March 13, 2020—Tony is joined by Christopher Pope, a senior fellow at the Manhattan Institute, whose research focuses on health care payment policy, hospital-market regulation, and insurance-market reform. Together, they compare the health care proposals and campaign promises from the two leading Democratic Party contenders with what is likely under President Trump if he prevails in November. Tony is also joined by Senior Portfolio Manager Mark Horst, who explores health care from an economic sector and investment perspective.
Wilmington Wealth Wise
Health care: The proposals, the promises, the positioning
Tony Roth: Welcome to Wilmington WealthWise, the podcast dedicated to financial literacy, where we take complex ideas from the investment world and make them accessible to everyone. I’m your host, Tony Roth, Chief Investment Officer of Wilmington Trust. Today’s podcast is entitled Health Care, Proposals, Promises, and Positioning, and today we’re going to try to look at three things. First, we’re going to take a look at the health care environment today and where we stand.
Second thing we’re going to do is take a detailed look at where we’re going in the world from a health care perspective given that we are in a presidential election, and there are a lot of various activities occurring within the policy arena of the health care world, and then last we’re going to look at health care from an investing perspective and take a look at where there may be opportunity both from the short-term perspective and the long-term perspective.
So, I am pleased to be joined today by two special guests. First, I would like to introduce my colleague, Mark Horst, who is a senior portfolio manager here at Wilmington Trust, as well as a health care analyst. Welcome Mark.
Mark Horst: Thanks Tony, happy to join you.
Tony Roth: And then secondly, we’re joined by Chris Pope. Chris is a senior fellow at the Manhattan Institute, and previously Chris was director of policy research at West Health, a medical research organization, health policy fellow at the U.S. House Committee on Energy and Commerce and research manager at the American Enterprise Institute. His research focuses on health care, payment policy, hospital market regulation, and insurance market reform.
His work has appeared in The Wall Street Journal, U.S. News & World Report, Politico, and other outlets in the media. Chris, welcome and thank you so much for joining us today.
Chris Pope: Great to be here. Thanks for inviting me.
Tony Roth: So, I thought we would start the conversation by just talking a bit about health care. Health care is such an interesting area because, obviously, it has very significant economic implications. In fact, health care is the second largest sector of our economy. Technology probably comprises around 22 or 23% of the U.S. economy.
Tony Roth: Health care has not only very important economic consequences, but it’s also a very emotional and a very personal issue for many. On the one hand, you have the Baby Boomers, a very growing part of our population in terms of individuals that are approaching retirement or retiring and looking for increasingly large consumption of health care, and they have strong views around health care; very important to their decisioning from a political standpoint. And, then also on the other side of the continuum, perhaps you have Millennials who are very focused on this idea that health care is not free to everybody in the United States, and that’s a very politically important issue to Millennials.
So, Chris, let’s start with you if we could and talk a little bit about we’ve been on a journey in the United States over the last decade where we had the Obamacare Act, the Affordable Care Act about a decade ago. We had subsequent pushback. We had a very important Supreme Court case named Sebelius, where essentially the Supreme Court validated most of the provisions, the constitutionality of most of the provisions of the Affordable Care Act, albeit we have a new case that’s now come in front of the Supreme Court relative to the individual mandate.
Now, that case won’t be decided until after the election, but it does seem as though there is another run being made at potentially trying to invalidate the Obamacare Act, and it’s a political football if you will, the president, as well as Sanders and Biden are all highlighting various angles on health care in their efforts to win the election in the fall.
So, let’s just start out, Chris, maybe at a very general level, which is that so much focus on health care in the country, how do you think of the sort of general obstacles, general feasibility, if you will, of major change in the health care arena from a public policy standpoint after the election regardless of who might win?
Chris Pope: I think that’s a great question. The first thing that I think of when I think of where we are with health policy is really to bear in mind that we didn’t start making health care policy yesterday or even ten years ago. Major health policy in the United States is basically 70 years old, really since World War II, and policy has been led over policy for decades really trying to tinker with the system, adapt, adjust, fix holes, patch up problems, respond to people’s needs, and so the health care system we have today is not necessarily any single ideological design.
