HH: I’m pleased now to welcome to the Hugh Hewitt Show Dr. Jon Gruber of the Massachusetts Institute of Technology, MIT. Dr. Gruber, welcome to the program, good to have you on the Hugh Hewitt Show.
JG: Thanks so much for having me.
HH: You may know my friends Jim and Nancy Poterba. They’re economists at MIT. Do you do any work with them?
JG: Oh, my goodness. Jim is the actual Godparent of my second son, and a very good friend.
HH: They’re, Nancy is an old and dear friend from undergraduate days. So tell them…I’ll be nice to you as a result of that, even though you’re behind this crazy Senate scheme.
JG: Well, I appreciate the kindness.
HH: Now let’s talk, Jon Gruber. The point of this is, I’ve been talking to a lot of proponents of Obamacare, because I really want them to answer the objections, because I want people to fairly hear the debate as it moves forward. So I’d like to run through some of the objections I routinely get from my audience, and have you answer them if you can.
JG: All right. That sounds great.
HH: The first one comes from seniors over and over again. They are afraid that they will be worse off, they’ll have fewer benefits or higher premiums after the Senate bill, and we’re using the Senate bill as the basis for this conversation, enters into law. Are they correct to be worried?
JG: I don’t think they’re correct, because I think that basically, I guess I’d make a couple of points. The first point is that this bill is cutting Medicare, in the sense that the monies that we’re using the help cover the uninsured in America, a lot of it’s coming from lower payments to Medicare. But the cuts in Medicare are quite small. If you look at past bills that have cut Medicare in 1990, 1993, 1997, all of them had cuts that are as large or even up to twice as large as what’s in this bill. So it’s not historically unprecedented. And more importantly, you know, as an economist, I’d like to answer your question by saying well look, we’ve done these cuts in the past. Is there any evidence that people on Medicare have suffered? There’s none. There’s been studies over and over again of all these past cuts dating back to the early 1980s in cuts in Medicare, and there’s no evidence that these cuts have in any way hindered the access of Medicare beneficiaries or harm their health.
HH: What about those who are enrolled in Medicare Advantage? Will they be worse off in having fewer benefits after this bill passes?
JG: Those who are enrolled in Medicare Advantage may see some fewer benefits. It’s true. What we’re doing with Medicare Advantage is right now, what the government essentially does is massively overpay the Medicare Advantage companies, and the Medicare Advantage companies use some of that overpayment to give extra benefits to seniors. And some of those extra benefits, when in a more competitive environment, will go away. That’s true.
HH: And so how many are we talking about? Between seven and eight million people will get fewer benefits after this passes?
JG: Oh, no, I don’t think it will be anywhere near that large. I mean, right now, we’ve got in Medicare Advantage, there’s on the order of that many people in Medicare Advantage total. And the vast majority, I think, will be unaffected. But I think, you know, there are a number who are getting these benefits because their insurers are massively overpaid, and their insurers presumably will cut back on the benefits when that overpayment ends.
HH: So whether or not they’re overpaid, though, they will have a different benefit scheme at the end of this, and it will be fewer benefits for the same money, correct?
JG: Well no, not for the same money, because the seniors don’t, the senior aren’t, first of all, it will not be the same money, because the seniors share in the some of the savings that the government will get for ending this overpayment to the Medicare Advantage plans. So the way it’s set up, seniors actually get the benefit when those payments fall, so it’ll end up, a minority of Medicare beneficiaries will end up with less benefits, but paying less money as well.
HH: And how much less money will they be paying?
JG: I can’t answer that. I don’t know.
HH: All right, Dr. Gruber, we’ve also got about a half trillion dollars in cuts. And where do you actually estimate the cuts in Medicare to fall out, between $450-550 billion, which are the range of estimate I’ve seen?
JG: Where within that range do I estimate it falling?
JG: Oh, I don’t have a good…I mean, I think…we have to be…one mistake we make in this debate is pretending with a false level of precision of our understanding. I think that’s about…I don’t think you can do much better than give a range like that.
HH: Well, that’s interesting.
HH: It’s that false level of precision…people really don’t know what’s on the other side of this, do they?
JG: Well no, I think with everything that we talked about in government, we talk about a stimulus package that’s $787 billion dollars. It’s not exactly that. We basically have estimates, and they’re our best estimates, but we have to understand that these are estimates. The government’s doing the best it can with its limited information. So I think if you talk about a range in Medicare like that, I think that’s about as precise as we can get, to be honest.
