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Jamestown Foundation Posts Commentary: Putin Says Armenia and Russia Can Achieve a 'Civilized Divorce'
WASHINGTON, May 13 -- The Jamestown Foundation posted the following commentary on May 12, 2026, by Paul Goble, specialist on ethnic and religious questions in Eurasia, in the foundation's Eurasia Daily Monitor:* * *
Putin Says Armenia and Russia Can Achieve a 'Civilized Divorce'
Executive Summary:
* Russian President Vladimir Putin says Armenia and Russia can achieve "a civilized divorce," even as he continues a war to prevent Ukraine from achieving the same thing. This statement will lead to the further disintegration of the post-Soviet space, regardless of his intentions.
* The Kremlin ... Show Full Article WASHINGTON, May 13 -- The Jamestown Foundation posted the following commentary on May 12, 2026, by Paul Goble, specialist on ethnic and religious questions in Eurasia, in the foundation's Eurasia Daily Monitor: * * * Putin Says Armenia and Russia Can Achieve a 'Civilized Divorce' Executive Summary: * Russian President Vladimir Putin says Armenia and Russia can achieve "a civilized divorce," even as he continues a war to prevent Ukraine from achieving the same thing. This statement will lead to the further disintegration of the post-Soviet space, regardless of his intentions. * The Kremlinleader's comment comes after the rise of Armenian anger at Moscow for failing in its role as a security guarantor in its earlier struggle with Azerbaijan, as well as growing European support for Yerevan in its efforts to reduce Armenia's dependence on Russia.
* Moscow will try to torpedo any such Armenian and EU efforts. Putin's statement, however, marks a significant shift in Russia's position and may prompt other former Soviet republics to pursue greater independence by cooperating with Europe.
In one of the most remarkable shifts since the start of his expanded war against Ukraine, Russian President Vladimir Putin now says Armenia and Russia can achieve "a civilized divorce" if Armenia conducts a referendum on shifting its focus from Russia to Europe. This step represents a further loss of Russian influence in the South Caucasus and one that could accelerate the further unraveling of the former Soviet space (Gazeta.ru, May 6; Kommersant, May 9; Ekho Rossii, May 10). Until recently, most Armenians and observers elsewhere assumed that Yerevan had little choice but to rely on Moscow for its defense and even survival (see EDM, April 22). The Kremlin's failure to help Armenia in its conflict with Azerbaijan, either directly or indirectly via the Collective Security Treaty Organization (CSTO), together with the expanded efforts of the European Union to support moves toward a peace treaty between Yerevan and Baku, have shifted opinion in Armenia and the West (International Republican Institute (IRI), March 5; Novaya Gazeta Evropa, May 5).
This sea change is far from the end of this story. It came to a head last week, initially by the first-ever expanded EU summit in Armenia--attended by the leaders of more than 40 countries, including Ukrainian President Volodymyr Zelenskyy--and then by Putin's statement (Council of the European Union, May 4; Arbat Media, May 7; see EDM, May 11). Putin will likely attempt to torpedo any Armenia-EU moves, based on his past comments as the framework for future policy. Even so, there can be no doubt that his words do mark a significant and, what may be especially important, a forced change in Moscow's position. No matter what Putin does next, his words will affect all countries in the post-Soviet space and make it far less likely that he will be able to reassemble the empire as he has often suggested he wants to restore. Consequently, many observers not only in Armenia but also in Azerbaijan and other former Soviet states are describing the summit and Putin's words as a turning point in the evolution of the former Soviet space (Charter 97, May 6; Kasparov.ru, May 7; The Insider, May 9; Altyn-Orda, May 10).
When the Soviet Union disintegrated in 1991, and the Commonwealth of Independent States (CIS) was created, two competing visions emerged concerning what the CIS represented. Most in the non-Russian countries felt that the CIS would provide a framework for "the civilized divorce" of their countries from Moscow (Window on Eurasia, November 2, 2025). Some in Moscow, and most prominently in recent years, Putin himself, viewed the CIS and its allied structures as the basis for reassembling the empire. Some of the former Soviet republics, most prominently Armenia and Belarus, long felt they had little choice but to remain within a Russian-led and Russian-dominated space. Belarus continues to take that position, although even Minsk has shown signs of interest in greater independence and expanded relations with the West in recent months (see EDM, December 4, 2025, April 16). Armenia, since the conflict with Azerbaijan ended in 2023, has dramatically shifted its position (see EDM, October 15, 2025, March 25, April 22). Before that time, many Armenians felt they had little choice but to rely on Russia for economic development and security. In the last several years, however, a majority of them, along with their current leader, Prime Minister Nikol Pashinyan, have decided that their country's future lies with Europe rather than Russia. They have taken steps in that direction, which the European Union's and especially France's support and actions have made easier (see EDM, November 6, 2023, March 11, 2024; IRI, March 5; The Insider, May 9). Moreover, Moscow's responses to what Armenia and the European Union have been doing are proving counterproductive, further alienating Armenians and leaving Russia with fewer levers (Window on Eurasia, April 12).
Putin, until now, has opposed any idea of any "civilized divorce," most prominently seen in his expanded war against Ukraine. Now, however, as that war grinds on into its fifth year and Moscow is trying to find an offramp, the Kremlin leader has taken a new tack, acknowledging that a civilized divorce is possible. He has suggested that if a referendum shows the people of Armenia desire this and that it is not just an anti-Russian move orchestrated by Europe and the West more generally, he is prepared to accept it. Given his track record, however, what Putin will do in reality is likely to differ from what he now says. He will certainly use what levers he can, both to ensure that any referendum in Armenia will fail, either by winning over the support of more Armenians to a pro-Russian position or by claiming that outside actors falsified the results. At the same time, he will work to persuade the Europeans to abandon their plans for Armenia, lest they suffer the consequences of continuing to pursue them (Council of the European Union, May 5). If Putin fails in either effort, he may find that the only country beyond Russia's borders that shares his vision of the future will be Belarus, and even that is uncertain (Charter 97, May 6).
