Medicare Spending Has Slowed Significantly Under Obama
For the past 18 months, Medicare spending has slowed down considerably - especially compared to the private sector.
By far, the biggest threat to the long-term solvency of the United States is the explosion of Medicare costs. Take current budget projections and remove Medicare, and Federal budget deficits are very manageable. Put it back in, and it looks like a disaster.
Which is why it’s amazing to me that there’s a little fact about Medicare under the Obama Administration that’s gone unheralded: the growth in Medicare outlays has significantly diminished – and it looks like a trend that will keep going strong in the future.
While our elected representatives wrangle over slicing entitlements, virtually no one seems to be paying attention to an eye-popping fact: Medicare reimbursements are no longer accelerating at a break neck-pace. The new numbers should be factored into any discussion about healthcare spending: From 2000 through 2009, Medicare’s outlays climbed by an average of 9.7 percent a year. By contrast, since the beginning of 2010, Medicare spending has been rising by less than 4 percent a year. On this, both Standard Poor’s Index Committee and the Congressional Budget Office (CBO) agree. (S&P tracks healthcare spending with the help of Milliman Inc., an independent actuarial and consulting firm.)
What explains the 18-month slow-down? No one is entirely certain. But at the end of July David Blitzer, the chairman of Standard &Poor’s Index Committee, told me: “I’m hesitant to say that this is a clear long-term trend. But it’s more than a blip on the screen.”
There are, no doubt, a number of factors influencing this slowdown in growth, but according to Zeke Emanuel, one of the major reasons for the slowdown is health providers preparing for the implementation of the Affordable Care Act:
Zeke Emanuel, an oncologist and former special adviser for health policy to White House Office of Management and Budget director Peter Orszag, is certain that this is what is happening. When I spoke to him last week, Emanuel, said: “This is not mere chance: this is directly related to the initiation of health care reform.” It is not the result of reform, Emmanuel emphasized. The reform measures that will rein in Medicare inflation have not yet been implemented. But, he explained, providers are “anticipating the Affordable Care Act kicking in.” They can’t wait until the end of 2013: “They have to act today. Everywhere I go,” Emanuel, added, “medical schools and hospitals are asking me, ‘How can we cut our costs by 10 to 15 percent?’
It’s important to remember when you look at CBO projections for spending, they do not include the several different cost control provisions, as the CBO has said that its impossible to estimate their impact. But if this article is accurate, it appears that those measures are having an effect now – even before they go into law.
I find that encouraging.
The continually escalating costs of medical costs is the problem. About 4 yrs ago I went in for abdominal surgery. Cost in the middle $30 thousands. A year later I was back having the same surgery, same surgeon, same hospital, same hospital stat. Cost? in the middle $60 thousands. Why?
I’m in my middle 60’s. When I fell off my bike when I was a kid and fractured my elbow, I got an unwieldly cast. Today, if I fractured my elbow, I would get surgery to put in a plate, or a screw, or something. Why? I’ll add, that probably the only joint in my body that doesn’t ache from arthritis is that elbow.
So what do those screws, plates or whatever actually do? Additional medical costs in my book, which is part of what drives up our medical cost
The number of doctors who are refusing new Medicare and Medicaid patients is also rising, as they find they are actually losing money on treating them. Some are even opting out entirely from both programs. That could be a factor, too.
J.
This is arguably a lot more important than the recent debt ceiling silliness. The rapid rise in health care costs will cause the private sector just as many problems as the public sector, so it’s encouraging to see the increase slow down. Now if we could just expand Medicare eligibility down to 55 it might be possible to make even more progress.
I hate to be a pessimist, but I can’t imagine that this is because of the ACA. What business cuts costs in anticipation of future decreases in reimbursements? Hospitals save money by figuring out ways to get reimbursed without spending money, not by cutting the claims they make to Medicare. I’m not sure why Medicare’s costs are down, but I imagine it’s party the recession. Either way, let’s hope this continues.
@Jay Tea: Doctors do not “lose” money by seeing Medicare patients, they simply don’t make quite as much as they would from privately insured patients. Doctors’ bills are a big part of our problem with rising medical costs, so they’re going to have to settle for one new luxury car every year instead of two,
And before anyone insists lowering their pay will reduce the number of doctors, France, Germany and Japan all have significantly more practicing physicians per capita than the United States, and they are paid less.
