The Changing Landscape of Certificate of Need Laws:
A Focus on North Carolina & South Carolina

One significant factor shaping the healthcare landscape is the presence of Certificate of Need (CON) laws. These regulations, adopted by many states (35+ states, including D.C.), require healthcare providers to obtain government approval before establishing or expanding certain healthcare facilities or services. These laws aim to control healthcare costs, prevent unnecessary duplication of services, and ensure fair access to care. CON laws have been a topic of ongoing debate in the United States, with their impact on the healthcare industry closely scrutinized. Recently, the states of North Carolina and South Carolina have made notable strides in reforming their CON laws, signaling a potential shift in how these regulations are perceived and implemented. This thought piece delves into the changing CON laws in North Carolina and South Carolina, exploring the expected benefits and the potential implications for the healthcare landscape.

CON laws were originally introduced in the US in the 1960s as a response to concerns over rising healthcare costs and to ensure the efficient allocation of resources. The primary goal was to govern healthcare spending, promote equitable access to care, prevent duplicative services, and ensure quality standards in healthcare delivery. By requiring providers to demonstrate the necessity of new projects, CON laws aimed to avoid unnecessary investments and maintain a more efficient healthcare system. However, over time these laws have faced criticism for their potential to stifle competition, limit innovation, and hinder the evolution of a patient-centered healthcare system.

North Carolina and South Carolina represent two states that have been at the forefront of CON reform. North Carolina’s CON program dates to 1971. The program applies to a wide range of healthcare services, including hospitals, surgery centers, imaging centers, and home health agencies. In 2021, North Carolina amended its CON laws, raising the dollar thresholds for diagnostic centers, major medical equipment, and capital expenditures for new institutional health services. South Carolina has had a CON program since 1976 and applies to a similar range of healthcare services as North Carolina’s program. In 2023, South Carolina repealed its CON program altogether, except for nursing homes and the Medical University of South Carolina. This signifies a major victory for healthcare reform advocates who argue that CON laws are outdated and unnecessary.

Competitive Market Dynamics

 The evolving CON laws will bring about increased competition among healthcare businesses; as barriers to entry are lowered, new players can enter the market more easily. The heightened competition will force established providers to differentiate themselves through innovative care models, advanced technologies, and superior patient experiences. Although the changes to the CON laws are expected to have a positive effect in accessing care and lowering costs for patients, some challenges remain. The introduction of competition in some markets may have a detrimental effect on the more traditional care delivery systems, causing pressure to operate less financially favorable services. Businesses may also need to invest in new technology or training to comply with the new regulations, adding to the expense of expansion. However, in most circumstances, the new laws will promote competition and innovation in the market and encourage providers to continuously improve the quality and efficiency of their services. This competitive environment can lower prices and enhance care for patients, as businesses will be more focused on providing high-quality services at a lower cost due to the increased competition and innovation.

Streamlined Expansion Opportunities 

With the revision of CON laws in North Carolina and South Carolina, healthcare businesses will experience greater ease in expanding their operations. The updated regulations focus on encouraging competition, enhancing healthcare quality, and fostering innovation. By reducing the administrative burdens associated with obtaining CON approvals, businesses will be empowered to pursue expansion plans more efficiently and effectively. As a result, healthcare providers can improve access to care and invest in cutting edge technology and facilities. Healthcare business expansion will not only improve business opportunities in revenue generation, but also will yield positive economic implications. The increased investment in new facilities, technologies, and workforce expansion generates job opportunities, and consequently, has a ripple effect on job creation in supporting industries such as construction, IT, and hospitality.


 The changing CON laws in North Carolina and South Carolina elicit a transformative impact on healthcare businesses seeking expansion and characterize a growing momentum for healthcare reform. While streamlining the process for providers, these new laws foster a more competitive landscape, which drives innovation and improves care quality. Nonetheless, as these laws undergo transformations, healthcare businesses face both opportunities and challenges when it comes to expanding their operations. The intricacies of the evolving healthcare regulatory environment are complex; the contrasting approaches to CON laws in North Carolina and South Carolina highlight the dynamic nature of healthcare regulation and policymaking, particularly on the duality between regulation and innovation. As the healthcare industry continues to grapple with developing CON laws, stakeholders must collaborate to strike a balance between innovation, market competition, and the goal of delivering high quality, accessible healthcare for all.

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