Recent trends in Certificate of Need (CON) regulation show states moving beyond traditional health planning metrics to emphasize health equity as a core requirement. While examining access challenges and health disparities has always been fundamental to sound healthcare planning, certain states are now codifying these considerations into their CON processes.
Through our regulatory consulting work at Ascendient, we've observed varying approaches to health equity requirements across state jurisdictions. Though New York's recent CON law revision represents perhaps the most sweeping reform, other states are making both formal and informal adjustments to their regulatory frameworks. These incremental changes signal a broader shift toward making health equity analysis a mandatory component of the CON process.
New York Requires Health Equity Impact Assessment
As of June 22, 2023, New York is requiring health service providers to commission health equity impact assessments alongside most CON filings. These assessments must be completed by an unaffiliated entity and require a thorough, data-driven summary of the proposed project's potential impacts on healthcare access, health equity, and health disparities.
New York’s assessment process mandates substantive community involvement through multiple channels including surveys, community forums, and stakeholder interviews, as well as gathering feedback from local health departments, community-based organizations, and residents.
The practical implications of this requirement are already evident in recent cases. Last year, St. Peter's Health Partners submitted a CON application to close the Burdett Birth Center at its Samaritan Hospital in Troy, NY, and was the first to commission a corresponding equity assessment. The assessment revealed that almost half of all newborns at Samaritan Hospital were from medically underserved populations, and that many mothers would have to double or even triple their travel distance to access alternative birthing locations for non-emergency deliveries – a significant burden in a market where many households do not own a car, and many more have only one vehicle.
The community's strong opposition to the closure, highlighted by the impact assessment, ultimately resulted in a $5 million state grant to subsidize the birth center. In exchange, St. Peter’s was required to develop a long-term sustainability plan for keeping the center open.
North Carolina Requires Culturally Competent Healthcare
While New York now requires health equity impact assessments, North Carolina has taken a different – but still significant – approach by focusing on culturally competent care its CON process. Policy Gen-5, which took effect Jan. 1, 2025, defines culturally competent care as “responsive, personalized care to individuals with diverse backgrounds, values, beliefs, customs, and languages.”
Under this framework, healthcare organizations must demonstrate concrete strategies for integrating cultural competence into their service delivery model. The policy mandates comprehensive demographic analyses of service areas, with particular attention to medically underserved communities. These analyses must examine multiple factors including age, gender, racial composition, ethnicity, languages spoken, disability status, education levels, household income, geographic location, and payor types.
The new policy applies specifically to CON applications for which there is a need determination in the North Carolina State Medical Facilities Plan (SMFP), and there are five key requirements. Applicants must:
- Describe service area demographics with specific focus on medically underserved communities.
- Outline strategies for providing culturally competent services.
- Document how these strategies reflect cultural competence.
- Provide evidence-based support demonstrating their strategies will effectively reduce health disparities.
- Describe methods for measuring and assessing increased equitable access and reduction in health disparities.
Notably, if the application is approved, the CON will come with conditions requiring the applicant to adhere to their described strategies.
This systematic approach transforms cultural competency from an aspirational goal into a potentially more enforceable requirement for healthcare service expansion in North Carolina.
Key Takeaways
As states continue to strengthen their focus on health equity in CON processes, healthcare organizations can take five proactive steps to prepare for new requirements.
- Conduct a comprehensive internal assessment of existing health equity-related policies: some text
- Review current policies (financial assistance, language assistance, disability accommodations, etc.).
- Compile existing initiatives and training programs focused on inclusion.
- Identify gaps that need to be addressed.
- Engage with internal stakeholders already doing this work: some text
- Connect with HR leadership on DEI and training initiatives.
- Consult community outreach teams on current health equity efforts.
- Meet with clinical and operational leaders about existing programs.
- Partner with data analytics teams on measurement capabilities.
- Map your organization's existing health equity data collection and analytics: some text
- Identify what health equity metrics you're already tracking.
- Review Community Health Needs Assessment (CHNA) and community benefit data, if applicable.
- When planning new projects or service changes, proactively analyze potential impacts: some text
- Assess travel times and transportation barriers and map effects on medically underserved populations.
- Consider alternatives when changes could reduce access.
- Create formal documentation of all health equity initiatives: some text
- Create an inventory of current health equity and cultural competency initiatives.
- Develop a framework for measuring their effectiveness.
- Prepare to demonstrate how these efforts align with evolving CON requirements.
Nikki Murdoch and Kim Meymandi contributed reporting and analysis to this post.
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