Medicare plans to expand its coverage of PET scans that are used to help diagnose Alzheimer’s disease, a major policy shift that could make it easier for patients to access new treatments entering the US market.

The proposal would abolish the current Medicare policy nationwide. Currently, the Seniors Program will cover one PET scan per age for patients participating in clinical trials.

Medicare’s proposal would allow regional organizations, called Medicare Administrative Contractors, to decide whether to cover the diagnostic tool. These regional contractors make coverage decisions based on whether the service is “reasonable and necessary” for a diagnosis.

Chiquita Brooks-LaSure, president of the Centers for Medicare and Medicaid Services, said in a statement Monday that the proposed policy “fulfills CMS’s commitment to allow broader coverage of this diagnostic test.” A CMS spokesperson said a final decision could come within 90 days.

Positron emission tomography scans are an important diagnostic tool that detects the presence of a protein amyloid in the brain associated with Alzheimer’s disease. Screenings are the most common way to help diagnose patients.

People on Medicare generally pay 20% of the cost of a PET scan after the deductible is met. The cost of a one-time scan would be about $313 per patient, according to one estimate in a study published in the medical journal JAMA Internal Medicine.

doctor. It’s possible for regional contractors to come to different coverage decisions for PET scans, said Sean Tunis, CMS’ former chief medical officer. But these organizations generally work together on key issues and there’s no reason to think their policies on PET scans will differ widely across the United States, said Tunis, now a consultant at Rubix Health.

Medicare’s coverage of PET scans should make it easier for patients to access new treatments like Leqembi, which was approved by the Food and Drug Administration earlier this month.

Medicare agreed to cover Leqembi’s treatment for Eisai and Biogen’s Alzheimer’s, but requires patients diagnosed with mild cognitive impairment or mild Alzheimer’s disease with documented evidence of amyloid on the brain.

Most patients choose positron emission tomography to confirm the presence of amyloid because imaging is less invasive than alternative diagnostic tools such as spinal taps. Blood tests are also in development, and some are already in use, but not yet widely deployed.

Medicare said it would also cover other antibody therapies for Alzheimer’s with the same terms if they receive approval from the Food and Drug Administration. Eli Lilly The US Food and Drug Administration (FDA) expects to make a decision on its treatment, donanimab, by the end of the year.

The Alzheimer’s Association, a pressure group that advocates for people living with the disease, said the new policy proposed by Medicare would remove unnecessary barriers for patients. Maria Carrillo, the consortium’s chief scientific officer, called the decision “a huge step forward”.

The first over-the-counter birth control pill in the United States can remain out of reach for some women and girls because health insurance plans are not required to cover the drug in its over-the-counter form.

The U.S. Food and Drug Administration on Thursday approved Opill oral contraceptives for sale without a prescription, a landmark decision that would make the pill easier to obtain by eliminating the need to visit a doctor’s office and refill prescriptions.

A third of adult women who have tried to obtain prescription contraceptives encountered barriers to accessing them, according to a survey published in the Journal of Women’s Health in 2016.

Opel manufacturer perego It expects the pill to be available in major stores and online in early 2024. Perrigo will announce the price of Opill in two months before the pill hits stores, Perrigo CEO Fredrik Welgren said during a call with reporters Thursday.

Welgren said the company is committed to ensuring that Opel is affordable. Perrigo sets up a program to help patients, so the cost of birth control pills isn’t a barrier for women struggling to make ends meet.

But some women and girls still face obstacles in obtaining an Opel. The Affordable Care Act does not require private health insurance to cover the cost of birth control pills when used without a prescription. Most health insurance companies are required to offer birth control for free when a doctor prescribes it.

State Medicaid programs are generally not required to cover over-the-counter drugs, according to the federal Centers for Medicare and Medicaid Services.

Welgren said Perego is enlisting private insurance programs and state health care programs to offer over-the-counter Opill to women and girls for free. But she said the Affordable Care Act needs to be amended to ensure that health insurance pays for over-the-counter birth control.

It’s unclear whether insurance coverage for Opel will be in place when the pill is available in stores early next year, Welgren said. “We have some work to do to make that happen. It will take some time,” she said.

Congressional Democrats and President Joe Biden are pushing to expand access to birth control.

senator. Patty Murray, D-WA, reintroduced legislation called Accessible Affordability in the Senate in May that would require health insurance companies to offer over-the-counter oral contraceptives for free.

