Iowa requires physicians to apply for a Certificate of Need (CON) in order to open a new facility in which to perform medical procedures. The issue is that the Health Facilities Council in charge of granting these certificates only does so if there is no other medical facility that offers the same services, or if the already-existing facility does not provide the service efficiently. This knocks out many potentially new providers from opening facilities since most services are already provided in some fashion. This erodes competition and prevents cost control on the services since ultimately only one provider is allowed to operate a facility that performs a certain type of medical procedure. Only facilities that have less than $1.5 million in costs per year are able to escape the review and need for a CON to open the facility. Providers like Dr. Lee Birchansky are thus unable to perform cataract surgeries in an already-existing facility, Fox Eye Laser and Cosmetic Institute, where he practiced for six years. At that point, he decided to make a change in ownership and UnityPoint Health St. Luke's withdrew, leaving Dr. Birchansky to operate on his own and apply for a CON, which the state has denied four times. The procedure would cost far less at the outpatient facility than it would in hospital, thus the argument that the CON prevents cost control due to the monopoly created in favor of large medical hospitals. Governor Branstad is opposed to CONs and is among many that are trying to change the law to stop the requirement of obtaining a CON in order to perform medical procedures in outpatient facilities.