Vermont
The Green Mountain State
Most RestrictiveCON Score
100
out of 100
National Rank
#43
tied for last
Governor
Phil Scott
Republican
Population
647K
smallest CON state
What Vermont's CON Covers
Vermont regulates virtually every healthcare service. The Green Mountain Care Board (GMCB) holds both CON authority and rate-setting authority — a combination unique in the nation.
Regulated Services
The GMCB Dual Authority
Vermont's Green Mountain Care Board is the only regulatory body in the nation that combines Certificate of Need authority with hospital budget review and rate-setting power. This means the GMCB doesn't just decide who can build — it decides what they can charge.
CON Authority
Controls market entry for all major healthcare services
Rate-Setting Authority
Reviews and approves hospital budgets annually
Capital Expenditure Review
Any project over $3M requires GMCB approval
Application Process
| Step | Process | Timeline |
|---|---|---|
| 1 | Letter of Intent filed with GMCB | Required before application |
| 2 | Full application with financial projections | Extensive documentation |
| 3 | Public comment period | 30-60 days |
| 4 | GMCB staff review and analysis | 90-180 days |
| 5 | Public hearing (if requested) | Additional 30-60 days |
| 6 | GMCB board vote | Final decision |
Who Benefits from Vermont's CON
UVM Health Network dominates Vermont's healthcare market. With 6 hospitals in a state of 647,000 people, the network has near-total control of inpatient care.
Dominant System
UVM Health Network
University of Vermont Medical Center + 5 affiliate hospitals
Hospitals
6
Market Share
~75%
of inpatient admissions
Status
Nonprofit
Academic Affiliation
UVM College of Medicine
Market Reality
State Population
647,064
Total Hospitals
14
ASCs
Minimal
CON barriers limit competition
The Structural Problem
Vermont is the smallest state with a full CON program, and it has the most comprehensive regulatory apparatus in the country. The GMCB reviews hospital budgets, sets rates, and controls market entry. In a state with fewer people than most mid-size cities, this creates a regulatory environment where one dominant system faces virtually no competitive pressure. UVM Health Network's ~75% market share is not the result of consumer choice — it's the result of regulatory design.
The Human Cost
Vermont's regulatory complexity has produced notable policy failures and access challenges.
Green Mountain Care Collapse
In 2011, Vermont passed Act 48 to create Green Mountain Care, a single-payer healthcare system. Governor Peter Shumlin championed it as a national model. By 2014, the projected costs ($2.6 billion in new taxes) forced Shumlin to abandon the plan entirely. The failure demonstrated that even total regulatory control cannot overcome the fundamental economics of a healthcare market distorted by decades of anti-competitive policy.
Rural Hospital Strain
Despite having the most comprehensive regulatory apparatus in the country, Vermont's rural hospitals face chronic financial strain. The GMCB's budget review process constrains revenue growth while CON laws prevent new entrants who might bring innovative care models. Several small hospitals have required emergency financial interventions. The regulatory framework designed to "protect" access has instead created a system where struggling hospitals can't adapt and new competitors can't enter.
The Cost of Dual Authority
Vermont's unique dual-authority model (CON + rate-setting) creates a regulatory burden that is disproportionate to the state's size. Healthcare providers must navigate both market-entry restrictions and annual budget reviews. The administrative costs of compliance fall hardest on smaller providers, reinforcing the dominance of UVM Health Network, which has the institutional resources to manage the regulatory process. The GMCB's own reports acknowledge that the administrative burden is significant relative to the state's healthcare market size.
Reform Status
Vermont has shown no meaningful movement toward CON reform. The GMCB's institutional authority makes change politically difficult.
Current System
What Reform Would Look Like
The Rojas Report Take
Vermont is the most instructive case study in American healthcare regulation.
A state of 647,000 people has built the most comprehensive healthcare regulatory apparatus in the country. The Green Mountain Care Board controls who can enter the market, what they can charge, and how much they can spend on capital improvements. This is not regulation — it is central planning.
The result is predictable. One system dominates. Competition is structurally impossible. Rural hospitals struggle despite being "protected." And when Vermont tried to take the logic to its conclusion with single-payer, the economics collapsed under the weight of a market that had never been allowed to function.
Vermont's CON score of 100 is not just a number. It represents the most complete version of the regulatory capture thesis: when you give a government board the power to control both supply and price, the market doesn't become more efficient — it becomes more dependent on the board. The GMCB is not a safety net. It is the architecture of a monopoly.
— The Rojas Report
Continue the Investigation
National Overview
50-State CON Rankings
Compare all 35 jurisdictions. Interactive table with scores, tiers, and reform status.
State Profile
Massachusetts
Score 90. Mass General Brigham's $18.5B empire. 8 ASCs per million vs. 16+ national average.
State Profile
New York
Score 65. Northwell's $17.6B empire. 26 regulated services. The state that started it all in 1964.
Sources: Green Mountain Care Board public filings and annual reports; Vermont Department of Health; UVM Health Network financial disclosures; National Conference of State Legislatures CON database; Mercatus Center CON research; Vermont Act 48 (2011) legislative record. All data verified as of March 2026.