Abstract
2018 was a pivotal year for the Social Security program. It was the first year since the 1983 amendments that the Old Age, Survivors and Disability Insurance (OASDI) trust funds spent more than they took in. This will continue until they are depleted in 2034. This article examines the operation of the OASDI program with particular attention to its funding. It concludes by questioning the myth that, until 2018, the OASDI trust funds held large amounts of surpluses. There has never been any real money there. It was spent by the Treasury Department as fast as it came in. The OASDI program has always been a pay-as-you-go system. That should be recognized by anyone involved in crafting a solution to the problem.
When most of us think of “Social Security” it means the Old Age, Survivors and Disability Insurance (Pub. L. 74-271; OASDI) program. OASDI is only one of the many programs in the Social Security Act (SSA) of 1935, as amended. The others include Unemployment Compensation (Titles III and XII), Supplemental Security Income (Title XVI; SSI), Medicare (Title XVIII), Medicaid (Title XIX), and the Children’s Health Insurance Program (Title XXI; CHIP).
Old Age and Survivors’ Insurance (OASI; Titles I and II of the act) is the foundation of the social insurance programs in the United States. It provides income to elderly and disabled workers and their dependents and survivors. Social Security Disability Insurance (SSDI; Titles XIV and XVI) was added later. Almost all of us will someday become (or are) old and many are or will become disabled. All of us have family members and friends who receive Social Security benefits. OASDI is an extremely important program to all Americans.
This article examines the OASDI program with particular attention to its funding problems.
Background
The Social Security Act was signed into law in 1935 as one of the most important responses to the Great Depression. It was amended in 1939 by the Federal Insurance Contributions Act (Pub. L. 86-272; FICA), which became Title II of the Social Security Act. Social Security initially applied only to covered workers in the private sector. Employees and their employers made equal mandatory contributions as a percentage of covered income to the Old Age and Survivors Insurance trust fund. The arrangement is essentially a very large defined-benefit pension plan that pays lifetime retirement benefits.
In 1954, Congress passed the Self Employment Contributions Act (Pub. L. 114-38; SECA), which extended OASI coverage to the self-employed. Also in 1954, coverage was extended to farmers and clergy. In 1956, OASI coverage was extended to active-duty military and naval personnel.
In 1957, Social Security Disability Insurance was added and expanded upon in 1960. SSDI is essentially an insurance program that protects workers against loss of income due to a physical or mental condition that precludes gainful employment. SSDI benefits convert to retirement benefits at the full retirement age (FRA). With the adoption of disability benefits, OASI became the Old Age, Survivors and Disability Insurance (OASDI) program.
Normal retirement age was originally 65. Early retirement at age 62, with reduced monthly benefits, was introduced for women in 1956 and for men in 1961. 1
During the 1950s and 1960s, OASDI was extended to state and local government employees on a voluntary basis (to the state) through what are known as Section 218 Agreements. Today, over 25% of public sector employees are not covered by OASDI (mainly K-12 teachers in 15 states, police officers and fire fighters). 2 Federal employees were covered beginning 1984.
The 1983 Amendments
By the late 1970s, it was evident that the OASDI program was approaching insolvency, due in part to congressional generosity and the inevitable effects of a maturing funded program. In 1983, the National Commission on Social Security Reform (Greenspan Commission) made a number of recommendations designed to save Social Security. They were quickly enacted and signed into law. The 1983 amendments advanced the effective date of the FICA tax rate and the wage base increase that had been enacted in 1977, gradually increased the full retirement age from 65 to 67, established federal income taxation of 50% of the OASDI benefits and required federal employees hired after January 1, 1984, to participate in Social Security.
The 1983 amendments were a great success. Beginning 1984 and continuing through 2010 the program ran a substantial surplus. Table 1 reports the operation of the OASDI trust funds for selected years 1980 through 2017 and projections through 2027. It displays end-of-year assets, income, expenditures and the “trust fund ratio” (TFR).
Operation of OASDI Trust Funds and Year of Depletion, Selected Years, 1980 to 2035 ($ Billions).
TFR entries for 1984 and 1985 do not compute due to a $12.4 billion loan from the HI trust fund to the OASI trust fund and repayment.
TFR entry for 1990 does not compute because reserves used in the calculations include January advance tax transfers.