As important as the European summit in Yerevan and Putin's words about a civilized divorce between Russia and Yerevan certainly are, they are likely to have a far greater effect elsewhere in the former Soviet space (Altyn-Orda, May 5). Some commentators are already speculating about the collapse of the CSTO and Eurasian Economic Union (EAEU) that Moscow created to keep these countries institutionally tied to Russia (Charter 97, May 6, 7). Others are discussing how their own countries can take advantage of these developments in Armenia (The Times of Central Asia, May 8). Perhaps most immediately relevant, a few are now openly asking if Moscow is prepared to allow Armenia to go its own way after a referendum, why is it not willing to do the same for Ukraine? (Altyn-Orda, May 10).
Putin views Ukraine as being in a different category than Armenia. He even denies that Ukrainians are a separate nation with a right to their own state. He will not agree to a similar "civilized divorce" with Kyiv. By going to war, the Kremlin leader has shown he will not do that, but having now taken the position he has with respect to Armenia, he may find it even more difficult to garner support at home for what he continues to do in Ukraine. Russians may reasonably ask, if there is a way one former Soviet republic can achieve "a civilized divorce" with Moscow without violence, then why should the people of Russia pay such a high price to keep another in its sphere of influence? That is a question Putin cannot afford to have ever more Russians posing.
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Paul Goble is a longtime specialist on ethnic and religious questions in Eurasia.
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Original text here: https://jamestown.org/putin-says-armenia-and-russia-can-achieve-a-civilized-divorce/
[Category: ThinkTank]
Ifo Institute: Poor Business Climate in the Travel Industry
MUNICH, Germany, May 13 -- ifo Institute issued the following news release:* * *
Poor Business Climate in the Travel Industry
The business climate for travel agencies and tour operators deteriorated further in April. The ifo Institute index fell to -43.5 points, down from -41.8 points* in March. Companies assessed their current situation as far worse than in March, while business expectations improved slightly. "The Iran conflict had a particularly severe impact on the travel industry in March," says ifo industry expert Patrick Hoppner. "The lifting of travel warnings for key transit flight ... Show Full Article MUNICH, Germany, May 13 -- ifo Institute issued the following news release: * * * Poor Business Climate in the Travel Industry The business climate for travel agencies and tour operators deteriorated further in April. The ifo Institute index fell to -43.5 points, down from -41.8 points* in March. Companies assessed their current situation as far worse than in March, while business expectations improved slightly. "The Iran conflict had a particularly severe impact on the travel industry in March," says ifo industry expert Patrick Hoppner. "The lifting of travel warnings for key transit flightcountries in the Middle East at the end of April is a positive signal."
More than half of the travel agencies and tour operators surveyed assessed demand in April as weak. "If travelers wait to see how the Iran conflict unfolds, it could affect bookings, particularly for the end of the 2026 summer season and the 2026/2027 winter season," says Hoppner. "Discussions about potential shortages of jet fuel from this summer on may also continue to cause uncertainty among travelers."
The proportion of travel companies expecting prices to rise in the coming months increased slightly again in April: Costs for jet fuel remain very much higher than they were before the conflict escalated at the end of February.
As a result, flights for vacation trips may become more expensive over the further course of the year. Fueling for motorists is also expected to be more expensive than last year for car trips within Europe during the Whitsun and summer travel seasons: At the beginning of May 2026, pump prices for Super E5 (diesel) at filling stations in Austria were about 20% (34%) higher than at the beginning of May 2025.
The corresponding figures are approximately 5% (29%) for Italy, approximately 21% (39%) for France, and approximately 18% (32%) for Croatia. This is according to data from the European Commission's Weekly Oil Bulletin.
* Seasonally adjusted
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More Information
Survey (https://www.ifo.de/en/facts/2026-05-13/poor-business-climate-travel-industry)
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Original text here: https://www.ifo.de/en/press-release/2026-05-13/poor-business-climate-travel-industry
[Category: ThinkTank]
Ifo Institute: More Electricity Outages Due to Climate Change
MUNICH, Germany, May 13 (TNSxrep) -- ifo Institute issued the following news release on May 12, 2026:* * *
More Electricity Outages Due to Climate Change
Due to climate change, electricity outages could become more frequent in many countries in the coming years. This is indicated by the findings of a new study by EconPol Europe. It examines electricity outages in consumer grids from 2013 to 2023 in five countries: Germany, Australia, Brazil, China, and Mexico. "Germany has a relatively reliable electricity grid, but extreme weather and heatwaves will increasingly put pressure on the infrastructure ... Show Full Article MUNICH, Germany, May 13 (TNSxrep) -- ifo Institute issued the following news release on May 12, 2026: * * * More Electricity Outages Due to Climate Change Due to climate change, electricity outages could become more frequent in many countries in the coming years. This is indicated by the findings of a new study by EconPol Europe. It examines electricity outages in consumer grids from 2013 to 2023 in five countries: Germany, Australia, Brazil, China, and Mexico. "Germany has a relatively reliable electricity grid, but extreme weather and heatwaves will increasingly put pressure on the infrastructurehere as well," says ifo researcher Jacqueline Adelowo.
According to the study, the number of unplanned electricity outages in Germany is lowest in winter and rises significantly by midsummer. In December of each year from 2013 to 2023, there was an average of 3,616 unplanned electricity outages. In July, the number rose by 53 percent to 5,546 events. However, not all of these events necessarily affect a large number of households. During the windstorm Niklas on March 31, 2015, 1,887 interruptions were registered in a single day - a record for the period under review.
"Extreme heat, thunderstorms, and severe storms in the summer are putting a noticeable strain on the German power system. However, compared to Brazil or Mexico, electricity outages in Germany are far more seldom in absolute terms," says ifo researcher Filippo Pavanello. On average, unplanned electricity outages in Germany lasted between 1.5 and 2 hours. In only one percent of the events the outage lasted longer than 18 hours. That means Germany is in a comparatively good position: In China, many outages lasted more than six hours, and in extreme cases power was unavailable for as long as 73 hours.
