Medicare Post-election by Stanford Health Policy on Exposure

Stanford Health Policy faculty members Michelle Mello, David Studdert and Laurence Baker discuss repealing the Affordable Care Act (ACA) and how it could affect health coverage in the United States.

Now that the United States has elected a Republican president and Congress, what is likely to happen to the Affordable Care Act (ACA)?

Michelle Mello and David Studdert: Exactly what will happen is unclear at this point, particularly since President-elect Trump’s own position on the ACA seems to be evolving by the day. In an interview on Nov. 11, he said he is interested in keeping some of the key provisions of the law, such as a ban on insurers discriminating on the basis of pre-existing conditions and provisions allowing young people to stay on their parents’ plans until age 26. But his opposition to other provisions, including the cornerstone provision requiring individuals to purchase insurance coverage, likely will remain. At this point, about the only thing one can say with certainty is that substantial change is coming.

Is the ACA likely to be repealed fully, or will some components be spared?

Mello/Studdert: On the campaign trail, President-elect Trump said repeatedly that repealing Obamacare is a priority. House Republicans have said the same. A complete repeal seems unlikely in the short term, though. There’s more opposition to some provisions of the act than to others, and millions of Americans now depend on health insurance coverage made available through the ACA. More likely, Republicans will target certain key elements – the individual mandate, minimum essential coverage rules, the subsidies available to low-income purchasers of health insurance and federal financing arrangements for the Medicaid program. Eliminating all of these features would spell the end of Obamacare as we know it. Eliminating any one of them would seriously threaten its viability, because the ACA’s strategy depends on having all major legs of the stool in place.

What is the legal process for repeal, and what issues would likely arise?

Mello/Studdert: Although Republicans will have a majority in the House and Senate, they fall just short of a filibuster-proof majority (60 votes) in the Senate. This is why a repeal is not likely to occur – at least not straight away – unless several Senate Democrats break ranks in the vote. A more likely scenario is that Republicans will use the budget reconciliation process to make the kind of changes mentioned above. Bills of this kind require only a simple 51-vote majority in the Senate, which they have.

Laurence Baker: Republicans have substantial ability to remove parts of the law under budget reconciliation. They can make changes to aspects of the ACA that involve financial in- and outflows to the federal government, but not other things. Reconciliation thus allows them to make changes to the major things like the mandate – because it involves a tax penalty – the subsidies and Medicaid. But they would not be easily able to repeal things like the exchange structures, guaranteed offers of insurance regardless of health status and other provisions. Guaranteed issue would be a real problem for insurance companies without the mandate, so repealing one but not the other threatens significant disruptions in insurance markets.

Most of the discussions thus far have focused on efforts to repeal the ACA’s expanding coverage aspects, but there are other aspects of the ACA that could be addressed. The ACA set up and funds the Center for Medicare and Medicaid Innovation (CMMI) and Patient-Centered Outcomes Research Institute (PCORI), two organizations that have not been discussed much in the repeal debates and which are seen by some Republicans in a more positive light. The ACA also makes changes to Medicare payments. It seems likely that repeal debates will focus more on coverage and less on these things, but it’s hard to tell at this point.

How will this affect Americans who current receive subsidies for health insurance?

Mello/Studdert: Elimination of the subsidies would have a major effect on the ACA’s core objective to cover the uninsured. By 2017, about 25 million people will have purchased their health insurance on the exchanges set up under the ACA, and about three-quarters of them will receive subsidies to help make premiums affordable. If the subsidies disappear, we should expect that health insurance will become unaffordable for many of these people or no longer look like a good deal. The tax credits and health savings accounts currently being discussed won’t make up for what is lost, and many people who currently have insurance can be expected to drop it. Elimination of the individual mandate will further open the way for this to happen.

Baker: The reality of the health care system is that there are not easily available alternatives to the ACA that would protect coverage and be palatable to broad groups of Republicans. Single-payer, or national health insurance, is a non-starter, so they’d be left with market-oriented reforms, and there are not obvious ways to pursue those without at least some core features of the ACA. Most of the proposals recently put forward for a replacement, including those highlighted by the Trump campaign, like cross-state competition, tax credits for insurance purchase and block granting Medicaid, would not really offer coverage to a large number of the people who would lose it under repeal. So a key question is what alternatives the Republicans come up with. In a similar way, the ACA and its provisions have become increasingly woven into our insurance system. Insurers and employers, among others, have made decisions and investments incorporating the ACA. Undoing those threatens disruptions and political challenges.

