Certificate of Need (CON) programs represent a patchwork of state regulatory programs across the United States that regulate the availability of selected health care services. Thirty-six states maintain laws designed to ensure access to health care services, maintain or improve quality, and control capital expenditures on health care services and facilities by limiting unnecessary health facility construction and checking the acquisition of major medical equipment. This article discusses the history of CON and explores controversies surrounding the current state of CON regulations.