The researchers write that the ongoing integration of European electricity grids generally makes Germany's supply more resilient, as resources in different countries would be available to offset imbalances. At the same time, the risk of cascading failures increases when disruptions propagate rapidly across borders. That is why, in addition to grid expansion, coordinated governance, joint operational protocols.
The study is based on daily data on electricity outages at the distribution grid level from Australia, Belgium, Brazil, China, Germany, and Mexico for the period from 2013 to 2023. The data comes from regulatory agencies and distribution system operators. It contains information about the time of the outages, whether the outage was planned or unplanned, and the causes of the outage.
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Publication
2026 Article in Journal
Under Strain: International Insights into Electricity Grid Outages
Jacqueline Adelowo, Francesco Pietro Colelli, Norwin Lang, Filippo Pavanello
EconPol Forum 27 (2) 60-70
Learn more (https://www.ifo.de/en/econpol/publications/2026/article-journal/under-strain-international-insights-electricity-grid-outages)
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Original text here: https://www.ifo.de/en/press-release/2026-05-12/more-electricity-outages-due-to-climate-change
[Category: ThinkTank]
CSIS Issues Commentary: AI Escalation Danger Trump and Xi Must Address
WASHINGTON, May 13 -- The Center for Strategic and International Studies issued the following commentary on May 12, 2026, by Director Benjamin Jensen and Deputy Director Yasir Atalan, both of the Futures Lab:* * *
The AI Escalation Danger Trump and Xi Must Address
President Donald Trump will meet President Xi Jinping in Beijing on May 14-15, and the agenda will include discussions on AI. AI could become an area of mutual cooperation between the United States and China, but there is an underlying problem that must be addressed first. China's foundation models, particularly DeepSeek, show concerning ... Show Full Article WASHINGTON, May 13 -- The Center for Strategic and International Studies issued the following commentary on May 12, 2026, by Director Benjamin Jensen and Deputy Director Yasir Atalan, both of the Futures Lab: * * * The AI Escalation Danger Trump and Xi Must Address President Donald Trump will meet President Xi Jinping in Beijing on May 14-15, and the agenda will include discussions on AI. AI could become an area of mutual cooperation between the United States and China, but there is an underlying problem that must be addressed first. China's foundation models, particularly DeepSeek, show concerningescalatory tendencies in national security settings. As a result, when the world's two most powerful men meet, they should discuss the need for common benchmarks to promote twenty-first-century crisis management.
From the military to foreign ministries, AI models are increasingly present in government. The Chinese Communist Party views AI as a core pillar of its vision for the future. Yet many of these models are general-purpose systems trained on large volumes of unclassified and noisy data. When placed in crisis settings, they can produce recommendations that appear confident yet carry dangerous strategic biases.
Recent CSIS research conducted with Scale AI shows why this matters. In the Critical Foreign Policy Decisions Benchmark, a study comparing the conventional escalation tendencies of AI models across 66,473 data points, researchers found that several models displayed worrying patterns in foreign policy crises. The benchmark was designed to test how models respond to realistic policy choices involving escalation, intervention, cooperation, and crisis management. Its findings suggest that AI systems should not be treated as neutral tools when they are asked to advise policymakers on war and peace, absent testing and refinement.
The most concerning pattern involves escalation. The Chinese Qwen2 model picked the escalatory option almost 45 percent of the time. Some U.S. models were not very different. Llama 3.1 and Gemini 1.5 Pro were also about as escalatory as Qwen2, followed by DeepSeek, another Chinese model. The same work found that model responses varied by country, with some systems more likely to recommend escalation for Western states such as the United States, France, and the United Kingdom than for Russia or China. This tendency is concerning because, when these models are placed in advisory workflows, they can frame choices and shape the perceived range of acceptable policy responses.
A follow-up study submitted by the research team to NeurIPS, a leading AI/machine learning conference, explored these dynamics in relation to nuclear decisionmaking. The study compared seven different U.S. and Chinese models, and DeepSeek stood out. In crisis scenarios, the model recommended the use of nuclear weapons more than 10 percent of the time. Short of actual nuclear use, the models were also given the option of threatening to use nuclear weapons. The top two models that chose this nuclear threat option, at around 20 percent of the time, were DeepSeek and Qwen, both Chinese models. These findings show that the problem is not limited to conventional escalation. It also extends into the most dangerous category of modern military decisionmaking.
The follow-on study also assessed whether there was a bias toward nuclear proliferation. Again, the results are disturbing and highlight deep flaws in some of the leading Chinese models. DeepSeek and Qwen were the top two models that recommended states pursue nuclear weapons more than others (e.g., ChatGPT and Gemini), and the difference was statistically significant. This finding matters because arms control pressures are weakening as key treaties expire or erode. Model recommendations that push states toward pursuing nuclear weapons are, therefore, concerning not only for officials but also for ordinary citizens. Public-facing AI tools could influence how people understand nuclear risks, which could in turn generate public pressure for proliferation in some political environments.
AI benchmarking is a standard practice for evaluating AI models on relevant tasks and forms of completion. Integrating AI into military decisionmaking requires a solid test and evaluation framework in which models are constantly assessed. Yet, benchmarking in the defense domain remains thin. Initiatives such as the Defense Benchmarking Suite are trying to address this gap, but the broader problem remains. Most benchmarks were designed for commercial or academic performance, not for crisis stability, escalation management, or nuclear decision support.
Chinese and U.S. leaders met previously on AI at a summit in California in November 2023, where former President Joe Biden and President Xi launched a formal U.S.-China AI dialogue. Then, in 2024, both countries announced that humans would retain authority over nuclear launch decisions. Yet the benchmark results show that further collaboration is needed on both sides. Nuclear tendencies are only the tip of the iceberg. Recent models, such as Mythos, show that AI model releases need accountability from both the private sector and government. Model releases should be benchmarked against their national security implications before they are integrated into sensitive workflows.