Michelle Mello is a professor of law and of health research and policy.

David Studdert is a professor of law and of medicine.

Laurence Baker is a professor of health research and policy, chair of the Department of Health Research and Policy in the School of Medicine and a senior fellow at the Stanford Institute for Economic Policy Research.

Few people understand the high costs of medical services in the United States better than David Chan, a practicing physician and Stanford economist specializing in health care. But even Chan isn’t immune from sticker shock at the doctor’s office.

On a recent visit to his doctor, Chan underwent a routine test for seasonal allergies. He figured it would cost about $500. The actual charge was closer to $5,000.

“I should be one of health care’s most informed customers,” says Chan, who is a faculty member at Stanford Health Policy. “But like most people, I didn’t think to ask the price for the test and my doctor probably didn’t know it, anyway.”

To Chan, a faculty fellow at the Stanford Institute for Economic Policy Research and assistant professor at the Stanford School of Medicine, the experience illustrates what’s hobbling U.S. health care.

Although much research into health economics has focused on issues related to insurance, the delivery of patient care — specifically, how to lower costs and manage quality at the ground level — “is really where health care becomes a black box,” says Chan. Economics haven’t figured out why costs and patient outcomes vary widely, even from one hospital to the next in the same city.

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Health policy expert Bob Kocher likes to show a slide of the signature page of the Affordable Care Act, which he helped draft when he worked in the White House.

The mottled page shows an official time stamp of March 23, 2010, and the choppy signature of President Obama, who had to use the 22 pens he would later gift each member of Congress who helped him pass the landmark health-care law.

“We thought it would be pretty simple,” Kocher recalled with a grin. “We had 60 Democrats in the Senate and a huge majority in the House, a popular president. But then you saw what happened.”

Kocher was the keynote speaker at Health Policy through 2020: The ACA, Payment Reform and Global Challenges, a half-day symposium of speakers and panels covering some of the greatest challenges facing health care and policy here at home and abroad.

“Everything that you could imagine that would throw a monkey wrench into it, did,” said Kocher, a physician and partner at the Silicon Valley venture capital firm, Venrock, which invests in health-care and technology startups.

Six years after its rocky start — and ongoing threats to repeal the law by Republicans — Kocher still believes the ACA has had a tremendously important impact on the nation.

“Despite the single worst launch of a website in the history of the internet,” he said, 20 million more Americans now have access to health care; 13 million more are privately insured by their companies; and 7 million more are enrolled in Medicaid.

“I believe the ACA is working better than expected by virtue of the fact that there’s nobody in the ecosystem who is not behaving differently,” Kocher said.

Large employers have been forced to engage with their employees about the costs and quality of their health plans, and hospitals are adopting new technology by “liberating their data” with electronic medical records and embracing telemedicine, Kocher said.

“And for the first time, you see patients beginning to engage with new technologies and their doctors willing to entertain new models.”

Kocher, who specializes in investing in healthcare IT and services, said technology would eventually strip away some of the cost of patient care.

“One of the fun parts of my job as a venture capitalist is that I get to see a lot of these embryonic ideas and many of them have powerful ways to pull down costs without hurting quality,” he said. “We’ll have the technology and coordinated care, and data that helps guide the care, so I’m more hopeful than ever about being a patient.”

Kocher, a consulting professor at Stanford Medicine, was one of 15 speakers at the symposium to launch Stanford Health Policy, a community of faculty, physicians, scholars and students across the campus who are focused on improving health care and policy here at home and around the world.

Precision Health

Stanford School of Medicine Dean Lloyd B. Minor shared what he called “some surprising statistics” with the 200 people at the symposium on Oct. 14.

When looking at a pie chart representing the determinants of health, Minor said, only 5 percent are genetically based, 20 percent are based on health care and another 20 percent are due to behavioral factors.

But a full 55 percent of the determinants of health are socially and environmentally determined, Minor said, and that presents challenges for academic medical centers.

“I’m really excited in that I believe that we are beginning to come up with some ways we can address that need, as a leading academic medical center, to chart the future for how we can improve the delivery of health care in our country and then ultimately around the world,” Minor said. “For us, that vision for how we fulfill that need begins with what we describe as precision health.”

