Ophthalmologist Jay Singleton has performed more than 30,000 eye surgeries in his career. For more than 20 years he’s run a vision center in New Bern, where patients receive routine checkups and treatments for eye disorders. But for most of his career, Singleton performed his surgeries inside the local hospital, CarolinaEast Medical Center.
Singleton thought he should be able to perform outpatient surgeries out of his vision center, where he spent years buying equipment and undergoing renovations for that purpose. He could also offer much lower prices than what patients are charged for procedures at the hospital.
However, North Carolina’s law required Singleton to first receive a certificate of need before he could offer surgeries at his vision center. That was an impossibility for him, because the state Department of Health and Human Services hadn’t determined a need for additional operating capacity in Craven County.
[Subscribe for FREE to Carolina Public Press’ Daily, Weekend and Election 2026 newsletters.]
“You can't even get your foot in the door to ask for something if you don't have (a need determination),” Singleton told CPP.
“I've tried to walk the pathway, and it does not work, and it does not work for anybody,” he continued.
“The people that they've given certificates of need to are always hospitals.”
So, in April 2020 Singleton sued the state, seeking to circumvent its bureaucratic planning process by arguing that it violated the state’s constitutional protections from monopolies and special privileges.
“In truth, banning Dr. Singleton from offering surgeries to all patients at his clinic serves one purpose only: protecting established providers from competition,” his complaint stated.
This is the final installment in Battling for Beds, a three-part investigative series by Carolina Public Press about how certificate-of-need disputes have hampered the state’s ability to meet healthcare needs in its fastest-growing communities.
This article will explore the various legal and legislative attempts to repeal the law, as well as possibilities for more targeted reform to the current system.
The first article in the series investigated the extent to which legal delays have undermined the state’s healthcare planning process. The second article analyzed the effectiveness of certificate-of-need laws and examined how they’ve been exploited to benefit incumbent hospitals.
Unique history with legal challenges
Singleton isn’t the first North Carolina doctor to be the face of a legal challenge to certificates of need.
In 2018, Winston-Salem surgeon Gajendra Singh sued over the state’s certificate-of-need laws in a case very similar to Singleton’s.
Singh owned and operated Forsyth Imaging Center, which offered cheaper, upfront pricing for things like MRI scans. But Singh couldn’t purchase a fixed MRI scanner without a certificate of need, so his center rented mobile units instead, which were more costly and less convenient.
Singh’s lawsuit seemed to be on a positive track after a superior court judge rejected the state’s motion to dismiss in late 2019. However, the case fell apart in the following months after Singh closed his imaging center because of financial challenges.
Singleton filed his lawsuit soon after, and it has been on a long journey up and down the court system since.
A trial court judge dismissed Singleton’s case in 2021, agreeing with the state’s argument that his claims weren’t legally valid. However, on appeal the state Supreme Court reversed, ruling that Singleton’s claims challenged the certificate-of-need laws on their face rather than narrowly pertaining to his own situation.
Because facial challenges must be heard by a three-judge panel, the case was sent back down to be re-litigated by a lower court. In December 2025, a panel of judges in Wake County rejected Singleton’s claims and upheld the state’s certificate-of-need law. Singleton’s lawyers appealed again, and the case now rests with the NC Court of Appeals.
In keeping with the convoluted nature of the case, the state’s attorneys argued to the three-judge panel that Singleton could have operated without a certificate of need this whole time, and that his facility wouldn’t be considered an operating room under their interpretation of the law.
This was an assertion that Singleton and his attorneys say hadn’t been made by DHHS previously. Singleton told CPP he stopped performing surgeries at CarolinaEast hospital and began offering them in his facility earlier this year, although he is continuing his bid to overturn the state’s certificate-of-need law.
There’s little doubt the case will eventually make its way back to the NC Supreme Court, according to Renée Flaherty, an attorney for the Institute for Justice — the libertarian think tank that championed Singleton’s case, and Singh’s lawsuit before that.
“Hopefully, we'll be back at the Supreme Court within a year or so, but it's always hard to predict,” Flaherty said. “These things move slowly.”
Outside North Carolina, there’s little precedent of a certificate-of-need law being successfully challenged in court.
In 1973, the state Supreme Court struck down the first iteration of North Carolina’s certificate-of-need program, finding that it was unconstitutional. The laws were brought back in 1978 under a different framework, and they’ve been in place since. The revised law has never faced a significant constitutional challenge until now.
