Abortion in the U.S.

• Most abortions in the U.S. today are performed surgically, typically using vacuum aspiration (VA).
• 9 in 10 abortions occur within the first 12 weeks of pregnancy.⁵
• Surgical abortions can be performed as early as pregnancy is first detected, using electric VA or manual vacuum aspiration (MVA).²¹
• Medical abortions are procedures using medications to induce abortion, such as mifepristone (also called RU-486) or methotrexate in combination with misoprostol.

Unintended Pregnancy And Surgical Abortion

• Almost half (49%) of the 6.3 million pregnancies each year are unintended; 54% of unintended pregnancies end in abortion.
• In 1994, there were about 1.43 million abortions in the United States; the abortion rate was 24.2 per 1,000 women aged 15-44.10
• The U.S. abortion rate and the percent of pregnancies ending in abortion have declined slightly but steadily since 1980. Since 1990, all measures of abortion, including the annual incidence, have declined.6
• About 15,000 women have abortions each year because they became pregnant after rape or incest.⁶
• 48% of women 15*44 have at least one unplanned pregnancy sometime in their lives; 28% have one or more unplanned births, 30% have one or more abortions and 11% have both.⁹
• An estimated 43% of women will have an abortion by the time they are 45, given current abortion rates.⁹

Who Has Abortions

• 55% of women having abortions are younger than 25; 33% are aged 20-24 and 22% are teenagers.⁸
• Six in 10 abortions occur to white women; however, their abortion rate is below that of minority women. Black women are nearly 3 times as likely as white women to have an abortion and Hispanic women are about twice as likely.⁸
• Two-thirds of all abortions are to never-married women.⁸

Who Provides Surgical Abortions

• 93% of abortions take place in clinics or doctors’ offices.⁶
• The number of known current abortion providers (hospitals, abortion clinics, family planning clinics that offer surgical services, and physicians’ offices) declined by 8% between 1988 and 1992 (from 2,582 to 2,380).⁶
• In 1992, just 12% of all ob/gyn residency programs provided routine first-trimester abortion training; three in 10 programs offered no first-trimester training.¹²
• According to a national survey of ob/gyns in 1997, 36% of ob/gyns say they “ever perform” surgical abortions.¹⁸

Barriers & Access To Surgical Abortion Services

• 84% of all U.S. counties lacked an abortion provider in 1992.6V52% of all abortion facilities provide services only through the 12th week of pregnancy.⁷
• In 1992, 4 in 10 clinics and physicians’ practices would not perform surgical abortions before 6 weeks since the beginning of a woman’s last menstrual period (LMP). Another quarter of facilities do not perform abortions until even later in pregnancy.⁷
• One-quarter of women who have non-hospital abortions travel at least 50 miles from their home to the abortion facility.⁷
• From 1996 to 1997, the number of arsons doubled and bombings tripled against abortion providers.¹³

Very Early Abortion Methods^3,14,21

Medical Abortion

• Among women participating in the U.S. clinical trials who underwent an abortion within 49 days (7 weeks) LMP, the use of mifepristone (with misoprostol) was 92% effective in terminating pregnancy.¹⁶
• Two percent of women who had a mifepristone abortion 49 days LMP in clinical trials required hospitalization, surgical intervention, and/or intravenous-fluid administration.¹⁶
• Several published studies on the use of methotrexate (with misoprostol) for abortion have found the drug to be up to 96% effective in terminating pregnancy within 63 days LMP.^1,2,4
• Of 178 women who underwent pregnancy termination with methotrexate within 63 days LMP in one study, 7 required surgical intervention.¹
• A review of 12 international published studies conducted between 1979 and 1993 of patient attitudes and reactions to early first-trimester medical abortion found that 60-70% of women chose medical abortion when offered a choice between surgical and medical abortion.¹⁹
• Over 2,000 U.S. women, who had a medical abortion with mifepristone and misoprostol during the U.S. clinical trials (1994-1995), found the method highly acceptable: 96% would recommend it to others, 91% would choose it again and 88% found it very or moderately satisfactory.²⁰