Source. Board of Trustees of the Old Age and Survivors Insurance and Federal Disability Trust Funds. The 2018 Annual Report. Table VI.A3, pp. 160-161, and table VI.B1, p. 166. Retrieved from www.ssa.gov/OACT/TR/2018/tr2018.pdf.
The TFR is a measure of how long full scheduled benefits can be paid from available resources. The balance of the OASDI trust funds at the beginning of the year (or end of the previous year) is divided by the scheduled expenditures during the year. For example, the assets at the end of 2017 (beginning of 2018) are divided by the expenditures for 2018 to get the TFR for 2018 ($2,891.8 billion ÷ $1,002.8 = 2.88). That means the OASDI trust funds can pay scheduled benefits for 2.88 years (on top of that funded by ongoing contributions) from assets available at the beginning of the year. The 2.88 is multiplied by 100 to get the reported TFR of 288.
Note how the TFR went from a low of 14 in 1983, increased to 21 in 1984 and then continued to grow to 357 in 2010. It has since declined to 299 in 2017 and will continue to shrink in the future until the OASDI trust funds are depleted in 2034.
It should be noted that the TFR for 1984 and 1985 were affected by a $12.4 billion loan from the Health Insurance trust fund to the OASI trust fund and its subsequent repayment.
The TFR, sometimes called the “fund ratio,” should not be confused with the “funded ratio” or “funding ratio” (assets ÷ liabilities) used to measure funding levels in defined-benefit pension plans. They are different.
Table 1 also shows the year of depletion of the OASDI trust funds. The depletion year retreated from 2049 in 1985 to 2034 in 2015 and has remained there since then. That means that the OASDI trust funds will be able to pay full scheduled benefits until 2034.
Depletion does not mean that OASDI benefit payments will cease. Rather, it means that they will continue to provide about 75% of the scheduled benefits paid from ongoing contributions. A 25% reduction in OASDI benefits would be catastrophic for the millions of Americans who rely totally or largely on OASDI in their old age or years of disability.
OASI Benefits
As reported in Table 2, there were almost 62.5 million OASDI beneficiaries as of June 30, 2018. They received over $81.0 billion in benefits payments per month. Total OASDI recipients included 43.1 million retired workers who received an average benefit of $1,413; 2.4 million spouses receiving an average benefit of $737; and 689,000 children receiving an average of $677. There were almost 6.0 million survivors of deceased workers receiving an average monthly benefit of $1,156. There were also 10.3 million disabled workers and their dependents receiving an average monthly benefit of $1,063.
Number of Beneficiaries, Total Benefits Paid and Average Monthly Benefits as of June 30, 2018.
Author’s calculations.
Source. Social Security Administration. Social Security Program Fact Sheet. June 30, 2018. Retrieved November 10, 2018, from https://www.ssa.gov/OACT/FACTS.
OASDI benefits are a statutory right that has been paid for by required contributions by covered employees and their employers. OASI retirement benefits are available to any claimant who has attained the minimum retirement age of 62 or over and has earned 40 credits (quarters of covered employment). In 2019, a worker must earn $1,360 in a quarter for it to count as a credit.
The OASI benefit amount is based on the highest 35 years (420 quarters) of covered earnings. Annual contributions are converted to current dollars, which produces the “average indexed monthly earnings” (AIME). This is then subjected to the three-segment formula formed by the curve’s two bend points. For 2019, AIME below $926 is multiplied by 90%, between $926 and $5,583 by 32%, and the remainder (up to the maximum wage base) by 15%. The sum of these amounts is the claimant’s “primary insurance amount” (PIA). 3 The maximum wage base for 2019 is $132,900 (indexed).
The bend points skew the benefit distribution in favor of low-wage earners. High earners receive higher benefits; but they are not proportionate to their contributions. Thus, replacement rates at the low end of the income distribution are much higher than at the high end.
SSDI Benefits
To be eligible for SSDI benefits, the disability must be determined to be permanent and total. Permanent means that the condition is expected to last at least 1 year or result in death. Total means that the claimant is unable to engage in “substantial gainful activity” (SGA). In 2018, SGA for sighted individuals was $1,180 and for the blind $1,970 per month.
The SSDI benefits are determined the same as OASI benefits. At the full retirement age, SSDI benefits are converted to retirement benefits and are paid from the OASI trust fund rather than the DI trust fund.
