In 2023, three hospitals in Connecticut nearly closed their doors while state regulators debated whether a larger health system could acquire them. The sale eventually went through, but only after 16 months of regulatory standstill.
For patients in those communities, that wait was not a minor bureaucratic hiccup. It was a period of instability that threatened to strip already vulnerable communities of essential care.
Connecticut’s Certificate of Need (CON) law played a large role in the regulatory freeze experienced by those community hospitals. Originally designed in the 1970s, CON laws rapidly gained popularity throughout the United States. In response to rising spending on healthcare in the United States, these laws were designed to act as a pre-approval system for significant health care projects. By the early 1980s, CON laws had reached the height of their popularity, bolstered by a federal mandate. However, federal policy reversed in 1987, after which some states decided to drop their own CON programs.
Today, Connecticut is one of 35 states that still require hospitals and clinics to obtain state permission before opening new facilities, buying advanced equipment like MRI machines, or even closing or transferring services. In 2023, Connecticut’s CON program was reformed to include, among other changes, expanded transparency and notice requirements around applications, exemptions for replacement of equipment, and more significant oversight authority by the Office of Health Strategy.
Supporters claim CON laws protect patients by reducing rapidly rising healthcare expenditures and advocating for the allocation of resources in an equitable fashion.
This experiment has gone on for decades, yet the evidence shows no measurable impact on health care costs or access attributable to CON laws. Instead, by artificially constraining resources, patients are often denied standard-of-care.
Take prostate cancer: recent evidence suggests that, in the United States, including here in New England, only about one-third of patients receive the recommended imaging before biopsy. By contrast, the United Kingdom has adopted near-universal pre-biopsy MRI. It’s not hard to see why. In Connecticut, patients can wait four to six weeks just to be scheduled for an MRI, a delay that undermines timely diagnosis and treatment. Beyond the considerable financial expense, adding new MRI machines to address these wait times also entails a time cost, with Connecticut’s CON applications requiring a median of 211 days for approval.
To be sure, no one wants an unchecked “medical arms race” where hospitals buy expensive gadgets they don’t use. But the healthcare market has changed since the 1970s. Insurers, including CMS, negotiate prices much more aggressively, quality reporting is widespread, and health systems face significant financial hardship. In this context, CON is less a safeguard and more a barrier to entry: one that delays expansions into underserved areas, by discouraging smaller, more nimble firms from becoming viable competitors.
What would Connecticut look like without CON laws?
We don’t have to guess. States like Florida, Texas, and California have already rolled theirs back. The results are striking, including faster access to services, more competition, and no evidence of declining quality.
That doesn’t mean policymakers should step aside entirely. But rather than streamlining outdated restrictions, Connecticut needs new strategies that actively build health care infrastructure where its needed. The goal should be to encourage innovation and expand access, not slow it down.
Ezra Klein, the New York Times journalist, in his book Abundance, argues for a new kind of legislation, one no longer held down by scarcity. Rather than restrictive CON laws, we can imagine policies that actively subsidize the placement of infrastructure like MRI machines in low-resource areas. That’s the kind of future Connecticut citizens deserve: one built not on rationing and delay, but on abundance and access.
Shayan Smani does medical research at the Yale School of Medicine.