“Around the country, there have been a lot of unsuccessful challenges to C.O.N. laws, unfortunately, most of them at the federal level,” Flaherty said.
“But we brought it in the only state that's had the courage to strike one down so far, so hopefully they'll do it again.”
Hospital industry defensive as lawmakers mull changes
Benton Sawrey was one of the lawyers who helped with Singleton’s case, serving as local counsel to the Institute of Justice, but he didn’t stay on for long.
In 2022 Sawrey was elected to the state Senate as a Republican representing Johnston County. He withdrew from the Singleton case, but in the years since he’s emerged as a leading proponent of certificate-of-need reform in Raleigh.
North Carolina is relatively unique in the restrictiveness of its certificate-of-need program, which requires reviews for 23 types of medical services, significantly more than most other states.
Meanwhile, the legislatures in bordering states like Tennessee and South Carolina have taken steps to rollback part or all of their certificate-of-need laws in recent years. New Hampshire was the last state to enact a full repeal in 2016.
In April 2025, Sawrey sponsored a bill that would repeal nearly every aspect of the state’s certificate-of-need law. Despite fierce opposition from the state’s hospital lobby, the bill passed the Senate with the support of every Republican and two Democrats: Julie Mayfield of Asheville and Dan Blue of Raleigh.
Although the repeal bill didn’t go anywhere once it reached the House of Representatives, Sawrey viewed the Senate vote as a sign of growing appetite among lawmakers for a significant change.
“More legislators are certainly coming around to the idea of a major overhaul of the certificate of need process,” he told CPP.
Each of the Democrats who supported the bill represent parts of the state that have been affected by delayed hospital projects. DHHS has approved hundreds of new hospital beds to be built in these growing areas, but the process of actually putting those beds into service has been stalled by litigation between competing hospital systems.
Sen. Mayfield, D-Buncombe, told CPP that her vote in favor of the repeal bill was based solely on the lack of hospital competition in her district.
“The C.O.N. process has prevented us in this region from having a real competitor to Mission Hospital,” Mayfield said.
“The thinking at the time was if we did away with C.O.N., then Advent could build the hospital that it wanted to build, and likewise UNC could build the hospital that it wanted to build, and Novant could build the small hospital that it wants to build.”
Ironically, none of those three systems have much interest in overhauling the current system. The North Carolina Healthcare Association, which represents the interests of hospitals, has consistently opposed any change to the state’s certificate-of-need program.
The lobbying group argues that certificates of need are essential to providing financial stability as many hospitals, particularly rural ones, face growing economic headwinds. Those include federal cuts to Medicaid and the rising costs of providing care.
Josh Dobson, a former state labor commissioner and Republican member of the state house of representatives, has led the NCHA since 2024.
In speaking to lawmakers, Dobson said he frames the issue as a matter of protecting rural hospitals. During his time as a legislator, he represented McDowell County, which is home to a community hospital owned by the Mission Health System.
“In those rural areas in particular, hospitals are not just a place you go when you get sick — they are economic anchors in those communities,” Dobson told CPP.
“My argument is: if you want to keep your rural hospital, if you want to keep the services that your rural hospital is able to provide, let's not make it more difficult for those hospitals to operate considering all the other challenges that we have.”
In response, Sawrey questioned whether sufficient demand even existed for competitors to come in and drive rural hospitals out of business.
“I understand that North Carolina has its unique challenges with a large rural population, but I don't think that a for-profit hospital system is going to go set up shop in an already struggling rural area and compete with a rural hospital system,” he said.
“Where you'll see the (increased) competition and access apply is especially in your suburban and urban areas, which will eventually trickle out and benefit the entire state as a whole.”
Piecemeal reform chips away
The push for reform has made small gains as larger debates about the certificate-of-need law play out in the courts and legislature.
The 2023 Medicaid expansion bill eliminated certificate-of-need requirements for psychiatric facilities and addiction treatment centers, and it also increased the cost thresholds that trigger certificate-of-need reviews for certain medical equipment.
Finally, the bill eliminated certificate-of-need reviews for ambulatory surgical centers and MRI scanners in counties with populations greater than 125,000 people. Those exemptions were scheduled to take effect starting at the end of 2025 and 2026, respectively.
More recently, the budget bill passed earlier this year included a provision that exempted inpatient rehabilitation services from certificate-of-need review, starting in October.