The photo accompanying this post says it all.
Some things in the ACA will work, some not so much. It will have to continue to be tweaked and evolve. It’s not the health care reform I would have wanted, but it is the health care reform we got. And so we must work with it.
This news is good news. But I’m sure the Tea Drinkers will tell us why this news actually portends the end of the world as we know it.
@Ben Wolf: Doctors’ bills are a big part of our problem with rising medical costs, so they’re going to have to settle for one new luxury car every year instead of two.
No, they aren’t going to have to settle. They’re not slaves — if they choose to not take Medicare/Medicaid patients, then they won’t. And if the government tries to force them, they can just close up their practices.
It’s happening now.
And Dr. Lee Gross spells it out in precise detail here: http://www.aafp.org/online/en/home/publications/news/news-now/opinion/20100804ptctrpt-gross.html
It’s simply not worth their time and effort. How you wanna address that?
J.
@Jay Tea:
How’s about, “Bye, bye.”
What are they going to do Jay, pick up and move to the great Galtian paradise that is Azerbaijan? Canada? The UK? Or are they going to close up shop and become an electrician? An engineer? I have no doubt that some may decide to retire early, but the idea that a whole lot of doctors are just going to throw away their “million” dollar educations because they have to be a little more cost conscience is ludicrous on its face.
@Hey Norm:
Your statement sums it up pretty well. The only issue with tweaking ACA is that our system of government isn’t very good at fine tuning anything. Any action will be heavily politicized (by both sides), and any action that succeeds will also be a siphon for generating revenues for non-related activities. If we can tweak ACA, we should also be able to tweak Social Security and Medicare, to fix problems there as well.
F*ck em’. They don’t like making 10% less, they can move to England. I’m sure they’ll be much better compensated there.
It doesn’t make sense to me that medicare costs are increasing at a slower rate because of something that hasn’t kicked in yet. I guess it’s possible, but I don’t find it particularly plausible.
4% is better than 9%, and I hope the trend continues.
@Jay:
Isn’t this the very argument that you, and others like you, use in regards to raising taxes; that businesses will cut costs and not hire in anticipation of future tax increases?
Do you even realize how inconsistent you are in your arguments?
@ EddieinCA…
Thanks. I was going to type the same thing. I think more than anything it points up the utter fallacy/ridiculousness/stupidity of the uncertainty argument.
Welcome news. Let’s hope it holds out.
However, I think that our optimism on this should be guarded. Google up a graph of Medicare spending. It hasn’t climbed on a nice, smooth basis but rather has proceeded in stepwise jumps.
Basically: not enough data. We’ll see.
@ Rodney…
Well we have tweaked them before. Reagan and Tip O’Neil got together and strengthened SS. So bi-partisan changes can happen.
Can we do the same today with tricorn wearing retards holding the majority in the House? Doubtful.
@EddieInCA:
You’re putting words in Jay’s mouth, then calling him inconsistent. Where did Jay make the similar statement about raising taxes? (he may have, I just don’t see where)
Others are only inconsistent if they made a statement similar to Jay’s and a statement about cutting costs and not hiring in anticipation of future tax increases?
I think you’ve stumbled on an issue that doesn’t exist.
@bACHMANN pERRY oVERDRIVE (formerly Hey Norm): Yes, they can do it, but certainly not very easily or often that well. To tweak or fine tune you need to be able go in repeatedly and make adjustments without grand sweeping gestures and massive efforts.
FTFY. (since you decided to be insulting I chose to fix your statement.)
@Jay Tea:
This is easily fixed: just take away the state protected racket the AMA has set up that allows them to charge monopoly prices by limiting the supply of doctors. Medicine is basically a closed shop union right now where the existing doctors artificially limit who is allowed to provide training and to how many people. Just end that and the threats to go on strike will end too.
Sorry Rodney….being willing to crash the economy for an unfounded tax cut catechism is retarded. Well that is insulting to retards I suppose.
@Hey Norm: I didn’t eliminate anyone you called retarded, I just added the label to all those responsible.
Before that I thought the discussion was interesting enough without adding derogatory labels.
Stormy gets it. The feds could create a huge supply of GP doctors who don’t need to charge exorbitant rates: it’s called “free medical school” + “trust-busting.”