Biden ordered the US Department of Health and Human Services in June to ensure that all contraceptives approved by the Food and Drug Administration are available without out-of-pocket costs.

An agency spokesperson said Friday that CMS encourages health insurance to cover over-the-counter birth control products for free. The spokeswoman said the agency is working on ways to ensure that contraceptives approved by the Food and Drug Administration are available for over-the-counter use without sharing costs.

Opill is 93% effective in preventing pregnancy. It is the most effective form of over-the-counter birth control in the United States, and must be taken at the same time each day to ensure its effectiveness.

Welgren said that 15 million women in the United States who are sexually active and do not want to become pregnant use a method of contraception less effective than Opal or no method of contraception at all.

Nearly half of the 6 million pregnancies in the United States each year are unintended, according to the Food and Drug Administration. According to the agency, unintended pregnancies are associated with premature birth, which can lead to poor health outcomes for newborn babies.

Medicare has agreed to pay for Leqembi’s treatment for Alzheimer’s disease, a major turning point for patients diagnosed with the early stages of the disease.

Leqembi is the only drug on the market now that has been shown to slow the progression of early-stage Alzheimer’s disease in a clinical trial. The monoclonal antibody, given twice monthly through an IV, slowed cognitive decline by 27% over the course of 18 months in the trial.

Leqembi is made by the Japanese pharmaceutical company Eisai and its partner Biogenheadquartered in Cambridge, Massachusetts.

Medicare’s decision to cover Leqembi, which came moments after the US Food and Drug Administration approved the drug Thursday, promises to make treatment more accessible to patients.

Medicare coverage is critical for most patients to have any hope of being able to afford Leqembi. Eisai priced Leqembi at $26,500 a year before insurance coverage, which is too expensive for Medicare patients, whose average income is about $30,000.

Medicare foots the majority of the bill, though many patients will still face several thousand dollars out of their own pockets.

Patients on traditional Medicare will pay 20% of Leqembi’s bill, according to the federal Centers for Medicare and Medicaid Services. That means those patients could see an annual bill of more than $5,000, according to an estimate from KFF, a nonprofit group that researches healthcare issues.

People with Medicare Advantage plans typically pay 20% more for drugs like Leqembi, up to the out-of-pocket limit, which was about $5,000 on average for in-network services, according to the KFF.

Patients with supplemental insurance such as Medigap or Medicaid may pay less, according to the KFF.

People with modest means may not be able to afford an out-of-pocket Leqembi even with Medicare coverage, said Tricia Newman, a Medicare expert at KFF.

Newman said this is particularly worrisome because blacks and Hispanics are more likely to develop Alzheimer’s disease but are likely to have lower incomes.

If demand for Leqembi is high, there are also concerns that patients could face long waiting times to see specialists and receive injections.

Medicare has certain conditions that must be met for patients to be eligible for Leqembi coverage.

To be diagnosed with Alzheimer’s disease or mild cognitive impairment, patients should undergo a cognitive assessment and undergo a positron emission tomography scan or a spinal tap to detect the amyloid protein associated with the disease. PET scans are the most common way to detect amyloid because they are less invasive.

Medicare currently covers one PET scan per age for amyloid detection. A spokesperson for the agency said CMS is reconsidering this policy and plans to release a proposed rule soon.

The requirement for clinicians to enter patient information into the registration system is controversial. The Alzheimer’s Association and some members of Congress are concerned that the requirement to collect data creates unnecessary red tape for patients to receive treatment.

The federal Centers for Medicare and Medicaid Services has created a nationwide portal that is supposed to make it easier for doctors to enter required information about their patients. CMS has released a video showing clinicians how to navigate the system:

Doctors can access free registration on this website.

doctor. The record is simple and unlikely to be burdensome for patients and doctors, said David Knopman, a neurologist who specializes in Alzheimer’s disease at the Mayo Clinic in Minnesota.

Patients diagnosed with mild cognitive impairment or mild Alzheimer’s disease need to talk to their doctor about whether Leqembi’s benefits outweigh the risks, according to CMS.

Although Leqembi slightly slowed cognitive decline in clinical trials, the treatment also carries serious risks of brain swelling and bleeding. In the trial, 13% of patients given Leqembi had swelling and 14% had bleeding.

