> In order to open a new hospital in most jurisdictions, by law you need the permission of other local hospitals

That doesn't really have much of an effect these days, though, because if anything, we already have an excess of hospitals in most areas where this would come into effect.

That's why hospitals have been hemorrhaging money, and so many have either gone broke and closed up entirely or been consolidated into larger hospital systems. The independent hospital is a dying breed, and it's been dying for a very long time.

In other words, there just simply isn't really any appreciable desire to open hospitals in those regions. The Certificate of Need isn't the limiting factor; their ability to break even on their operating expenses is.