Wake County Hospital Systems Seek More Than 700 New Acute-Care Beds; State Plan Allots 233
WakeMed, UNC Health Rex and Duke filed competing certificate-of-need applications for far more beds than North Carolina's 2026 plan allows in Wake County, while neighbors in Rolesville fight the rezoning for one proposed WakeMed hospital.
Three Hospitals, One Number
Wake County's hospitals have all filed their paperwork, and the math doesn't work. WakeMed, UNC Health Rex and Duke University Health System are asking North Carolina for more than 700 new acute-care beds combined[1]. The state's own plan for 2026 says the county needs 233[4].
That gap isn't an error. It's the whole point of the process. North Carolina runs a "certificate of need" system, CON for short, and it's built to produce exactly this kind of mismatch. A hospital can't just build beds because it has the money and the land. First it has to convince the state there's a need. Every year, regulators run a formula based on population and how full existing hospitals already are, and that formula spits out one number per county[4]. This year, Wake County's number is 233.
So three systems with real capital and a fast-growing market are all competing for a much smaller pot than they asked for. Most of what got filed this summer will be turned down. That's not a prediction — it's baked into how the review works, and the prior round of this same fight showed the pattern already.
What Happened Last Time, and What's Happening Now
A year ago, in the previous review cycle, regulators rejected every proposed brand-new hospital in the county and cut back the two big incumbents. UNC Health Rex asked for 106 beds and got 51. Duke asked for 101 and got 52[5][6]. Nobody got what they filed for, and nobody built a hospital from scratch.
This year's applications are bigger, and the new-hospital idea is back. WakeMed filed four separate projects worth about $919.2 million altogether, including two brand-new 45-bed hospitals — one in Wendell, one in Rolesville — plus bed additions at its existing Cary and Raleigh campuses[1][2]. UNC Health Rex went a different way: it asked for all 233 beds the state says the county needs, all at its one existing Raleigh hospital, for about $169.6 million[1]. Duke split its ask between two hospitals it already runs — 150 more beds at Duke Raleigh and 120 more at its Cary location — with the Raleigh beds phased in through 2029[1].
Look at the cost per bed and the strategies split cleanly. Rex's plan works out to roughly $728,000 per bed, because it's adding capacity to a hospital that already has an ICU, surgical suites and specialists on call at night. WakeMed's plan averages closer to $4 million per bed, mostly because two of its four projects are entirely new buildings, not additions to something already running[1]. Rex and Duke argue that's the cheaper, faster, safer way to hit the same population target. WakeMed argues speed and low upfront cost aren't the only things that matter — location is too.
Why WakeMed Wants to Build Where Nobody Lives Yet
WakeMed's case rests on geography. The company points out that Wake County's growth isn't happening downtown — it's happening in the towns ringing it, places like Wendell, Rolesville and Garner[1][2][10]. A patient having a heart attack out there, the argument goes, shouldn't have to be driven past a growing suburb to reach the nearest hospital bed.
There's a second layer to that argument, and it's about who WakeMed already treats. As the county's safety-net and trauma system, WakeMed says it takes patients regardless of whether they can pay, and that building where the population is actually moving is how it keeps affording to do that[1][2][10]. That's WakeMed's framing of its own motive. It also has a separate, less publicly stated interest: it's a county-owned system currently negotiating a major combination with Charlotte-based Atrium Health, a deal that would bring in at least $2 billion in capital investment over a decade[14]. Locking in beds in the fastest-growing parts of the county now, before Duke or Rex can claim that ground, is valuable regardless of the merger — but the merger raises the stakes further.
Rex and Duke aren't neutral referees here either. Under CON rules, competing systems formally comment on each other's applications during the review, so arguing that a rival's project is unnecessary duplication isn't a side fight — it's part of the process itself[1]. Both academic systems are also expanding out of their home bases in Durham and Chapel Hill into Wake County precisely because it's the state's biggest, richest patient market.
The Argument Underneath the Argument
Zoom out, and all three systems are aiming at the same handful of neighborhoods: Cary, Garner, Wendell, Rolesville, Wake Forest — the fast-growing, well-insured edges of the county[1][18]. That's not a coincidence. Patients with good commercial insurance are the patients who make hospitals money, and that money is what subsidizes the services that lose money — trauma care, psychiatric beds, rural clinics. Whoever gets those suburban beds gets the profitable base that keeps the rest of the system running.
