Onsite wastewater treatment systems (OWTS) serve 20–25% of the households in the USA, and large parts of rural Canada, Australia, and Europe. Urbanization and newer environmental standards are leading many communities that currently rely on OWTS to think of alternatives. We study this decision-making in 19 municipalities across the USA through the unique lens of feasibility reports commissioned by the respective municipalities and authored by engineering/design consulting firms. The reports omitted certain essential information relevant to the decision-making process, and were not of high quality due to a lack of specificity on various parameters. However, the reports evaluated a balanced mix of decentralized and centralized treatment options, and the final recommendations were not biased in any particular direction. Most municipalities failed to take any follow-up action on the report recommendations, calling into question the motive behind commissioning these reports. Although not representative of the entire USA, the small sample of feasibility reports evaluated here is indicative in nature and provided significant insights about the inputs that help municipalities make decisions on complex issues.