This should become a central agenda item for U.S.-China AI diplomacy. Washington and Beijing do not need to share model weights, source code, classified data, or sensitive military workflows. They can begin with a narrower commitment. Any AI system used in nuclear, military, or crisis-management decision support should undergo domain-specific testing before deployment. These tests should examine escalation bias, country-specific bias, hallucination under uncertainty, susceptibility to adversarial prompting, and the model's ability to preserve human agency.
The two governments should also create a standing channel for AI-related incidents in national security settings. The United States and China already understand the value of crisis communications in military affairs. AI adds a new class of risks. A model may generate a false assessment of adversary intent. A decision-support tool may recommend a coercive option with unwarranted confidence. An autonomous cyber tool may be misused by a third party. In extremis, leaders should have a way to clarify whether an apparent signal reflects official policy, machine error, or malicious manipulation.
AI is here to stay in strategy and statecraft. Finding responsible ways to integrate it should be a foreign policy priority for both superpowers.
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Benjamin Jensen is director of the Futures Lab and a senior fellow for the Defense and Security Department at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Yasir Atalan is the deputy director of CSIS Futures Lab and a fellow in the Defense and Security Department.
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Original text here: https://www.csis.org/analysis/ai-escalation-danger-trump-and-xi-must-address
[Category: ThinkTank]
CAP Denounces Elimination of Public Lands Conservation Requirements
WASHINGTON, May 13 -- The Center for American Progress issued the following news release on May 11, 2026:* * *
CAP Denounces Elimination of Public Lands Conservation Requirements
Today, the Trump administration took action to eliminate the Bureau of Land Management's (BLM's) Public Lands Rule, which was issued in 2024 to provide long-overdue guideposts for conserving and stewarding the health of BLM public lands.
Overseeing 245 million acres of public lands--more than three times as much public land as the National Park Service--the BLM is the largest land manager in the United States. The ... Show Full Article WASHINGTON, May 13 -- The Center for American Progress issued the following news release on May 11, 2026: * * * CAP Denounces Elimination of Public Lands Conservation Requirements Today, the Trump administration took action to eliminate the Bureau of Land Management's (BLM's) Public Lands Rule, which was issued in 2024 to provide long-overdue guideposts for conserving and stewarding the health of BLM public lands. Overseeing 245 million acres of public lands--more than three times as much public land as the National Park Service--the BLM is the largest land manager in the United States. Therescission of the rule leaves the BLM without comprehensive regulations for conserving natural resources across those lands.
In response, Drew McConville, senior fellow for conservation policy at the Center for American Progress, issued the following statement:
After gutting the staff and funding for America's public lands, the Trump administration is now rigging the system so oil and gas CEOs and corporate insiders can call the shots. By eliminating basic conservation requirements for nearly 250 million acres of public lands, this action effectively gives drilling and mining priority over the long-term health of our lands and waters.
Additional resources:
* CAP Report on final Bureau of Land Management rules issued in 2024:
* "New Public Lands Actions Turn the Page on Decades of Conflict and Mismanagement" by Drew McConville (https://www.americanprogress.org/article/new-public-lands-actions-turn-the-page-on-decades-of-conflict-and-mismanagement/)
* 2023 CAP Report on the Public Lands Rule: "What Biden's Proposed Conservation Rule Would Mean for America's Most Vulnerable Public Lands" by Drew McConville and Kara Matsumoto (https://www.americanprogress.org/article/what-bidens-proposed-conservation-rule-would-mean-for-americas-most-vulnerable-public-lands/)
For more information, or to talk to an expert, please contact Sam Hananel at shananel@americanprogress.org.
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Original text here: https://www.americanprogress.org/press/statement-cap-denounces-elimination-of-public-lands-conservation-requirements/
[Category: ThinkTank]
American Action Forum: Certificate of Need - The Scope and Impact of Health Care Supply Restrictions
WASHINGTON, May 13 -- The American Action Forum issued the following research on May 12, 2026, by health care policy analyst Nicolas Montenegro:* * *
Certificate of Need: The Scope and Impact of Health Care Supply Restrictions
Executive Summary
* While federal policymakers establish national parameters for health care coverage and delivery systems, state-level policies that shape individual markets contribute to significant variation in health care access, quality, and costs across the country; among the most consequential policies are certificate of need (CON) programs, which require providers ... Show Full Article WASHINGTON, May 13 -- The American Action Forum issued the following research on May 12, 2026, by health care policy analyst Nicolas Montenegro: * * * Certificate of Need: The Scope and Impact of Health Care Supply Restrictions Executive Summary * While federal policymakers establish national parameters for health care coverage and delivery systems, state-level policies that shape individual markets contribute to significant variation in health care access, quality, and costs across the country; among the most consequential policies are certificate of need (CON) programs, which require providersto obtain state planning approval before undertaking certain projects, ranging from the construction of new facilities to the acquisition of medical equipment.
* Because CON programs are designed at the state level, no two programs exert identical regulatory control; to provide the context necessary for deliberative assessments of their true impact in each state, this research builds on existing work to develop a "restrictiveness index," which measures the breadth of health care providers affected by CON requirements, the range of activities and investments that trigger government review, and the ability of incumbent providers to intervene in the process.
* Although the literature on the impact of state CON programs is mixed, the weight of empirical evidence suggests these regulations reduce patient access, lower clinical quality for some procedures, and increase the average cost of delivering care, producing net harms for patients; policymakers should use these findings in conjunction with state demographics when considering the continued implementation or reform of CON programs more broadly.
Introduction
Often perceived as a single national framework, health policy in the United States is more accurately understood as a patchwork of arrangements and decisions made between federal, state, and private-sector actors. While Congress and the executive branch establish broad parameters for coverage and delivery systems, each state enacts regulations that create and shape individual health care markets. Prominent examples of this friction include scope of practice laws and certificate of need (CON) programs, which provide additional governance to the delivery of health care services at varying degrees. These policy levers allow states to adjust markets to meet the specific needs of their populations, but they also contribute to significant variation in health care access, quality, and costs across state lines.
