North Carolina Certificate of Need Laws
North Carolina
Most Restrictive
Year Enacted
1977
Services Regulated
—
National Rank
43 of 51
Top Systems
- Atrium Health
- Novant Health
- UNC Health
Reform Status
Most Restrictive with no active reform bill.
Key Case
No major case law on record.
North Carolina's CON law is a textbook case of regulatory capture. In Charlotte, two hospital systems, Atrium and Novant, control nearly 100% of the market. The state uses its power to pick winners and losers, stifling competition and leaving patients with fewer choices and higher costs.
2 Services Behind the Gate
- ✓Hospitals
- ✓Imaging (MRI, CT, PET)
The Permission Process
The review process is lengthy and allows incumbent systems to file a 'contested case' against a new applicant. This legal challenge mechanism significantly raises the cost and time required to bring new services to a community, protecting established players from competition.
, Dr. Gajendra Singh, whose application for a new hospital was blocked
In 2021, both UNC Hospitals and Duke University Health System submitted competing applications to acquire a new PET scanner. The state’s healthcare planning agency determined that only one scanner was needed in the service area.
Instead of allowing both qualified providers to offer the service and compete on quality and price, the state regulators engaged in central planning. They evaluated both proposals and ultimately decided that Duke's application was a 'more effective alternative.'
As a result, UNC's application was denied. This case is a stark illustration of how CON laws replace market competition with government decision-making. The state, not patients or referring physicians, decided who was better equipped to provide a critical service. This process limits patient choice and reinforces the market position of state-favored incumbents.
Data derived from state Department of Health and Human Services filings, public court records, and reports from the Mercatus Center at George Mason University and the National Conference of State Legislatures.
3 Systems. One Market.
Insurer Dominance
- Market share of Blue Cross and Blue Shield of NC
- Learn about the history and impact of CON laws across the United States.
Combined hospital market share of Atrium & Novant in Charlotte
Novant Health's estimated market share in Coastal North Carolina
, North Carolina Court of Appeals, 2023
Explore the case of Kentucky, one of the most restrictive CON states in the nation.
Reform Status: Most Restrictive
National Reform Efforts
An overview of the legislative battles to repeal or reform CON laws.
Data sourced from state agencies, Cicero Institute, and public records.
Last updated: April 2026