Who Pays For Surgical Abortions

• In 1993, the average amount paid for a non-hospital abortion at 10 weeks was $296; however, the cost ranged from $140 to more than $1,700.⁷
• About 13% of all abortions are paid for with public funds, virtually all of which are state funds. Currently, 16 states pay for all or some abortions for poor women.¹⁵
• In the private sector, over two-thirds of typical fee-for-service and managed care plans routinely cover abortions.¹⁷

Provider & Public Opinion On Medical Abortion

• As of 1997, most providers said they were at least somewhat familiar with mifepristone; fewer were familiar with methotrexate.¹⁸
• About half of all ob/gyns (54%) said they would offer mifepristone abortions if approved in the U.S., including 35% of ob/gyns who do not perform surgical abortions.¹⁸
• Among providers familiar with mifepristone, most said they considered it safe (96% of ob/gyns) and effective (94% of ob/gyns).¹⁸
• As of 1997, 43% of women and 51% of men had heard of either mifepristone or methotrexate; among women who had heard of the methods, 72% knew they could be used to end a pregnancy.¹⁸

References

1. Creinin M, Darney P. “Methotrexate and Misoprostol for Early Abortion.” Contraception. 1993; 48:339-348.

2. Creinin M. “Methotrexate for Abortion at 42 Days Gestation.” Contraception. 1993; 48:519-525.

3. Expanding Options For Early Abortions Packet. Overview and Fact Sheets. Reproductive Health Technologies Project, Washington D.C.: 1998.

4. Hausknecht R. “Methotrexate and Misoprostol to Terminate Early Pregnancy.” The New England Journal of Medicine. 1995;333:537-540.

5. Henshaw S. “Abortion Services in the United States, 1995-1996.” Family Planning Perspectives. (Forthcoming, Nov/Dec 1998).

6. Henshaw S, Van Vort J. “Abortion Services in the United States, 1991 and 1992.” Family Planning Perspectives. 1994; 26:100-106, 112.

7. Henshaw S. “Factors Hindering Access to Abortion Services.” Family Planning Perspectives. 1995; 27:54-59, 87.

8. Henshaw S, Kost K. “Abortion Patients in 1994-1995: Characteristics and Contraceptive Use.” Family Planning Perspectives. 1996; 28:140-147, 158.

9. Henshaw S. “Unintended Pregnancy in the United States.” Family Planning Perspectives. 1998; 30:24-29.

10. “Induced Abortion.” Facts in Brief. Jan. 1997, New York, N.Y. The Alan Guttmacher Institute.

11. Forrest JD. “Timing of Reproductive Life Stages.” Family Planning Perspectives. 1993; 82.

12. MacKay H, Trent MacKay A. “Abortion Training in Obstetrics and Gynecology Residency Programs in the United States, 1991-1992.” Family Planning Perspectives. 1995; 27:112-115.

13. National Abortion Federation Website (http://www.prochoice.org)

14. Schaff E, Eisinger S, Franks P, Kim S. “Methotrexate and Misoprostol for Early Abortion.” Fam Med. 1996;28:198-203.

15. Sollom T, Gold R, Saul R. “Public Funding for Contraceptive, Sterilization and Abortion Services, 1994.” Family Planning Perspectives. 1996; 28:166-173.v

16. Spitz I, Benton L, Bardin W, Robbins A. “The Safety and Efficacy of Early Pregnancy Termination with Mifepristone and Misoprostol: Results from the First Multicenter U.S. Trial.” The New England Journal of Medicine. 1998; 338:1241-1247.

17. Uneven & Unequal: Insurance Coverage and Reproductive Health Services. 1994, New York, N.Y. The Alan Guttmacher Institute.

18. Views of Americans and Health Care Providers on Medical Abortion: What They Know, What They Think, and What They Want.. 1998, Menlo Park, CA. Kaiser Family Foundation.

19. Winikoff B. “Acceptability of Medical Abortion in Early Pregnancy.” Family Planning Perspectives. 1995;27:142-148 & 185.

20. Winikoff B, Ellertson C, Elul B, Sivin I. “Acceptability and Feasibility of Early Pregnancy Termination by Mifepristone-Misoprostol.” Archives of Family Medicine. 1998; 7:360-366.

21. Winkler J, Blumenthal P, Greenslade F. “Early Abortion Services: New Choices for Providers and Women.” Advances in Abortion Care. 1996; 5. Carrboro, NC. IPAS.

