While Florida has seen the most new hospital builds opened or announced in 2026, North Carolina has had the most competition across systems with certificate-of-need proposals, according to a review of Becker’s coverage.
The contrast underscores how a state’s certificate-of-need laws — or lack thereof — shape not just how much hospital growth occurs, but what form it takes: system-by-system building in states without CON requirements, versus a more concentrated fight over a fixed number of approved beds in states that still regulate them.
Becker’s has covered 33 Florida-specific capital growth or expansion stories — by far the most of any state. Several include significant investments, including Jacksonville, Fla.-based Baptist Health breaking ground on a more than $500 million hospital in Sunrise in January, and Sarasota (Fla.) Memorial Health Care System sharing plans to invest more than $1 billion in capital projects, including a $507 million hospital in North Port, currently under construction.
After Florida dropped its certificate-of-need requirement for new hospital builds in 2019, the state saw a boom in new capital projects, with at least 65 plans announced from 2020 to 2022 — a regulatory opening that set the stage for the pace systems are still keeping today. With several major health systems expanding their Florida presence.
For example, Cleveland Clinic announced plans in February for a $500 million, 200-bed hospital in West Palm Beach. Altamonte, Fla.-based AdventHealth is also growing in its home state, recently completing three hospital projects there.
Beyond new hospitals, Nashville, Tenn.-based HCA Healthcare has built several new freestanding emergency departments in the state in 2026, totaling 81 by the end of the first quarter.
The state’s population growth, especially among older adults, is a key driver of these investments. Florida is now home to about 4.5 million residents 65 and older, a figure expected to reach 6 million by 2030, and hospital visits among seniors climbed 7.5% from 2019 to 2024.
All told since 2020, the state has added 49 new hospitals and more than 3,000 hospital beds, while 38 unique health systems presently operate there — a density that has pushed some out-of-state systems to enter through partnerships rather than standalone builds.
Meanwhile, North Carolina, which still maintains a certificate-of-need requirement for new hospital construction, has seen continued competing CON applications for new hospital builds and expansions, with five proposed over three days in June. The systems included Chapel Hill-based UNC Health, which filed two separate CON applications for hospitals in Wilmington and Asheville, respectively; Greensboro-based Cone Health, proposed a $320 million, 56-bed acute care hospital in Forsyth County; Gastonia-based CaroMont Health, plans an 18-bed neighborhood hospital in Cleveland County; and Charlotte-based Atrium Health, is seeking a full-service hospital in New Hanover County.
The Wilmington filings illustrate just how tight capacity has gotten. New Hanover County’s metro area ranked the seventh-fastest-growing in the U.S. from 2024 to 2025, its existing hospital is already operating above 92% capacity, and the state identified a need for 225 additional beds in the area — which is why multiple systems are chasing the same CON approval rather than just one.
The proposals — and subsequent approvals — have also been frequently followed by appeals, with systems asking administrative law judges to reverse the approvals and award the beds to themselves instead. AdventHealth and UNC Health, for example, each appealed regulatory bed approvals that favored Mission Health and Novant Health in the Buncombe County area in May.
CaroMont President and CEO Chris Peek framed the state’s approach as less about scale than location. “The future of healthcare isn’t just bigger buildings. It’s smarter ones, built around where patients live and how they use care,” he said. Statewide, North Carolina grew 1.3% — the nation’s third-fastest rate — with Charlotte adding more than 20,000 residents a year and Raleigh recently surpassing 500,000 people.
The North Carolina Hospital Association told Becker’s at that time the demand is straightforward: the state has one of the fastest-growing populations in the country, and healthcare infrastructure must keep up.
Texas and Tennessee also saw significant competition over new builds in 2026, though neither generated the kind of head-to-head CON fights that defined North Carolina. In Texas, growth has been driven largely by systems racing to add capacity across a booming, CON-free market — Dallas-based Baylor Scott & White Health announced plans to operate 12 emergency hospitals statewide by 2028, while Fort Worth, Texas-based JPS Health Network broke ground on a $1.5 billion hospital, among several other large projects.
Tennessee’s competition has been more regulatory in nature. HCA Healthcare and Chattanooga, Tenn.-based Vitruvian Health have sparred over a proposed freestanding emergency department in Bradley County, with HCA ultimately cleared to build amid the pushback. Nashville, Tenn.-based Vanderbilt University Medical Center needed a court order to move forward with a new hospital — together pointing to a state where both market demand and regulatory friction are shaping who gets to build next.
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