Maximum and Minimum Benefits
There is a “family maximum benefit” formula that limits the maximum benefit monthly amount that can be paid on a worker’s earnings record. It is similar to the PIA calculations but it has three bend points instead of two and therefore four segments instead of three. 4
There is also a “Special Minimum Primary Insurance Amount” that is based on an alternate benefit formula. It applies to low-wage workers who have contributed to OASDI for many years. The provision has been in the Social Security Act since 1939. However, when it was first indexed in the 1970s, it was indexed to the Consumer Price Index (CPI) rather than the “average wage index” (AWI). Since wages increase more rapidly than prices, the minimum affects fewer people each year. In 2017, the minimum benefit applied to only 39,347 claimants. For people turning 62 in 2019 or later, it will have no effect at all. It is unlikely to be resurrected. 5
Supplemental Security Income
There is also a needs-based Supplemental Security Income program. SSI was established in 1974 to provide additional benefits to low-income OASDI beneficiaries and others. About 8.2 million people received $55 billion in SSI benefits in 2017, most on the basis of blindness or disability. However, 33% of SSI recipients also receive OASDI benefits. 6
For 2019, the maximum SSI benefit is $771 for an individual, $1,157 for an eligible couple and $386 for an “essential person.” The maximum SSI benefit is reduced by subtracting “monthly countable income.” 7
SSI benefits are paid directly from the federal General Fund. They are not a funded benefit.
COLA
Since 1975, OASDI and SSI benefits have been subject to an annual “cost-of-living adjustment” (COLA). The amount of the COLA is based on the change in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W) for the third quarter (July, August and September) of the current year compared to the same quarter in the previous year. For 2019, it is 2.8%. 8
OASDI Funding
The law requires that revenue from the FICA payroll tax go into one of two Social Security trust funds maintained by the Treasury Department: the Old Age and Survivors Insurance trust fund and the Disability Insurance trust fund. OASI is funded by a 5.3% payroll tax paid by workers and employers (10.6% total) and the SSDI by a 0.9% (1.8% total). The combined total is 12.4%.
Between 1995 and 2014, the number of disabled workers and their dependents grew from 5.9 million to 10.9 million and the DI trust fund was facing depletion. A provision of the Bipartisan Budget Act of 2015 (Pub. L. 114-74) temporarily reallocated part of the 12.4% payroll tax from the OASI trust fund to the DI trust fund. For 2016 through 2018, the OASI tax rate was reduced from 10.6% to 10.3% and the DI rate increased from 1.8% to 2.37%. Effective 2019, they revert back to 10.6% and 1.8%. 9
Taxation of Social Security Benefits
The 1983 amendments required that some OASDI benefits be subject to income taxation. Individuals with incomes of $25,000 or more and married couples filing jointly with incomes of $32,000 pay income taxes on 50% of their benefits with revenues going to the OASDI trust fund. In 2017, such revenues made up 4% of OASDI income.
The Omnibus Budget Reconciliation Act of 1993 (Pub. L. 103-66) increased the amount of OASDI benefits subjected to income taxation. Individuals with incomes of $34,000 or more, and married couples filing jointly with incomes of $44,000 or more, pay taxes on an additional 35% of their benefits with the additional revenue going to the Medicare trust fund. Note that these thresholds are different from the earlier ones. In 2017, such revenue made up 8% of the Health Insurance (HI) trust fund income. In total, 85% of OASDI benefits for those with incomes above the threshold amounts are subject to income taxation. 10
The two threshold levels are not indexed. That means that they apply to more OASDI recipients each year. Eventually, if left unchanged, they will apply to all recipients.
The Current Funding Situation
The Greenspan Commission and Congress “saved Social Security” for half a century (1984-2034). However, the 1983 amendments did not address the demographic impact of the massive post–World War II baby-boom generation. The leading edge of the “boomers” (born 1946) reached the Social Security early-retirement age of 62 in 2008 and age 65 in 2011. About 10,000 boomers per day have been retiring ever since. This will continue until the last of the boomer (born 1964) retire about 2031 (1964 + 67). However, the OASDI funding problem will continue long after as the boomers continue to live and collect their lifetime benefits.
