TriStar Summit Medical Center’s new 3-story patient tower in Hermitage, Tenn., was presented with CON regulations when adding 18 critical care beds, an updated visitor lobby and new cafeteria. | Photo Credit: Courtesy of Barge
By Michael Compton
Certificate of Need (CON) laws are regulations that require healthcare facilities to obtain state approval before expanding their practices, such as building new facilities, adding to existing facilities and offering certain services. The laws are designed to prevent oversupply in healthcare by limiting the unnecessary duplication of services and ensure communities have equitable access to healthcare services. CON laws were first mandated in 1974 through the National Health Planning and Resources Development Act, where states were required to adhere to them to receive federal funding.
More states are starting to reform or repeal CON laws, driven by growing demand for healthcare access and evidence that the CON is not curbing healthcare expansion like it intended to. With successful reform, healthcare providers can expect fewer regulatory hurdles such as streamlined approval processes for expansions and renovations, leading to increased demand for architectural and engineering services to support these projects.
Recent CON law reforms are moving healthcare project timelines forward to create more accessible care and develop healthcare design opportunities. With fewer regulatory hurdles, healthcare clients can shift more confidently from concept to groundbreaking to support a growing pipeline of new builds, expansions and renovations. For healthcare designers, staying up to date on changes to state-driven CON laws will be essential to maximizing the return on these reforms.
The Consequences of CON Laws
The main consequences of CON laws are delayed timelines and increased costs for new healthcare infrastructure projects. In states with CON laws, healthcare providers must obtain state approval before building new facilities, a process that can typically take months or even years, delaying critical infrastructure projects significantly. CON laws can also increase the cost of these important projects, with legal, administrative and consulting costs being added to project budgets. Further, CON laws often favor existing providers, reducing competition from newer entrants. The lack of competition could result in higher prices for care and reduced innovation.
Some states have more restrictive CON laws than others. In New York, the CON process governs not only the construction of new healthcare facilities, but also renovations, expansions and even the acquisition of major medical equipment. This means that if a hospital wants to add a new wing, upgrade its emergency department, or install advanced imaging equipment, they must first go through a lengthy CON review.
Today, 35 states maintain some form of regulation, with varying scopes that are becoming increasingly debated. The growing number of states imposing reforms indicates they are rethinking CON regulations to improve access and adapt to the evolving needs of healthcare. Twelve states have fully repealed or let their CON laws expire. Georgia, Iowa, Kentucky, Massachusetts, Nebraska, Oklahoma, Tennessee, Virgina, Washington and West Virginia passed multiple reforms between 2022 and 2024. In 2023, South Carolina repealed most CON laws applying to general hospitals and outpatient services. In 2021, Montana exempted all CON regulations but those for long-term care. Connecticut added targeted exemptions for specific services, like harm reduction centers, to allow for more responsive and community-focused care delivery.
CON reforms are helping to:
- Expedite project launches: Without CON restrictions, providers can skip lengthy approval processes — often taking months or years — and move directly into planning, design and construction.
- Allow for more flexible facility design: Providers can plan for services based on real-time community needs without having to resubmit plans for regulatory approval.
- Expand service offerings: Hospitals and clinics can add beds, open new departments, or acquire advanced equipment without waiting for state approval, allowing them to meet spikes in demand, such as during flu season or public health emergencies.
- Encourage innovation and competition: With fewer barriers, new entrants like urgent care centers, telehealth hubs, and specialty clinics, can enter the market more easily, increasing access and driving innovation in care delivery.
- Improve access in rural and underserved areas: In regions where CON laws previously blocked new facilities, reforms allow providers to establish care centers where they’re most needed, improving equity and access.
Private developers and healthcare providers have a clearer path into the market when fewer CON restrictions are in place. Projects may be approved faster, new technologies can be explored, and community needs can be met with heightened. Taking out the uncertainty of waiting for CON approval and extra costs associated with it makes healthcare infrastructure a much more appealing investment.
Addressing Population Demand
Fewer CON laws are allowing healthcare providers to respond more quickly to growing demands for equitable healthcare access, whether from population growth, shifting demographics, or urgent public health needs. A key challenge ahead is the projected patient bed shortage, driven largely by the baby boomer population and continued decline in hospital staffing.
For architects and designers, these reforms highlight the need to future-proof facilities with flexibility in mind, creating spaces that can quickly adapt to new technologies, expanded services and updated building codes over time. Telehealth integration is a key future-proofing strategy in healthcare design. Its rapid adoption during the COVID-19 pandemic has made it a lasting preference for many patients. Telehealth supports chronic care, mental health, and follow-up visits, especially in rural or underserved areas, while easing pressure on physical infrastructure and expanding access to care.
Responding To Emerging Trends: Specialty Centers and Freestanding Healthcare Facilities
Architects and engineers are seeing a rise in demand for healthcare facilities that are accessible and can offer flexible design options to accommodate various types of care or patients, such as urgent care centers, ambulatory surgical centers, and freestanding emergency departments, amid CON reform. For example, some facilities may be required to serve as patient rooms one day and chemotherapy infusion centers the next. These facilities call for highly tailored and customizable design strategies to create adaptable, sustainable and technology-enabled spaces.
As more providers invest in these facilities, designers are helping them to reimagine how care can be delivered, bringing specialized services into retail settings, suburban corridors, and underserved communities. Examples of specialized healthcare services architects are designing for include:
- Behavioral & mental health facilities
- Outpatient surgery centers
- Specialty clinics (e.g., oncology, cardiology, orthopedics)
- Telehealth & virtual care hubs
- Micro-hospitals & freestanding ERs
- Precision medicine & genomics labs
Opportunity for More Innovation
With fewer regulatory roadblocks, healthcare design innovation becomes a differentiator for providers to stand out from the competition and create environments that improve patient outcomes and streamline operations. CON reform gives healthcare design teams an opportunity to rethink spaces to help providers stay relevant in the market.
For example, providers are looking for environments that are efficient and modern, such as customizable modular design strategies and sustainable elements, such as natural lighting. Trends also focus on patient-centered and staff-focused design, such as quiet areas, staff safety, acoustic treatments, and streamlined workflows, that promote wellness and clinical outcomes. Providers can differentiate themselves by designing environments that elevate the patient experience, boost operational efficiency, and embody a forward-thinking brand rooted in future-readiness, sustainability and wellness.
As CON laws continue to shift, architecture and engineering firms that stay informed and ready to respond will have the edge in bringing new projects and design strategies to the industry.
Michael Compton is a board-certified healthcare architect and leader with Barge Design Solutions in Florida and can be reached at michael.compton@bargedesign.com.