This Summary presents background, findings, and data from the Economic and Social Research Institute’s (ESRI) full report, Privatization of Public Hospitals. Section I provides background about public hospital conversions, including the role of public hospitals, reasons for conversion, the mechanisms of conversion and new ownership entities, and analysis of national and regional public hospital data. Section II provides a discussion of the five case studies of public hospital conversions and the key findings from the case studies. Attachment A is a table of public hospital conversions and closures by region and state.

• Summary of Findings:

This report examines the trends in the closure of public hospitals and their conversion to private ownership. It also provides case studies of communities where major privatizations have occurred.

Report (.pdf)

Summary of Findings (.pdf)

Privatization of Public Hospitals

Full Report available in PDF format.Summary available in PDF format.Return to top

Privatization of Public HospitalsReport

Sex In The 90s:Kaiser Family Foundation/ABC Television 1998 National Survey of Americans on Sex and Sexual Health

Methodology:The Kaiser Family Foundation and ABC Television 1998 National Survey of Americans on Sex and Sexual Health is a random-sample telephone survey of 1,204 adults 18 and older living in the United States. It was designed by staff at the Foundation and Princeton Survey Research Associates (PSRA) and conducted by PSRA between April 24 and May 10, 1998. The margin of sampling error is plus or minus 3 percentage points.

Questionnaire and Toplines

INTRODUCTION: Hello, my name is _______ and I’m calling for Princeton Survey Research of Princeton, New Jersey. We are conducting a national opinion survey about some important social issues, like health and family.

First, I have some questions about some social issues in this country . . .

1. Unplanned pregnancy and sexually transmitted diseases are bigger problems in the United States than in many other Western countries, and people have many different explanations for why this is so. Please tell me whether YOU think each of the following contributes a lot, some, only a little or not at all to these problems in the U.S.

A lot Some Only a little Not at all DK/Ref. a. A lack of openness about sex and sexual issues 35 34 15 12 4 =100 b. Poverty and poor education 46 29 15 8 2 =100 c. A decline in moral values 65 20 8 5 2 =100 d. Too much casual sex in the movies and on TV 55 25 13 6 1 =100 e. Inadequate sex education in the schools 32 32 20 13 3 =100 2. Do you think the way TV programs show sex and nudity tends to ENCOURAGE irresponsible sexual behavior, DISCOURAGE irresponsible sexual behavior, or don’t you think it has much effect on people’s sexual behavior?

74 Encourages irresponsible sexual behavior 3 Discourages irresponsible sexual behavior 20 No effect 3 Don’t know/Refused 100 3. In your opinion, if TV characters in entertainment programs are talking about or engaging in sexual activity, should they talk about condoms or make other references to “safer sex,” or NOT?

77 Should 18 Should not 5 Don’t know/Refused 100

4. How well do you think the way sex is usually shown on TV and in the movies reflects your own sex life?Would you say . . .

3 Very well 16 Somewhat well 23 Not too well 50 Not well at all 8 Don’t know/Refused 100

5. To what extent do you think TV and movies send the message that. . . (INSERT). Do you think TV and movies send this message a lot, somewhat, only a little, or not at all?

A lot Some Only a little Not at all DK/Ref. a. To have a great sex life you must changepartners often 41 29 14 14 2 =100 b. You can have spontaneous sex without worryingabout the consequences 53 25 11 9 2 =100 c. Only thin, beautiful people can have great sex 53 22 8 14 3 =100 d. Older adults can have great sex 14 31 33 19 3 =100 e. To have a “normal” sex drive means alwaysbeing in the mood for sex 41 31 13 12 3 =100 READ: On a different topic . . .

6. Do you have any children — either adult children or children who are still growing up?

70 Yes, have children 30 No children * Refused 100

7. Are any of your children age 18 or under?

40 Yes, have children age 18 or under 30 No children under 18 0 Don’t know/Refused 30 Have no children at all/DK/Ref 100

8. Starting with the older, please tell me the ages of your children who are age 18 or under.RESULTS NOT REPORTED

AGE OF TARGET CHILD:

49 8-12 51 13-18 100 READ: Please answer the next few questions thinking about your (AGE) year old . . .

9. Have you ever had a conversation about a sexual issue with your (AGE) year old because of something one or both of you saw . . .