It’s really an incremental product of trying to respond to a whole host of different concerns and balance different tradeoffs, and that means the system we currently have reflects many preferences that people have that have kind of built up, difficult tradeoffs, and it’s actually pretty hard to change, because the reason that we have the system that we have is really it meets a lot of the different often conflicting needs, and so when you try to change it, you quickly learn why it is that we have the system that was produced in the shape that it is today, and that makes it very hard to change.
Tony Roth: And, Chris, when I think about it, the health care system in the U.S. is somewhat a unique animal, if you will, in that we have this very deeply capitalist approach to our economy and our society, yet health care is special because everybody on some level does need health care, if not deserve health care, and consequently, there’s an awful lot of regulation that goes into health care, and, of course, there are very unique risks.
There’s a paternalistic protective role that government needs to play, and so compared to most other areas of the economy, it should not be surprising that we do have significant amount of regulation and legislation around health care.
Chris Pope: Yeah, that’s certainly the case. Even just to talk about the dollars involved, about half of health care spending in the United States is public spending. It’s Medicare. It’s Medicaid. It’s other entitlement programs. And, the half of health care spending that is private spending is mostly employer controlled. It’s employer-sponsored insurance. It’s employer’s that pick insurance plans, and then those essentially determine how hospital and physician services are paid for, and individual consumers really don’t have that much control over much health care spending.
That’s very, very different to most other sectors of the economy. When you buy a car, these are marketed to individuals. When you buy groceries, it’s individuals that are making the purchase choice. With health care, individuals really control only a very small share of spending, at least to the extent—and to the extent that they do control it, it’s very much within the context of employer plans that often they don’t control themselves.
Tony Roth: So, let’s talk about, Chris, the specifics around some of the candidates. We have the President, of course, who, not really clear what his real goals are with respect to health care, but he does have a new proposal. Tell us about what the President might do if he’s reelected if you think he would do anything different relative to his first term in terms of health care.
Chris Pope: Yeah. So, I think the main thing to notice about a potential Trump reelection is that when he came in 2017, the Republicans controlled both houses of Congress, and so there was this initial push for a legislative revision of the Affordable Care Act. That ended up not really going anywhere other than really the repeal of the individual mandate, and the big difference, I think, most people probably agree, is that if Trump wins reelection this November, it’s very unlikely that the Republicans are going to pick up the House, and so there’ll be even less possibility for major legislation to come through in Trump’s second term other than we saw in the first term.
So, I think, in Trump’s second term, we probably would be talking about executive orders really or bipartisan agreements potentially, but even with executive orders, most of the things that the Trump administration would want to do, it’s already had three years to do. So, to what extent—the extent to which they might want to do major executive orders in health care, I’m not sure there’s a huge amount left that they haven’t already done.
Tony Roth: And his major interest in any event is to limit government spending on this sector in any case rather than expand it, correct?
Chris Pope: Yeah. I mean, with spending that is, you’re very much talking about budget agreements with Congress. The Budget Director at the White House, Mulvaney is definitely a fiscal conservative. The past couple of years, the administration has been very much in favor of spending restraint. I think that would continue to some extent, although I think that, again, is probably going to be sensitive to staffing decisions if there were to be a second term.
Tony Roth: Okay. So, then on the other side of the continuum, you have, of course, Bernie Sanders who has talked, I think, very eloquently around the idea that we’re one of the only major developed countries in the world, as noted earlier, that does not offer free health care essentially to everyone, and, in fact, he has talked about the per capita spending on health care in the U.S. as being twice as high as most of the other major industrialized countries that do offer Medicare for all. So, when we think about Sanders, I think we all know what he’d like to do in terms of a sort of a public plan with entitlements for everybody. How realistic is that in your mind, and also I think it’d be really interesting, Chris, to get your take on why it is that our per capita spending is, in fact, so high relative to other countries without being able to offer the universal entitlement?