HH: That’s a 20% swing from $450 billion to $550 billion, and that’s a huge swing, though.
JG: Well, but remember, what we’re talking about is projecting what’s going to happen to Medicare over the next decade, in a world with huge uncertainty about what’s going to happen with medical costs. We hope that this bill is going to lower medical costs that’ll push us towards the low end of that range. But there could be an incredible new innovation in technology and medicine that we haven’t thought of yet. That could push us of the high end of that range. So we just don’t know.
HH: One of the standard objections I receive, I find it very persuasive, is that Medicare is broke right now. It’s deeply in the hole in its actuarial obligations. Why would we assume that you could take a half trillion dollars out of a program that’s already bankrupt, and use that savings to extend health care coverage to 25-30 million people who are not presently covered?
JG: Well, I think that basically, there’s really two separate issues. I mean, whether… I mean, Medicare now is, it’s not bankrupt, but it is in dire financial straits. I mean, we have a situation where the Medicare Trust Fund is projected to run out of money towards the end of the next decade, and that is an issue. Now these cuts, putting these cuts in Medicare by itself will not affect that financial position. If you take the money out of Medicare and use it to finance the uninsured, that’s not really going to affect that position. So basically, the issue is, really, the question you want to ask is, well, would a better use of this money be to shore up Medicare, or to cover the uninsured? And I think if you look at the money, it would be trivial in terms of shoring up Medicare. I mean, basically, if you took all this money and used it to shore up Medicare, you’d just extend the life of the trust fund another couple of years. I mean, the Medicare problem is a deep, fundamental problem that is about, it’s not about Medicare. It’s about how we deliver medical care in this country, and the fact that we over-deliver medical care in many, many instances, and deliver it very inefficiently. And that’s a big problem.
HH: And then, will this change the underlying assumptions about Medicare going forward? Does the Senate health care bill fix Medicare for the long run?
JG: The Senate health bill does not fix Medicare for the long run. I don’t think anyone’s…I hope no one’s making that claim. I believe it moves, I believe for reasons we can get into, it moves us towards fixing Medicare, because it moves us towards controlling health care costs. And as I say, it’s not about Medicare. It’s about the underlying trends in health care costs. That’s what’s driving our problem.
HH: Well then, if it doesn’t fix the Medicare budget problem looking out years, does it make it worse?
JG: It does not make it worse, no.
HH: Even though a half a trillion dollars is taken out of Medicare?
JG: No, but you don’t understand, this is a half trillion dollars that are reductions in Medicare spending. So for example, let’s say we just pass that part of the bill. Then that would make the Medicare situation better by a half trillion dollars. These are not cuts…the financial problem is the result of we’re collecting less in payroll taxes, and we need to pay the benefits, and to pay out providers. If we cut what we pay by half a trillion, and don’t cut the payroll taxes that go in, we just make the program half a trillion better off. What we’re doing instead is taking the half a trillion and doing something actually, I think, is much more important, which is covering 30 million people with insurance.
HH: I just wanted our audience to understand that. I understand completely what you’re saying. So the question becomes, why not use that half trillion to fix Medicare right now? Why doesn’t the Senate prove, and the Congress prove, that they can fix a problem before building another vast, government entitlement, not one of which has ever come in remotely close to the spending projections associated with it, whether it’s Social Security, Medicaid, Medicare, anything that the government’s done, never comes close.
JG: Okay, well two points there. One point is why not use this money and reinvest it in Medicare? Well basically, because you don’t solve the problem. As I said, if you took all this money, and all this bill did was cut Medicare by half a trillion and put that money back in the trust fund, all you do is you extend the life of the trust fund for four or five years, I don’t know exactly, but less than a decade, okay? And then you’d be right back where you were. The fundamental problem with Medicare is that health care costs are growing too fast. That’s why we need to pass health care reform that’s going to address the problem of cost control, and not just delay our day of reckoning by five years. We need to do something much more fundamental than that. But on your second point, let me just address your second point about the projections being off.
HH: Go ahead.
