Certificate of need programs were initiated 3 decades ago in the United States for the purpose of limiting expenditures for particularly costly interventional cardiovascular services and technologies.1 Certificates of need are a kind of regionalization, a process by which specialized procedures like coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are deliberately distributed in a presumably rational and efficient geographic context. However, certificate of need regulations have fallen out of favor in many states; they have been repealed by 19 states entirely and by 25 states for CABG surgery.1 Little has been done in recent years to examine the impact of certificates of need on cost or on quality of care except for studies related to CABG surgery and PCI.2,3