That's also exactly why defenders of the CON law say the cap matters. NCDHHS and the North Carolina Healthcare Association, the hospital industry's lobbying group, argue that if three systems all built for the same well-insured suburbs, each would end up with beds sitting half-empty. Empty beds still cost money to staff and maintain, and those costs get passed on to everyone's bills. On this view, the review isn't rationing care — it's what keeps money flowing from profitable suburban beds to the unprofitable services attached to them[8][16].
Critics see the same set of facts and draw the opposite conclusion. Carolina Journal, published by the free-market John Locke Foundation, points to the 700-versus-233 gap as proof the law itself is broken, treating demand for beds as evidence of an artificial shortage[7]. State Sen. Benton Sawrey and other repeal supporters cite a Mercatus Center analysis of roughly 25 years of data finding that states with CON laws average about 30% fewer hospitals per 100,000 residents than states without them[19]. They also note that Congress required states to adopt CON laws in the 1970s to help control health costs, then eliminated that federal requirement in 1986 after concluding it wasn't working[13]. To repeal advocates, letting a hospital formally object to a rival's application isn't quality control — it's incumbents using state process to block competitors[7][13].
Both sides are reading the same numbers. One side sees waste being prevented. The other sees competition being blocked. The state has already started chipping away at the law in pieces: the 2026 budget repeals CON review for inpatient rehabilitation beds starting October 1, 2026, and a bill for full repeal passed the state Senate 31-17 back in April 2025, though it's been sitting in a House committee ever since[8][9].
A Fight the State Formula Can't Settle
None of that state-level argument matters much to Toni Kenion. She's a former WakeMed emergency nurse who now leads the Barrington Homeowners Association in Rolesville, and her group isn't fighting the hospital in principle — they're fighting where it would go[3]. WakeMed wants to build a 45-bed hospital on Burlington Mills Road, and the site sits next to their subdivision and close to Rolesville Middle School. Their objections are concrete: ambulance sirens at night, floodlights, round-the-clock traffic next to homes and a school[3][15].
To build there, WakeMed needs the town to rezone 31 acres from residential to commercial use, and that decision belongs entirely to Rolesville's town board — not to the state[3][15]. A certificate of need from NCDHHS only says a hospital is allowed to exist somewhere in the county. It says nothing about which parcel of land. Even if WakeMed wins every bed it asked for in Raleigh, the town board can still say no to this specific site, which is why WakeMed asked to push the rezoning vote back to October 8[3][15]. The company is offering the town about $53.8 million in investment and roughly 77 full-time jobs by 2030 — the trade-off Rolesville's board has to weigh against its residents' objections[15].
What Doesn't Change, No Matter Who Wins
Strip away the competing filings and one plain fact remains: Wake County is adding people faster than it's adding hospital beds, and nobody disputes that[1][4]. The disagreement is only about who builds the new beds, and where. Given how the last round went, the likely outcome is a repeat: existing hospitals get partial approvals, brand-new hospitals get turned down[5][6].
If that pattern holds, patients in towns like Wendell and Rolesville will keep driving farther for inpatient care at least through the late 2020s. And the money at stake doesn't disappear just because most of it gets denied — a single 45-bed hospital is roughly a $300 million commitment, hard to walk back once it's approved[1]. Coverage of this fight has split along familiar lines: Carolina Journal's opinion arm treats the bed gap itself as proof of broken regulation[7], while North Carolina Health News and public radio outlets have focused less on the beds and more on the pending WakeMed-Atrium merger, framing consolidation and future prices as the bigger risk[10]. A Hoodline piece on the Rolesville dispute leans on the sympathy of a former nurse fighting her own former employer, giving WakeMed's access argument for the site comparatively little space[3]. One group has been largely absent from all of this coverage: patients without strong insurance, who aren't the customer any of these three projects is really designed around, and who have no formal seat at the review table.
Summary
Three hospital systems want to add beds in Wake County, North Carolina. Together they asked the state for more than 700 new acute-care beds[1]. But North Carolina's 2026 State Medical Facilities Plan says the county needs only 233[4]. That gap is the whole story: state regulators must pick winners, and most of what was requested will be denied.
