North Carolina, Tennessee, South Carolina, Nebraska and Delaware have all moved this cycle to scrap or loosen certificate-of-need laws — joining Montana and Georgia, which cleared similar reforms in earlier cycles.
As of its most recent update, the National Conference of State Legislatures counts 35 states and Washington, D.C., still maintaining some form of CON law, but the political momentum has been toward fewer barriers, not more.
However, a smaller group of states has moved the opposite way this year, adding new licensing hurdles, upholding existing restrictions in court or quietly widening the fees and reporting burdens that come with running an ASC.
Here’s where the ground is getting harder, not easier:
North Carolina. The state most associated with CON repeal is also the one that just handed regulators a win. On Dec. 20, 2025, a three-judge panel unanimously upheld North Carolina’s CON law against a constitutional challenge from New Bern ophthalmologist Jay Singleton, who was denied approval to dedicate an operating room to complex eye procedures because the state found no unmet need in a market it said already had 80 operating rooms across nine providers. The ruling keeps CON intact while the state’s planned near-total repeal, set to phase in through January 2026, with an interim exemption limited to ASCs in counties over 125,000 people, works its way through the legislature. Mr. Singleton’s attorneys plan to appeal to the state Supreme Court, so the fight over how far repeal actually reaches isn’t over.
Massachusetts. Gov. Maura Healey’s market-oversight law, H.5159, closes a door that independent physicians had been using to build surgical capacity without going through ASC licensure. Starting Oct. 1, 2025, any office-based practice performing liposuction or procedures involving more than minimal sedation, a category that covers plastic surgeons, dermatologists, oral surgeons and ophthalmologists doing in-office cases, must obtain a state license from the Department of Public Health or face fines of up to $10,000 a day.
New Jersey. Assembly Bill 5809, signed in July 2025, lowered the state’s ambulatory care facility assessment rate from 2.95% to 2.5%, but the same law eliminated the $350,000 annual cap on the assessment and, starting in 2026, extends it to facilities earning under $300,000 a year and to one-room surgical practices that were previously carved out. Smaller and newer centers, the ones with the thinnest margins to absorb a new fee, are the ones picking up the difference.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
