Hover a state to see its grade display. Click on a state to see detailed scoring information.


MergerWatch assigned a grade to each state based on how useful its state hospital oversight laws – called Certificate of Need or CON laws – are in protecting community access to needed health care. A robust CON law ensures that the affected community is notified about a proposed hospital merger and has an opportunity to comment, and requires state regulators to consider those comments and the potential impact on patients’ access to care if the merger were approved.


The MergerWatch Project conducted a review of the laws in each state that regulate proposed hospital transactions, such as mergers, acquisitions and closings. These laws are generally referred to as Certificate of Need (CON) programs, although the name may be different in some states (such as Determination of Need in Massachusetts). We developed a list of key policies within these CON laws that are essential to ensuring that the potential impact of a transaction on community access to care is considered, and that affected consumers are engaged in the review process. We then evaluated whether these key policies were present in each state’s CON program and assigned a point grade from 4 to 0, depending on whether the policy was robust, weak or non-existent. Those policies that we determined to be especially important to achieving an effective hospital oversight system were given extra weight in our grading system. The grades given to each state were assigned based on the weighted score. MergerWatch recognizes that some states conduct oversight of proposed hospital transactions under laws other than Certificate of Need, a few of which our outlined in the report. California is the only state without a Certificate of Need program that we included in our grading system because its Attorney General Review process so closely mirrors CON. By narrowing our focus to Certificate of Need, we were able to compare a specific type of program among different states.


Download our report: When Hospitals Merge: Updating State Oversight to Protect Access to Care.