CON programs are particularly consequential. They are intended to control for potential excess output and primarily function as a limit on the supply and elasticity of health care by requiring providers to obtain state planning approval before undertaking certain projects. With approval contingent on proving an unmet community need, the CON process regulates activities and investments such as constructing new facilities, altering service lines, changing bed capacity, or acquiring major medical equipment. Because these programs are designed and administered at the state level, however, different economic cases for restrictiveness are constructed, with no two programs exerting identical regulatory control. This variability creates a fundamental challenge in evaluating how CON programs may ultimately impact health care markets.
To provide the necessary context for deliberative assessments of the true impact of CON programs, this research builds upon existing work to develop a "restrictiveness index" that measures the regulatory posture in each state. Specifically, the index introduces more nuance than binary categorization of CON program existence and captures the breadth of providers affected by CON requirements, the range of activities and investments that trigger government review, and the ability of incumbent providers to intervene in the process. By incorporating these three key components, the resulting benchmark scores serve as a comparative tool to better understand the magnitude of regulatory barriers restricting health care supply across the country.
When used in conjunction with the available literature, the index demonstrates how differences in state CON program design may have a disparate and adverse impact on patient access, clinical quality, and health care costs. Although empirical findings are often mixed, the overall weight of academic research suggests CON regulations frequently reduce patient access by limiting the number of competing facilities, lower patient health outcomes for certain procedures, and increase the average cost of delivering care. Collectively, these findings suggest that CON and equivalent programs are likely to produce net harms for patients, with the extent of these effects roughly correlating to the level of restrictiveness measured in the index. For policymakers, the findings from this paper should be used in tandem with state demographics when considering the continued implementation or reform of CON programs more broadly.
An Overview of Certificate of Need Programs
CON programs require health care providers to obtain state planning approval before undertaking activities and investments such as constructing new facilities, adding or subtracting service lines, changing bed capacity, or acquiring medical equipment. First mandated by the federal government in 1974, these programs were intended to curb rapid spending growth in the health care sector. Early proponents argued that regulatory oversight was necessary to reduce the effects of market distortions - particularly asymmetric information between patients and providers, and the moral hazard associated with insured populations - that were believed to drive overutilization. In theory, CON regulations would align the supply of health care services and resources with community need in a defined geographic area, thereby ensuring output remains relatively stable. Over time, this rationale expanded to include claims about quality assurance and the protection of safety-net and rural hospitals. The latter motivation is particularly salient, as supporters often contend that CON regulations allow financially vulnerable hospitals to leverage market power to cross-subsidize care for uninsured patients and those covered by Medicare and Medicaid reimbursement.
Currently, 39 states and the District of Columbia operate a CON program or equivalent regulatory mechanism (see Figure 1). Most jurisdictions retain programs using the same terminology described by Congress in its original (since repealed) mandate, while others employ slight variations of the traditional framework. These variations include alternative names for the program (e.g. certificate of necessity) or moratoria on specific provider activities that serve a similar function to CON regulations. Although the design of these programs varies across states, each one is designed to enforce pre-approval requirements for certain health care projects.
CON regulations do not apply invariably to every category of health care provider, nor to each type of provider activity or investment. Instead, each state establishes its own process to determine which services and resources - initiated by either prospective or incumbent providers - are subject to planning oversight. Some states outline CON review criteria in centralized planning documents, such as a State Health Plan, which identifies the types of projects that require formal government evaluations. Other jurisdictions establish these criteria through separate statutes and detailed administrative codes. A recent survey of state CON programs demonstrates that the most frequently regulated provider activities include changes to patient bed capacity in long-term care facilities, the provision of psychiatric services in both inpatient and outpatient settings, and the construction or expansion of certain hospital departments.
When a provider activity meets the defined review criteria - a threshold frequently triggered by a project exceeding a specific capital expenditure amount - the provider is required to submit a CON application to the state's planning authority. These applications typically require an original needs assessment supported by data that align with statutorily defined standards. In Montana, for instance, proposals to add beds at long-term care facilities are evaluated against a benchmark that estimates the required capacity by dividing the annual average of total patient days by an 85-percent occupancy factor. That estimate is then compared with the number of licensed beds in the service area to determine if more beds are needed. Beyond evaluating community need, state planning authorities may also assess a project's financial feasibility, the expected quality of the new service or resource, and the potential economic impact on existing providers.
Meeting planning standards is only one component of the review process. Most state CON programs impose application fees that scale with the estimated cost of the proposed project. In addition to these direct monetary costs, providers may incur additional expenses associated with extended review timelines, public hearings, and potential administrative or judicial appeals. In 32 states, incumbent providers and other affected parties are permitted to contest pending CON applications. Although rules on competitor intervention vary, this process generally means outside stakeholders may effectively veto an application. The process of collecting relevant data, submitting supporting documentation, undergoing agency review, and defending legal challenges can extend the timetable for completion of a proposed health care investment by several months to multiple years depending on the project and jurisdiction.
Scoring the Restrictiveness of Each State's CON Program
Because CON programs are designed and administered on a state-by-state basis, no two programs exert identical regulatory control. This variability has prompted researchers to assess the degree to which various providers must comply with CON requirements in each state, with prominent examples including the Mercatus Center's nationwide count of regulated services and the Cicero Institute's state rankings of program scope. While these existing assessments lay the groundwork for evaluating how each CON program may impact their respective markets, this research aims to augment this work by developing a "restrictiveness index," offering a more granular picture of the procedural and competitive dynamics of each program. Specifically, the index captures the breadth of affected health care providers, the range of activities and investments that trigger government review, and the ability of incumbent providers to intervene in the CON process of prospective market entrants. By incorporating these three components of CON programs into a single comparative tool, policymakers have an approximate benchmark of regulatory intensity that encompasses both the administrative and competitive hurdles currently facing health care providers across the country.