Chris Pope: Well, I think there are probably two main ways to think about how realistic it is. Firstly, from a pure fiscal point of view, how much would the plans cost, and the figures that you see cited are basically $3 to $4 trillion a year in additional public spending. So, when you bring that down to what would that cost on a per-household level, we’re talking about a payroll tax increase of about 15 percentage points.
So, that’s a very, very substantial amount for most households, and I think going to be particularly tricky. I don’t think there’s any real appetite for that, and even when it comes to Senator Sanders being asked how much it’s going to cost, he’s very, very reluctant to talk about that, and doesn’t really have much of a plan in terms of raising the funds to pay for what he himself is proposing.
Tony Roth: Is there a way that they can push the health care costs down dramatically so that it’s more highly regulated from a cost standpoint so that the tax hit would be far more tolerable.
Chris Pope: So, I think one of the main reasons why health care spending is so much higher in the United States than in other countries is that health care is simply just a labor intensive industry, and it’s an industry that requires a lot of very skilled labor, and the United States just has higher wage rates than other countries, and this isn’t just in health care. It’s in every sector of the economy that our wages are really twice as high as many other countries like France.
It’s not just doctors that are paid two, three times as much here as they are in France. You find even that teachers are paid twice as much here as they are in France, and so if you want the medical system to treat people to an equivalent level, you just have to spend more on it, and then there’s also the complicating factor that our disease burden is higher.
We have a much higher obesity rate than many other countries around the world, and that means that our population tends to suffer from what we may think of the more expensive diseases, diabetes, cardiovascular diseases, cancer. The rates of all those diseases are significantly higher and are often twice as high as they are in other countries, and so the money to treat cases has to come from somewhere, and this obviously tends to come from insurance premiums and taxes and so on, and then there’s a third consideration which accounts for our higher spending, which is that we just have a much higher level of care than many other countries do.
If you go to an American hospital, like the equipment is more modern. The service level is at a higher level. The intensive care is higher. And so to support this level of service, we spend a lot more, and also we don’t ration care to the extent other countries do.
In single-payer countries like Britain or Canada, there are many, many treatments that are just not available to people. Like Britain, for instance, has, essentially, a rule that if a drug costs more than $30,000 per year of life that it saves, it’s just not going to be covered. And, that’s across the board. And, this is an absolute rule in terms of drugs, but it’s a soft rule that applies to many other types of services—that you’ll find care that’s just not available for orthopedic services, but then also for really expensive neurological services, you’ll have long waiting lists and patients won’t be able to access the services.
So, that does save money. It does mean that these countries spend a lot less on health care, but they’re just not getting the services that Americans are accustomed to.
Tony Roth: The other thing I wanted to ask on this point is that I’ve always had a perception, perhaps falsely, that one of the reasons that our costs are so much higher is due to the legal system in the U.S. and the liability insurance. Is that really material or is that a myth?
Chris Pope: Yeah, I mean, it has some impact, and I think it’s been quantified certainly as a share of physician services. There have been various attempts to quantify. I think it’s only maybe a couple of percentage. I think the furthest you can take that argument is you can probably say that more tests get ordered, that the physicians are more risk adverse in their practice and so tend to spend more in terms of the nature of service delivery, but I think it’s probably not accounting for the great difference in the spending levels between countries. Those are really about rationing, is about wage levels, and it’s about access to care.
Tony Roth: Well, let’s pivot to Biden, and I think Biden is, really, we’re focusing on in the sense that in this stage after the Super Tuesday win, if he keeps his momentum, he’s likely the candidate on the Democratic side, and when we look at the electoral math, he’s got a good chance of unseating President Trump.
Obviously, he was involved in, as the Vice President at the time, the installment of the Affordable Care Act, Obamacare. He seems to be pretty happy with that. He’s talked about some expansion, but what are your thoughts in terms of what might get done if we do have a President Biden?
Chris Pope: Well, that’s a great question. I think, first of all, and probably just—and people I think instinctively understand this is it would, to a large extent, be a restoration of the Obama administration. I think Vice President Biden sees himself a bit in that sense, priorities from the administration, it would probably be in line very much with where the Obama administration were.