As of 2015, life expectancy of OASDI recipients at age 62 was 20.0 years for men and 22.8 years for women. 11 The average man retiring at age 62 in 2008 will continue to receive OASI benefits until age 82 in 2028. The average woman until age 84.8 in about 2030. Those who retire after 2008 will extend the Social Security funding problem much further. The impact of the baby boom and increased life expectancy will be with us for a long time to come.
Table 3 reports the number of OASDI covered workers and beneficiaries for selected years 2000 through 2017 and projections (based on intermediate assumptions) from 2018 through 2060. It also shows contributing covered workers per beneficiary. Note how the number of contributing workers per OASDI recipient declines from 3.4 in 2000 to 2.8 in 2017 and is projected to decline to 2.1 by 2060.
OASDI Covered Workers and Beneficiaries, Selected Years, 2000 to 2017, and Projections Through 2060.
Source. Board of Trustees of the Old Age and Survivors Insurance and Federal Disability Trust Funds. The 2018 Annual Report. Table IV.B3, pp. 61-62. Retrieved from www.ssa.gov/OACT/TR/2018/tr2018.pdf.
Table 3 also shows the number of OASDI beneficiaries per 100 covered workers. That reflects the replacement of the large baby-boom generation by subsequent generations with significantly lower birth rates.
Effective 2010, OASDI costs exceeded income for the first time since 1982. However, OASDI trust fund reserves continued to grow because of the payment interest until 2018. That was when expenditures were projected to be larger than income and the trust funds experienced a deficit of $1.7 billion (Table 1).
What Needs to Be Done
The Board of Trustees of the OASDI trust funds and its Office of the Chief Actuary (OACT) has warned for many years what the impact of the boomers would be. The Board of Trustees’ annual reports have been citing what it would take to make the OASDI trust funds fully solvent over the 75-year projection period for the decades.
As of 2018, long-term solvency would require (1) a permanent payroll tax rate increase of 2.78 percentage points; (2) a scheduled immediate and permanent benefit reduction of about 17% for all current and future OASDI beneficiaries, or 21% reduction applied to those eligible for benefits in 2018 or after; or (3) some combination thereof. 12
These are serious measures. The result would be an OASDI tax rate of 9.98% for workers and their employers, or a monthly benefit reduction for retired workers and their dependents from $1,368 (from Table 1) to $1,136, or some combination thereof (author’s calculations).
There are a number of ways to increase contributions (revenue) and/or reduce benefits (cost) instead of, or in conjunction with, an across-the-board increase in the payroll tax rate or a reduction in benefits. They include the following:
Increase or eliminate the maximum wage base thereby increasing OASDI contributions on high-income earners. That would require creating a separate schedule for OASDI contributions from that used to determine the PIA (benefits). It would also further weaken the theory that benefits are related to contributions.
Adjust the bend points (or add a third bend point) to the benefit formula. This could result in reducing the benefits of high-income earners without reducing them for low-wage workers.
Increase the income taxation on Social Security benefits from the current 85% to 100%. This would disproportionately affect high-benefit recipients.
Extend OASDI coverage to the 25% of state and local government employees who are not now covered. This would increase contributions in the short run to pay for benefits due later.
Reduce the COLA calculations. There are various ways in which this could be done. Arguably, this can be justified because the spending of older people is different from the young.
Further increase the full retirement age and possibly index it to future improvements in life expectancy of OASDI recipients. The fact that life expectancy at birth has declined in the last 2 years will not affect OASDI funding for many years.
At one time, another proposed solution was to allow the SSA to invest a portion of the OASDI surplus in equities and other financial markets to gain a higher rate of return than is available from the Treasury. This would have been controversial and potentially dangerous. However, since the surplus no longer exists (if it ever really did), the point is moot. One cannot invest IOUs.
The fix would have been far less drastic if made say 10 or 20 years ago. The longer Congress postpones taking action, the more drastic the problem will become and the solution will be.
Legislative Proposals
There are always a number of proposals in Congress to amend the Social Security Act. Many of them are to improve benefits for certain groups: women, widow(er)s, students, state and local government employees subject to benefit reductions under the “windfall elimination provision” (WEP) and the “government pension offset” (GPO). They are well-intentioned, but do not address the OASDI funding problem.
A number of bills were introduced in Congress in 2017 that do address OASDI underfunding and extend the funds’ depletion date. When such a bill is introduced, it is referred to the SSA’s Office of the Chief Actuary for a cost analysis. The analyses include calculating the proposed legislation’s impact on the “actuarial balance.” It is complicated.