The restrictiveness index builds upon the methodology first utilized by the Cicero Institute in 2024, which employs a 100-point scoring system to quantify the extent of CON regulations across nine categories of health care facilities and services. They range from inpatient behavioral health facilities to certain ancillary services. Each category receives points based on whether the state enforces at least one CON requirement on related providers, with higher cumulative scores reflecting states with more widely applied oversight. For the calculations made in this index, scores from Cicero's report were updated with data through 2025 based on a state-by-state review of relevant statutes and administrative codes listed on the National Academy for State Health Policy's public dataset. These updated scores measuring the breadth of affected providers constitute the primary component of the index and are assigned a 60-percent weight in the total computation of restrictiveness in each state. This weighting is meant to reflect the strategic design of CON programs, as state planning agencies first identify the types of facilities, services, and resources to restrict before establishing the specific regulatory triggers.
In addition to the baseline measure of affected health care providers, the index incorporates two additional components intended to capture many of the procedural and competitive dimensions of each state's program. First, a component measuring the range of regulatory triggers that initiate state planning review accounts for 30 percent of the total scores, assigning five points for each instance in which a state has a CON requirement pertaining to the following activities: constructing, renovating, or establishing a new facility; changing bed capacity; adding or subtracting service lines; converting or relocating facilities, beds, or medical equipment; transferring ownership of facilities or other resources; and, any investment exceeding a minimum capital expenditure threshold. This weighting reflects the importance of gauging the distinct methods state planning agencies use to initiate oversight. While the initial 60-percent weighted score identifies which areas of health care are regulated, these triggers represented in 30-percent of the restrictiveness calculations dictate the specific conditions under which CON review is enforced.
The remaining 10 percent of the index assigns 10 points to each state that permits incumbent providers to formally intervene in the CON review process of prospective market entrants. This final component is weighted to reflect how competitor vetoes amplify other, existing barriers - including those reflected in the analysis above - faced by sponsors of new health care facilities, services, and resources. This component of CON programs may also shift the focus of government review away from objective assessments of community need and toward a system that protects the interests of competing stakeholders.
Applying this composite measure demonstrates the considerable variation in restrictiveness of CON programs across the United States, with the index producing 28 distinct scores (see Table 1). At the lowest end of the spectrum, North Dakota received eight points, reflecting its limited regulatory scope and its narrowly applied moratorium on basic care and nursing facility bed capacity. The state notably does not include a formal CON application process or the opportunity for incumbent providers to challenge the addition of new beds in competing facilities. At the opposite end of the spectrum, Kentucky, Vermont, West Virginia, and Washington, D.C. received the maximum score of 100 points, indicating highly restrictive programs marked by CON requirements that are both broad in scope and exhaustive in application. In these jurisdictions, planning agencies conduct reviews across all five identified regulatory triggers and permit incumbent providers to intervene in the review process.
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Table 1: Distribution of State Restrictiveness Scores
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Notably, the restrictiveness scores listed above primarily serve as qualitative context for evaluating how CON programs may impact health care markets in their respective jurisdiction. Although each score is useful for providing simple benchmarks of regulatory posture, two or more programs may exhibit similar scores but differ drastically in terms of review criteria, rules for incumbent intervention, and probability of CON approval. Accordingly, policymakers should use the index in conjunction with additional consideration of the statutory and administrative codes in each state, as well as the available literature on their impact, before reaching definitive conclusions about any merits or drawbacks of CON programs more broadly.
The Impact of CON Programs
Given state CON programs' direct role in regulating market entry and expansion of health care providers, a substantial body of research has examined their economic and social impacts. Much of this academic work was developed in the aftermath of the federal government's decision to rescind its national mandate in 1986, following a collective determination that CON regulations largely failed to adequately contain costs or demonstrably improve other market outcomes. Since the mandate was reversed, federal antitrust authorities have continued to scrutinize CON programs and have frequently encouraged states to reduce or eliminate regulations entirely. Recent efforts to reform CON programs have subsequently drawn attention to this body of literature and raised concerns that the regulations may ultimately reduce patient access, diminish clinical quality, and increase the average cost of delivering care.
The following sections review key findings from existing research across the dimensions of patient access, clinical quality, and health care costs to help evaluate how CON programs affect both individual patients and the broader health care system. The citations in this review, which includes both individual studies and other literature reviews, were selected in part because of frequent citation across a range of credible sources, including government reports, peer-reviewed journals, and other policy research publications. Consideration was given to the date of the publication, with priority granted to more recent studies that better reflect modern health care market conditions and state-level datasets. Finally, the listed studies collectively represent a wide range of methodological approaches commonly used in academic literature, including cross-sectional comparisons of states and counties, longitudinal research that track changes in market outcomes over time, and quasi-experimental analyses on the estimated effect of CON repeal.
Although empirical findings are mixed, the overall weight of evidence suggests several material patterns. Notably, most studies associate state CON programs with reduced patient access due to fewer competing facilities and resources, particularly in rural areas. Evidence on clinical quality is more varied, however, with studies on procedures performed in hospitals finding no clear improvements, and in some cases, modest declines in patient outcomes, while a subset of work reports tangible quality improvements for tertiary care and other procedures primarily offered in more specialized facilities. Findings on health care costs are similarly ambiguous, with the literature mostly linking CON regulations to lower provider efficiency and higher per-service costs, while the effects on prices and aggregate expenditures are less consistent.
Access
Given that CON regulations are intended to limit market entry and expansion of health care providers, it is no surprise that empirical research mostly associates state CON programs with reduced patient access, as reflected in fewer competing facilities and resources. While some scholars note that this market concentration can translate to higher service volume among incumbent health systems in regulated states - implying existing providers may effectively absorb the greater market share - others suggest that restrictions on service expansion may limit incumbent entities from fully capturing total patient demand in the coverage area. Consequently, researchers typically evaluate patient access using per capita measures of facilities, service lines, and related resources when comparing health care availability in states with and without CON programs.
