Certificate-of-need laws remain one of the biggest regulatory forces shaping where and how ASCs can grow, and the landscape is shifting rapidly state by state. With courts pausing repeal efforts in some markets, others raising cost thresholds or carving out ASC exemptions, CON policy is increasingly influencing expansion strategy, competition and patient access nationwide.
Here are five key updates ASC leaders should know heading into 2026:
1. CON requirements still vary widely by state in 2026: CON laws, which regulate the development of healthcare facilities and services within specific geographic areas, remain in place across much of the U.S.
On Dec. 12, 2025, the National Academy for State Health Policy updated its database of CON laws, showing that 35 states and the District of Columbia, maintain CON requirements in 2026, while 15 states do not. With several legislatures actively reviewing CON policies this session, the state-by-state divide continues to shape where ASCs can expand without regulatory approval.
2. North Carolina’s CON repeal efforts have been paused amid ongoing legal challenges: North Carolina had originally planned to repeal its CON laws by the end of 2025, but a recent court ruling has halted those plans.
On Dec. 12, 2025, a North Carolina trial court upheld the constitutionality of the state’s CON laws, rejecting a years-long legal challenge arguing that the regulations create monopolies for incumbent providers. While broader repeal remains uncertain, the state continues to operate under an interim policy implemented Nov. 1, 2023, exempting ASCs in counties with populations over 125,000 from CON approval.
3. New York finalized CON reforms to raise cost thresholds and streamline review: Effective Aug. 6, 2025, the New York State Department of Health adopted revisions to its CON regulations to modernize oversight and reflect rising construction costs. The changes doubled the CON application threshold for general hospitals from $15 million to $30 million and increased the threshold for other facilities, including ASCs, from $6 million to $8 million. The revisions also expanded administrative and limited review eligibility, raised the architectural self-certification threshold to $30 million and exempted certain lower-risk renovation projects from full CON review.
4. Georgia carved out new exemptions for certain single-specialty ASCs: In 2024, Georgia advanced CON reforms that exempt certain single-specialty ASCs from CON review if they are owned by a single physician or practice, and remain below specified capital expenditure and operating room thresholds.
The reforms also allow non-owner physicians within the same specialty to practice in these centers and permit joint ventures with hospitals, including external management arrangements. The Georgia Department of Community Health is expected to issue additional recommendations that could lead to further policy changes.
5. CON repeal debates are intensifying as some states report post-repeal growth: While CON laws were designed to prevent unnecessary duplication of healthcare services, critics argue they restrict competition and favor large incumbent systems.
Montana, which repealed its CON law in 2021, has seen a 12.5% increase in the number of ASCs, home health agencies and inpatient addiction treatment centers, according to an October report from the Frontier Institute. Leaders say the repeal has lowered barriers to entry and expanded access to same-day surgical care, particularly in rural areas that previously lacked outpatient facilities.
