The public health benefits of air pollution control

Abstract

The US Congress is currently engaged in a debate regarding restriction of Environmental Protection Agency (EPA) authority under the Clean Air Act. The discussion has been focused on the cost to business to comply with the Clean Air Act and the potential negative effect on employment. As heath care professionals, we believe it is necessary to review some of the facts since the Clean Air Act was initiated and the role of the Clean Air Act in the future.In the past year, the House of Representatives has passed a number of bills that would stop, delay, or weaken the EPA rules issued under the authority of the Clean Air Act. The House has passed legislation that would prevent or delay clean up of emissions from cement kilns, coarse particulate matter pollution, industrial boilers, mercury and toxic pollutants from power plants, and pollution from power plants that blow across state borders to neighboring downwind states. Additionally, the House has passed legislation that would subject all future EPA/Clean Air Act rules to a cost/benefit assessment that is heavily tilted in favor of the regulated industry.Why is the House engaged in this attack on the Clean Air Act? Opponents of the EPA have portrayed the agency as a prime example of government overreach and a bureaucratic agency run amok. Opponents of the EPA say the rules are “job-destroying regulations” that create regulatory uncertainty and hurt the overall US economy. Supporters of the EPA counter that complying with the Clean Air Act rules will create new jobs, largely in sectors that install and maintain pollution control equipment.What is missing from the discussion are the health effects of air pollution and the potential health gains that can be made by reducing air pollution. We believe that an analysis of available health and economic data show that air pollution standards have significant net benefits for our society at large.There is compelling evidence that air pollution has severe adverse health effects, particularly for respiratory health. Several studies have demonstrated a strong relationship between short-term exposures to ozone and asthma exacerbations.1EPAAir quality criteria for particulate matter (final). US Environmental Protection Agency, Washington (DC)2004Google Scholar, 2EPAAir quality criteria for ozone and related photochemical oxidants (final). United States Environmental Protection Agency, Washington (DC)2006Google Scholar, 3World Health OrganizationHealth aspects of air pollution: Results from the WHO project “systematic review of air pollution in Europe.”. WHO Regional Office for Europe, Copenhagen (Denmark)2004Google Scholar Strickland et al4Strickland M.J. Darrow L.A. Klein M. Flanders W.D. Sarnat J.A. Waller L.A. et al.Short-term associations between ambient air pollutants and pediatric asthma emergency department visits.Am J Respir Crit Care Med. 2010; 182: 307-316Crossref PubMed Scopus (268) Google Scholar compared air pollution data with more than 90,000 emergency department visits in Atlanta and found that ozone and primary pollutants from traffic sources, even at relatively low ambient concentrations, were associated with increased emergency department visits for pediatric asthmatic patients. The Strickland study builds on an extensive body of literature documenting the relationship between air pollution and asthma emergency department visits and hospitalizations. Ambient air pollutants independently contribute to the burden of emergency department visits for asthma both in children and adults. Internationally, the increase in emergency department visits associated with air pollutants ranges from approximately 5% to 8%.5Villeneuve P.J. Chen L. Rowe B.H. Coates F. Outdoor air pollution and emergency department visits for asthma among children and adults: a case-crossover study in northern Alberta, Canada.Environ Health. 2007; 6: 40Crossref PubMed Scopus (143) Google Scholar, 6Jalaludin B. Khalaj B. Sheppeard V. Morgan G. Air pollution and ED visits for asthma in Australian children: a case-crossover analysis.Int Arch Occup Environ Health. 2008; 81: 967-974Crossref PubMed Scopus (47) Google Scholar, 7Szyszkowicz M. Ambient air pollution and daily emergency department visits for ischemic stroke in Edmonton, Canada.Int J Occup Med Environ Health. 2008; 21: 295-300PubMed Google Scholar, 8Barnett A.G. Williams G.M. Schwartz J. Neller A.H. Best T.L. Petroeschevsky A.L. et al.Air pollution and child respiratory health: a case-crossover study in Australia and New Zealand.Am J Respir Crit Care Med. 2005; 171: 1272-1278Crossref PubMed Scopus (286) Google Scholar, 9Peel J.L. Tolbert P.E. Klein M. Metzger K.B. Flanders W.D. Todd K. et al.Ambient air pollution and respiratory emergency department visits.Epidemiology. 