Here is how the rule works. North Carolina has a 'certificate of need' law, often shortened to CON. A hospital cannot simply build beds because it has the money. It must first get state permission. The state runs a yearly count of how many beds each county will need, then opens a review. Systems file competing applications, comment on each other's plans, and regulators award the beds. Losers can appeal. The law dates to the 1970s, when Congress pushed states to adopt it to hold down health costs[13].
WakeMed filed four projects totaling 233 beds and about $919.2 million, including two brand-new hospitals — one in Wendell and one in Rolesville, 45 beds each[1][2]. UNC Health Rex asked for all 233 beds at its Raleigh hospital, at about $169.6 million[1]. Duke sought 150 more beds at Duke Raleigh and 120 more at its Cary hospital off Green Level Road[1]. A similar round a year earlier ended with regulators rejecting every proposed new hospital and cutting Rex and Duke to about half the beds each had sought[5][6].
The main dispute is not really about whether Wake County is growing. All sides agree it is. The fight is over who decides. Supporters of the law say a state cap stops systems from overbuilding beds that patients ultimately pay for. Critics, including Carolina Journal and Republican state senators who passed a full repeal bill in 2025, say the cap creates an artificial shortage and shields big incumbents from competition[7][8]. A separate local fight runs alongside it: homeowners in the Barrington subdivision in Rolesville are fighting the rezoning WakeMed needs to build one of the new hospitals next to their neighborhood[3].
The Event
In August 2026, WakeMed, UNC Health Rex and Duke University Health System filed competing certificate-of-need applications with the North Carolina Department of Health and Human Services for new acute-care beds in Wake County[1]. The combined requests exceed 700 beds, against the 233 beds the state's 2026 State Medical Facilities Plan identifies as needed in the county[1][4]. WakeMed's filings cover four projects worth about $919.2 million, including proposed new 45-bed hospitals in Wendell and Rolesville[1][2]. Separately, the Rolesville Board of Commissioners is weighing the rezoning and annexation WakeMed needs for the Rolesville site on Burlington Mills Road, a decision WakeMed asked to push to Oct. 8[3][15].
Undisputed Facts
- North Carolina's 2026 State Medical Facilities Plan sets Wake County's acute-care bed need at 233 beds[4].
- WakeMed, UNC Health Rex and Duke University Health System each filed certificate-of-need applications in the Wake County acute-care bed review, and their combined requests total more than 700 beds[1].
- WakeMed's filings include four projects — new 45-bed hospitals in Wendell ($318.7 million) and Rolesville ($302.4 million), 88 beds at WakeMed Cary ($168.6 million) and 55 beds at its Raleigh campus ($129.5 million)[1][2].
- UNC Health Rex applied to add 233 acute-care beds at its Raleigh hospital at a projected cost of about $169.6 million[1].
- Duke applied for 150 additional beds at Duke Raleigh Hospital (about $346.2 million, phased through July 2029) and 120 additional beds at its Cary hospital off Green Level Road[1].
- In the prior review round, decided in early 2026, regulators approved 51 of the 106 beds Rex sought and 52 of the 101 beds Duke sought, and rejected the proposed new hospitals[5][6].
- NCDHHS granted WakeMed a certificate of need in October 2025 for a 32,000-square-foot Rolesville healthplex and emergency department, projected to open in fall 2027[11].
- The Barrington Homeowners Association in Rolesville, led by former WakeMed emergency nurse Toni Kenion, opposes the hospital's location next to their subdivision; WakeMed is seeking to rezone the 31-acre site from residential low to commercial high[3][15].
- Senate Bill 370, a full repeal of North Carolina's certificate-of-need law, passed the state Senate 31-17 in April 2025 and has since sat in the House Rules Committee[8].
- The 2026 state budget repeals certificate-of-need review for inpatient rehabilitation beds and services starting Oct. 1, 2026[9].
The Pressure
Strip away the moralizing and blame. What structural realities persist regardless of which narrative wins?
- Land grab before the rules change
- A repeal bill already passed the state Senate once and the 2026 budget stripped certificate-of-need review from rehabilitation beds[8][9]. Every system has reason to lock in approved beds now, while the law still keeps rivals out of the space it wins.
- Chasing the insured suburb
- All three systems aimed at the same fast-growing, well-insured edges of Wake County — Cary, Garner, Wendell, Rolesville, Wake Forest[1][18]. Commercially insured suburban patients cross-subsidize money-losing services. That is why the requests cluster geographically instead of spreading out.