JG: You’ve raised three examples – Social Security, Medicare, Medicaid, all of which are examples from before we had a Congressional Budget Office. If you look since we’ve had a Congressional Budget Office, there has been no systematic understatement of what programs are going to cost. In fact, if you look at Medicare part D, they overstate how much it was going to cost. They overshot by a large amount. So those examples, you know, in the old days before we had an honest broker keeping an eye on things, it is true. Politicians were good at understating costs. But that can’t be done anymore.
HH: Well now, the CBO only estimates out ten years, correct?
JG: That is true.
JG: Well actually, no, they estimate ten years, but they also make statements in general about what will happen over the next decade as well.
HH: One of the criticisms of the Senate version of Obamacare is that years 11-20 will be phenomenally expensive, and will not balance out. How do you respond to that, Jon Gruber?
JG: Well I mean, first of all, based on what I said before, it’s hard to predict what’s going to happen in years 11-20, both hard to predict either bad or good. But the best predictors at CBO, and they claim that actually, Obamacare does better in the second decade than the first, that is the deficit reduction in the first decade is a little more than a $100 billion. In the second decade, it’s more like $500 billion or more. So actually, what’s very nice, and what the President relayed that in principle, is that this is not a system where you can sort of game, like what was done with some of the Bush tax cuts, where there games to fit them into a tax window so they’d seem like they wouldn’t cost too much. This is something where actually the further out you go, the more fiscally responsible it becomes, and that’s pretty unusual for our government.
HH: What is the biggest driver, Jon Gruber, of that additional claimed advantage in years 11-20 – higher taxes or fewer benefits?
JG: The main driver of that is essentially changes to the way we deliver health care, part of which, one of the main drivers is the excise tax on high cost health insurance plans, which will induce health insurers to deliver more effective, cost effective plans. But there’s also a number of things which aren’t tax or cuts in benefits. They’re just innovations and moves towards cost control, which are going to ultimately deal with our fundamental problem, which are health care costs are growing faster than our standard of living.
HH: Now one of those would be the information technology, and the promise of advantages from the widespread application of information technology, correct?
JG: Yes, although I don’t believe that…I believe that’s a great thing to do to improve the function of a health system, but I don’t believe that that’s actually going to be a huge point of cost savings.
HH: Okay, then we don’t disagree, because I’ve had doctor after doctor call in and say it just doesn’t save any money whatsoever.
HH: Indeed, it’s profoundly expensive in many instances.
JG: And once again, you know, I keep coming back to them, because they are neutral. The Congressional Budget Office agrees. They said that part doesn’t save much money.
HH: Now in terms of what’s going to happen to doctors and the deficit projections of CBO in years 1-10, is the CBO projection based upon the cuts to doctor reimbursement which are called for in current law occurring?
JG: Say it one more time?
HH: Are the budget deficit projections that CBO has put forward, that this will save about $100 billion dollars over the first ten years, right?
HH: Are those based upon the expected, or mandated cuts in physician reimbursements actually taking place?
JG: No, they’re not. It’s a totally separate issue.
HH: Now I’ve had a conversation with a couple of your colleagues who signed the November 7th letter who’ve come around to they had to write me afterwards to make sure that they were clear, that they weren’t misleading the audience, so I want to make sure you’re clear. Are you, what I’m saying is the CBO’s estimate says those reimbursement cuts are going to happen, and therefore, the Senate bill is going to not cost as much as people say it’s going to cost.
JG: No, that’s not…that’s nothing to do with the SGR physician fix. This is a totally separate issue. What the CBO does say is there are sets of cuts, you know, which amount to about half a trillion as you said, which CBO has said will become law, and that’s consistent with the fact that we have cut Medicare in 1990, 1993, 1997, each time by more than this bill cuts, and each time we’ve kept our promise. The only time we haven’t kept our promise was with the physician fix, which was a badly designed policy, which was a promise that shouldn’t have been kept, quite frankly. And if your listeners want to learn more about that, there’s going to be a very significant discussion of that coming out from the Center on Budget and Policy Priorities tomorrow, which will discuss that history.
HH: Doctors have been calling in waves to this program to say not only are those cuts, those reductions in reimbursements going to happen, they are already in the coding system, they’re already being employed, and they are about 20%, generally. Are they wrong, Dr. Gruber?