2005; 16: 164-174Crossref PubMed Scopus (390) Google Scholar, 10Moore K. Neugebauer R. Lurmann F. Hall J. Brajer V. Alcorn S. et al.Ambient ozone concentrations cause increased hospitalizations for asthma in children: an 18-year study in Southern California.Environ Health Perspect. 2008; 116: 1063-1070Crossref PubMed Scopus (72) Google ScholarImprovements in air quality have direct positive effects on health. Friedman et al11Friedman M.S. Powell K.E. Hutwagner L. Graham L.M. Teague W.G. Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma.JAMA. 2001; 285: 897-905Crossref PubMed Scopus (445) Google Scholar showed that improvements in air quality in preparation for the 1996 Atlanta Olympics lead to significantly lower rates of childhood asthma events, including reduced emergency department visits and hospitalizations. Avol et al12Avol E.L. Gauderman W.J. Tan S.M. London S.J. Peters J.M. Respiratory effects of relocating to areas of differing air pollution levels.Am J Respir Crit Care Med. 2001; 164: 2067-2072Crossref PubMed Scopus (215) Google Scholar demonstrated that children in southern California who moved to communities with higher air pollution levels had lower lung function growth rates than children who moved to areas with lower air pollution levels. O'Conner et al13O'Connor G.T. Neas L. Vaughn B. Kattan M. Mitchell H. Crain E.F. et al.Acute respiratory health effects of air pollution on children with asthma in US inner cities.J Allergy Clin Immunol. 2008; 121 (e1): 1133-1139Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar have demonstrated that short-term increases in air pollution levels, less than current EPA standards, result in adverse respiratory effects, including mortality, in inner-city children with asthma.Air pollution also affects allergies. Eckl-Dorna et al14Eckl-Dorna J. Klein B. Reichenauer T.G. Niederberger V. Valenta R. Exposure of rye (Secale cereale) cultivars to elevated ozone levels increases the allergen content in pollen.J Allergy Clin Immunol. 2010; 126: 1315-1317Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar have shown that increased ozone exposure during the growth phase of plants results in increased protein and allergen content in plants. Other studies have linked climate-forced temperature changes and increased CO2 concentrations to earlier, prolonged, more prolific, and more allergic pollen production.15Beggs P.J. Impacts of climate change on aeroallergens: past and future.Clin Exp Allergy. 2004; 34: 1507-1513Crossref PubMed Scopus (323) Google Scholar, 16Ziska L. Knowlton K. Rogers C. Dalan D. Tierney N. Elder M.A. et al.Recent warming by latitude associated with increased length of ragweed pollen season in central North America.Proc Natl Acad Sci U S A. 2011; 108: 4248-4251Crossref PubMed Scopus (264) Google Scholar Air pollution affects cardiovascular diseases as well. In a 2010 statement, the American Heart Association found compelling evidence linking air pollution and heart disease, concluding that fine particulate matter is a “modifiable risk factor contributing to cardiovascular morbidity and mortality.”17Brook R.D. Rajagopalan S. Pope 3rd, C.A. Brook J.R. Bhatnagar A. Diez-Roux A.V. et al.Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association.Circulation. 2010; 121: 2331-2378Crossref PubMed Scopus (4357) Google ScholarThese health effects have costs. EPA projects that by 2020, the Clean Air Act standard will prevent 230,000 premature deaths, 75,000 cases of chronic bronchitis, 200,000 heart attacks, 2.4 million asthma exacerbations, and 120,000 emergency department visits. The economic value of these avoided health events is estimated to exceed $2 trillion. The public and private industry costs of complying with the Clean Air Act standards are estimated to be $65 billion.18EPA report to congress: the benefits and costs of the Clean Air Act 1990 to 2020. Available at: http://www.epa.gov. Accessed March 17, 2012.Google Scholar The populations that could contribute to the benefit/cost ratio might differ, as presented in the following examples.Regulated industries use a different set of numbers to describe air pollution rules. EPA is in the process of promulgating 4 different rules that will affect coal-fired power plants. These 4 rules are the cross-state air pollution, mercury and air toxics standard (MATS), water cooling, and coal combustion residual product rules. America'sPower, a coalition of coal-based energy companies, commissioned a study that estimates compliance with these 4 forthcoming EPA rules will cost the US economy 1.65 million jobs, largely resulting from higher energy costs leading to job losses in energy-dependent industries. They also