Minor said precision medicine, now embraced by the Obama administration, is about using genomics, big data science and personalization in order to individualize the treatment of acute diseases such as cancer, heart and neurological diseases.

“It’s about understanding the determinants and predisposing factors of disease in being able to more effectively intervene earlier,” he said. “And of course there’s no better place to do that than at Stanford because our academic medical center is such an integral part of this great research university.”

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The ACA Moving Forward

Kocher, who often lectures in health economics and policy courses at Stanford, conceded there are serious problems with Obamacare and offered some solutions moving forward.

But the climbing cost of health care and prescription drugs in the United States — which continue to outpace the economy and job growth — is his first concern.

Health insurance on average costs a family of four is $18,000 a year.

“That’s the price of a Corolla,” he said, referring to Toyota’s compact car. “The idea that you’re effectively buying a new car every year doesn’t feel like we’re getting the right amount of cost pressure on the system that we need. So I think that’s going to be the most fundamental problem going forward.”

Despite the gnashing of teeth over what would become of the ACA under a Trump or Clinton administration, Kocher predicted few changes.

“If Hillary Clinton wins, her priorities are actually going to be totally separate from ACA tweaks,” he said, adding that she likely would first focus on K-through-12 education, work on infrastructure spending and then international affairs.

“The odds that she wants to relive 1993 seems implausible to me,” he said.

As first lady, she pushed President Bill Clinton’s universal health-care plan with a mandate for all employers to provide health insurance coverage to all employees. The Health Security Act was widely condemned by conservatives and the health insurance industry and after a rancorous year of debate and counter-proposals, it died.

And what happens to the ACA if Donald Trump is elected president on Nov. 8?

“I can’t bring myself to comment,” Kocher said, lowering his head and chuckling.

He quickly moved on to some suggestions to make health care work better and faster.

“The first thing we need is to make these adolescent exchanges grow into adults and be stable and work better,” Kocher said of the health insurance marketplaces, which have foundered in some states and thrived in others.

He said the Covered California exchange, which insures some 1.7 million Californians, is the only exchange working really well because it has large bidding regions, doesn’t let all insurance providers into the system and does great outreach to young, healthy people.

Secondly, he said, the market power of hospitals has become too strong.

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“I realize there are some hospital leaders in the room and I salute you — you’ve done many things right, including getting market power,” Kocher said, addressing David Entwistle and Chris Dawes, the CEOs of Stanford Health Care and Lucile Packard Children’s Hospital, respectively, who also spoke at the symposium.

“But we need to figure out how to make the demand side of the equation more balanced with the supply side.”

He called health care today “massively inefficient” and “insanely unaffordable,” and said the average hospital stay is now $6,000 in the United States.

Kocher said he recently took his daughter to an emergency room and was charged $52 for a Tylenol. He told them he was a doctor and offered a Tylenol from his backpack.

“But I was told I couldn’t because of the safety of the hospital,” he said, shaking his head.

Kocher said hospitals must be accountable for their quality of the care and fined for failure to achieve promised quality indicators. As hospitals continue to bundle services and acquire private practices and physicians, costs have not gone down as expected.

Instead, hospital prices nationally have risen 6 to 9 percent in the last five years, faster than the rate of inflation. Perhaps, he suggested, some procedures and services should be tied to Medicare rates above a certain percentage of market share. And federally subsidized drug prices should be tied to patient income, not the facilities they use.

Kocher said there continues to be great debate over how high the penalty should be for those who decline to join a health exchange if they are uninsured by an employer.

The annual fee for not having insurance in 2016 is $695 per adult and $347.50 per child.

A higher mandate, he said, would get a lot more people into the system.

“But there’s no chance Congress is going to think about that.”

You can watch all the videos from the event here: 

Health Policy through 2020 by Stanford Health Policy on Exposure

There is much debate among health policy researchers about the performance of the Medicare Advantage plans, which are sold and run by private insurance companies, but are regulated by the government to provide Medicare benefits.

Enrollment in Medicare Advantage plans — mostly commonly HMOs and PPOs — grew from 5.4 million consumers in 2005 to 16.8 million in 2015, or about 31 percent of the Medicare population, according to the Kaiser Family Foundation.

