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A Certificate of Need (CON), in the United States, is a legal document required in many state and some federal jurisdictions before proposed acquisitions, expansions, or creations of facilities are allowed. CONs are issued by a federal or state regulatory agency with authority over an area to affirm that the plan is required to fulfill the needs of a community. The concept of the Certificate of Need first arose in the field of health care and was passed first in New York in 1964 and then into federal law by the Richard Nixon administration in 1972. Certificates of need are necessary for the construction of medical facilities in 35 states and are issued by state health care agencies:
The certificate-of-need requirement was originally based on state law. New York passed the first certificate-of-need law in 1964, the Metcalf- McCloskey Act. From that time to the passage of Section 1122 of the Social Security Act in 1972, another 18 states passed certificate-of-need legislation. Section 1122 was enacted because many states resisted any form of regulation dealing with health facilities and services.
A number of factors spurred states to require certificates of need in the health care industry. Chief among these was the concern that the construction of excess hospital capacity would cause competitors in an oversaturated field to cover the costs of a diluted patient pool by over-charging, or by convincing patients to accept hospitalization unnecessarily.
In some instances where state and federal authorities overlap, federal regulations may defer authority from the federal agency to the state agency with concurrent authority as to the issuance of a certificate of need. However, deferment of this authority is not required. For example, the Department of Housing and Urban Development has issued the following determination:
HUD conducts the same analysis of need whether or not the state has a CON process. There is wide variation in the methods CON states use to decide whether or not to issue a certificate. HUD believes that the Act's required need assessment is best performed using a method that is applied consistently to hospitals in all states. Should the state's CON process and HUD's assessment of need reach differing conclusions on the need for a proposed project, HUD will review the case closely to determine if its conclusion should be changed.
Since new hospitals cannot be constructed without proving a "need," the certificate-of-need system grants monopoly privileges to already existing hospitals. Consequently, Alaska House of Representatives member Bob Lynn has argued that the true motivation behind certificate-of-need legislation is that "large hospitals are... trying to make money by eliminating competition" under the pretext of using monopoly profits to provide better patient care.
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