Swelling and bleeding were usually mild, with no obvious symptoms, but these episodes can be fatal, according to an independent Food and Drug Administration review of clinical trial data. When symptoms do appear, they include headache, confusion, dizziness, vision changes, and nausea.

People who have two copies of a gene mutation called APOE4 are at increased risk of swelling and bleeding and patients should be tested to confirm if they have the mutation before taking Leqembi, according to the US Food and Drug Administration. A CMS spokesperson said Medicare covers testing for the APOE4 mutation.

And according to the Food and Drug Administration, patients who take anticoagulants appear to be more likely to have bleeding in the brain.

Three patients who received Leqembi died in the trial, although the Food and Drug Administration could not determine if these deaths were related to the treatment.

Patients who have been appropriately diagnosed and informed should be able to decide for themselves whether they want to take Leqembi after weighing the benefits of the treatment against the risks of potentially serious side effects, Knopman said.

Mortgage rates last week hit their highest level since the end of May, which in turn affected mortgage demand.

Total mortgage application volume last week decreased 4.4% from the previous week, according to the Mortgage Bankers Association’s seasonally adjusted index. Demand is now at its lowest level in a month.

The average contract interest rate for 30-year fixed-rate mortgages with matching loan balances ($726,200 or less) rose to 6.85% from 6.75%, with the score increasing to 0.65 from 0.64 (including origination fees) for loans of 20%. low premium.

While that was the average rate for the week, a separate survey from Mortgage News Daily showed that the rate was over 7% last Thursday. It has remained above that level since then, rising to 7.08% on Tuesday of this week.

As a result, mortgage demand to buy a home, which has been rising for three consecutive weeks, fell 5% during the week and was 22% lower than the same week a year ago.

“Rates are still more than a percentage point higher than they were a year ago, and housing affordability remains a challenge in many parts of the country,” Joel Kahn, MBA’s deputy chief economist, wrote in a statement. However, the average loan-to-request size fell to $423,500 – its lowest level since January 2023.

The decline in loan size, according to Kan, is likely driven by lower home purchases in some of the higher-priced markets and increased activity at some of the lower-priced levels.

Home loan refinance applications were down 4% for the week and were 30% lower than the same week a year ago. As the summer progresses, the year-over-year comparison is likely to shrink, as it did last summer when mortgage rates rose dramatically for the first time since before the pandemic, and thus refinancing demand fell off the high slope.

While the 30-year flat rate remained above 7% for the past week, it may be affected by employment data scheduled for release on Thursday and Friday. This could affect the Fed’s next moves, which are likely to include further rate hikes.

Medicare said Friday it would allow drug companies to publicly discuss historical drug price negotiations for the program, ignoring a confidentiality requirement that the industry has argued violates the First Amendment in lawsuits filed this month.

In initial guidance issued in March, Medicare prohibited the industry from publicly disclosing information about the low price the federal government initially offered for targeted drugs under the program, as well as the government’s reasons for choosing that price point.

Medicare also prohibited the companies from disclosing any oral conversations during the negotiation period. It also requires companies to destroy any information within 30 days if the property is no longer selected for negotiations.

In revised guidance issued Friday, Medicare said the company “may choose to publicly disclose information related to ongoing negotiations at its discretion.”

The Inflation Reduction Act, passed last year, allowed Medicare to negotiate prices directly with drug companies for the first time. The program is a mainstay of the Biden administration’s efforts to control rising drug prices in the United States

merckAmerican Chamber of Commerce, Bristol-Myers Squibb The drug industry lobby group Pharmaceutical Research and Manufacturers in America asked federal courts this month to declare drug price negotiations unconstitutional.

Merck, Chamber, and Bristol Myers Squibb argued in their lawsuits that Medicare had imposed a gag order effectively banning companies from publicly disagreeing with the federal government’s position in violation of the First Amendment.

However, the industry lawsuits also focus on broader allegations that the software violates due process and expropriation of private property without fair compensation under the Fifth Amendment to the US Constitution.

Health and Human Services Secretary Xavier Becerra pledged on Friday to press ahead with negotiations despite lawsuits from the drug industry.

“Pharmaceutical companies have achieved record profits for decades,” Becerra said in a statement. “They are now lining up to block the work of this administration to negotiate better drug prices for our families.