estimate approximately $127 billion in compliance costs between 2012-2020.19NERA study impacts of EPA regulations (CSAPR, Utility MACT, CCR & 316[b]) 2011. Available at: http://www.epa.gov. Accessed March 17, 2012.Google Scholar The report does not disaggregate costs among the 4 rules.The EPA has a different set of cost estimates. For the MATS rule, EPA estimates the annual compliance cost to be $9.6 billion and the annual health savings ranging from $37 to $90 billion.20EPA fact sheet: mercury and air toxics standards, benefits and costs of cleaning up toxic air pollution from power plants. Available at: http://www.epa.gov/mats/pdfs/20111221MATSimpactsfs.pdf. Accessed March 17, 2012.Google Scholar The EPA projects employment effects to include adding 46,000 one-time jobs for installation of pollution control equipment and the addition of 8,000 long-term jobs in the electric power industry. The EPA does not estimate employment effects across the US economy.Economists have also studied the cost benefits of air pollution controls. Morgenstern et al21Morgenstern R.D. Pizer W.A. Shih J.S. Jobs versus the environment: an industry level perspective.J Environ Econ Manage. 2002; 43: 412-436Crossref Scopus (136) Google Scholar examined the employment effects of environmental regulations on 4 industries with significant pollution, including iron and steel mills, pulp and paper mills, the plastics industry, and petroleum refineries. The study concluded that for every $1 million spent in environmental controls, 1.5 jobs were created.21Morgenstern R.D. Pizer W.A. Shih J.S. Jobs versus the environment: an industry level perspective.J Environ Econ Manage. 2002; 43: 412-436Crossref Scopus (136) Google Scholar Bezdek et al22Bezdek R.H. Wendling R.M. Diperna P. Environmental protection, the economy, and jobs: national and regional analyses.J Environ Manage. 2008; 86: 63-79Crossref PubMed Scopus (82) Google Scholar found that environmental regulations have both positive and negative job effects but that the net employment effect of environmental regulations is positive.The lack of clarity regarding the competing cost and benefit numbers presents challenges in data interpretation. Intuitively, it is obvious that complying with air pollution regulations has significant costs for the regulated industries. Equally clear and well documented by research is that exposure to air pollution exacts a health and economic toll on the general population. Available evidence suggests that the economic value of the health benefits from reduced air pollution significantly outweigh the costs. Polluting industries are effectively externalizing their production costs on the general population through high pollution levels that lead to reduced health and higher health expenditures.There are other factors to consider. For the MATS rule, industry leaders estimate that 60% of power plants have already installed pollution control equipment to comply with forthcoming standards.23Rago J. A life in energy and (therefore) politics. The CEO of America's third-largest utility on competing in an electricity market built on political fads and lobbyists. Wall Street Journal October 22, 2011 The Weekend Interview.Google Scholar Blocking the MATS rules, as many in Congress have suggested, effectively rewards the recalcitrant 40% of power plants that continue to emit harmful levels of pollution while punishing the responsible 60% who have incurred the cost of installing pollution control technology.Fortunately, in drafting the Clean Air Act, Congress has addressed how to balance competing cost/benefit claims under the Clean Air Act. The 1990 Clean Air Act Amendments explicitly state that the EPA should set air quality standards to protect the public health, including vulnerable populations, irrespective of costs. This provision has been repeatedly tested in the courts, and the Supreme Court has consistently upheld the EPA's authority to set standards based on protecting the public health.The EPA's authority to regulate air pollution is a matter of law. Air pollution's significant adverse health effects are a matter of fact. The effect of air pollution regulations on the economy is a matter of debate, but available data suggest the substantial health and economic benefits from reductions of air pollution. Congress has a history of engaging in endless debate without reaching consensus. In this important policy issue, we urge Congress to respect the law, consider the facts, and allow the Clean Air Act standards to move forward.Our strong opinion is that the benefits of the Clean Air Act far outweigh the costs in the long run. For our nation's future, as health care professionals, we urge Congress to stop the debate about the EPA's authority and