Sawrey said that type of piecemeal approach to reform is helpful in some ways, but he’d prefer to see a “larger, global conversation” on the issue.
“We're still keeping some of the big parts of certificate of need in place without addressing some of the underlying issues that C.O.N. is exacerbating,” he said.
Part of North Carolina’s Congressional delegation is also wading into the issue. On Monday, Sept. 14, a subcommittee of the House Judiciary Committee focusing on “Administrative State, Regulatory Reform, and Antitrust” conducted a field hearing in Charlotte in which they discussed, among other topics, certificate-of-need reform.
Several Republican members of North Carolina’s delegation were in attendance, but Democrats on the subcommittee skipped the meeting, according to reporting from Business NC.
Hospital industry shrugs off legal delays
Perhaps the largest untouched issue is legal delays which have stalled the deployment of new hospital beds and other needed equipment.
Previous installments of this series revealed that the state has struggled to add new hospital beds to meet demand in growing areas, because competing health systems continue to trap those projects in lengthy appeals processes.
Sawrey said he’s “very much concerned” about those delays. One example he pointed to was a certificate-of-need fight between Duke Health and WakeMed, which for three years stalled WakeMed’s acquisition of a linear accelerator to treat cancer patients at its oncology center.
“The process isn't working the way it should,” Sawrey said.
“There's clearly a demand for WakeMed to have a linear accelerator …. They should be able to make these investments without these delays and provide service to their patients, because at the end of the day it's about getting care to the patient.”
In contrast to Sawrey’s perspective, WakeMed itself supports the state’s certificate-of-need law, according to spokesperson Kristin Kelly.
Kelly told CPP that WakeMed wouldn’t comment on its appeal fight with Duke Health, but offered an enthusiastic defense of the current certificate-of-need law, arguing that it “promotes healthy and fair competition while working to keep health care costs low.”
WakeMed isn’t blameless when it comes to contesting competitors’ projects via appeal, having done so with approved expansions at Raleigh hospitals belonging to UNC and Duke. To date, DHHS has approved more than 300 new hospital beds in Wake County that have remained undeveloped because of litigation between the three health systems.
UNC Health, Duke Health, AdventHealth and Novant Health all affirmed their support for the state’s certificate-of-need laws in email responses to questions sent by CPP. All four have spent time on both ends of the appeals process involving various certificates of need.
“AdventHealth doesn’t automatically appeal whenever an outcome is unfavorable,” spokeswoman Victoria Dunkle said.
“For example, after AdventHealth was not awarded a PET scanner in Buncombe County, we assessed the circumstances and determined that an appeal was not in the best interest of the community. Each decision is guided by what will best serve the people who rely on our healthcare system.”
Exploring solutions beyond a full repeal
Mark Hall, a professor of health policy at Wake Forest Law, suggested that addressing problems with the state’s certificate-of-need program doesn’t need to be an all-or-nothing approach, and that a blanket repeal of the law could actually help to further stifle competition in areas with one dominant system.
“If you just got rid of it and said, ‘Let competition take over,’ there's a good chance that you'll have somewhat of a free for all,” Hall said.
“Who's likely to get the jump on that gun, so to speak? Probably, it's going to be the large, established hospitals.”
In place of a full repeal, Hall said the state could amend its decision-making process to favor new competitors over incumbents.
Access to a new provider is already a factor that DHHS takes into account when weighing certificate-of-need applications, but it is primarily used as a tiebreaker, Hall said. Larger incumbents with a greater scope of services still often get an edge over prospective newcomers.
As far as limiting appeals and delays to approved projects, Hall suggested that a challenger to an approved project could have to pay for the financial consequences of the delay if their appeal isn’t successful.
Under the current law, appellants already must post a bond which may be worth up to $300,000 in the case of large projects, but the challenger only loses that money if a judge rules their appeal to be “frivolous” or “intended to cause an unnecessary delay,” which is exceedingly rare.
Making the financial risk more severe “might make challengers think a little more carefully about how strong their case is and how important it is to make a challenge,” Hall said.
Noting the increasing numbers of hospital beds and other medical equipment getting entangled in long legal fights, Sawrey said it's become clear the current planning process has become untenable.
“The only people winning are lawyers that litigate these issues,” Sawrey said. “I just don't see a lot of advantage for the state or the patients at the end of the day.”
This article first appeared on Carolina Public Press and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.