With no certificate-of-need law, a fast-growing population and a regulatory environment that has historically favored outpatient development, Texas is one of the most active ASC markets in the country
Here is where things stand.
1. Texas is a free-market ASC state
Texas has no certificate-of-need law governing ASC development, a structural advantage that has made it one of the most active development markets in the country.
According to L.E.K. Consulting’s 2024 ASC Insights Study, states without CON regulation consistently logged compound annual growth rates of 2% to 4% in Medicare-certified ASC development between 2019 and 2023, among the higher brackets nationally.
According to 2021 data, Texas has the second-most ASCs in the nation, with 497. The combination of population scale, regulatory openness, and physician entrepreneurship has made Texas a recurring destination for new ASC development and acquisition activity. Texas, North Carolina, Florida and Virginia were named the four best states to start a business in 2025, according to CNBC.
Additionally, major operators have treated the state as a growth priority. Surgery Partners and Baylor Scott & White Health formed a joint venture to co-own Physicians Centre Hospital, a 16-bed physician-owned surgical facility in Bryan, Texas.
2. New development continued through 2024 and 2025
Texas has remained a popular choice for leaders breaking into the outpatient surgery market. Becker’s reported on 11 ASCs that opened or planned to open in Texas in 2024 alone, including new facilities from SuraVision in Houston, Austin Regional Clinic, Kelsey-Seybold in Webster and Katy, Peterson Health in Kerrville, and UT Health in San Antonio.
In 2025, Texas added two new ASC openings tracked by Becker’s. Major health systems including Baylor Scott & White and St. David’s HealthCare, a subsidiary of HCA Healthcare, continued expanding their ambulatory footprints across the state.
3. Texas is the epicenter of the most significant ASC antitrust case in recent memory
The state’s free-market environment is also home to an enforcement action that has drawn more national attention than any other in the ASC space. The FTC alleged in a September 2023 lawsuit that U.S. Anesthesia Partners and its private equity backer Welsh, Carson, Anderson and Stowe executed an anticompetitive scheme to consolidate anesthesiology practices in Texas, buying up almost every large anesthesia practice in the state to create a single dominant provider that could demand higher prices.
The FTC settled with Welsh Carson in January 2025, requiring the firm to limit its involvement with USAP and notify regulators of future acquisitions. USAP reached its own agreement in principle with the FTC in April 2026, with a federal court staying the case in May while USAP implements required relief over 180 days.
A class-action lawsuit against USAP expanded in February 2026 to include patients who received care in ASC settings, adding a private litigation layer to the ongoing federal enforcement action.
4. Texas was also a focal point of the Ascension-AmSurg FTC consent order
Texas appeared again in the most significant ASC transaction of 2025. When the FTC issued its consent order requiring Ascension to divest seven AmSurg ASCs before closing its $3.9 billion acquisition, Waco, Texas, was among the five metropolitan areas identified as markets where the combination would substantially reduce competition. The consent order reflects the FTC’s position that ASC competition is a local, market-by-market question, and that Texas markets are competitive enough to warrant protection.
5. Texas ASCs are ground zero for a new federal prior authorization pilot
Texas is one of six states included in CMS’ Wasteful and Inappropriate Service Reduction model, which took effect January 1. The WISeR pilot requires prior authorization for select services including electrical nerve stimulator implants, epidural steroid injections, percutaneous vertebral augmentation, and image-guided lumbar decompression, which are procedures that represent meaningful volume for spine and pain management ASCs across the state.
CMS will use AI-assisted and clinical review to process authorizations and plans to introduce a “gold carding” exemption for high-approval providers in 2026. The pilot runs through 2031, making Texas a long-term testing ground for a model that could reshape prior authorization nationally if CMS expands it.
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.