protect Americans’ heath. The US Congress is currently engaged in a debate regarding restriction of Environmental Protection Agency (EPA) authority under the Clean Air Act. The discussion has been focused on the cost to business to comply with the Clean Air Act and the potential negative effect on employment. As heath care professionals, we believe it is necessary to review some of the facts since the Clean Air Act was initiated and the role of the Clean Air Act in the future. In the past year, the House of Representatives has passed a number of bills that would stop, delay, or weaken the EPA rules issued under the authority of the Clean Air Act. The House has passed legislation that would prevent or delay clean up of emissions from cement kilns, coarse particulate matter pollution, industrial boilers, mercury and toxic pollutants from power plants, and pollution from power plants that blow across state borders to neighboring downwind states. Additionally, the House has passed legislation that would subject all future EPA/Clean Air Act rules to a cost/benefit assessment that is heavily tilted in favor of the regulated industry. Why is the House engaged in this attack on the Clean Air Act? Opponents of the EPA have portrayed the agency as a prime example of government overreach and a bureaucratic agency run amok. Opponents of the EPA say the rules are “job-destroying regulations” that create regulatory uncertainty and hurt the overall US economy. Supporters of the EPA counter that complying with the Clean Air Act rules will create new jobs, largely in sectors that install and maintain pollution control equipment. What is missing from the discussion are the health effects of air pollution and the potential health gains that can be made by reducing air pollution. We believe that an analysis of available health and economic data show that air pollution standards have significant net benefits for our society at large. There is compelling evidence that air pollution has severe adverse health effects, particularly for respiratory health. Several studies have demonstrated a strong relationship between short-term exposures to ozone and asthma exacerbations.1EPAAir quality criteria for particulate matter (final). US Environmental Protection Agency, Washington (DC)2004Google Scholar, 2EPAAir quality criteria for ozone and related photochemical oxidants (final). United States Environmental Protection Agency, Washington (DC)2006Google Scholar, 3World Health OrganizationHealth aspects of air pollution: Results from the WHO project “systematic review of air pollution in Europe.”. WHO Regional Office for Europe, Copenhagen (Denmark)2004Google Scholar Strickland et al4Strickland M.J. Darrow L.A. Klein M. Flanders W.D. Sarnat J.A. Waller L.A. et al.Short-term associations between ambient air pollutants and pediatric asthma emergency department visits.Am J Respir Crit Care Med. 2010; 182: 307-316Crossref PubMed Scopus (268) Google Scholar compared air pollution data with more than 90,000 emergency department visits in Atlanta and found that ozone and primary pollutants from traffic sources, even at relatively low ambient concentrations, were associated with increased emergency department visits for pediatric asthmatic patients. The Strickland study builds on an extensive body of literature documenting the relationship between air pollution and asthma emergency department visits and hospitalizations. Ambient air pollutants independently contribute to the burden of emergency department visits for asthma both in children and adults. Internationally, the increase in emergency department visits associated with air pollutants ranges from approximately 5% to 8%.5Villeneuve P.J. Chen L. Rowe B.H. Coates F. Outdoor air pollution and emergency department visits for asthma among children and adults: a case-crossover study in northern Alberta, Canada.Environ Health. 2007; 6: 40Crossref PubMed Scopus (143) Google Scholar, 6Jalaludin B. Khalaj B. Sheppeard V. Morgan G. Air pollution and ED visits for asthma in Australian children: a case-crossover analysis.Int Arch Occup Environ Health. 2008; 81: 967-974Crossref PubMed Scopus (47) Google Scholar, 7Szyszkowicz M. Ambient air pollution and daily emergency department visits for ischemic stroke in Edmonton, Canada.Int J Occup Med Environ Health. 2008; 21: 295-300PubMed Google Scholar, 8Barnett A.G. Williams G.M. Schwartz J. Neller A.H. Best T.L. Petroeschevsky A.L. et al.Air pollution and child respiratory health: a case-crossover study in Australia and New Zealand.Am J Respir Crit Care Med. 2005; 171: 1272-1278Crossref PubMed Scopus (286) Google Scholar, 9Peel J.L. Tolbert P.E. Klein M. Metzger K.B. Flanders W.D. Todd K. et al.Ambient air pollution and respiratory emergency department visits.Epidemiology. 