The Certificate of Need (CON) program is a polarizing fixture in U.S. healthcare policy. Aimed at controlling costs, improving care quality, and ensuring equitable access to medical services, CON laws require healthcare providers in many states to gain state approval before expanding facilities, adding services, or purchasing costly equipment like MRI scanners. But what are CON laws, how do they work, and do they achieve their goals? This guide explores the history, mechanics, debates, and current state of CON programs across the U.S., with a detailed list of states that enforce them as of 2025.

What Are Certificate of Need (CON) Laws?

At its essence, a Certificate of Need is a regulatory hurdle. Healthcare providers—hospitals, nursing homes, or clinics—must prove a “public need” to state agencies before launching major projects. Whether it’s building a new hospital wing, acquiring advanced medical equipment, or starting specialized services like dialysis, CON laws aim to prevent overbuilding, curb healthcare spending, and prioritize underserved areas. Yet, these regulations spark fierce debate: do they protect patients or stifle competition?

The History of CON Laws in the U.S.

The CON program began with New York’s 1964 Metcalf-McCloskey Act, the first state-level attempt to manage healthcare growth. Its national breakthrough came with the 1974 National Health Planning and Resources Development Act, which tied federal funding to state CON adoption. By the 1980s, nearly every state had a program to control costs and avoid redundant facilities. The federal mandate ended in 1986, leaving states to decide their own paths. Today, 35 states plus Washington, D.C., maintain some form of CON regulation, though the scope varies—Florida, for instance, dropped hospital requirements in 2019, while South Carolina fully repealed its program in 2023.

How Does the CON Process Work?

The CON process is straightforward but rigorous. Providers submit applications to state health agencies, detailing why their project meets a community need—say, a shortage of hospital beds or imaging services. The review often includes public hearings, where competitors (like nearby hospitals) can oppose the plan, arguing it duplicates existing resources. The goal? Limit wasteful spending, ensure high patient volumes for quality care, and direct resources to underserved regions. Critics, however, call it a bureaucratic barrier to innovation.

Pros and Cons of CON Laws

The Case For CON

Supporters argue CON laws prevent a free-for-all healthcare market. Without oversight, providers might cluster high-profit services—like MRI centers—in wealthy areas, ignoring rural or low-income communities. By requiring justification, CON aims to optimize resource distribution and stabilize costs.

The Case Against CON

Opponents say CON regulations harm more than they help. Research from the Mercatus Center shows CON states often have fewer hospitals, lower bed counts, and higher costs per service than non-CON states. Critics argue these laws entrench existing providers, block new entrants, and worsen rural access—a “competitor’s veto” that favors monopolies over patients. A 2021 Kaiser Family Foundation report found fewer ambulatory surgery centers in CON states, pushing procedures to costlier hospitals.

The data is inconclusive: some studies show minimal cost impact, while others tie CON to reduced hospice or dialysis access. Vermont credits CON with sustaining rural hospitals, but the broader picture remains murky.

The Changing Landscape of CON in 2025

The CON debate is heating up. South Carolina’s 2023 repeal (source) and Florida’s 2019 partial rollback (source) signal a deregulation trend, driven by free-market advocates like Governor Ron DeSantis. Yet, states like New York and North Carolina cling to robust CON frameworks, citing rising healthcare costs. As telemedicine and outpatient care grow, many wonder if CON—rooted in the era of hospital sprawl—still fits today’s needs.

Which States Have CON Laws in 2025?

Based on the National Conference of State Legislatures (NCSL) and updated through 2025, 35 states plus Washington, D.C., enforce some form of CON law. These vary widely—some cover hospitals, others focus on nursing homes or equipment like MRI scanners. Here’s the full breakdown:

States with CON Laws (35 + D.C.)

• Alabama: Covers hospitals, nursing homes, and equipment.
• Alaska: Limited scope (e.g., nursing homes, certain facilities).
• Arkansas: Regulates hospitals and long-term care.
• Connecticut: Applies to healthcare facilities and services.
• Delaware: No active CON (repealed in the 1980s).
• Florida: Partial—covers nursing homes and hospices, not hospitals (since 2019).
• Georgia: Includes hospitals, nursing homes, and equipment.
• Hawaii: Broad coverage of healthcare services.
• Illinois: Scaled-back program for various services.
• Iowa: No CON (repealed in the 1990s).
• Kentucky: Regulates hospitals, nursing homes, and more.
• Louisiana: Focuses on nursing homes and long-term care.
• Maine: Covers healthcare facilities and services.
• Maryland: Applies to multiple healthcare sectors.
• Massachusetts: No CON (repealed in the 1980s; uses alternatives).
• Michigan: Includes hospitals, nursing homes, and equipment.
• Mississippi: Regulates healthcare facilities.
• Missouri: Debated but active, with reduced scope.
• Montana: Primarily for long-term care.
• Nebraska: Covers certain healthcare services.
• Nevada: No CON (repealed in the 1980s).
• New Hampshire: No CON (repealed in 2016).
• New Jersey: Reformed to focus on specific services.
• New York: Robust program for facilities and equipment.
• North Carolina: Covers hospitals, nursing homes, and more.
• Ohio: Limited regulation for long-term care (most repealed by 1997).
• Oklahoma: No CON (repealed in the 1980s).
• Oregon: Regulates hospitals and long-term care.
• Rhode Island: Applies to healthcare facilities.
• South Carolina: Active but facing repeal efforts.
• Tennessee: Covers various healthcare services.
• Vermont: Regulates hospitals and facilities.
• Virginia: Includes facilities and equipment.
• Washington: Narrow scope (e.g., nursing homes).
• West Virginia: Applies to healthcare services.
• Washington, D.C.: No formal CON program.

States Without CON Laws (15)

1. Arizona: Repealed 1985.
2. California: Repealed 1987.
3. Colorado: Repealed 1987.
4. Idaho: Repealed 1983.
5. Indiana: Repealed 1999 (fully phased out by 2019).
6. Kansas: Repealed 1985.
7. Minnesota: Repealed 1984 (has a public interest review instead).
8. New Mexico: Repealed 1983.
9. North Dakota: Repealed 1987.
10. Pennsylvania: Repealed 1996.
11. South Dakota: Repealed 1988.
12. Texas: Repealed 1985.
13. Utah: Repealed 1987.
14. Wisconsin: Repealed 2011 (fully phased out by 2015).
15. Wyoming: Repealed 1989.

The Future of Certificate of Need Laws

The Certificate of Need program reflects a tug-of-war between regulation and competition. It curbs redundant facilities but can raise costs and limit access. As states weigh repeal or reform, the CON saga mirrors America’s broader healthcare challenge: balancing efficiency, equity, and innovation. For the latest state-by-state updates, check the NCSL’s CON resource page.

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References

1. Kaiser Family Foundation. (2021). What’s Behind High U.S. Health Care Costs? Retrieved from https://www.kff.org/health-costs/issue-brief/whats-behind-high-u-s-health-care-costs/
2. National Conference of State Legislatures (NCSL). (2024). Certificate of Need State Laws. Retrieved from https://www.ncsl.org/health/certificate-of-need-state-laws
3. State Policy Network. (2023). South Carolina Removes Its CON Laws. Retrieved from https://spn.org/blog/south-carolina-removes-its-con-laws/
4. Office of the Governor, State of Florida. (2019). Governor Ron DeSantis Signs CS/HB 21, Expanding Healthcare Access in Florida. Retrieved from https://www.flgov.com/2019/06/25/governor-ron-desantis-signs-cshb-21-expanding-healthcare-access-in-florida/