Delaware Promised to Improve Healthcare Access to Secure a Federal Grant. Will Delaware Deliver?

We at Caesar Rodney Institute commend the state for its successful application for a grant under the Rural Health Transformation Program (RHTP). This program, authorized by the One Big Beautiful Bill Act, is designed to improve healthcare access, quality, and outcomes in rural areas. Delaware’s official application for the federal Rural Health Transformation Program focuses on increasing the pipeline of physicians by establishing a medical school as well as expanding residency programs.

Many Delawareans are understandably excited about the prospect of a new medical school. While this is promising for the longer term, the state has also committed to a policy that would improve healthcare access and quality much sooner: eliminating or substantially reforming Delaware’s Certificate of Public Review (CPR) program.

The Hidden Barrier to Healthcare Access: Delaware's Certificate of Public Review

Under Delaware's Certificate of Public Review (CPR) program, Delaware's version of a Certificate of Need (CON) law, applicants must establish that there is a need for additional healthcare capacity before a certificate is granted to build additional facilities or make major equipment purchases. This requirement was based on the mistaken idea that excess capacity raises prices. Instead, this program has proven to be a barrier that prevents new entrants, thus protecting existing healthcare suppliers from competition. Health policy economist Matthew D. Mitchell's 2025 review of the empirical literature found that the weight of the evidence shows Certificate of Need laws increase healthcare spending while reducing quality and access to care, including for underserved populations. Reduced competition leads to higher prices, less access, and possibly lower quality care. In a joint statement, the Federal Trade Commission and the Antitrust Division of the U.S. Department of Justice concluded that CON laws "create barriers to entry and expansion, limit consumer choice, and stifle innovation," while allowing incumbent providers to thwart or delay new competitors from entering the market.

Delaware’s CPR program considers the ‘need of the population’ and the effect on existing providers. Undue weight is given to ‘current capacity’, which effectively allows existing providers to influence whether new competitors can enter the market.

The application process, established under Delaware's Certificate of Public Review statute (16 Del. C. Chapter 93), is itself risky and unnecessarily burdensome. Applicants are asked to provide demographic data, utilization rates, and information on the anticipated impact on existing providers. Extensive financial data are required, along with any other studies or analyses that applicants may have conducted to reach the decision to file the application.

Applicants must provide highly detailed data, which will be made public thereby possibly giving away their competitive advantage. Applications can be denied on a wide range of factors. Although only two applications out of 28 were denied (2014-2020), there are no data on deterred applications. That may be the program's greatest hidden cost. Moreover, delays in obtaining certificates can substantially increase the cost of expansions. Only 6 applications of 30 were decided in under 90 days.

Why CPR Keeps Healthcare Providers Out of Delaware

Delaware's CPR law doesn't just delay healthcare expansion—it discourages many medical providers from investing in Delaware in the first place. The reasons are found both in who administers the program and in how the law is structured.

The CPR review is conducted by the Health Resources Board. The board members are appointed by the Governor and consist of many industry insiders. Records of votes by members are incomplete or missing, according to the Joint Legislative Oversight and Sunset Committee's Staff Recommendations and Findings Report. This paints a picture of a regulatory agency that has been captured by industry insiders with the goal of limiting competition.

Based on its March 2021 review of Delaware’s CPR program, the Joint Legislative Oversight and Sunset Committee recommended: 1) changing the Health Resources Board to an advisory board that would assist the applicable department in Delaware Health and Social Services; 2) creating a statewide database of healthcare facility utilization levels; and 3) reducing the membership of the Health Resources Board from its then-21 members to just 5 to 7 members. These recommendations focused on improving how the CPR program was administered—not on whether the law itself continued to unnecessarily restrict competition. Delaware's CPR law still limits new entrants into the healthcare market.

We, at CRI, have heard from health care providers, “We don’t want to come to Delaware because of the CPR law. It isn’t worth the investment to risk approval.” It is clear that the current program has been dominated by industry insiders who make decisions without basis in data and with no public scrutiny or accountability.

The chilling effect of the mere existence of the CPR program on new entrants is very real. It is likely the program's greatest cost. But it leaves no data because those providers never applied.

A 2025 study published in the Southern Economic Journal found that repealing Certificate of Need laws for ambulatory surgery centers increases access to medical services by making surgeons more likely to continue practicing in rural communities. By removing unnecessary regulatory barriers, Delaware could make it easier to attract and retain specialists while expanding access to outpatient surgical care in underserved areas.

Delaware Made a Promise. Now It Should Keep It.

Delaware's commitment to CPR reform extended beyond the Executive Branch. In its official Rural Health Transformation Program (RHTP) grant application, the State noted that it had received a letter of support from Delaware's entire General Assembly committing to regulatory reforms, including Certificate of Public Review (CPR). The grant application further states:

“Delaware commits to eliminating or loosening Certificate of Need laws (known as ‘Certificate of Public Review’ in DE) to reduce regulatory barriers for providers establishing new facilities in rural areas. Timeline: Legislation drafted by September 30, 2026; legislative sponsor identified by January 31, 2027; brought to vote by June 30, 2027. Improvement to Access, Quality, Cost of Care: Removes regulatory barriers that prevent new facilities from opening in underserved rural areas, increasing local access to care and reducing transportation costs and time for rural patients.” (p. 12)

CRI continues to support full repeal of Delaware's Certificate of Public Review law, as proposed in House Bill 318, sponsored by Representative Bryan Shupe. Although the bill did not advance out of committee, it remains the most direct and immediate way to encourage new healthcare suppliers to come to Delaware. Delaware would not be breaking new ground—many other states have eliminated their Certificate of Need (CON) laws, as shown in the Mercatus Center’s interactive state map. 

Patients Can't Wait

“I can’t get an appointment for months!” How often do we hear this? Delaware’s citizens are suffering from a lack of healthcare access now. Of all the commitments outlined in the state’s Rural Health Transformation Program (RHTP) narrative, eliminating Delaware’s Certificate of Public Review (CPR) law is the single policy most likely to increase healthcare supply, expand healthcare access, and lower healthcare costs when we need it most. It costs taxpayers nothing.

Delaware made this commitment to secure federal funding. Here is hoping that, at last, the RHTP grant gives the state government the incentive to honor that commitment by finally eliminating the Certificate of Public Review law once and for all in Delaware.