Some argue the private alternative to the traditional insurance program for seniors is less expensive than the public programs; others say it’s just the opposite. And still others argue that that the government overpays for people enrolled in private plans since traditional Medicare could have covered these patients for less money.  But there had not been broad analyses of the prices actually paid by these plans.

Now, researchers from Stanford Medicine, the Stanford Law School and the Graduate School of Business have conducted one of the largest systematic analyses of the prices that Medicare Advantage plans pay to doctors and hospitals, relative to the prices paid by Medicare fee-for-services or commercial plans.

They found Medicare Advantage plans actually pays 8 percent less to hospitals for their services than traditional Medicare. If you make adjustments for the smaller, cheaper network of hospitals that Advantage plans allow their patients to use, the program pays 5.6 percent less to hospitals than FFS Medicare.

The researchers shared their findings in an online article in Health Affairs this week.

“The surprise is that Medicare Advantage is paying hospitals less,” said lead author Laurence C. Baker, professor of health research and policy at Stanford Medicine and a senior fellow at the Stanford Institute for Economic Policy Research. 

“That suggests that in an era when there are real questions about escalating health-care costs, we may want to think more about the potential benefits of Medicare Advantage plans,” Baker said. “It seems they are negotiating better prices.”

Either way, the savings or losses are always going to impact the patient.

“If you’re looking at it as a question of policy, this may be useful,” Baker said. “In the long run, we could pay less taxes to support the Medicare program and maybe people in Medicare Advantage would get to share in those savings.”

The other co-authors of the study are M. Kate Bundorf, professor of health research and policy and a faculty research fellow at the National Bureau of Economic Research; Aileen M. Devlin, a research fellow at the Law School and Daniel P. Kessler, a professor in the Law School and the Graduate School of Business.

They used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by Medicare Advantage, FFS Medicare and commercial plans in 2009, 2011 and 2012.

The data included information from Aetna, Humana, and UnitedHealthcare on approximately 40 million individuals who represent all 50 states, accounting for 27 percent of the nonelderly population covered by commercial insurance, and 31 percent of the elderly Medicare Advantage population.

The authors also found the rates paid to hospitals by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and that these rates are continuing to grow.

Some of the difference is a result of the much higher prices commercial plans pay for very profitable services such as orthopedics and interventional cardiology.

“However, commercial plans pay higher prices than FFS Medicare for almost all types of admissions in almost all geographic areas,” they wrote. “Thus, our work echoes the growing concerns expressed by several researchers about the consequences of high commercial-plan prices for health spending.”

The Asia Health Policy Program at Stanford’s Shorenstein Asia-Pacific Research Center, in collaboration with scholars from Stanford Health Policy's Center on Demography and Economics of Health and Aging, the Stanford Institute for Economic Policy Research, and the Next World Program, is soliciting papers for the third annual workshop on the economics of ageing titled Financing Longevity: The Economics of Pensions, Health Insurance, Long-term Care and Disability Insurance held at Stanford from April 24-25, 2017, and for a related special issue of the Journal of the Economics of Ageing.

The triumph of longevity can pose a challenge to the fiscal integrity of public and private pension systems and other social support programs disproportionately used by older adults. High-income countries offer lessons – frequently cautionary tales – for low- and middle-income countries about how to design social protection programs to be sustainable in the face of population ageing. Technological change and income inequality interact with population ageing to threaten the sustainability and perceived fairness of conventional financing for many social programs. Promoting longer working lives and savings for retirement are obvious policy priorities; but in many cases the fiscal challenges are even more acute for other social programs, such as insurance systems for medical care, long-term care, and disability. Reform of entitlement programs is also often politically difficult, further highlighting how important it is for developing countries putting in place comprehensive social security systems to take account of the macroeconomic implications of population ageing.