If there’s an Obama second term and the Dems find their gonads, the mere threat of this could suffice to bring doctor fees down and the profession to heel.
with tricorn wearing retards holding the majority in the House
Hm. My 6-year-old is retarded, and much nicer than any GOP House member.
@Anderson:
I’m not even arguing for free medical school. For 75% of medicine, full medical school is overkill. Yeah, if I’ve got vague symptoms, I need someone with highly detailed knowledge of every detail of the human body. But as an example, a recent interaction with a doctor involved a small growth on my chin that he injected with anesthetic, cut off, and sent to a lab. Then a month later he told me what the lab report said.
That doesn’t require eight years of training and shouldn’t have cost $200 (and that’s just his fees, not counting the lab work).
@rodney dill:
Rodney –
You must be new here. Most of us regulars know Jay Tea’s arguments inside and out. You can look through the archives if you wish to see how many times he has pushed the “Tax increases are bad because businesses will not hire in anticipation of those tax increases” argument.
In other words… You don’t know what the f**k you are talking about, Rodney.
EddieinCA and Bachmann Perry Overdrive –
Tone down the language or I’m going to start deleting your comments.
Copy that, Mr. Knapp.
@Stormy Dragon: I have not seen a Dr. in years (except for a hand surgeon about 18 mos ago). I see a nurse practitioner. I recently had an infected cyst removed from my back by her.
3 visits: 1) for antibiotics, 2) to have it removed, 3) get the stitches removed.
Time spent on procedures: 1) 5 min. 2) app 20 min 3) 5 min
Total bill: $647.00.
I know there are many costs associated with running a medical office: receptionist, billing office nurse, cleaning and sterilization, etc… and I forget how much the insurance actually paid, and I know it was considerably less, but….
Six hundred and forty-seven buckaroos????
@EddieInCA: Rodney is a headliner here Eddie.
@OzarkHibilly:
Part of the problem is that the NP is still required to be supervised by a doctor, so the savings aren’t nearly as much as it should be with that option.
@EddieInCA:
Uh, your comment I responded to, was @Jay, not @Jay Tea
@OzarkHibilly:
or at least a headcase here.
@Jay Tea:
The number of doctors who are refusing new Medicare and Medicaid patients is also rising, as they find they are actually losing money on treating them. Some are even opting out entirely from both programs. That could be a factor, too.
How could that be a factor? Do you think because a small amount of doctors are refusing new Medicare patients, that those patients suddenly stop seeing doctors? The vast majority of doctors do see Medicare patients. They seem to be cutting costs and thus decreasing the growth of outlays.
1. Jay != Jay Tea. Two different posters.
2. I’ve heard the “break the AMA” suggestion before, and then I’ve read pushback against that (suggesting that the AMA does not, in fact, wield the sort of power that some suggest it does, artificially lowering the # of docs). Anyone here actually have some facts on that?
3. I’m suspicious of the idea of subsidizing medical education, since higher education is the other big offender in terms of cost growth. Wouldn’t subsidizing it just jack up the tuition even more?
I’ve heard the “break the AMA” suggestion before, and then I’ve read pushback against that (suggesting that the AMA does not, in fact, wield the sort of power that some suggest it does, artificially lowering the # of docs). Anyone here actually have some facts on that?
The AMA does not have the power to limit the number of docs. There are three bottlenecks, medical schools, residencies, and licensure. Medical schools for MDs are licensed by the LCME, which is sponsored by the American Association of Medical Schools (AAMC) and the AMA, but is not under the direction of either. Residency slots are determined by the ACGME, which is a group of organizations among which the AMA is one of five, and the limit on the number of slots is due in large part because of the federal government, which funds them. State licensure is determined by state medical boards and boards of medical examiners, which are state-run. Most of what power the AMA does yield is “soft power,” based on the perception that they represent doctors (though fewer than a quarter of doctors are actually members of the AMA).
In addition to the above, you can actually become a Doctor of Osteopathy (DO) by attending a medical school credentialed by the American Osteopathy Association (AOA). The AOA also has residencies, though most DO grads go through traditional residencies.
@mantis:
How could that be a factor? Do you think because a small amount of doctors are refusing new Medicare patients, that those patients suddenly stop seeing doctors?