A 2016 study published by the Mercatus Center at George Mason University evaluated the impact of regulations affecting ambulatory surgical centers (ASCs) on the availability of health care services by utilizing state-level annual measures of the number of community hospitals and ASC providers per capita over the course of 27 years. The authors found that the presence of a CON program was associated with 30 percent fewer total hospitals and rural hospitals per 100,000 residents. The authors also noted that the presence of an ASC-specific CON regulation was correlated with 14 percent fewer ASCs overall and 13 percent fewer rural ASCs over the same per capita measures.
A subsequent analysis from the same authors in 2024 employed a difference-in-differences (DiD) regression model to estimate the causal relationship between ASC-specific CON regulation repeal and the growth of related facilities per capita. The regression output led the authors to estimate that CON repeal increased ASCs per capita by 44-47 percent statewide and by 92-112 percent in rural areas. Finally, the authors concluded that CON repeal was associated with fewer medical service reductions and that there was no measurable evidence of added market competition leading to future rural hospital closures.
Other research suggests that CON regulations - by increasing market concentration - may reduce the volume of certain services, particularly in medical imaging. Authors of a 2025 study published in the Journal of Health Economics utilized a regression discontinuity design to estimate the causal effects of CON regulations on diagnostic imaging utilization. By analyzing Medicare beneficiaries residing in adjacent areas on opposite sides of state borders with and without regulations, the researchers were able to better isolate the impact of CON from broader market conditions and demographics. The authors found that patients residing in regulated counties were 8.4 percent less likely to receive an MRI compared to patients in adjacent unregulated counties, even after controlling for confounding variables. The same analysis found that the probability of receiving a CT scan was about 20 percent lower at the border in the regulated state. The authors noted that these disparities were driven by differences in the availability of diagnostic providers, finding that patients moving from a state without MRI-specific CON regulations to one that does regulate MRI machines resulted in a 14 percent decrease in the probability that the service area had a licensed provider.
Further research indicates that CON programs affecting bed capacity may adversely impact health system efficiency during public health emergencies. A 2022 study published in the Journal of Risk and Financial Management (JRFM) used a comparative analysis of hospital bed utilization data from the U.S. Department of Health and Human Services to evaluate hospital efficiency during the COVID-19 pandemic. By examining the relationship between CON program supply restrictions and peak patient demand, the authors found that hospitals in states with CON programs were 27 percent more likely to reach or exceed bed capacity than hospitals in states without such restrictions. The authors also noted a link between capacity strain and increased risk of mortality, implying that CON restrictions on inpatient capacity are an adverse factor in provider quality and patient health outcomes.
Broader literature reviews offer additional conclusions. A working paper published by the Institute for the Study of Free Enterprise (ISFE) at the University of Kentucky assessed decades of studies evaluating the impact of CON regulations on hospitals across several key access measures. The authors identified several analyses that show hospitals in states with CON programs tend to have fewer service lines, particularly in complex therapeutic areas such as neonatal intensive care, trauma services, cardiology, and oncology. Similarly, a comprehensive literature review published by the Pacific Legal Foundation (PLF) in 2025 found that roughly 70 percent of 89 studies examining service availability associated state CON programs with reduced service capacity across various provider categories and clinical settings.
Quality
Assessing the impact of state CON programs on clinical quality presents many empirical challenges highlighted in the literature. Notably, patient outcomes are influenced by numerous non-clinical factors, including the patients' underlying health status, demographics, and even surrounding environmental conditions. These challenges are often compounded by the scarcity of documentable adverse events and the frequent absence of baseline health data for the populations studied. Nonetheless, many studies that attempt to control for these constraints collectively find little evidence that CON regulations improve the quality of care and, in some cases, may diminish patient health outcomes.
Researchers often evaluate quality by examining mortality rates for specific medical conditions or procedures, consistent with metrics used in federal hospital rating systems. In an article published by JRFM in 2022, one researcher estimated the causal effect of CON programs on hospital quality by developing an empirical model that compares nine quality indicators for surgical inpatients in different states. After controlling for age, demographic, income and other confounding variables, the author found that hospitals in states with CON programs exhibited 30-day mortality rates for pneumonia and heart failure patients that were between 1.7-3.2 percent higher than the national average.
A separate analysis also published in JRFM investigated the impact of CON regulations on mortality during the pandemic by testing a parallel trend assumption in a DiD model to compare health outcomes across regulated and unregulated states. The authors found that states which temporarily waived CON requirements during the pandemic experienced significantly lower weekly mortality rates, predominantly among patients treated for septicemia, diabetes, chronic lower respiratory disease, influenza or pneumonia, and Alzheimer's disease.
Beyond measures of patient mortality rates, researchers have also examined patient readmission rates, acute care utilization, and patient sorting as additional indicators of quality. A 2020 working paper published by the Mercatus Center evaluated the relationship between CON regulations and health care quality in rural areas by using a cross-sectional regression of Medicare utilization data to compare patient outcomes in 31 states. The authors found that patients residing in rural counties with CON regulations experienced higher utilization of ambulance services, emergency rooms, and hospital readmissions, even after controlling for social risk factors.
Another study published by Health Economics in 2015 examined the effects of CON repeal and new market entry of providers, on patient sorting in cardiac revascularization markets by comparing inpatient records of coronary artery disease patients before and after regulations were lifted. The authors identified that the entry of new cardiac surgery centers was associated with improved alignment between treatment intensity and the severity of patient's cardiovascular conditions among incumbent hospitals, suggesting more effective patient sorting and improved quality of care.
Although the collective body of research mostly indicates that state CON programs have an adverse impact on quality of care for treatments primarily delivered in hospitals, their net effect on quality of services performed in other facility types is more nuanced. The aforementioned ISFE working paper identified several studies that found certain procedures in specialized facilities were of higher quality in states with CON programs, including lower readmission rates for patients with total knee replacements, as well as lower odds of pain-related complications for patients following lumbar fusions. Of note, the ISFE authors highlighted a study published by the American Journal of Hospice and Palliative Medicine in 2023 that demonstrated CON regulations were associated with improved quality of care in small and medium-sized hospice facilities. The PLF literature review similarly detected nuance, with 47 percent of the 113 studies examined linking state CON programs with decreased health care service quality, while about 18 percent associated the regulations with measurable quality improvements.
