Oklahoma
Oklahoma has rolled back much of its Certificate of Need program, retaining CON only for long-term care facilities. Following the 2024 repeal of psychiatric CON requirements (HB 2330), the remaining regulations protect entrenched nursing home operators while the real story is what dominant systems do with the structural advantages they retain.
CON Restrictiveness
National Rank
Ranked by restrictiveness
Governor
Kevin Stitt
CON Enacted
1971
Major Reform
2018
Services Regulated
3
Dominant System
Saint Francis
Scope of Regulation
Remaining Regulated Services
Oklahoma has systematically dismantled its CON apparatus over four decades. The broad CON law was largely repealed in the late 1980s, further narrowed in 2018 (SB 1388), and in May 2024, Governor Stitt signed HB 2330 repealing psychiatric and chemical dependency CON requirements. The remaining CON requirements cover:
- Nursing facilities (new construction)
- Specialized facilities for persons with developmental disabilities
- Residential care facilities
Hospitals, ASCs, and most acute care facilities are exempt from CON requirements following the 2018 reform.
Application Process
| Reviewing Body | Oklahoma State Dept. of Health (OSDH), Health Facility Systems Division |
| Reform Year | 2024 (HB 2330) |
| Review Period | 80-100 days |
| Competitor Objection | Still permitted |
Market Concentration
Tulsa Market
Highly Concentrated
Saint Francis dominates with 1,112-bed flagship; 56.2% of OK hospitals in monopoly markets (HHI>5,000)
Dominant Systems
Saint Francis ($2.04B), INTEGRIS ($1.84B), OU Health ($1.64B)
Saint Francis Beds
1,112
Largest in the Tulsa metro
Exhibit F: The Saint Francis 340B Operation
Saint Francis is a confirmed 340B covered entity registered in HRSA's OPAIS database. It operates the precise infrastructure that characterizes the highest-earning DSH participants nationally: a dedicated Cancer Center oncology pharmacy, a home infusion and specialty pharmacy, and a 110-location employed physician network registered as child sites.
Estimated 340B Revenue
$60-130M
annually (revised upward from $30-80M)
Warren Clinic Sites
110
potential 340B child sites
Annual Surplus
$308M
system operating surplus
Oncology Markup
4.9-11.3x
median 340B markup on oncology drugs
The 340B Infrastructure
Cancer Center Oncology Pharmacy
Oncology drugs dominate the 340B program, accounting for over $40 billion systemwide in 2019 alone. The Saint Francis Cancer Center with its dedicated oncology pharmacy is precisely the infrastructure class generating the highest 340B margins. The median markup on 340B acquisition costs at DSH hospitals for oncology drugs is 4.9x, and as high as 11.3x for specific drugs.
Warren Clinic Network (110 Locations)
340B eligibility extends to off-site outpatient facilities registered on the hospital's Medicare cost report. With 110 Warren Clinic locations, every one can potentially serve as a 340B-eligible child site. Between 2005 and 2011, the number of hospital 340B sites nearly quadrupled nationally. The average 340B hospital now has contracts with over 20 pharmacies. Saint Francis's Warren Clinic network is not incidental to its 340B program. It is the geographic expansion engine that maximizes 340B capture.
Home Infusion & Specialty Pharmacy
The system operates dedicated home infusion and hospice pharmacy operations, extending 340B drug acquisition discounts beyond the hospital walls and into outpatient and home settings.
The Transparency Gap
Saint Francis does not disclose its 340B revenue or how savings flow to patients. Oklahoma has no state-level transparency reporting requirement equivalent to Minnesota's.
When Minnesota became the first state to require 340B reporting and included office-administered drugs in the second year, estimated net 340B revenue jumped 112% to $1.34 billion statewide. Even states trying to create transparency are finding that first-pass data severely undercounts the program.
There are no data or studies suggesting that uninsured patients typically benefit directly from 340B discounts. There is documented evidence that uninsured patients frequently pay full price for 340B prescriptions even when they are patients of a 340B hospital.
The absence of disclosure is not merely an opacity finding. It is the program working exactly as critics have described: a federal subsidy designed for vulnerable patients, warehoused inside a system generating $308M in annual surplus, with no public accounting for where the spread goes.
Revised Estimate
The original $30-80M savings estimate understates the likely figure. Among the top 340B DSH hospitals analyzed for price transparency, the per-hospital 340B discount realization was estimated at $86-162 million for 2021. Saint Francis, an 1,112-bed DSH hospital with a Cancer Center, a dedicated oncology pharmacy, a 110-location employed physician network, and a home infusion operation, is not a median institution. It sits in the top tier of DSH participants by scale. $60-130M annually is the defensible range given the system's size and oncology infrastructure.
Reform Status
Significant Reform, Incomplete Victory (Updated 2024)
Oklahoma's multi-decade CON reform—from the late 1980s hospital deregulation through SB 1388 (2018) and HB 2330 (2024)—has eliminated requirements for hospitals, ASCs, psychiatric facilities, and most acute care. This was real progress. But the remaining regulations in long-term care still create barriers where incumbent nursing homes weaponize the appeals process to block competitors (as documented in the Wood Manor and Hometown Memory Care cases), and the larger issue is that CON reform alone does not address the structural advantages that dominant systems like Saint Francis have accumulated through 340B, tax exemption, and market concentration.
Evidence of Harm
| 340B Transparency | None Required |
| Charity Care Disclosure | Minimal |
| Market Concentration | Highly Concentrated |
| CON Reform | Partial (2018) |
The Rojas Report Take
Oklahoma's 2018 CON reform was real progress. Eliminating certificate requirements for hospitals and surgical centers removed a layer of anti-competitive protection that had shielded incumbents for decades. Governor Stitt deserves credit for signing it. But the reform addressed the regulatory barrier without touching the financial moat.
Saint Francis Health System in Tulsa is the case study. An 1,112-bed DSH hospital with a $308 million annual surplus, a dedicated Cancer Center oncology pharmacy, 110 Warren Clinic locations functioning as 340B child sites, and an estimated $60-130 million in annual 340B revenue. It does not disclose how those savings reach patients. Oklahoma does not require it to. Uninsured patients nationally have been documented paying full price for 340B drugs at participating hospitals.
The pattern is now familiar across every state we investigate: CON reform removes the front door lock, but the structural advantages of tax exemption, 340B exploitation, and market concentration keep the building impenetrable. Oklahoma opened the door. The question is whether anyone can afford to walk through it when the dominant system on the other side has a $275 billion federal subsidy stack behind it.
Related Content
The National CON Investigation
Our complete analysis of Certificate of Need laws across 35 jurisdictions.
The 340B Drug Program
$81.4B in discounted drugs. Zero disclosure requirements. The second-largest federal drug program.
The $275B Systematic Advantage
Annual subsidies flowing to hospital systems. The full breakdown.