- The formula is the referee
- NCDHHS's bed number comes from a published population-and-occupancy formula in the State Medical Facilities Plan, not from a judgment about any one applicant[4]. It moves year to year — the prior plan produced a different Wake figure — so systems that lose one round can refile when the number resets.
- Zoning outranks the state permit
- A certificate of need lets a hospital build; it does not tell a town where. Rolesville's board still controls the rezoning and annexation for WakeMed's site, and can stop the project regardless of what Raleigh regulators decide[3][15].
Material realityWake County keeps adding people faster than it adds hospital beds, and that is not in dispute. What is in dispute is who builds them and where. Right now three large systems have capital and a growth market, and the state has a formula that says 233 beds[1][4]. Most of the more than 700 beds requested will be denied — that outcome is built into the process before any hearing happens. The prior round shows the likely shape: existing hospitals get partial awards, brand-new hospitals get rejected[5][6]. Two things then persist no matter which story wins. First, patients in eastern Wake County towns like Wendell and Rolesville will still drive farther for inpatient care through at least the late 2020s. Second, the money is real and lumpy — a single 45-bed hospital is a roughly $300 million commitment that is hard to reverse once approved[1].
Narrative as a weaponThree groups are actively shaping how this reads. The hospital systems want you to see growth outrunning capacity, because that makes their applications a public service rather than a market play — and each wants you to see its rivals' bids as duplication. Repeal advocates on the right, chiefly Carolina Journal and the John Locke Foundation, want the 700-versus-233 gap to read as government rationing, because the arithmetic is easy to grasp and the counterargument about duplicated suburban capacity is not. Health-policy nonprofits and public radio want you to watch the WakeMed-Atrium merger instead, because consolidation and price are their standing concerns. The Rolesville homeowners want a location fight, not a health-policy fight, and they say so — which is also their most effective posture. Missing from nearly all of it: patients without good insurance, who are not the customers any of these projects are designed around, and who have no organized voice in the review.
How Each Side Sees It
Each major actor’s view — how it frames things, its underlying incentive, and how it’s materially affected. Tap a side to read it.
Frames it asWakeMed argues that beds should follow patients, and that Wake County's growth is happening in the towns on the edge — Wendell, Rolesville, Garner — not only in downtown Raleigh. Its case is that a person having a heart attack in eastern Wake County should not have to be driven past growing suburbs to reach a bed. It also points to what it already does: as the county's safety-net and trauma system, it treats patients regardless of ability to pay, and says building where the population is going is how it keeps doing that[1][2][10].
WhyWakeMed is a county-owned system negotiating a combination with Charlotte-based Atrium Health that would bring at least $2 billion in capital investment over a decade[14]. Winning bed awards now locks in a footprint in the fastest-growing parts of the county before Duke or UNC Health Rex can claim it. Approved beds are also durable assets: under certificate-of-need law, a competitor cannot easily match them later[13].
Impact on themWakeMed has about $919.2 million in proposed projects riding on the review[1][2]. If regulators repeat last cycle's pattern and reject new hospitals, both the Wendell and Rolesville projects fail, and the Rolesville rezoning fight becomes moot. WakeMed also faces political exposure: county commissioners have already delayed a vote tied to the Atrium deal after public pushback[12][14].
Frames it asBoth argue that adding beds to an existing hospital is the cheaper, faster and safer way to meet need. Rex asked for the full 233 beds at one Raleigh campus for about $169.6 million — roughly $728,000 per bed. WakeMed's four projects average close to $4 million per bed, largely because two are new hospitals built from nothing[1]. The argument is that a bed inside a hospital that already has an intensive care unit, surgical suites and overnight specialists costs less and is staffed better than a bed in a small new building. Duke makes the same case for phasing beds into Duke Raleigh starting in 2027, years before WakeMed's proposed 2033 completion dates[1].
WhyBoth are academic systems expanding out of Durham and Chapel Hill into Wake County, the state's biggest and richest patient market. Each also has an interest in the other side losing: under certificate-of-need review, competitors formally comment on each other's applications, so opposing a rival's project is part of the process, not a side fight[1].