The objective of the workshop is to explore the economics of ageing from the perspective of sustainable financing for longer lives. The workshop will bring together researchers to present recent empirical and theoretical research on the economics of ageing with special (yet not exclusive) foci on the following topics:

• Public and private roles in savings and retirement security
• Living and working in an Age of Longevity: Lessons for Finance
• Defined benefit, defined contribution, and innovations in design of pension programs
• Intergenerational and equity implications of different financing mechanisms for pensions and social insurance
• The impact of population aging on health insurance financing
• Economic incentives of long-term care insurance and disability insurance systems
• Precautionary savings and social protection system generosity
• Elderly cognitive function and financial planning
• Evaluation of policies aimed at increasing health and productivity of older adults
• Population ageing and financing economic growth
• Tax policies’ implications for capital deepening and investment in human capital
• The relationship between population age structure and capital market returns
• Evidence on policies designed to address disparities – gender, ethnic/racial, inter-regional, urban/rural – in old-age support
• The political economy of reforming pension systems as well as health, long-term care and disability insurance programs

Submission for the workshop

Interested authors are invited to submit a 1-page abstract by Sept. 30, 2016, to Karen Eggleston at karene@stanford.edu. The authors of accepted abstracts will be notified by Oct. 15, 2016, and completed draft papers will be expected by April 1, 2017.

Economy-class travel and accommodation costs for one author of each accepted paper will be covered by the organizers.

Invited authors are expected to submit their paper to the Journal of the Economics of Ageing. A selection of these papers will (assuming successful completion of the review process) be published in a special issue.

Submission to the special issue

Authors (also those interested who are not attending the workshop) are invited to submit papers for the special issue in the Journal of the Economics of Ageing by Aug. 1, 2017. Submissions should be made online. Please select article type “SI Financing Longevity.”

About the Next World Program

The Next World Program is a joint initiative of Harvard University’s Program on the Global Demography of Aging, the WDA Forum, Stanford’s Asia Health Policy Program, and Fudan University’s Working Group on Comparative Ageing Societies. These institutions organize an annual workshop and a special issue in the Journal of the Economics of Ageing on an important economic theme related to ageing societies.

More information can be found in the PDF below.

Americans spent $3 trillion on health care in 2014, or about $9,523 per person. That’s up 5.3 percent from the previous year. That increase isn’t expected to slow down; for about the next decade, the U.S. government  expects spending to grow 5.8 percent on average each year.

As policymakers look for ways to cut down this spending, one idea gaining traction is to incentivize consumer-directed health plans (CDHP). These high-deductible, low-cost plans are already growing in popularity. About 20 percent of people who are covered by employer-sponsored health insurance are enrolled in some type of CDHP.

In theory, CDHPs would reduce health-care costs because consumers would choose less expensive health care when they pay for it themselves. But does that theory pan out in practice? M. Kate Bundorf, an associate professor of political economy, examines the benefits — and the trouble spots. Bundorf is also a core faculty member at Stanford Health Policy.

In a Q&A, Stanford postdoctoral fellow Darika Saingam explains why Thailand's battle against drugs continues and what is needed to introduce good policy that works to prevent illegal drug trade and supports recovering addicts.

Despite Thailand’s decade-long crackdown on drugs, demand for illegal substances has risen. A green leaf drug known as ‘kratom’ is a symbol of this rise as young people eagerly adopt the drug for entertainment and join an older generation of laborers who chewed it to survive long hours of work in the fields—and are now heavily addicted. Curtailing substance abuse and its consequences takes good public policy and solutions must be area-specific and evidence-based, according to a Stanford postdoctoral fellow.

Darika Saingam, the 2015-16 Developing Asia Health Policy Postdoctoral Fellow, has conducted two cross-sectional surveys and more than 1,000 interviews with drug users, recovered addicts, and local public officials in an effort to better understand the evolution of substance abuse in southern Thailand.

At Stanford, she is preparing two papers that offer policy options suitable for Thailand and other developing countries in Southeast Asia. Saingam spoke with the Shorenstein Asia-Pacific Research Center (APARC) where she will give a public talk on May 17. The interview text below was edited for brevity.

For decades, Thailand has been an epicenter of drugs. Can you describe the extent of the problem today?

According to a 2014 report, 1.2 million people were involved in illegal drug activities across Thailand. The total number of drug cases saw a 41 percent increase from 2013 to 2014. New groups of drug traffickers are mobilizing while existing groups are still active. Drug users who are young become drug dealers as they get older. The number of drug users below 15 years of age has increased dramatically.

According to your research, what drives Thais toward illegal drug use and the trafficking business?

Adults in Thailand use drugs to relieve stress and counteract the effects of work. Adolescents use them for entertainment. Historically, farmers and laborers from rural areas of Thailand would use opium for pain relief. More recently, a consumable tablet known as yaba has become popular along with crystal methamphetamine and marijuana. Young people are increasingly using yaba and kratom.

