How Certificates of Need and Convenience Limit Health‑Care Investment and Access in Puerto Rico

<jats:p>This policy report examines Puerto Rico’s certificates of need and convenience (CNC) regime in light of the broader empirical literature on certificate-of-need (CON) laws, recent reform trends in the United States, and the structural constraints facing Puerto Rico’s health-care system. CON and CNC laws require prior government approval before certain health-care facilities, services, equipment, or expansions can enter the market. Although these regimes are often justified as tools for planning, cost containment, and quality protection, the evidence reviewed in this report generally shows that they tend to restrict entry, protect incumbent providers, increase administrative burdens, and limit service availability, while evidence of consistent public benefits remains mixed or context-dependent. The report situates this evidence within Puerto Rico’s distinctive policy environment, including federal Medicare and Medicaid funding disparities, provider financial distress, workforce shortages, high insurance coverage but comparatively low per capita health spending, and existing federal quality and participation standards. It argues that Puerto Rico’s CNC framework should be understood as a discretionary supply-control system that can delay investment, complicate service expansion, and reinforce geographic and administrative barriers to care. The report recommends a strong presumption in favor of repealing Puerto Rico’s CNC requirements or, at minimum, substantially narrowing the categories subject to review. It further recommends Medicare-aligned exemptions, objective thresholds, fixed timelines, limits on incumbent-driven delays, and stronger public reporting. The policy objective is to move Puerto Rico away from broad prior-approval barriers and toward modern oversight tools that protect patients while enabling timely investment, innovation, and competitive provision of care.</jats:p>