No, but they might see them with less frequency. Fewer doctors means longer wait times (and other inconveniences). Longer wait times (and other inconveniences) mean fewer visits for non-emergencies. A lot of doctors do take medicare, but we’re starting from a point where there are too few primary care doctors to begin with. The difficulties of Medicare patients finding doctors is not undocumented.
If they do really slash rates (or ever fail to implement DocFix), this really could be a source of cost-savings.
No, but they might see them with less frequency. Fewer doctors means longer wait times (and other inconveniences). Longer wait times (and other inconveniences) mean fewer visits for non-emergencies.
I suppose that’s possible, but I’d like to see some evidence that a small decrease in the number of doctors accepting Medicare patients is causing old folks to see the doctor less often. In my experience, if the choice is between a slightly longer wait and not seeing the doctor, most old folks are going to wait.
@mantis: FWIW, I’m not really convinced that the lack of access to doctors is causing the decrease in growth rate. But I think it really does become an issue if rates are really slashed or if DocFix ever fails to get passed.
I should add that there is a level in between “Accepting Medicare patients” and “Not accepting Medicare patients” which is actually quite common: Accepting Medicare only for pre-existing patients. In other words, if you just hit 65 or whatever, they won’t stop seeing you, but if you’ve just moved to town, and you’re on Medicare, they won’t see you.
This New York Times article explores the issue:
The solution to this problem is to find doctors who accept Medicare insurance — and to do it well before reaching age 65. But that is not always easy, especially if you are looking for an internist, a primary care doctor who deals with adults. Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare, according to the hospital’s Web site. {…}
Two trends are converging: there is a shortage of internists nationally — the American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs — and internists are increasingly unwilling to accept new Medicare patients.
“If you have just moved into town and are 64,” said Dr. Jeffrey P. Harris, an internist and the president of the American College of Physicians, “it is easier for you to see a doctor than if you had just moved into town and are 65.”
That second paragraph is really important, because they’re being sent to the back of what is already a long line. My wife has a colleague that has been in town for less than 18 months and already has enough patients that she can pick and choose future patients.
@Stormy Dragon: Stormy, supervised as in how? Because in all the years I have been seeing her, I have never seen a doctor in the office at the same time she is. Yes, there is a doctor “over” her, but to be honest, I could not say that they have ever even met.
(Yes, I am sure they have, but you could not prove it by anything I have ever seen or heard)
Yes, hospitals are cutting costs in anticipation. I have cut a million from my group’s practice while expanding. I am meeting to night to continue some more cutting. Hospitals are convinced, rightly or wrongly, that they need to cut. They are also consolidating for protection. This is all concerns over ACA related fees. No one is worried about private carriers cutting fees.
Secondly, while some PCPs may not be seeing patients, it is being picked up by specialists. It also appears to be regional. Besides, there really is not anyway to cut Medicare spending w/o affecting physician salaries. Some on the right (Goodman) try to sell this fantasy. It is not possible.
Steve
@Stormy Dragon:
Not only are you right but you’re understating the problem if anything. Not only is the medical profession a “closed shop union right now where the existing doctors artificially limit who is allowed to provide training and to how many people”, it also determines the work rules (“standards of care”). This creates a situation in which not only do physicians constrain the supply but also create their own demand.
@OzarkHibilly: This is kind of murky area. Right now, there is a mid-level provider in town that is not getting appropriate supervision. The local doctors are trying to put this person before a disciplinary board. If he ends up there, the doctor that’s supposed to be supervising him will end up in trouble, too.
Trumwill: thank you.
Anecdotal:
I’m getting over a bout of prostatitis. Soon as I had symptoms I used the Google and quickly concluded that’s what it was, and I knew I’d be getting Cipro.
It was after hours so I called my doctor. Could they just call in a scrip? No. No, no: I had to go to the ER.
5 1/2 hours at the ER before the doctor finally took my history, ordered various tests and concluded it was almost certainly prostatitis. He ordered Cipro.
I don’t have the bill yet, but it’ll be in the 4 figures. For something that could have been handled with a search engine and a pharmacist at a cost of $20.
Now, I hear people saying: yes, but it could have been something else. True. But if as happened the very first Cipro knocked it down by 90% then I guess I was right. If it hadn’t I could then have gone for more care.
Add the 4 figure cost of the ER and a day’s work blown by the fact that I didn’t get home until 3:00 am. All for what?