JG: Well, no, for one thing, that’s a separate issue. There’s a separate issue which was there was a technical mistake in the 1997 cut. The 1997 cut Medicare significantly. What was supposed to be a small part of that was a reduction in physician reimbursement. Because of essentially a technical mistake, that became a much larger cut, and that’s why Congress has been undoing those, that’s why Congress has been undoing those physician cuts every year instead of letting them take place. Congress sort of votes to fix them year by year, and ultimately the House now wants to sort of fix it once and for all, but that’s a separate financial issue.
HH: But in terms of the overall health of American medicine, it’s not a separate issue. It’s part of this. If those cuts continue to happen, doesn’t that impact adversely the availability of doctors to do the work?
JG: You know, Hugh, there’s really no evidence that it does. I mean, the honest truth is there’s a lot of anecdotal evidence of doctors saying well, I won’t see patients. But the truth is, when these cuts…a lot of these cuts did happen. From 1997-2001, physician reimbursement was cut a lot. And there’s no evidence that Medicare patients suffered in terms of access. I think the thing we have to remember, that just because reimbursement’s cut, doesn’t mean that people will suffer. A lot of providers are massively over-reimbursed, to be honest. And even if they’re not over-reimbursed, even if they’re reimbursed properly and it falls, they’re still dedicated and will see their patients. So I think we cannot equate reimbursement falls and access.
HH: Let’s pause on that, because there’s a lot of disagreement, obviously, on that point. And on that turns a great deal of whether or not this is a meritorious argument, because if…would you agree with me, Dr. Gruber, that if this reform, all of the reforms that happen, end up driving doctors out of practice, or increasing their refusal to see patients, we will have done a very bad thing?
JG: If it does, if there’s a significant reduction in the number of doctors, if patients don’t have access to doctors, that would be a bad thing. I would agree.
HH: All right, I want to read to you a few objections that I received yesterday. From a surgeon in Oregon, representative of many surgeons, “What has happened in recent years to Medicare reimbursement for coronary artery bypass procedures, and aneurism repairs, hernia repairs, emergency gallbladder surgeries? They have been reduced by more than 50%.” Do you think he’s making that up? Or do you think that’s true?
JG: I believe he’s making that up. That sounds too big, but I guess it depends on your definition of recent years and other things. But that’s too big. I think the scheduled cuts, I believe the number overall, I can’t say procedure by procedure, has been less than 20%. I don’t know about that specific procedure, but 50% sounds outrageous.
HH: And how much do you…he asked me a question, how much do you think Medicare pays for a surgeon to perform a lower leg amputation? Do you have any idea, by the way, Doc? I didn’t.
JG: No, I have no idea.
HH: He said President Obama has said between $30-50,000 dollars. The actual reimbursement is $862 dollars. How much does Medicaid pay compared to non-governmental insurance? Do you have any idea of that?
JG: Are you saying Medicaid or Medicare?
JG: Medicaid pays much too poorly. I completely agree with that. Medicaid’s a totally separate issue. Medicaid pays well below Medicare, like 25 or 30% below, and Medicaid reimbursements, which are unfortunately not decided by the federal government, but rather by state governments, and many states are a travesty.
HH: Does anything in the Senate bill do anything to raise Medicaid reimbursements?
JG: Not in the Senate bill. In the House bill, they put some money into that, but not in the Senate bill.
HH: And so, will the Senate bill increase the availability of access to health care for people who are receiving Medicaid?
JG: Well, I mean, the only sense in which it would is there’s a large section of the Senate bill, as well as the House bill, to improve investments in physician manpower. To the extent that those are successful, that will improve access. But there won’t be a reimbursement increase as far as I know in the Senate bill.
HH: And in fact, if Medicare reimbursements are going down, and just to get your assessment of that, how much are Medicare reimbursements going to go down?
JG: Medicare reimbursements?
JG: Of physicians, not at all. There’s not, I mean, once again, there’s this separate problem of physician cuts, and that’s got nothing to do with this health reform. If this health reform never happened, we’d be dealing with that problem.
HH: I understand that, but for clarity’s sake, if that schedule reimbursement cut happens…
JG: If the scheduled reimbursement falls, it would be about a 20% reduction for physicians.
HH: And so that’s a bad thing, right?
JG: Yes, I agree. I don’t think that could stand. I think we’re going to have to fix that.
HH: And so the Senate bill does not fix that, does it?
JG: The Senate bill does not fix that, because the Senate bill’s not about that. I mean, the Senate…
HH: But Dr. Gruber, clarity…
JG: …appropriation didn’t fix it, either.
