Imagine having to ask your competitors for permission to open a new business: a corner café, a diagnostic clinic, or a surgical center. For decades, that was the reality in South Carolina health care. Certificate of Need (CON) laws gave entrenched hospital systems the power to contest new outpatient facilities, imaging centers, and physician-led ventures. It stifled competition, raised costs, and preserved the status quo.

That era is ending. In 2023, the South Carolina legislature repealed most CON requirements. By 2027, all remaining hospital CON provisions will be gone. This is more than a regulatory shift; it is a once-in-a-generation opportunity, if physicians choose to act.

CON laws did not protect patients; they protected monopolies

For years, CON was defended as a way to reduce overcapacity and control costs, but in practice, it functioned as a moat around hospital monopolies. Independent physicians and entrepreneurs faced long, expensive, and adversarial hearings just to expand services or open a new facility. This protected incumbents, not patients. When Governor McMaster signed Senate Bill 164 into law, the landscape began to shift. The CON repeal, with limited exceptions for nursing homes and hospitals through January 1, 2027, cleared the path for competition, access, and innovation.

But the law doesn’t guarantee a better future; it only removes the barrier. What happens next is up to us.

The evidence for repeal is clear and promising.

Nationwide data shows that repealing CON laws increases access without triggering the hospital closures critics often predicted could happen due to financial malfeasance and outdated business models unrelated to CON laws. One analysis found ASC growth surged by 44-47 percent statewide, and up to 112 percent in rural areas, after CON repeal. Other studies confirm more facilities, not fewer beds. Here in South Carolina, we’re already seeing the effect:

• Over 80 ambulatory surgical centers are now licensed statewide.
• New investments are rising post-repeal.
• Updated rules mandate quality oversight, indigent care commitments, and hospital transfer agreements, balancing accountability with flexibility.

According to Mercatus projections, full repeal could increase South Carolina’s hospital count from 82 to 116, including nine new rural hospitals. The data is clear, and the door is open.

The danger now: hesitation

Hospitals know what’s coming. Most are engaged in planning and building new projects before the 2027 cutoff, staking out territory before true competition arrives. If independent physicians and aligned investors wait too long, they risk missing the window. Hospitals may stop building after 2027, satisfied with their expanded footprint. Once those new systems are in place, they will dominate the next decade. This moment requires urgency, not just from policymakers but from physicians.

We have seen this before, and we have seen how it ends.

South Carolina has learned the hard way what happens when momentum is wasted. The V.C. Summer nuclear collapse showed us that infrastructure projects, even those born of good intentions, can fail spectacularly without clear leadership and accountability. In other states, partial CON repeals led to early expansion, but it was hospital systems, not independent doctors, who seized the advantage. Physicians in South Carolina have a narrow window to lead. That means stepping into roles as owners, founders, collaborators, and community-based innovators.

This is not anti-hospital; it is pro-choice.

We need hospital systems. They are essential for complex care and emergencies. But we also need diversity in how and where care is delivered. A stronger, more resilient system includes:

• Physician-led birthing centers
• Outpatient specialty hubs
• Micro-hospitals
• Hybrid models that blend insurance, cash-pay, and direct employer contracts

When physicians lead these efforts, the result is often more affordable, more agile, and more connected to local needs.

What happens next is up to us

Here’s what I believe:

• Physicians must act, especially those who have long seen the gaps in access, efficiency, and affordability. If we don’t move, someone else will.
• Investors should partner with doctors, not systems, to co-create care models that are rooted in trust, autonomy, and clinical excellence.
• Policy leaders must protect choice by ensuring rural access, requiring transparency, and rejecting efforts to reintroduce regulatory bottlenecks through the back door.

I co-founded the South Carolina Health Forum to support this work.

We launched the South Carolina Health Forum with one goal: to gather physicians, innovators, investors, and policymakers around a shared mission: building a more pluralistic, accessible, and sustainable health care ecosystem in South Carolina.

CON repeal is just the beginning. Now we need bold, physician-led action to make good on its promise.

The moment will not last forever.

On January 1, 2027, CON for hospitals disappears. That is the deadline, not the starting gun. The systems that will shape post-CON South Carolina will already be in motion long before then. Physicians: Do not wait.

Build. Partner. Lead.

Because when the door swings wide, it won’t reopen.

Marcelo Hochman is a facial plastic and reconstructive surgeon.