In terms of things that are going to cost money, you’re going to need new legislation. So, if you’re thinking about adding subsidies to the Affordable Care Act for people to purchase coverage from the individual market, insurance from the individual market, that would require congressional appropriation, which currently would mean having some votes from a Republican Senate or having Mitch McConnell willing to go along with it.
So, I think it is possible, I think, that you could have a legislative deal where Republicans would add some funds for subsidies for the individual market in return for some Republican priorities. Potentially some insurance reforms that Republicans have been looking to do.
And then, again, on drug prices, to what extent you would have any big action there. I think any radical change is very, very unlikely in either direction, just because Democrats are likely to hold the House, and the majority of either party is likely to be very slim in the Senate. So, I think you’re likely to have not a huge amount of change legislatively.
Even if there is a public option established, it’s unlikely to differ very greatly from the private insurance options that currently exist, because getting a public option that is very different to private options would require a large amount of subsidies, and for that to happen you would need probably a very strong Senate majority for Democrats to be able to push it through, and that still seems very unlikely.
In terms of executive orders, what could be done? I think you probably see a Biden administration maybe try to roll back some of the executive orders that the Trump administration has done. Although, even then I think it would probably be more tinkering at the edges. So, I think—with either Biden or Trump winning—from a health policy point of view, because Congress is still likely to be so divided regardless of what happens, you’re likely to see continuity, and that’s probably a quite substantial contrast with Sanders or Warren, who probably would have been very aggressive using executive orders in a way that neither Trump nor Obama have in the past, and probably would have explored some fresh territory.
So, I think you’re likely to see a fair amount of continuity in the health care space regardless of who wins the presidency in the fall.
Tony Roth: Great, Chris. Thank you. So, let’s pivot and get Mark involved in the conversation here. So, Mark, one of the areas that, of course, and Chris has touched on it, is drug pricing, that has been very much in the press over the last several years. I think Chris has given us a pretty clear indication that we’re not likely, assuming that we don’t have a Sanders presidency, so we’re unlikely to have a scenario where we have, from the top down, a real change in how companies can price for drugs.
Yet, there’s still some self-policing involved, obviously. Can you tell us a little bit about how the industry has evolved from pharmaceuticals, drug manufacturers, etcetera, in terms of how they’re pricing their medicines and what impact that’s had on their profitability, and their appeal as an investment destination?
Mark Horst: Yeah. Thanks Tony, and it’s interesting you mentioned self-policing, because that’s really what the biotech and pharmaceutical companies have done over the past several years really as an effort to diffuse some of the egregious actions that were taken five to six years ago from the likes of Martin Shkreli and others that were increasing prices 700, 1500% per year on drugs that had very limited usage across the marketplace.
Today, most pharmaceutical and biotech companies are increasing drugs once a year as opposed to four or five times a year doing it at the beginning of each year with an average price increase probably in the low-to-mid-single digits. So, they have really adjusted to the new framework that’s out there in terms of drug pricing.
Chris talked about the cardiovascular industry. That’s an area where we’ve actually seen new therapies have to come out and cut prices based on initial launch as they are competing head-to-head against legacy products that have gone generic. Brand names such as Lipitor and Plavix were highly effective in reducing cholesterol and improving cardiovascular outcomes.
As a result, the burden for these new therapies to show a differentiated outcome makes it harder. And, if they can’t do that in order to compete in the marketplace, they’re forced to cut price. Now, to your second point about impacting the marketplaces and the investment community, one of the things that I look at, and a lot of others have started to look at today, is not what the annual revenue increase is on a particular drug, but what is the script growth, (i.e., what is the underlying volume growth that these drugs are seeing), and from an investor standpoint, we look for drugs that are not only increasing revenues, but also increasing adoption across their respective industries. Those are the drugs and companies that have really outperformed over the last couple of years.