Impact on themIn the prior round each got roughly half of what it asked for[5][6]. Duke's current filings total 270 beds across two campuses, including a $346.2 million Duke Raleigh project[1]. A denial does not just delay construction — it means waiting for a future year's plan to open new bed capacity at all.
Frames it asState planners and the North Carolina Healthcare Association, the hospital industry's lobby, argue the cap is what keeps the system solvent. Their reasoning runs like this. Empty hospital beds still cost money to staff and maintain. Those costs get folded into what everyone is charged. Well-insured suburban patients are also the profitable patients — so if three systems all build for them, each ends up with underused beds while the emergency rooms that take uninsured patients lose the revenue that subsidizes them. On this view the review is not a brake on care; it is the mechanism that keeps unprofitable services — trauma, psychiatric beds, rural care — attached to profitable ones[8][16].
WhyThe agency's statutory job is to hold total bed supply near projected need, using a published population-based formula rather than each system's own forecast[4]. Established hospitals have a separate incentive that overlaps with the agency's: the law also protects them from new entrants[13].
Impact on themNCDHHS must deny most of what was filed, then defend the denials on appeal — the standard next step after a contested award[5]. Every denial adds evidence to the repeal side's argument that the law rations care.
Frames it asRepeal supporters — including state Sen. Benton Sawrey, R-Johnston, and the free-market Carolina Journal and John Locke Foundation — say the 700-versus-233 gap is the argument. Three systems with capital in hand want to build. A state formula says no. Their strongest specific evidence is national: a Mercatus Center analysis of about 25 years of data found certificate-of-need states average roughly 30% fewer hospitals per 100,000 residents than states without the law[19], and Congress eliminated the federal CON mandate in 1986 after concluding it wasn't controlling costs[13]. They also note the review lets a hospital formally object to a competitor's project — which they call incumbents using the state as a shield[7][13].
WhyA broader deregulatory project. Senate Bill 370 would repeal the law outright; it passed the Senate 31-17 in April 2025 and stalled in the House[8]. Advocates want individual denials to build public pressure on House leadership.
Impact on themThey are winning in pieces rather than all at once. The 2026 budget repealed certificate-of-need review for inpatient rehabilitation beds effective Oct. 1, 2026[9]. Supporters and opponents both say rural areas would see the biggest effect from a full repeal, though they disagree sharply on whether that effect is more access or fewer rural hospitals[8].
Frames it asTheir argument is narrow and they keep it narrow on purpose. They say they want WakeMed in Rolesville — just not a 24-hour campus at the edge of their yards. Their objections are concrete: ambulance traffic, sirens at night, floodlights, and the site's closeness to homes and to Rolesville Middle School[3][15]. They frame the rezoning request — from residential low to commercial high on 31 acres — as the town changing the deal people bought into. Toni Kenion, who leads the association, spent years as a WakeMed emergency nurse, which is the point they press hardest: this is not anti-hospital sentiment[3].
WhyProperty values and neighborhood character, plus a straightforward land-use goal — push the campus to a different parcel, not out of town.
Impact on themThey control a real chokepoint. Even a state certificate of need cannot override local zoning. The Rolesville Board of Commissioners must approve the rezoning and annexation, and WakeMed asked to delay that vote to Oct. 8[3][15]. WakeMed projects about $53.8 million in investment and roughly 77 full-time jobs by 2030 at the site — the tax base and payroll the town weighs against the neighbors[15].
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The Bias Ledger average rating 4.5
The same story, as framed by outlets across the spectrum, ordered least to most biased. The bias score (1 = straight, 10 = heavily spun) is an AI assessment of that framing — click an outlet to see its track record. The tell is the word choice or omission that reveals the angle.