2005; 16: 164-174Crossref PubMed Scopus (390) Google Scholar, 10Moore K. Neugebauer R. Lurmann F. Hall J. Brajer V. Alcorn S. et al.Ambient ozone concentrations cause increased hospitalizations for asthma in children: an 18-year study in Southern California.Environ Health Perspect. 2008; 116: 1063-1070Crossref PubMed Scopus (72) Google Scholar Improvements in air quality have direct positive effects on health. Friedman et al11Friedman M.S. Powell K.E. Hutwagner L. Graham L.M. Teague W.G. Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma.JAMA. 2001; 285: 897-905Crossref PubMed Scopus (445) Google Scholar showed that improvements in air quality in preparation for the 1996 Atlanta Olympics lead to significantly lower rates of childhood asthma events, including reduced emergency department visits and hospitalizations. Avol et al12Avol E.L. Gauderman W.J. Tan S.M. London S.J. Peters J.M. Respiratory effects of relocating to areas of differing air pollution levels.Am J Respir Crit Care Med. 2001; 164: 2067-2072Crossref PubMed Scopus (215) Google Scholar demonstrated that children in southern California who moved to communities with higher air pollution levels had lower lung function growth rates than children who moved to areas with lower air pollution levels. O'Conner et al13O'Connor G.T. Neas L. Vaughn B. Kattan M. Mitchell H. Crain E.F. et al.Acute respiratory health effects of air pollution on children with asthma in US inner cities.J Allergy Clin Immunol. 2008; 121 (e1): 1133-1139Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar have demonstrated that short-term increases in air pollution levels, less than current EPA standards, result in adverse respiratory effects, including mortality, in inner-city children with asthma. Air pollution also affects allergies. Eckl-Dorna et al14Eckl-Dorna J. Klein B. Reichenauer T.G. Niederberger V. Valenta R. Exposure of rye (Secale cereale) cultivars to elevated ozone levels increases the allergen content in pollen.J Allergy Clin Immunol. 2010; 126: 1315-1317Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar have shown that increased ozone exposure during the growth phase of plants results in increased protein and allergen content in plants. Other studies have linked climate-forced temperature changes and increased CO2 concentrations to earlier, prolonged, more prolific, and more allergic pollen production.15Beggs P.J. Impacts of climate change on aeroallergens: past and future.Clin Exp Allergy. 2004; 34: 1507-1513Crossref PubMed Scopus (323) Google Scholar, 16Ziska L. Knowlton K. Rogers C. Dalan D. Tierney N. Elder M.A. et al.Recent warming by latitude associated with increased length of ragweed pollen season in central North America.Proc Natl Acad Sci U S A. 2011; 108: 4248-4251Crossref PubMed Scopus (264) Google Scholar Air pollution affects cardiovascular diseases as well. In a 2010 statement, the American Heart Association found compelling evidence linking air pollution and heart disease, concluding that fine particulate matter is a “modifiable risk factor contributing to cardiovascular morbidity and mortality.”17Brook R.D. Rajagopalan S. Pope 3rd, C.A. Brook J.R. Bhatnagar A. Diez-Roux A.V. et al.Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association.Circulation. 2010; 121: 2331-2378Crossref PubMed Scopus (4357) Google Scholar These health effects have costs. EPA projects that by 2020, the Clean Air Act standard will prevent 230,000 premature deaths, 75,000 cases of chronic bronchitis, 200,000 heart attacks, 2.4 million asthma exacerbations, and 120,000 emergency department visits. The economic value of these avoided health events is estimated to exceed $2 trillion. The public and private industry costs of complying with the Clean Air Act standards are estimated to be $65 billion.18EPA report to congress: the benefits and costs of the Clean Air Act 1990 to 2020. Available at: http://www.epa.gov. Accessed March 17, 2012.Google Scholar The populations that could contribute to the benefit/cost ratio might differ, as presented in the following examples. Regulated industries use a different set of numbers to describe air pollution rules. EPA is in the process of promulgating 4 different rules that will affect coal-fired power plants. These 4 rules are the cross-state air pollution, mercury and air toxics standard (MATS), water cooling, and coal combustion residual product rules. America'sPower, a coalition of coal-based energy companies, commissioned a study that estimates compliance with these 4 forthcoming EPA rules will cost the US economy 1.65 million jobs, largely resulting from higher energy costs leading to job losses in energy-dependent industries. They also estimate approximately $127 