Tony Roth: So, when you think about the system as a whole, specifically thinking about pharmaceuticals and drugs, it sounds like the system is working. It does sound like on the one hand companies are able to earn a fair, but not exorbitant, profit because there is competition, and it is continuing to incent companies, from a research and development standpoint, to continue to produce new benefits. And, indeed, these companies are attractive investment opportunities. Does that sound right?
Mark Horst: The other thing, the dynamic that’s going on, given these events, is these companies are really focused on developing therapies where there are currently limited effective drugs on the market or effective therapies or they think there’s truly an unmet medical need. And where that exists, we think that they can still return—generate an adequate rate of return.
The important thing to remember is all this, a lot of these drugs that come to the market often are the third and fourth iteration of the drug. So, they may have had previously clinical trials that failed to get them to a point of success, and these companies still need to get rewarded, but to that point, I still think they can get rewarded by the market, again, for things that are innovation and improve health care outcomes.
Where we see that, I think, they can have price and generate positive returns not for the company, but also for the investors.
Tony Roth: And certainly, we’re all living with a fairly scary situation right now around the coronavirus, and we see many companies around the world, and including in the United States, that are moving very quickly to try to develop both a therapy and a vaccine for the virus. And, so, there does seem to be incentive for companies to do this. The system seems to be working fairly well.
So, Mark, there’s been a lot of volatility actually in the health care sector from a market standpoint. In fact, despite the significant drawdown that we’ve seen in the market over the last couple of weeks due the coronavirus, because the other major dimension that’s impacting markets, of course, is the presidential election, and because Biden has had this resurgence, we’ve seen a significant resurgence in the health care sector generally. If you think about where valuations are today, and assuming that we have a Biden presidency, when you think about the investment opportunities over the long term for long-term investors, what do you see as the opportunity, both in terms of the overall sector, and what specific industry groups do you think may be most appealing?
Mark Horst: Yeah. I mean, obviously the market’s been a pretty volatile place over the last 10 or so trading days. We’ve had some big up days. e’ve had some big down days. Health care has participated on both sides of the market, and interestingly, you mentioned it, really on Wednesday, after the Super Tuesday primaries, health care was the best performing sector and the managed care stocks.
You think about companies such as United Health Care, Anthem, and Cigna all rallied over 10% on the day. Really, as the Democrat shifted, and really, with Biden taking the lead, the most negative outcome that could have happened or could have been viewed by the market seems to be less likely today. So, these stocks, the managed care stocks, the health care service stocks, were underperforming, and more recently they’d been the strongest performers.
So, in the last five days, we’ve seen those managed care stocks up almost 10%. Conversely, other areas that had been more safe havens in health care, such as life science and tools, health care technology, medical devices. These are areas that were deemed to have less government involvement, or could be less impacted from potential presidential mandates, outperformed pretty handily last year, but more recently they actually underperformed by almost 7 to 8% to the managed care stocks.
Overall, though, despite kind of the near-term underperformance with the medical device stocks, that’s an area we continue to like on a longer-term basis—and it’s not just medical device stocks. It’s across the industry where companies that we think are generating innovation, are creating new therapies that are differentiated to create differentiated outcomes; we think those companies will be rewarded.
Tony Roth: So, Mark, when you think about the short term and your optimism, I think, for the overall health care sector and the specific areas that you’ve mentioned, we do have key landmarks ahead of us in the coming weeks. If we continue to see a resurgence of the Vice President, Biden, and he continues to collect delegates at a much faster rate than Sanders does, do you think that this is a good entry point for investors that may not be overweight, these areas within the health care sectors, such that they potentially have an opportunity to take advantage of this or do you think that the big rally we’ve already seen is pretty much fully pricing in a Biden outcome whether it be at the Democratic nomination level or even at the presidency level in terms of the fall?
Mark Horst: Yeah, it’s interesting when you think about the positive action that health care stocks have had over the past couple of days. But, if we step back and take a longer term look, and kind of since the end of 2018, health care as a sector has underperformed the broader S&P 500 by almost 10%. And if you think about technology, another sector where companies that are driving innovation can be rewarded, it’s underperformed the tech sector by over 30%.
