for most of the healthcare economy. The remaining CON laws for long-term care facilities face little political opposition, as they are seen as a tool for managing capacity in a specialized sector. There is no significant legislative push for further changes.
The Rojas Report Take
North Dakota is a prime example of how a state can thrive without extensive Certificate of Need laws. The market is largely free, allowing providers to respond to patient needs without government permission slips. While market concentration is a concern, this is a separate issue from CON. The state's low score of 5/100 is a badge of honor, reflecting a commitment to economic liberty in healthcare. The focus should now be on fostering more competition between the dominant players, rather than re-imposing outdated regulations.