“We will not back down,” Becerra said.

HHS will release a list of 10 high-cost drugs it has selected for negotiation by September. The companies have to decide whether to participate in the negotiations in the following month.

Drug makers who choose not to participate face severe financial penalties. They can avoid these penalties by ending their participation in Medicare and Medicaid drug discount programs.

The companies have argued that opting out of rebate programs is not a feasible alternative because the programs account for nearly half of the state’s annual spending on prescription drugs.

A top Democratic lawmaker launched an investigation Monday into a planned merger between the PGA Tour and Saudi-backed LIV Golf.

senator. asked Richard Blumenthal, D-Conn. , details the agreement between the two organizations, including how the new combined entity will operate in light of human rights abuses in Saudi Arabia, in letters to PGA Commissioner Jay Monahan and LIV Golf CEO Greg Norman.

Blumenthal’s letter comes as the PGA Tour-LIV deal faces intense scrutiny and skepticism about whether the merger can be completed, given the severity of past claims in the golf leagues’ past litigation against each other.

The Saudi government has been accused of widespread human rights abuses, including orchestrating the murder of Washington Post journalist Jamal Khashoggi in 2018.

September 11, Family United, a group representing families of victims of the terrorist attack, slams the merger over Saudi Arabia’s involvement. Blumenthal previously sided with the families of the victims when another organization, the 9/11 Justice Group, protested a LIV event at a golf course owned by former President Donald Trump.

Blumenthal, who chairs the Senate Permanent Subcommittee on Investigations, wrote that the merger announcement on June 6 was “an abrupt and drastic reversal of a situation regarding LIV Golf.” The tour and its commissioner had previously spoken out strongly against the LIV and its role in professional golf.

Meanwhile, the Saudi government’s private investment fund, which owns LIV, has made clear plans to use investments in sports to achieve the Saudi government’s goals, according to Blumenthal’s letter.

“The PGA Tour agreement with PIF regarding LIV Golf raises concerns about the role of the Saudi government in influencing this effort and the risks posed by a foreign government entity taking control of a cherished American institution,” Blumenthal wrote.

Before the merger was agreed upon, the rivalry between the PGA and the LIV involved legal action between the two. The entities have agreed to crush all pending lawsuits as part of their plan to combine the business and rights into a yet-to-be-named for-profit corporation.

Monahan told CNBC’s “Squawk on the Street” on Tuesday that the merger benefits golf despite past “tensions.”

The agreement will require approval by the PGA Tour Policy Council, according to a note to players from Monahan.

“We are confident that once Congress learns more about how the PGA Tour will take control of this new venture, they will understand the opportunities this will create for our players, our communities, and our sport, all while protecting an American golf institution,” the tour said. CNBC said in a statement later Monday.

LIV Golf declined to comment on Blumenthal’s letters.

Blumenthal requested answers to several inquiries, including a chart of the company’s structure and records of any disputes between corporate heads and any other stakeholders, by June 26.

CNBC channel Jessica Golden Contribute to this report.

The US Food and Drug Administration has authorized the temporary import of an unapproved chemotherapy drug from China in an effort to ease an acute shortage of cancer drugs in the United States, according to an update posted on the agency’s website on Friday.

A document showed that Qilu Pharmaceutical, which manufactures and markets cisplatin injections in China, obtained the Food and Drug Administration’s permission to export the drug to the US market weeks ago.

A letter dated May 24 from Qilu’s deputy general manager notified healthcare professionals of the approval.

Qilu is coordinating with Toronto-based Apotex to distribute 50-milligram vials of cisplatin in the United States

Health care providers can start ordering the drug Tuesday through wholesalers.

Cisplatin is a generic drug that has been available for decades in the United States and is distributed by several approved manufacturers. These manufacturers could not keep up with demand. The Qilu version of cisplatin is not approved in the United States

Headquartered in Jinan, Shandong Province, Qilu says it is one of the top 10 pharmaceutical manufacturers in China.

The FDA told CNBC this week that the agency is considering importing unapproved chemotherapy drugs, but did not disclose at the time the names of any manufacturers that might supply the drug.

A spokesperson for the US Food and Drug Administration said the agency evaluates the quality of imports of unapproved drugs to ensure they are safe for American patients.