So, I feel like a lot of these concerns about government involvement or potential factors have been really priced into the stocks today. The thing that we continue to focus on is are there going to be unexpected changes in the policy? Are they going to take more of an onerous approach to health care that could either stifle innovation or potentially reduce the current standard of care? That would get us more cautious, but, overall, I think health care is a very interesting sector today if we’re assuming that the most negative outcome in a Sanders presidency appears to be on hold.
Tony Roth: So, thank you very much, Mark, and, Chris, I’m going to give you the last perspective, if you will, today before I wrap us up, and what I’d like to ask you, Chris, is that while I know that your specialization is not necessarily investing, I think it would be really helpful for our listeners to hear from you, Chris, what you think about the various industry groups within health care. Whether it be the insurers, the pharma and biotech companies, the servicers and providers, hospitals, etcetera, where do you think, from a public policy standpoint, or even from a private sector standpoint, where do you see the greatest interests and the greatest potential as we move forward over the next decade? Because that obviously has to inform where investors might find opportunity.
Chris Pope: That’s an interesting question. The one thing that I think is probably the most transformative trend that we’re likely to see is really what’s happening with Medicare Advantage, which is the private Medicare plans. And these, over the past decade, have basically soared from the private Medicare plans being about 20% of Medicare to this year something like 38/ 37% of Medicare beneficiaries being enrolled in private plans. And within five years, it could well be the case that the majority of Medicare beneficiaries are in private Medicare Advantage plans.
That’s really potentially quite transformative to the health care sector as a whole, because these are plans that are more oriented towards managed care, potentially more integrated, more of an HMO-type model. And, once you have the majority of Medicare beneficiaries in Medicare Advantage plans, that changes the political dynamic about how Washington starts to think about Medicare. How it starts to think about managed care, and how it thinks about these plans.
A similar dynamic’s been happening on Medicaid with the growth of managed care—with the growth of managed care organizations running these essentially at the state level. So, I think that really is a growth opportunity, and even on the sort of the commercial private insurance side, I think people are sort of thinking about where does that go in the future? And I think a lot of people are starting to think about does the employer market shift away? The Trump administration’s been thinking about this; does the employer market shift away from employers purchasing plans to individuals purchasing plans? Are there policy changes that could be made to move in that direction? And, again, I would say that probably favors the managed care carriers over traditional fee-for-service insurers.
Tony Roth: Very interesting. Well, I want to thank you, Chris, and Mark, as well, for what’s been, I think, a very fascinating and very important conversation today. Thank you both for being here. Let me summarize, I think a three key takeaways.
I think the first thing is that we don’t expect to see really any major public policy changes. It’s such a big space, of course. There will always be changes on the margin, but we’re not—we’re just not seeing anything on the scale of the Affordable Care Act a decade ago coming up on the horizon unless somehow the Supreme Court should essentially strike down the individual care mandate of the Affordable Care Act, which would be a real wildcard. But, other than that, we’re really not seeing any major changes from a government standpoint in the U.S.
Second thing is that there are a lot of interesting investment opportunities overall, and we think that the health care sector, which is a fairly defensive area of the market during a recession, and we are—somewhat fearful of a recession now given the coronavirus, we think that the health care sector is an area that deserves an overall overweight in investment portfolios. And, then, thirdly, there are some really interesting specific areas within the health care sector that we think remain interesting, notwithstanding the recent rally we’ve seen just over the last week or so, namely the medical device area, certain companies that are carefully selected within the pharmaceutical and drug area, and then, lastly, potentially, over the longer term, looking at the transitions that are occurring towards the managed care arena that Chris talked about, and that’s something that we’re going to continue to monitor as portfolio managers.
So, I want to thank, again, our listeners for listening today, and I want to remind everybody that we welcome any suggestions for future podcast episodes or topics, as well as your feedback. Those ideas can be sent to WealthWise@wilmingtontrust.com. Thank you all very much.
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