Based on parents with at least one child age 8 to 18, (target child chosen randomly for those with more than one child in age range); n=329

Yes No DK/Ref. a. On the news 63 36 1 =100 b. On a television show 70 30 0 =100

10. Thinking about the last time you had a conversation because of something you saw on television, which comes closer to how you felt …

Based on parents who had a conversation about a sexual topic with target child because of something on TV; n=257

65 It was a good opportunity for you and your child to talk about sexual issues 31 It raised a sexual issue you did not want to talk about with your child at that time 4 Don’t know/Refused 100 11. Thinking about sexual content on television. . . Have you ever (INSERT) because of sexual content you saw (on TV)?

Yes No DK/Ref. a. Q11a based on parents with at least one child age 18 or under; n=491Not allowed (one of your children/your child) to watch a certain show 76 24 * =100 b. Q11b-f based on totalTurned off the television 60 39 1 =100 c. Talked to a health care provider about a sexual topic 46 52 2 =100 d. Talked to a health care provider about a sexual topic 9 91 0 =100 e. Had a conversation with a sexual partner about a sexual topic 44 54 2 =100 f. Tried something new sexually 13 85 2 =100

READ: Next I have some questions about sex education . . .

12. In general would you say that young people today get information about sex and birth control at…

22 About the right time 24 Too soon 47 Too late 7 Don’t know/Refused 100

13. In general do you SUPPORT or OPPOSE sex education courses being taught to . . .

Support Oppose DK/Ref. a. High school age students — that is children age 15 to 18 85 12 3 =100 b. Junior high school age students — that is children age 12 to 14 76 21 3 =100 c. Elementary school age students — that is children 6 to 12 35 60 5 =100

14. If sex education is taught in HIGH SCHOOLS, do you think it should or should not…

Should Should Not DK/Ref. Sex education should not be taught at all a. Tell young people NOT to have sexualintercourse before marriage? 68 27 4 1 =100 b. Tell young people who ARE sexually activeto use protection, such as condoms, to prevent against pregnancy and disease? 92 5 2 1 =100 c. Teach the basic facts of human reproduction? 94 4 4 1 =100 d. Discuss how to know when you are readyto have sex? 74 19 6 1 =100 e. Discuss how to talk about sex with a partner? 74 21 4 1 =100

15. Some people believe that whether or not young people are sexually active, they should be given information to protect themselves from unplanned pregnancies and sexually transmitted diseases. Others believe that telling young people about birth control and sexually transmitted diseases only encourages them to have sex. Which come closer to your view?

83 They should be given information 14 Information only encourages them to have sex 3 Don’t know/Refused 100

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Sex In The 90s:Kaiser Family Foundation/ABC Television 1998 National Survey of Americanson Sex and Sexual Health:Survey Part One Part Two Part Three ABC Television

This paper describes the nature of employer coverage; its decline, especially among low-wage workers and low-income families; and the factors that are undermining its reach.

• Issue Paper
• Issue Paper

16. Do you think sex education courses should ONLY teach abstinence — that is NOT having sex until marriage — OR should courses teach about BOTH abstinence AND give teens enough information to help them prevent unplanned pregnancies and the spread of sexually transmitted diseases if they DO decide to have sex?

18 Only abstinence 81 Both 8 Don’t know/Refused 100

17. Do you think that HIGH SCHOOL health clinics should provide young people with condoms and other forms of birth control if students ask for them?

57 Yes 40 No 3 Don’t know/Refused 100

18. In general, at what age do you think most young people have sexual intercourse for the first time?Teens = (13-18) Perceptions Fall 1997 Survey* 15 12 or younger 2 11 13 5 15 14 12 21 15 18 17 16 29 6 17 16 5 18 or older 14 10 Don’t Know/Refused 4 100 100

*PSRA for The Kaiser Family Foundation and YM Magazine

19. When you were growing up, did you have sex education courses in school?

41 Yes 59 No * Don’t know/Refused 100

20. Still thinking back to when you were growing up, would you say you got a lot of information about sex from (INSERT), some, only a little or no information at all?