Doctors say some cancer patients could die if a national shortage of drugs like cisplatin is not resolved soon. There are shortages of at least 13 other cancer medications across the United States

Cancer drug shortages have forced some hospitals to ration drugs by reducing dosage to expand supply and prioritize patients with the best chance of recovery.

Cisplatin is widely used to treat cancers of the testicle, lung, bladder, cervix, and ovary, among other conditions. Up to 20% of cancer patients are treated with cisplatin and other platinum-based chemotherapy drugs, according to the National Cancer Institute.

The World Health Organization says medicine is an essential part of basic healthcare.

A national shortage of cisplatin began in February after a pharmaceutical company based in India temporarily halted production for the US market.

Intas Pharmaceuticals decided to pause production after last year the US Food and Drug Administration found a “chain of failures” in its quality control unit.

An Intas spokesperson told CNBC this week that the company is working with the Food and Drug Administration to bring the production back to the United States, but no date has been set yet.

Leqembi’s new Alzheimer’s antibody treatment could cost Medicare up to $5 billion a year, according to research published in a leading medical journal this week.

Medicare will spend about $2 billion annually if about 85,700 patients test positive for the disease and are treated with Esay And Biogen Leqembi product, according to research published in JAMA Internal Medicine on Thursday.

According to the study, the program for seniors would spend $5 billion if about 216,500 patients became eligible for the staggering treatment.

The authors said the estimated costs for Medicare are conservative, and spending on Leqembi may increase more than expected depending on demand and other factors.

The researchers who conducted the JAMA study included physicians, along with Public health and policy experts. They are affiliated with the University of California Los Angeles, the Rand Corporation, Harvard Medical School, and Beth Israel Deaconess Medical Center in Boston, among other institutions.

Eisai and Biogen have priced twice-monthly antibody injections at $26,500 per year.

There are also an estimated $7,300 in additional annual costs per patient associated with neurologist visits, MRI exams, PET scans, injection administration, and monitoring and treatment for potential side effects, according to the researchers.

The study assumed that Medicare would cover 80% of the costs with patients left to pay the remaining 20% ​​in whole or in part depending on whether they had supplemental insurance.

Patients may face an annual bill of about $6,600 per year depending on which state they live in and whether they have supplemental insurance, according to the study. Some low-income people who qualify for Medicare and Medicaid will pay nothing out of pocket.

The Alzheimer’s Association, which lobbies on behalf of patients living with the disease, estimates that Alzheimer’s and other forms of dementia will cost $345 billion this year. Those costs could rise to $1 trillion by 2050, according to the association.

“This is the case without a cure. Prevention and treatment are the only way to reduce this cost over time,” Robert Egge, the federation’s chief of public policy, said in a statement.

“But it’s not the cost that should determine whether people have access to life-enhancing care — it’s about the impact on people,” Egge said. “Therapies taken in the early stages of Alzheimer’s disease can mean a better quality of life.”

Leqembi had a positive effect on patients with early-onset Alzheimer’s disease in clinical trial results published in the New England Journal of Medicine in January.

The expensive treatment is not available to the vast majority of patients right now because Medicare has severely restricted antibody coverage.

Medicare has promised broader coverage for Leqembi if the US Food and Drug Administration (FDA) grants full approval of the treatment in July. Leqembi received emergency approval from the Food and Drug Administration in January.

The Alzheimer’s Association, members of Congress and state attorneys general are pressing for Medicare to repeal its restrictions and fully cover Leqembi.

Antibody therapy, which targets brain plaques associated with the disease, slowed cognitive decline by 27% in the Eisai clinical trial.

There are currently no other medications on the market that have shown this level of effectiveness in slowing Alzheimer’s disease. Eli Lillydonanemab showed promising clinical trial results earlier this month. The company plans to apply for full FDA approval this quarter.

Leqembi and donanemab both carry serious risks of brain swelling and bleeding.

CEOs of the three pharmaceutical companies that control 90% of the global insulin market will testify May 10 before the Senate Health Committee on price cuts for diabetes drugs, according to committee chair Sen. said Bernie Sanders on Friday.

Those companies — Eli Lilly, Novo Nordisk and Sanofi — announced in March that they would cut prices of their most widely used insulin products by 70% or more.

On Friday, Sanders called the move an important step forward that was the result of “public outrage and strong grassroots efforts.”

But the Vermont Independent added that Congress must ensure insulin, which has increased in price by more than 1,000% since 1996, is affordable.