The actuarial balance is defined as the difference between the “summarized cost rate” (SCR) and the “summarized income rate” (SIR). The SCR is the ratio of the present value (p.v.) of cost to the taxable payroll for the years in a given period, expressed as a percentage. The SIR is the ratio of the p.v. of scheduled non-interest income to the p.v. of the taxable payroll for the years in a given period, expressed as a percentage.
Table 4 reports the SCR, SIR, actuarial balance and year of depletion of the OASDI trust funds for recent legislative proposals reviewed by the OACT. There were four bills that, if enacted and signed, would have extended the year of depletion of the OASDI trust funds.
Recent Proposals Affecting OASDI Trust Funds Solvency.
Source. Social Security Online. Office of the Chief Actuary. Actuarial Publications. Proposals affecting trust fund solvency. Retrieved November 15, 2018, from www.ssa.gov/oact/solvency/index.html.
The “Save Social Security Act of 2017” (H.R. 1631) was introduced March 20, 2017, by Charles Crist (D-FL, 13). It would extend the year of depletion to 2064.
The “Social Security for Future Generations Act of 2017” was introduced June 8, 2017 (H.R. 2855), by Alfred Lawson (D-FL, 5). It would extend the depletion date to 2049.
The “Protecting and Preserving Social Security Act” (H.R. 3302 and S. 1600) was introduced July 20, 2017, by Representative Ted Deuch (D-FL, 22) and Senator Mazie Hirono (D-HI), respectively. It would extend the year of depletion to 2059.
The “Student Security Act of 2017” (H.R. 4584) was introduced December 7, 2017, by Thomas Garrett (R-VA, 5). It would extend the year of depletion to 2035.
Each of these bills was referred to the House Ways and Means Committee and S. 1600 to the Senate Committee on Finance. As of this writing (November 2018) no further action has been taken. Hopefully, this will end once the Democrats take control of the House in January 2019.
The Real OASDI Funding Problem
Thanks to the 1983 amendments, the OASDI trust funds ran a surplus from 1984 through 2017, 34 years. The surplus peaked at $190.4 billion in 2007 (not shown) and then declined to a deficit of $1.7 billion in 2018. The deficit is projected to reach $169.0 billion in 2027 (Table 1).
The sum of the annual surpluses over the 34-year period was $2.9 trillion and they averaged $84.3 billion per year (author’s calculations). However, throughout the period, there was no actual money (assets) there (other than in the sense that they were backed by the full faith and credit of the United States [as is the dollar]).
By law, all OASDI revenue goes into the OASI and DI trust funds administered by the Treasury Department. Amounts not needed to pay OASDI benefits and expenses accumulate as surpluses (or, if negative, as deficits). In return the Treasury gives the SSA special non-marketable certificates (IOUs). The Treasury pays the SSA interest on the amounts deposited with additional IOUs. The certificates are accounted as assets for the SSA and a debt for the Treasury. For the federal government’s annual unified budget, it is a wash. They cancel out.
What has the Treasury done with all that money? It spent it, of course. What else could it do? The OASDI surpluses became part of the unified federal budget and were converted into “spending authority” for other government programs. In effect, the $2.9 trillion allowed the federal government to live beyond its means for 34 years. The surpluses masked a big chunk of the annual federal deficit for three decades.
The exception was the last 3 years of the Clinton administration (1998-2000) and the first year of the Bush administration (2001) when the unified federal budget actually ran surpluses. Interestingly, the total 4-year OASDI surplus of $557.0 billion was almost equal to the federal budget surplus of $559.3 billion. 13
With the OASDI surplus gone, the federal government will have to offset it with increased revenue by raising payroll taxes (unlikely), cut spending on other government programs (difficult) or borrow more from the public (likely). That, of course, will add to the national debt.
The National Debt
The United States differs from other countries in that its reported national debt includes “debt held by the public” and “intra-governmental debt.” The latter represents money owed by a federal agency to the Treasury or vice versa. From the perspective of the unified federal budget, they cancel out. The important part of the national debt is the “debt held by the public” (also known as “public debt”). Debt held by the public includes a relatively small amount held by the Federal Reserve Bank.
