In November of 2024, I discussed a rising lawsuit challenging North Carolina’s Certificate of Need (“CON”) program, which requires state approval for health care providers to expand into other markets or make improvements to capital infrastructure.[1] In April of 2020, Dr. Jay Singleton brought a suit against North Carolina’s current CON program under “the Monopolies Clause, Exclusive Emoluments Clause, and Law of the Land Clause of the North Carolina Constitution.” These were the same constitutional bases by which the previous CON system had been stricken down in 1973.[2] Considering this historical basis, the North Carolina Supreme Court permitted Singleton’s challenge to the CON program and remanded the issue to the Wake County Superior Court.[3]
Facing a three-judge panel consisting of Republican Judges Jeffrey Foster and Troy Stafford, and Democratic Judge Jacqueline Grant, the bench ruled unanimously against Dr. Singleton.[4] In particular, the court’s opinion found that the CON law served the public interest and did not monopolize healthcare accessibility, as New Bern residents near Dr. Singleton’s location could access “80 operating rooms from nine different providers in the wider region.”[5] Now, the substance of Dr. Singleton’s constitutional claims will make their way up the state appellate ladder, and his counsel “look[s] forward to taking this fight back to the North Carolina Supreme Court, which [they] expect will treat the CON law with the genuine skepticism it deserves under the North Carolina Constitution.”[6]
From the judicial path, it appears that it may be another few years before the fate of North Carolina’s CON program is decided. However, recent legislative efforts have reignited the debate around the effectiveness of the modern CON program. Introduced by Republican Senators of the 2025-2026 Session, S.B. 370 repeals the entirety of the state’s CON laws from the healthcare system.[7] Currently, S.B. 370 has passed the Senate, and is now under review by the House Committee on Rules, Calendar, and Operations of the House.[8] Previously, efforts to limit or remove the CON system were denied by Republican House leadership. Critics argued that aggressive lobbying from the hospital industry had stymied needed reform.[9] Now, however, House Speaker Destin Hall could shake up the chances for CON reform to pass the house.[10]
Looking to our neighbors, North Carolina could follow the significant CON reform that South Carolina passed with the 2023 State Health Facility Licensure Act (the “Act”).[11] The Act removed the need for a CON for almost all healthcare facilities in South Carolina, except for hospitals and nursing homes.[12] The Act still requires a CON for hospitals when there is a change in the number of beds, or if there is a change in the classification of bed licensure.[13] However, South Carolina instituted a sunsetting rule on hospitals, eliminating these CON requirements for hospitals on January 1, 2027.[14] As South Carolina’s legislative efforts have shown, a gradual change away from CON regulations may be the answer for lowering some of North Carolina’s healthcare costs. South Carolina’s sunsetting rule allows smaller healthcare providers to expand without CON requirements. This would allow smaller providers, like Dr. Singleton, to branch out before major hospital expansions.
From an economic perspective, this rise of supply is a meaningful step toward lowering state-wide healthcare costs. However, the meaningful benefits of removing CON regulations will likely not be seen till years after repeal. For instance, the Institute for Justice has compiled numerous studies on CON regulations nationwide, finding that hospital charges in states without CON laws are “5.5% lower five years after repeal.”[15] In comparison, hospital expenditures are “20.6% higher per capita in states with CON laws.”[16] Of course, differing changes to various CON statutory constructions will vary in cost effectiveness. For this reason, South Carolina created a six-member CON Study Committee with the State Health Facility Licensure Act, reporting on the quality and quantity of healthcare access in rural areas.[17]
Overall, the North Carolina General Assembly’s new political makeup is more likely to reform the state’s controversial CON program. Though Dr. Singleton’s constitutional challenge is facing a long road to the North Carolina Supreme Court, his lawsuit has reignited an important debate on the effectiveness of the current healthcare system. Hopefully, North Carolina will follow in South Carolina’s footsteps, reducing medical costs and increasing healthcare accessibility to rural communities.
[1] Spencer Lewis, Don’t fall for the CON: A Challenge to North Carolina’s Certificate of Needs, Wake Forest L. Rev. (Nov. 14, 2024), https://www.wakeforestlawreview.com/2024/11/dont-fall-for-the-con-a-challenge-to-north-carolinas-certificate-of-needs/; S.B. 993, 1977 Gen. Assemb., Reg. Sess. (N.C. 1978).
[2] Singleton v. N.C. Dep’t of Health & Hum. Servs., No. 260PA22, 2024 WL 4524680, at *1 (N.C. Oct. 18, 2024); see In re Certificate of Need for Aston Park Hosp., Inc., 193 S.E.2d 729, 735–36 (N.C. 1973) (“we hold that G.S. s 90—291 is a deprivation of liberty without due process of law . . . [s]uch requirement establishes a monopoly in the existing hospitals contrary to the provisions of Article I, s 34 of the Constitution of North Carolina and is a grant to them of exclusive privileges forbidden by Article I, s 32.”).
[3] Singleton, 2024 WL 4524680, at *1.
[4] Jane Winik Sartwell, Judges reject arguments against NC Certificate of Need law, Carolina Public Press (Dec. 15, 2025), https://www.northcarolinahealthnews.org/2025/12/24/judges-reject-arguments-against-nc-certificate-of-need-law/.
[5] Id.
[6] Id.
[7] S.B. 370, 2025–2026 Gen. Assem., Reg. Sess. (N.C. 2025).
[8] H.B. 455, 2025–2026 Gen. Assem., Reg. Sess. (N.C. 2025).
[9] Grace Hayba, Cost vs. care: NC bill renews debate over certificate of need laws, WRAL News (Apr. 25, 2026, 10:40 AM), https://www.wral.com/lifestyle/health/nc-bill-debate-certificate-need-laws-april-2025/.
[10] Id.
[11] S.B. 164, 125th Gen. Assemb., Reg. Sess. (S.C. 2023).
[12] Id.
[13] Id.
[14] Id.
[15] Jaimie Cavanaugh and Matthew D. Mitchell, Striving For Better Care: A Review of Kentucky’s Certificate of Need Laws, Inst. for Just. 21 (Aug. 2023).
[16] Id.
[17] S.B. 164, 125th Gen. Assemb., Reg. Sess. (S.C. 2023).
