Certificate-of-Need Repeal Is a Win for Tennessee Patients
David Williams
June 15, 2026
This op-ed was originally published in The Tennessean.
Tennessee has made great strides in removing burdensome certificate-of-need (CON) laws that have limited access to vital health care for far too long. On May 5, Gov. Bill Lee (R) approved another major reform. Under the new law, acute care hospitals will be exempt from CON beginning in July 2030, allowing systems to meet growing patient needs without going through the restrictive regulatory process.
CON laws have been debated for years. The Taxpayers Protection Alliance (TPA) and the Institute for Justice (IJ) have long pointed out that these laws limit access to care. According to an IJ analysis, “For every [empirical analysis] associating CON laws with increased access, there are more than five associating it with diminished access.”
Those opposed to reform claim that tax-paying hospitals will harm charity care for underinsured and uninsured Tennesseans. The facts, however, tell a different story.
In 2024, TPA analyzed the charity care levels and payer mix – the breakdown of what kind of insurance patients use to pay providers, if any – of 16 medium and large Tennessee hospital systems. TPA found that tax-paying hospitals are among the leading providers of charity care in the state, including for patients with TennCare (Tennessee’s Medicaid program that provides free or low-cost health insurance to low-income individuals). By the numbers, tax-paying hospitals dedicated 26% of their total revenue to charity care compared to only 18% for nonprofit systems.
In fact, a tax-paying health system, HCA Healthcare, contributed the highest amount of charity care in proportion to revenue out of every other hospital on the list. On the other hand, several nonprofit hospital systems that strongly opposed CON repeal were at the bottom of the list of charity care providers in Tennessee.
Those numbers are consistent with other analyses of hospital charity care across the country.
According to a study published by experts at the Johns Hopkins Bloomberg School of Public Health, for-profit hospitals spent $3.8 for every $100 in total expenses incurred on charity care, while nonprofit hospitals spent only $2.3 for every $100. The authors state that their results “suggest that many government and nonprofit hospitals’ charity care provision was not aligned with their charity care obligations arising from their favorable tax treatment.”
This demonstrates that with more tax-paying hospitals at the table, Tennesseans could see an increase in charity care and access, proving that CON repeal could not have come at a better time. Nashville and surrounding counties are attracting new residents and employers, while health systems are facing pressure to expand services to meet the needs of patients in aging suburban communities and underserved rural areas.
These needs go beyond access points. New hospitals will need to offer the right services, expertise and resources to support patients with increasingly complex needs – including the Tennesseans in underserved rural areas who rely on hospitals to receive timely, high-quality care, regardless of their ability to pay.
All hospitals, regardless of tax status, are required to treat every patient who walks through their doors, and tax-paying hospitals are doing their part in meeting a level of demand that the current system is struggling to absorb. Pointing fingers at these hospitals, which have historically provided some of the highest levels of charity care in Tennessee, is counterproductive.
Policymakers’ focus must remain on increasing health care access. Now is the time to coalesce around Tennessee’s growing health care needs and equip the state’s providers with the resources to meet them.
As the state prepares for its next phase of growth, Tennessee leadership must prioritize patients by embracing opportunities that expand access and align the state’s health care infrastructure with ever-growing demand.