“Iowa makes it a crime for doctors to open up a new location and offer services without obtaining special permission known as a ‘certificate of need.’ Permission is not easy to come by: Dr. Birchansky must persuade state officials that his outpatient surgery center is ‘needed’ in the proposed location through a cumbersome process that resembles full-blown litigation and that allows existing businesses (his competitors) to oppose his application. This process amounts to nothing more than certificates of monopoly.”

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