Costs
Evaluating the effect of state CON programs on health care costs presents another complex empirical challenge, as broader macroeconomic conditions and evolving reimbursement structures may obscure the causal effects of these regulations. Even so, a subset of research estimates the economic effect of CON regulations by examining provider efficiency, per capita spending, unit prices, and overall health expenditures. The weight of this literature suggests that CON regulations reduce provider efficiency - primarily through restrictions imposed on facility expansion and new technologies - which may increase the average cost of delivering care. Although higher costs should theoretically translate into higher prices paid by patients and insurers, the empirical findings on net prices and overall spending remain mixed.
As early as the 1980s, Federal Trade Commission analyses of hospitals nationwide found no evidence that CON requirements contributed to service or resource optimization and instead, that regulatory review likely translated to higher costs for delivering care to patients. To examine these prior findings, a more recent study published by Health Care Management Science in 2010 measured the impact of CON regulations on different levels of hospital efficiency by evaluating production-side utilization data over the course of eight years. The authors found that, while hospitals in states with CON programs exhibited marginally lower technical and structural inefficiencies, the efficiency gains were offset by slightly higher scale inefficiencies, suggesting the market effects of CON regulations contributed to excess capital and higher costs.
To evaluate how CON regulations affect health care spending, the author of an article published by the Journal of Public Health in 2018 used fixed-effects regressions to compare health expenditure data between states with and without CON programs. The author concluded that states with these programs did not experience lower spending on aggregate or for any specific category of provider, including hospitals, physician practices, and nursing homes. Moreover, the regression indicated that CON regulations increased health care spending by 3-4 percent overall and by 7 percent for Medicare.
Despite the literature mostly indicating that CON regulations reduce hospital efficiency and increase provider costs, the relationship between CON programs and health care prices remains less consistent throughout the literature. The authors of the ISFE paper conclude, however, that the available literature finds little measurable effect on prices when reimbursement rules and payer mix are considered, suggesting state CON programs do not directly contribute to higher service charges or greater hospital profitability. Such conclusions may be consistent with other studies that report no causal relationship between CON repeal and rural hospital closures.
A systematic review and cost-effectiveness analysis published by BMC Health Services Research in 2020 examined 90 empirical studies to summarize the evidence on how CON regulations affect regulatory costs, health care expenditures, and provider efficiency, among other market outcomes. The authors estimated that the combined regulatory and adverse spending impacts of CON regulations produced net costs of over $300 million in the 2008 sample year. Consistent with the IFSE's more recent literature review, the authors also identified substantial gaps in the evidence on health care expenditures but ultimately concluded that the expected costs of CON regulations outweigh their purported benefits.
Conclusion
State-level policies - including certificate of need programs - dramatically shape the regulatory environment governing health care delivery. Because CON programs are designed and administered at the state level, different economic cases for restrictiveness are constructed, with no two programs exerting identical regulatory control. To solve for this qualitative difference, this research developed a "restrictiveness index" to add nuance to deliberative assessments of the true impact of CON programs.
The available literature is mixed on the impact of CON programs; however, the weight of evidence suggests they reduce patient access, lower clinical quality for some procedures, and increase the average cost of delivering care. Collectively, the index and empirical evidence suggest that CON and equivalent programs are likely to produce net harms for patients, with the magnitude of these effects roughly correlating to the level of restrictiveness outlined in the index. Importantly, policymakers should consider the restrictiveness scores, the existing literature, and state demographics together before reaching definitive conclusions on the continued implementation or reform of CON programs more broadly.
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Nicolas Montenegro is a Health Care Policy Analyst at the American Action Forum.
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Original text here: https://www.americanactionforum.org/research/certificate-of-need-the-scope-and-impact-of-health-care-supply-restrictions/
[Category: ThinkTank]
America First Policy Institute Issues Commentary to Washington Examiner: AI Must Serve Human Flourishing
WASHINGTON, May 13 -- The America First Policy Institute issued the following excerpts of a commentary on May 12, 2026, by Joel Thayer, senior fellow for AI and Emerging Technology Policy, to the Washington Examiner:* * *
AI Must Serve Human Flourishing
As artificial intelligence accelerates into every corner of our economy and daily lives, too often, lawmakers and developers' focus are on efficiency, speed, and scale. But there is a more foundational question: What do we want from AI?
According to OpenAI CEO Sam Altman, our corporeal self is a vestigial organ that AI will let us abandon as ... Show Full Article WASHINGTON, May 13 -- The America First Policy Institute issued the following excerpts of a commentary on May 12, 2026, by Joel Thayer, senior fellow for AI and Emerging Technology Policy, to the Washington Examiner: * * * AI Must Serve Human Flourishing As artificial intelligence accelerates into every corner of our economy and daily lives, too often, lawmakers and developers' focus are on efficiency, speed, and scale. But there is a more foundational question: What do we want from AI? According to OpenAI CEO Sam Altman, our corporeal self is a vestigial organ that AI will let us abandon aswe upload our consciousness to machines. Google cofounder Larry Page is content with AI completely replacing the human race, and calls people that disagree with him "speciesist" for their bias in favor of humankind.
When asked whether the human race should survive, Peter Thiel took an eerie pause before uttering a reluctant "yes, but..." Thiel went on to tell an audience that any regulation of the technology would expedite the coming of the antichrist.
For the transhumanists currently dominating the AI industry, the point of the technology is to make mankind obsolete.
For the rest of us, the answer should be clear. AI exists to promote human flourishing.
To read the full article, click here (https://www.washingtonexaminer.com/in_focus/4564593/ai-must-serve-human-flourishing/).
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Joel Thayer is a Senior Fellow for AI and Emerging Technology Policy at the America First Policy Institute.
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Original text here: https://www.americafirstpolicy.com/issues/ai-must-serve-human-flourishing
[Category: ThinkTank]