A recent court case in Missouri illuminated the convoluted nature of certificate of need (CON) laws, showing again that the 35 states maintaining this counterproductive legislation would do well to eliminate it.

These protectionist laws enable healthcare businesses to shut competitors out of their market simply by convincing regulators that no other medical services are needed in the area. As this case illustrated, even when petitions for a permission certificate prove successful, the befuddling legal procedures waste time and money.

Show-Me State CON

Missouri has 91 individual CON restrictions, so any provider hoping to operate there faces a labyrinth of barriers. One rule requires a facility to obtain a certificate before purchasing a piece of medical equipment costing more than $1 million. This particular stipulation turned a simple attempt to provide cancer treatment into a bewildering legal battle. 

Timeline Of Confusion

In the summer of 2022, Missouri’s Northeast Regional Medical Center (NRMC) ended its radiation oncology services when it retired the linear accelerator necessary for the procedure. This left some patients with a 200-mile round trip for treatment. But, in October of that same year, nearby Hannibal Regional Medical Center received zoning approval to open a radiation center.

On May 29, 2024, Hannibal Regional filed a letter of intent to buy a linear accelerator, which they estimated would cost $7 million—enough to require a CON—for their proposed facility. During the June 2024 session, the legislature granted $15 million in tax funding for the center, and then-Gov. Mike Parson signed the spending bill on June 28.

On June 17, NRMC announced its intention to offer radiation again. According to Hannibal Regional President Todd Ahrens, his organization just became aware of NRMC’s intention shortly before Hannibal Regional applied for its own accelerator’s CON.

Next comes perhaps the oddest twist in the series.

On Sept. 25, Missouri resident Tina Binder filed a lawsuit challenging Hannibal Regional’s $15 million award, stating that it should not have been granted prior to a CON procurement. In response, a judge granted a temporary restraining order (TRO), halting the progress on the new center.

Also on Sept. 25, NRMC announced they had secured the purchase of a used accelerator, which would cost less than the $1 million CON cost threshold. 

Binder has no evident ties to either side and says she is “just a regular old taxpayer concerned about taxpayer dollars.” She filed the suit after an NRMC lobbyist spoke to her, and she admittedly said she has little understanding of the issue. 

On Oct. 1, Hannibal Regional received its CON. The lawsuit over the original grant, however, still had to proceed. But finally, on April 7, 2025, Judge Cotton Walker found in favor of Hannibal Regional, saying a CON had never been needed for the original funding. According to Walker, the center’s plans did not fall under the state’s CON requirements. 

Summary

The preceding was just a very truncated version of the staggering list of legal proceedings undertaken to open a simple medical facility. Numerous serious issues with CON legislation should be apparent.

Most importantly, allowing one business legally to prevent competition is tax-funded monopoly building. No excuse can justify the existence of such laws, especially in health care. 

Furthermore, having 91 arbitrary and complex rules for permission slips that have nothing to do with safety defies logic. 

Finally, although a concerned citizen undertook this lawsuit to ensure proper use of tax dollars, she ultimately understood little about what she was fighting. In their dealings with her, a medical business used methods that seem questionable, at best. And CON law allows this all to happen in 35 states, at taxpayers’ expense.