“We must, however, make sure that those price cuts take effect in a way that results in every American getting the insulin they need at an affordable price,” Sanders said in a statement announcing the scheduled testimony of Eli Lilly CEO David Ricks. Paul Hudson, CEO of Sanofi, and Lars Froergaard Jørgensen, CEO of Novo Nordisk.

Sanders noted that corporate versions of insulin cost at least $275 before the announced price cuts.

Eli Lilly declined to comment when asked about the scheduled hearing. A Sanofi spokesperson said the company supports efforts to reduce costs and believes other parts of the healthcare system need to do more to help patients. Novo Nordisk said its CEO looks forward to a “productive and collaborative discussion on this important issue.”

CEOs of the three major pharmacy benefits directors CVS Healthand Express Scripts Optum Rx Also testifying, according to Sanders’ office, those executives are David Joyner, president of CVS Health Pharmacy Services. Adam Kautzner, President, Express Scripts; and Heather Cianfrocco, CEO, Optum Rx

Pharmacy benefit managers are the middlemen who negotiate drug prices with manufacturers on behalf of health insurance plans. PBMs have been criticized for inflating drug prices and not giving consumers all the discounts they negotiate.

The Department of Health and Human Services estimates that 17% of patients using insulin in 2021 had to ration the drug due to rising costs.

About 19% of insulin users with private insurance metered the drug, and 29% of uninsured insulin users did, according to HHS.

The drug companies’ decision to lower insulin prices came a month after President Joe Biden called in his State of the Union address to Congress for a cap on insulin prices at $35 per month.

The Biden Inflation Act capped people on Medicare, the government-run health coverage program primarily for seniors, but the law did not cover people with private insurance.

According to HHS, more than two million patients with diabetes who take insulin are privately insured.

The department says about 150,000 patients taking insulin will not have insurance.

On Thursday, two senators, Jane Shaheen, D-NH, and Susan Collins, R-Maine, introduced bipartisan legislation that would require private health insurance to set prices at $35 per month for at least one of every type and dose of insulin. The bill includes other measures to reduce prices.

Types of insulin include rapid, short, intermediate, and long-acting, as well as pre-mixed. Dosage forms include vials, pens, and inhalers.

Home prices fell in January, just 3.8% more nationally than they were a year ago, according to the US National Security Agency’s Standard & Poor’s CoreLogic Case-Shiller Home Price Index. This is down from 5.6% in December.

Prices have been dropping for seven months in a row, but the decline was a bit smaller in January. This was most likely due to a brief drop in mortgage rates and the resulting jump in sales.

The 10-city complex rose 2.5% year over year, down from 4.4% in December. The 20-city composite also rose 2.5%, down from 4.6% in the previous month.

Home prices have fallen due to higher mortgage rates. The average rate on a 30-year fixed mortgage hit more than a dozen record lows during the first two years of the pandemic, falling briefly to less than 2%, but growing sharply. Since the fall, the price has been hovering in the high 6% range, although it has been volatile in recent weeks due to several bank failures and the resulting stress on the banking industry in general.

“Nevertheless, the Fed remains focused on its inflation-lowering targets, which suggests rates may remain elevated in the near term,” Craig Lazzara, managing director at S&P DJI, said in a statement. So mortgage financing and the possibility of economic weakness is likely to remain a headwind to home prices for at least the next several months.

Prices were down year-over-year in San Francisco (-7.6%), Seattle (-5.1%), Portland, Oregon (-0.5%) and San Diego (-1.4%). It was flat in Phoenix.

Miami, Tampa and Atlanta again had the highest annual price gains among the 20 largest cities. Miami prices increased 13.8%, Tampa prices increased 10.5%, and Atlanta prices increased 8.4%. However, all 20 cities reported lower prices in the year ending January 2023 compared to the year ending December 2022.

Homebuyers may see more flexible sellers this spring, but there are still very few homes available for sale. Mortgage lending may also contract given the stress on the banking system.

“More expensive and less available borrowing, especially with an uncertain economic outlook, is likely to continue to dampen buyer demand. Although home sales are expected to rebound in line with seasonal trends, the pace of spring sales is expected to remain lower. Since last year, Hannah Jones, economic data analyst at Realtor.com said: “Because uncertainty and rising costs limit activity.”