Table 5 reports the growth of the U.S. national debt for selected years 2000 to 2017 and estimates (projections) from 2018 to 2023. The gross debt grew by $4.4 trillion (78.6%) under the Bush administration (2000-2008) and by $9.5 trillion (95.0%) under the Obama administration (2008-2016). The national debt held by the public grew by $2.4 trillion (70.6%) under the Bush administration and by $8.4 trillion (144.8%) under the Obama administration. By another measure, debt held by the public has grown from 34.7% of U.S. Gross Domestic Product (GDP) in 2000 to 76.5% in 2017 and is projected to reach 81.3% by 2023.
Growth of the U.S. National Debt, Selected Years, 2000 to 2023 ($ in Trillions).
Also known as “intragovernmental debt.” Includes Federal Reserve System debt.
Source. Office of Management and Budget. Historical tables. Table 7.1—Federal debt at end of year: 1940-2023. Retrieved November 18, 2018, from www.whitehouse.gov/omb/historical-tables/.
Effective September 2018, over half (51.0%) of the U.S. public debt is owed to foreign governments and other foreign entities. Our largest foreign creditor is Mainland China, which holds $1,151.4 billion (18.5% of the total public debt). Our next largest creditor is Japan with $1,028.0 billion (16.5%). The other large creditors are Brazil, $317.0 billion (5.1%); Ireland, $290.4 billion (4.7%); and the United Kingdom, $227.2 billion (4.4%). 14
Appraisal
By one measure, 2018 was a pivotal year for OASDI funding. It was the first year that expenditures exceeded income (including interest payments) since 1982. It was the year that the OASDI trust funds went from a surplus of $44.1 billion to a deficit of $1.7 billion. The deficit will continue to grow over the next decade until it reaches $169.0 billion in 2027 (Table 1). The Social Security Administration will start to redeem its IOUs from the Treasury Department and continue to pay full scheduled OASDI benefits until 2034. However, this is smoke and mirrors.
The $2.9 trillion surplus existed essentially as an accounting device as a way to keep score. The current and impending deficits are also a bit fictional. They will morph into increased annual budgetary deficits and then to additional national debt. That is serious.
Fundamentally, the OASDI program is, and always has been, a pay-as-you-go system. The requirement that OASDI payroll taxed go into the trust funds administered by the Treasury amounts to a way to keep score of OASDI revenues and expenditures. There never was any real money (assets) in the trust funds. It was spent by the Treasury as quickly as it came in.
The OASDI surpluses have masked a large part of the federal deficits for 34 years. Now that they are gone, the SSA will redeem its IOUs from the Treasury. They will be paid from the General Fund, which means they will add to the federal deficits and subsequently added to the national public debt. Beginning 2018 or 2019, the U.S. national debt held by the public will increase appreciably. Given that U.S. public debt is already over 80% of GDP (Table 5
Conclusion
In the author’s opinion, it is not necessary to fully fund OASDI for the next 75 years to comply with the fictions of OASDI trust funds that emerged in the 1970s. It is only necessary to increase revenue and/or cut expenditures to the extent to bring them into balance in the short run, say 10 years.
The full funding concept emerged in the Employee Retirement Income Security Act of 1974 (Pub. L. 93-406; ERISA). ERISA established the Pension Benefit Guaranty Corporation (PBGC) to insure defined-benefit pension plans. When a covered private sector defined-benefit pension plan fails (as they often do), the PBGC acquires its benefit obligations. In order not to get stuck with large amounts of pension debt, the law originally required that existing pension plans become fully funded in 40 years, new plans and enhancements to older plans had 30 years. Over the years, the requirement was strengthened a number of times. It is now 7 years.
Governments do not go out of business and therefore do not have or need PBGC-like benefit insurance. However, the full-funding requirement was extended to state and local government plans by the Governmental Accounting Standards Board (GASB) and then Congress applied the concept to Social Security as well. By 1983, when the Greenspan Commission made its recommendations to Congress, the concept was generally accepted and incorporated into its thinking. If it is understood that OASDI is a pay-as-you-go system, that is regrettable. It confuses things.
Given the large number of ways in which OASDI funding improvements can be structured (discussed above), it should still be rather easy to reform it on a pay-as-you-go basis without causing undue hardship to its most vulnerable recipients. Several bills have been introduced to address this.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.