| Outlet | Vantage | Bias | How they frame it | The tell |
|---|---|---|---|---|
| CBS17 | U.S. center, Nexstar-owned local | 2 | '3 Wake County hospitals seeking state approval for more acute care beds' — a flat inventory of each application, cost and completion date[1]. | Almost no framing at all; the limitation is the opposite kind — it lists filings without explaining that most must be denied, so a casual reader may think all of it is being built. |
| WRAL | U.S. center, Raleigh local | 3 | Frames WakeMed's filings as a '$919 million expansion' set against an 'uncertain' Atrium Health deal, tying the bed requests to the merger fight[2]. | Leads with the dollar total rather than the bed count, and pairs the review with the merger — a real connection, but it steers readers toward a consolidation storyline rather than the capacity math. |
| North Carolina Health News | U.S. center-left; nonprofit health outlet funded largely by health-focused foundations | 4 | 'State, local officials, lawmakers press for delay on WakeMed/Atrium deal' — the risk it centers is consolidation and price, not bed scarcity[10]. | Sources are weighted toward officials asking to slow the deal. The competing view — that scale brings capital a county system cannot raise alone — appears mainly as the systems' own claim. |
| Carolina Journal | U.S. right; published by the free-market John Locke Foundation | 5 | 'CON regulators reject new Wake County beds, new hospital' — the news frame is the state as the actor that says no[6]. | The verb 'reject' is put in the headline and the agency is the subject. Accurate as to the prior round's outcome, but it foregrounds denial rather than the statutory bed formula that produced it. |
| Hoodline | U.S. local, AI-assisted aggregation | 6 | 'Rolesville Neighbors Fight WakeMed's 45-Bed Hospital Plan Next Door' — a neighborhood-versus-institution story built around one resident[3]. | 'Next door' and the former-nurse detail make the opposition sympathetic before any argument is weighed. WakeMed's access rationale for northeastern Wake County appears late and briefly. |
| Carolina Journal (Opinion) | U.S. right; John Locke Foundation opinion section | 7 | 'Hospital expansion numbers expose CON's flaws' — argues the requested-versus-allowed gap is itself proof the law is broken[7]. | Treats demand for beds as equal to need for beds. Three systems each bidding for the same profitable suburban patients could also mean duplication, not shortage — the column does not engage that reading. |
References
- 3 Wake County hospitals seeking state approval for more acute care beds — CBS17 · U.S. center; Nexstar-owned Raleigh broadcast station
- WRAL Investigates: WakeMed eyes $919 million expansion as Atrium deal faces uncertain future — WRAL · U.S. center; Capitol Broadcasting, Raleigh
- Rolesville Neighbors Fight WakeMed's 45-Bed Hospital Plan Next Door — Hoodline · U.S. local aggregation, AI-assisted; no declared political orientation
- North Carolina 2026 State Medical Facilities Plan — North Carolina Department of Health and Human Services · State government primary source
- 2025 Wake Acute Care Bed Review Findings — Required State Agency Findings — North Carolina Department of Health and Human Services, Division of Health Service Regulation · State government primary source
- CON regulators reject new Wake County beds, new hospital — Carolina Journal · U.S. right; published by the free-market John Locke Foundation
- Hospital expansion numbers expose CON's flaws — Carolina Journal (Opinion) · U.S. right opinion; John Locke Foundation
- Could proposed WakeMed-Atrium deal become catalyst for broader hospital reform? — WRAL · U.S. center; Capitol Broadcasting, Raleigh
- NC budget repeals CON for inpatient rehabilitation care — Carolina Journal · U.S. right; John Locke Foundation
- State, local officials, lawmakers press for delay on WakeMed/Atrium deal — North Carolina Health News · U.S. center-left; nonprofit funded largely by health-focused foundations
- WakeMed gets OK for new emergency center in Rolesville — WRAL · U.S. center; Capitol Broadcasting, Raleigh
- Wake County Commission Delays Vote on Legal Documents Related to WakeMed, Atrium Health Strategic Combination — Wake County Government · County government primary source
- Certificate of Need: The Regulation Blocking Greater Access to Higher-Quality and Lower-Cost Care — Cato Institute · U.S. libertarian think tank; advocates CON repeal
- Wake County commissioners hear from the public about proposed hospital merger — WUNC · U.S. center-left; NPR member station, UNC-Chapel Hill licensee
- WakeMed — 4801 Burlington Mills Rd project file — Town of Rolesville · Municipal government primary source
- Cost vs. care: NC bill renews debate over certificate of need laws — WRAL · U.S. center; Capitol Broadcasting, Raleigh
- Proposed Atrium, WakeMed merger prompts concern from Treasurer Briner — Carolina Journal · U.S. right; John Locke Foundation
- Everyone wants to build hospitals in fast-growing Wake County — Axios · U.S. center; commercial digital outlet
- Certificate-of-Need Laws: Are They Achieving Their Goals? — Mercatus Center, George Mason University · U.S. free-market research center; advocates CON repeal