billion in compliance costs between 2012-2020.19NERA study impacts of EPA regulations (CSAPR, Utility MACT, CCR & 316[b]) 2011. Available at: http://www.epa.gov. Accessed March 17, 2012.Google Scholar The report does not disaggregate costs among the 4 rules. The EPA has a different set of cost estimates. For the MATS rule, EPA estimates the annual compliance cost to be $9.6 billion and the annual health savings ranging from $37 to $90 billion.20EPA fact sheet: mercury and air toxics standards, benefits and costs of cleaning up toxic air pollution from power plants. Available at: http://www.epa.gov/mats/pdfs/20111221MATSimpactsfs.pdf. Accessed March 17, 2012.Google Scholar The EPA projects employment effects to include adding 46,000 one-time jobs for installation of pollution control equipment and the addition of 8,000 long-term jobs in the electric power industry. The EPA does not estimate employment effects across the US economy. Economists have also studied the cost benefits of air pollution controls. Morgenstern et al21Morgenstern R.D. Pizer W.A. Shih J.S. Jobs versus the environment: an industry level perspective.J Environ Econ Manage. 2002; 43: 412-436Crossref Scopus (136) Google Scholar examined the employment effects of environmental regulations on 4 industries with significant pollution, including iron and steel mills, pulp and paper mills, the plastics industry, and petroleum refineries. The study concluded that for every $1 million spent in environmental controls, 1.5 jobs were created.21Morgenstern R.D. Pizer W.A. Shih J.S. Jobs versus the environment: an industry level perspective.J Environ Econ Manage. 2002; 43: 412-436Crossref Scopus (136) Google Scholar Bezdek et al22Bezdek R.H. Wendling R.M. Diperna P. Environmental protection, the economy, and jobs: national and regional analyses.J Environ Manage. 2008; 86: 63-79Crossref PubMed Scopus (82) Google Scholar found that environmental regulations have both positive and negative job effects but that the net employment effect of environmental regulations is positive. The lack of clarity regarding the competing cost and benefit numbers presents challenges in data interpretation. Intuitively, it is obvious that complying with air pollution regulations has significant costs for the regulated industries. Equally clear and well documented by research is that exposure to air pollution exacts a health and economic toll on the general population. Available evidence suggests that the economic value of the health benefits from reduced air pollution significantly outweigh the costs. Polluting industries are effectively externalizing their production costs on the general population through high pollution levels that lead to reduced health and higher health expenditures. There are other factors to consider. For the MATS rule, industry leaders estimate that 60% of power plants have already installed pollution control equipment to comply with forthcoming standards.23Rago J. A life in energy and (therefore) politics. The CEO of America's third-largest utility on competing in an electricity market built on political fads and lobbyists. Wall Street Journal October 22, 2011 The Weekend Interview.Google Scholar Blocking the MATS rules, as many in Congress have suggested, effectively rewards the recalcitrant 40% of power plants that continue to emit harmful levels of pollution while punishing the responsible 60% who have incurred the cost of installing pollution control technology. Fortunately, in drafting the Clean Air Act, Congress has addressed how to balance competing cost/benefit claims under the Clean Air Act. The 1990 Clean Air Act Amendments explicitly state that the EPA should set air quality standards to protect the public health, including vulnerable populations, irrespective of costs. This provision has been repeatedly tested in the courts, and the Supreme Court has consistently upheld the EPA's authority to set standards based on protecting the public health. The EPA's authority to regulate air pollution is a matter of law. Air pollution's significant adverse health effects are a matter of fact. The effect of air pollution regulations on the economy is a matter of debate, but available data suggest the substantial health and economic benefits from reductions of air pollution. Congress has a history of engaging in endless debate without reaching consensus. In this important policy issue, we urge Congress to respect the law, consider the facts, and allow the Clean Air Act standards to move forward. Our strong opinion is that the benefits of the Clean Air Act far outweigh the costs in the long run. For our nation's future, as health care professionals, we urge Congress to stop the debate about the EPA's authority and protect Americans’ heath.