HH: Clarity here. If, in fact, the CBO’s deficit projections include the reimbursement rates which are scheduled to go into effect, whether or not they occur…
HH: Isn’t that deficit projection bogus?
JG: The overall…one’s separate from this bill, it is true that CBO, if they assume those cuts will go in place, is probably understating the long run deficit, because politically, we probably won’t let that stand. But there’s other things like that as well. I mean, we haven’t discussed the alternative minimum tax. There’s many things which are political difficult, which we’re going to have to deal with.
HH: I know that, but President Obama said he wouldn’t sign a bill, he would not sign a bill unless it was deficit neutral.
HH: This bill is premised on those cuts occurring, though those cuts are not part of this bill. Isn’t that true?
JG: No, look, I appreciate your effort to understand this, but you’re really misleading your listeners. The bottom line is this bill has nothing to do with physician cuts. Just because they’re both health care, they’re totally separate issues. This bill is more than deficit neutral. This bill reduces the deficit increasingly over time. There is a separate issue that we have these scheduled physician cuts that CBO assumes will take place, and probably won’t. But that’s going to happen even if this debate had never happened. If we go back in time a year, and this bill never even comes up, that problem exists. What President Obama said was this bill cannot increase the deficit, and it definitely does not. It reduces it.
HH: But Dr. Gruber, I’m afraid, as a journalist, as opposed to an economist, that for clarity’s sake, people have got to understand that the Senate version the health care bill is based on a mirage that you and I both agree should not occur, whether or not it does occur. Doctors disagree. They say it’s already occurring, and that the deficit promise that’s being made, that it will assuage deficits by $100 billion over ten years, is simply not true, because the premise is not true.
JG: But Hugh, you’re not clarifying. You’re obfuscating. Okay, basically, once again, the argument you just made, you can make the same thing about every single bill before the Senate now. Let’s take a transportation bill.
HH: I think you’re right. I believe that’s true.
JG: We could do that same argument every single bill.
HH: Yes, I know. I agree.
JG: So unless you want to shut down the legislative process, I don’t think you should hamper this health reform with the fact that the Congress has made promises in terms of one specific area that it’s unlikely to keep. That’s not being added to the cost of this health reform, as opposed to every other bill that goes through Congress.
HH: Dr., Professor, that’s where clarity enters in. People think this is all about health care, and the comprehensive solution to health care is being proposed. But as you’ve already sort of clarified in the course of this conversation, we’re not fixing Medicare, we’re not fixing the doctor reimbursement problem, so we’re not really fixing health care in America, are we?
JG: But once again, what matters for health care in America is not the physician problem. It’s not the Medicare trust fund. It’s the fact there’s fundamentally, if we don’t control health care costs, in one hundred years, America will be bankrupt. That’s fundamentally what this is about.
HH: I understand that’s your point of view, but if a person’s point of view was that the solution to health care requires a comprehensive solution to the physician availability, to physician incentive to stay in the game, not to leave the game as the Investor’s Business Daily poll showed, to fix Medicare so we have a fiscal sanity going forward, then this bill doesn’t do any of that.
JG: This bill doesn’t do a lot of things. This bill doesn’t deal with the war in Afghanistan. I mean, this bill doesn’t do a lot of things. What you have to ask yourself is, I don’t think we want the perfect to be the enemy of the good here. You have to ask yourself, on net, is this bill a good thing?
HH: And that’s…okay, let’s go to that. Let me ask you to listen to a quote from President Obama made many times over the course of this year of debate.
BHO: Here’s a guarantee that’s I’ve made. If you have insurance that you like, then you will be able to keep that insurance. If you’ve got a doctor that you like, you will be able to keep your doctor.
HH: Can he make that guarantee?
JG: Yeah, he can, because the law has actually grandfathering provisions that say that literally, if you like, it’s literally in the law, there’s a grandfathering provision that says if you like your plan today, you don’t have to give it up.
HH: Is it true for people to believe that when their employer controls their health care decision?
JG: Well, their employer controls their health care decision today. So basically, I guess the issue is that, it’s always true today that your employer could drop your health insurance tomorrow. And under the bill, it’s true as well. So in some sense, that doesn’t change. The issue is really does this bill make that worse, and the answer is no.
