Certificate-of-need laws play a heavy hand in the development and expansion of ASCs and other medical practices across the U.S., and they vary drastically state-by-state.
Here are four updates to state-level CON laws since Jan. 1, 2026, as reported by Becker’s:
1. North Carolina’s ongoing legal battle over CON: A six-year-old legal conflict over the state’s CON laws was revived April 1 by an amicus curiae brief filed on behalf of Jay Singleton, DO, an ophthalmologist, and the John Locke Foundation, a free-market think tank based in Raleigh, N.C.
Dr. Singleton, owner of Singleton Vision Center in New Bern, N.C., originally filed a lawsuit in April 2020, alleging that under current law, he can only perform an “incidental” amount of surgeries, as state planners believed they had “no need” for his services around New Bern.
Dr. Singleton’s case was first dismissed June 11, 2021, in Wake County Superior Court. On Oct. 18, 2024, the state Supreme Court issued an unsigned, unanimous, four-page ruling that gave the case new life while leaving the question of CON laws’ constitutionality open. Dr. Singleton takes his case back to the high court this week.
In December 2025, a trial court upheld the CON laws, rejecting Dr. Singleton’s challenge. In the new filings, the foundation asks the state Supreme Court to use Dr. Singleton’s case to address the issues of “tiers of scrutiny” in dealings with constitutional questions in the state’s courts.
2. Tennessee’s vote on CON laws delayed: Legislators in Tennessee delayed a vote on a bill that would loosen the state’s certificate-of-need laws. The vote was originally set for March 30. Its sponsor, state Representative Johnny Garrett, a Republican from Goodlettsville, requested that the vote be pushed to the week following. If passed, the bill would go to the governor’s office for final approval.
Lawmakers are facing pressure to speed up the planned repeal of the law to avoid losing more than $200 million in federal funding for rural health initiatives. Every state submitted applications seeking a share of the $50 billion Rural Health Transformation program, which was launched in 2025. But CMS and President Donald Trump’s administration have tied some of that funding to certain policies at the state level, including the elimination of CON, according to the report.
Tennessee has had plans to repeal the 40-year-old law by Dec. 1, 2027, since 2024. When Gov. Bill Lee applied for the first round of the RHTF, he pledged that the legislature would eliminate CON by Jan. 1, which would require lawmakers to speed up their repeal efforts this legislative session.
3. Michigan weighs loosening CON: Michigan lawmakers are weighing legislation that would eliminate hospital outpatient facility fees and loosen certificate-of-need requirements for imaging services. House Bill 5709 would eliminate CON requirements for certain imaging services at outpatient centers. The MHA said the change could drive up costs and reduce access in rural and underserved areas by fragmenting service delivery.
4. Maryland’s dual CON reform bills: Companion bills in the Maryland Senate and House propose removing an exception to the state’s certificate-of-need laws. Under the bills, healthcare facility mergers would require a CON or Maryland Health Care Commission approval. Previously, those mergers could qualify for an exemption. The bills propose requiring healthcare entities to provide a 90-day notice to the commission before completing any merger, acquisition or material transaction.
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