If there’s an internist shortage and people on Medicare are having trouble getting seeing doctors, I don’t actually see the two as related. Fix the doctor shortage and people on Medicare will probably have a lot less trouble. Conversely, if Medicare didn’t exist and everyone was on private plans (or no plans) the doctor shortage would still exist, but the doctors would just be using a different criteria to pick and choose patients.
As far as actual policy I’d like to see congress working on, it would be the following 3 items:
1. Make the “Doc Fix” permanent. Either implement it or repeal it, but stop with the yearly fixes.
2. Increase the number of physicians, especially primary care practice types.
3. Expand Medicare
@EddieInCA: I’m not sure what you mean by “you or others like you”, but no, I’ve never argued that.
@EddieInCA: ah I see…FYI, I am not Jay Tea. Different Jay.
About doctor salaries – thanks to Trumwill for the very informative posts.
Cuts to physician reimbursements affect specialties differently. The docs who are buying one luxury car per year probably work in a hospital or in a huge practice with controlled overhead or in a specialty that is cushioned from cuts (surgery, anesthesia, radiology, etc).
Small practice primary care docs (the type of docs that we need most) are more vulnerable to the cuts and may no longer make enough money to offset rising student loan costs. So docs in primary care (outpatient OB, pediatrics, internal med) will retire early, join larger group practices, close their practices to join hospitals, stop accepting insurance, or even re-train to become specialists.
The net result will be an effectively higher per capita number of docs for the rich/insured, and a lower per capita number for the old/sick/poor. These are all bad consequences for our healthcare.
@Trumwill: I assume the murkiness surrounds just what is “appropriate supervision”?
For the record, my NP works in a clinic in a small town (>2000). If she left, there would be no one for quite some distance. Also, this has been so for 5 yrs plus, so I assume it is sanctioned here anyway.
I have several things to add to this conversation:
1. While Law Schools are profit centers, Medical Schools are expensive. Even if the LCME wanted to prevent any medical schools from forming, the American Osteopathy Association would love for their to be more DO schools because they want a larger voice in the medical establishment. The problem is getting funding.
2. Even if a bunch more medical schools were opened, it actually wouldn’t increase the number of doctors without other changes. The real bottleneck is residencies, as far as that goes. Right now extra residency slots are filled by foreign-trained doctors. The end result of more medical schools without more residency slots is replacing foreign-trained doctors with American-trained ones. This might be desirable, but it won’t alleviate the shortage.
3. The best way to alleviate the shortage is by either increasing the number of residency slots or allowing foreign doctors to practice here without going through residency. Residency slot numbers are not one of the things limited by the medical establishment. Funding goes through the federal government, and if the ACGME doesn’t want the residency programs to happen, the federal government could work with the AOA. Notably the PPACA does have provisions for increasing the number of residency slots.
4. The normal rules of supply and demand don’t apply as strongly as one might think in the medical profession. The biggest shortages that exist right now are in primary care, where the pay is the least. If limiting the number of doctors automatically reduced salaries, primary care docs would be making more and specialists would be making less. As it stands, primary care doctors in the US are not necessarily paid more than in Canada.
5. Increasing the number of primary care physicians may lead to better care, but it’s far from certain that it would actually reduce costs. Since doctors are paid for each thing they do, more doctors doing more things would rack up larger bills collectively (even if they were individually being paid less or being paid less for each thing they did). When people can’t get in to see a doctor, sometimes they will go to an ER, but often they will forego care. I know that for my part, if I am feeling sick and any appointment I make is going to be more than a couple weeks out, I will let things run their course rather than spend 5 hours in an ER.
6. In a single-payer system, the government can cut back reimbursements and pay without adverse consequences. It’s harder to do in a mixed system like hours, particularly when there is a shortage. Sending Medicare/Medicaid recipients to the back of what is already a long line could save money, but it could have adverse effects on wait times and by extension, people seeing the doctor at all. Of course, it’s good for the people at the front of the line. The more doctors that rely on private insurance, the easier it is for people with private insurance to see a doctor. It’s zero-sum, as far as that goes.