Thailand is still a developing country, but it is industrializing quickly. Social and cultural norms have been shifting and people want an improved quality of life. A lot of young people are unemployed and lack social support and are therefore more likely to turn to drug trafficking for economic opportunity. The economic recession and political strife in countries bordering Thailand have exacerbated the situation.

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Photos (left to right): A man holds up a kratom leaf. / Saingam examines kratom leaves as part of her research to understand illegal cultivation practices.

What is kratom and why is it popular?

For nearly a century, the native people of Thailand have chewed kratom. It is a leaf that grows on trees resembling a coffee plant. Historically, kratom was used to reduce strain following physical labor, to be able to work harder and longer, and to better tolerate heat and sunlight. Kratom is also embedded in Thai culture and given as a spiritual offering in religious ceremonies. My field research in the southern province of Nakhon Si Thammarat has shown that these motivations are still true today.

Within the past seven years, kratom use has skyrocketed and people are using it in increasingly harmful ways. Chewing kratom is not immediately harmful to health, but combining it with other substances is. This is the recent trend. Users have created new ways to consume it such as in a drink known as a ‘4x100.’ It contains boiled kratom leaves, cough syrup and soft drinks. Additional methamphetamines and benzodiazepines are sometimes added to that mixture.

What strategies must be employed to control substance abuse?

The first step is to realize that the patterns of substance abuse are specific to each location therefore solving the problem must also be. Drug usage is also dynamic. Placing hard control measures on one substance often provokes the emergence of another in its place therefore a holistic approach is important.

Thailand should employ multiple strategies toward effective prevention and control of substance abuse. These strategies include examining the problem and creating policies from an economic perspective (supply and demand), an institutional perspective (national and international drug control cooperation), and a social perspective (structural supports for recovered addicts and mobilization of public participation).

What is the Thai government doing to address the drug problem, and what could they be doing better?

Politicians in Thailand must do a better job at representing the people. Government health workers are often gathering information, assessing needs, and reporting findings to politicians, but these needs are not being accurately addressed. An example of this is politicians ordering to cut down kratom trees – a public display that does not get at the root cause of the problem. The reality is that drug users will quickly find substitutes. According to my study, of the regular users that stopped using kratom, more than 50 percent turned to alcohol instead and did so on a daily basis. This is merely a shift from one substance to another.

On the upside, a crop substitution program created under King Bhumibol Adulyadej offers a successful working model. The program works to replace opium poppy farming with cash crop production. It began in 1969 and is cited for helping an estimated 100,000 people convert their drug crop production to sustainable agricultural activities. Crops cultivated can be sold for profit in nearby towns. The program has also introduced a wide variety of crops and discouraged the slash-and-burn technique of clearing land. It is win-win because it stymies drug trade and provides economic opportunity while also being ecologically sound. This type of program should continue to be scaled up.

Can this model be co-opted elsewhere? What lessons from other countries could inform Thailand’s approach?

Yes, the model could plausibly be implemented in other areas in Thailand and in other Southeast Asian nations.

I think a judicial mechanism such as the kind seen in France could benefit the rural areas in Thailand. The French government has established centers across the country that act as branches of the court that try delinquency cases of minor to moderate severity, and also recommend support services for drug users. Members of the magistrate and civil society actors manage center operations thus placing some responsibility back onto the local community.

I believe an opportunity also exists for Thailand to legalize kratom. Legalization would show a respect for the cultural tradition of chewing kratom leaves and allow the government to suggest safer ways of using it. Bolivia has created a successful model of this through its legalization of coca leaves. Coca in its distilled form is cocaine, but left as a leaf, it is not a narcotic. Indigenous peoples are allowed to chew coca leaves. The government policy is being credited for a decrease in cocaine production as well.

Nearly 100 health economists from across the United States signed a pledge urging U.S. presidential candidates to make chronic disease a policy priority. Karen Eggleston, a scholar of comparative healthcare systems and director of Stanford’s Asia Health Policy Program, is one of the signatories. 

The pledge calls upon the candidates to reset the national healthcare agenda to better address chronic disease, which causes seven out of 10 deaths in America and affects the economy through lost productivity and disability.

Read the pledge below.