HH: No, that’s not what he said. I’ll play it again, so that we hear it all clearly.
BHO: Here’s a guarantee that’s I’ve made. If you have insurance that you like, then you will be able to keep that insurance. If you’ve got a doctor that you like, you will be able to keep your doctor.
HH: Is that true, Jon Gruber?
JG: That statement played in that clip is not true.
HH: All right, that’s all…
JG: No, no, no. But let me finish. The statement that if you have insurance that you like this bill will not cause you to lose it. That’s a true statement.
HH: But that’s not the statement he made. The President sold this bill…
JG: But once gain, he was talking about a health insurance bill. He wasn’t talking about the world. He wasn’t saying I promise no one would ever lose their doctor, and that’s just, you know, that’s just parsing, that’s just trying to parse his language too fine. He was talking about a health care bill, and this health care bill will not cause you to lose your doctor or have to lose anything you like.
HH: All right, we disagree about that interpretation, but that’s yours. I have a different one. The audience may disagree. Another question, is has been widely reported that you have said that this health care reform, I assume it would be the Senate version, will save 80,000 jobs in the small business sector over the next decade. Is that correct?
JG: That’s correct. That’s for a report I did for the small business majority.
HH: And how will that happen?
JG: Basically, that’ll happen because small businesses will get to take advantage of much more stable and lower cost insurance environment. In particular, today, if you’re a small business, typically you have to rely on a broker to find you what you hope is the lowest cost plan. You don’t really get to shop effectively across options. We’re setting up an exchange where the small business can actually go in and effectively shop across their options and find the lowest option, potentially saving…small businesses today spend 4-10% of their health insurance bill on brokers alone, not to mention another 20% they spend in administrative costs that will go away. In addition, there’s a small business credit that’s part of this bill that’s really focused on trying to help small businesses get started with offering health insurance.
HH: Will brokers go away under the new bill?
JG: No, I don’t think they will. I think that brokers do a lot, serve a lot of functions. I think that brokers whose only job is to go out and shop and find you the lowest price, and you don’t talk to them the rest of the year, I think brokers like that may be reduced. Brokers who do a lot of what other brokers do, which is advise you on what kind of benefits to use, things like that, there’ll still be a role for them, just like there’s still a role for real estate agents and others. But I think a certain kind of broker, which is literally just serving the function that we can do online much better now, that kind of broker will suffer under competitive pressure under this model.
HH: You have also been reported to have concluded that the Massachusetts plan, of which you had a hand in crafting, has resulted in substantial reductions in individual premiums in Massachusetts. Is that correct?
JG: That’s correct.
HH: And has it overall been judged a success in your view?
JG: Look, on this one, Hugh, I’ve got to admit, I’m totally biased. You know, I helped design it, and I’m on the board that’s running it. So in my view, it’s been an enormous success. I’m happy to discuss the facts with you, but I have to admit on this one, that I’m kind of a biased guy to ask.
HH: Did it cost more than was expected?
JG: No, it actually, I’m pretty proud of that. It actually cost, I projected what it would cost in 2005 before anyone had ever done a plan like this. And in 2009, when we were fully implemented, we came in just about on budget, so it actually cost about what was projected.
HH: What are the critics, when they say it has failed, referring to?
JG: Basically, they’re referring to the fact that they don’t like the fact it succeeded. Let me tell you what the only plausible criticisms that it’s failed. First of all, we did not appropriately budget for the transition. That is, we had the right number for what it would cost when it was fully implemented. But we assumed it would phase in over three years, and it would cost one-third the first year, two-thirds the second year, three-thirds the third year. That didn’t happen. Actually, the first year it cost a lot more than one-third. It was more than a half. So we fell short in the transition. That was one problem. We didn’t properly account for how rapidly this program would be up and running. So that’s one valid criticism the people have made, and I think you know, that’s a reason why the Senate’s going a little slower than we went. We passed the law in April, 2006, that had to be running in October, 2006. It was crazy. The Senate’s giving us three years. So hopefully, we’ll get that transition better. So that’s one legitimate criticism. Another legitimate criticism is that basically, it’s not clear whether or physician supply has been adequate to deal with the increased demand of patients. I think there’s no consistent evidence here, but I think that’s one where there’s studies both ways. Some studies say we’re falling short in physicians, other studies say we’ve had enough. So that’s another area of criticism.