7. People should be wary before concluding that doctors will have no choice but to see Medicare/Medicaid patients unless we are going to pass laws forcing them to. While many doctors cannot afford to forego Medicare patients entirely, they can limit the number of Medicare patients they see, by limiting themselves to only existing patients, for example. Doctors can also specialize in fields where they are less likely to rely on Medicare patients, or relocate to parts of the country where the bulk or entirety of their practice will be insured patients. The burgeoning field of geriatrics may either die a slow death or be staffed with doctors who find a way to make it profitable (on Uncle Sam’s dime).
8. Increasing the number of doctors might help with access, and therefore allow the government to pay doctors less. First, however, see #5. Second, consider the wide latitude doctors have in drumming up their own business. They get to decide what is necessary and what is paid for. For some unscrupulous doctors, this is a gold mine (see McAllen, TX). But even for scrupulous ones, there are a lot of gray areas in medicine where every problem is a nail that you have multiple hammers for. So somewhere in here, we really need to evaluate standards of care and make what may seem to be heartless decisions about what is and is not warranted and under what circumstances.
@OzarkHibilly: How far are we talking, if you don’t mind my asking?
Come to think of it, the only MLPs my wife has worked with are PAs and not NP’s. I’m not sure if the rules and regs around NPs are the same as for PAs.
I do know that supervision can occur from a distance, at least in the case of a shortage. My wife interviewed for a position in West Texas. The town was being held down by a PA that was being supervised as part of a larger practice based in a town about 45 miles over.
And supervision does not necessarily mean that the doctor has to be there, or working, if they are on call. Call is handled by both docs and PAs around here. But for a lot of problems, the PAs will have to call the doctor in.
I haven’t seen my wife in approaching three days, but when she gets home, I’ll ask her. You’ve got me curious.
@Trumwill: Not all that far as the crow flies and not even all that far as the car drives: another 15 miles or so. But the travel time is 20-25 mins more and that is if the weather is good as the roads aren’t.
I do know she can order tests, x-rays and scrips etc, w/o a Drs. signature.
The CEO of Wellpoint makes about 60 million a year. The two may be related.
@michael reynolds: We could also allow pharmacists to prescribe your Cipro, as they are authorized to do in France. Gateway requirements are a big part of the problem with rising medical costs.
@OzarkHibilly:
Yes, the Doctor isn’t really doing anything other than fulfilling a regulatory requirement. But you can bet they’re being well paid to do that nothing and that part of it is coming out of your fee.
@Trumwill:
We also need more graduated levels of expertise within medicine. If you’re building a bridge you need an engineer. If you’re remodelling the kitchen you just need a contractor. The problem is that medicine right now insists on using the equivalent of engineers to remodel the kitchen.
@Stormy Dragon:
Of that I am sure.
@rodney dill: Rodney, that means you fit right in… Those of us here who are not headcases, are just simply headaches.
Damn socialists. Their entire country is falling apart, but the liberal media is covering it up. Stalin probably got his scripts filled there.
@michael reynolds:
Generally, I’m with you on this. The absolutely insistence on having patients come in for an office visit (or go to the ER) for something that could likely be discussed over the phone is silly and wasteful.
But there always is the possibility that something that would be caught in person would not be caught during a phone conversation. It’s hard to know where to draw the line.
“or at least a headcase here.”
At least somebody still has a sense of humor here.
“I’m getting over a bout of prostatitis…………….etc.”
I have absolutely no doubt this is true, Michael, and unfortunate. But (surprise!!) I think we will come at this differently. I suspect you believe it to be an evil cabal to increase revenue. I see it differently, and I’ve cited examples from my father’s experience. This is driven by two things: 1) worry about getting sued in the one in a million event you had a more serious issue, and 2) who give’s a shirt? Someone else pays. No consumer or doctor exposure to price discipline.
BTW – having had that, hope you are feeling better.
@OzarkHibilly: I asked my wife about it after her post-three-day-marathon hibernation. She says that the rules over what qualifies as oversight are impossibly vague. Nurse Practitioners tend to be authorized to work more independently than Physician Assistants, though a lot of PA’s do work pretty independently.
@Stormy Dragon: To some extent, I think we have gotten used to engineers designing the kitchen. My brother was recently incensed when he went to the doctor only to go to a Mid-Level Provider. He gives a $20 copay either way, so to him that $20 entitled him to see an actual doc. This isn’t an argument against giving MLPs more leeway or anything, just that I don’t know that it will result in more people going to see them, if they don’t see the savings themselves.