A lot Some Only a little No info. at all DK/Ref. Did not have sex education in school (Q19) a.Sex education in school Based on total 6 17 16 1 1 59 =100 Based on those who had sexed. in school; n=510 15 43 39 2 1 NA =100 b.Your parents 13 22 27 38 * NA =100

21. Thinking about your (AGE) year old, have you ever talked with him or her about…

Based on parents with at least one child age 8 to 18, (target child chosenrandomly for those with more than one child in age range); n=329

Yes No DK/Ref. a. The basics of reproduction — that is “the birds and bees” 79 21 0 =100 b. HIV/AIDS and other sexually transmitted diseases 80 20 0 =100 c. Issues about relationships and becoming sexually active 63 37 * =100 d. The importance of using protection, such as condoms, to preventpregnancy or disease if they become sexually active 52 48 0 =100

22. When you were growing up did your parents talk with YOU about (INSERT) or not?

Yes No DK/Ref. a. The basics of reproduction — that is “the birds and bees” 41 58 1 =100 b. Sexually transmitted diseases 21 78 1 =100 c. Issues about relationships and becoming sexually active 31 68 1 =100 d. The importance of using protection, such as condoms, to prevent pregnancy or disease if you became sexually active 25 75 * =100

23. Compared to your parents when you were growing up, do you think, (you were/you are/you would be) more open with your child(ren) about sex and sexual issues in general, less open, or about as open as your parents were with you?

79 More open 2 Less open 17 About as open 2 Don’t know/Refused 100

24. Americans have different views about sexual issues. For each of the following statements, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree. (First/Next)

Strongly agree Somewhat agree Somewhat disagree Strongly disagree DK/Ref. a. Americans overall are uptight aboutsex and sexual issues 27 36 21 14 2 =100 b. I personally have a hard time talking aboutsex and sexual issues 11 22 25 41 1 =100 c. If Americans were more OPEN talking aboutsex there would be LESS of a problem with unplanned pregnancy and sexually transmitted diseases in this country 41 27 16 14 2 =100 d. Sexual issues are private and should only bediscussed among intimate couples 26 25 25 23 1 =100

25. When you were growing up, did you have sex education courses in school?

85 Long-term monogamous relationships 9 Several relationships with different partners over a life time 6 Don’t know/Refused 100

26. What is your opinion about a married person having sexual relations with someone other than their marriage partner–is it always wrong, almost always wrong, wrong only sometimes, or not wrong at all?

January 1991* 79 Always 71 12 Almost always 17 6 Sometimes 10 2 Not wrong at all 1 1 Don’t Know/Refused 1 100 100

*PSRA for Troika Productions and Lifetime Television

27. For each of the following statements, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree.

Strongly agree Somewhat agree Somewhat disagree Strongly disagree DK/Ref. a. In general Americans have a hard timetalking about sex and sexual issues 27 39 19 13 2 =100 b. Making sex a forbidden subject only encouragesyoung people to want to have sex 36 29 18 16 1 =100 c. Sometimes it is harder for couples to TALKabout sexual issues like birth control and sexually transmitted diseases than to HAVE sex 29 38 17 13 3 =100

READ: Now some questions about you . . .

28. How would you rate your SEX life these days? Please use a ten point scale, where ten means great and one means terrible.

15 10 7 9 18 8 11 7 7 6 11 5 1 4 2 3 2 2 8 1 10 Not applicable/Abstinent (VOL.) 100 6.77 Mean 7.00 Median

29. Are you currently married, LIVING AS married, widowed, divorced, separated, or have you never been married?

56 Married 4 Living as married 8 Widowed 10 Divorced 3 Separated 19 Never married * Gay(VOL.) 0 Refused 100

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Sex In The 90s:Kaiser Family Foundation/ABC Television 1998 National Survey of Americanson Sex and Sexual Health:Survey Part One Part Two Part Three ABC Television

Part 5

Appendix Table 1: Medicaid Eligibility Levels for Pregnant Women and Children Pregnant Women, Infants and Children(as of May 20, 1998) Other Eligibility Categories Pregnant Women and Infants Children Under Age 6 Children Ages 6 to 14 Children Ages 14 to 19 Asset Test Required for Children (4) Max. AFDC Payments (7/16/96) (5) Medically Needy, 1996 (percent of Federal Poverty Level) United States 133 133 100 45 49 Alabama 133 133 100 100 No 15 N/A Alaska 133 133 100 90 No 76 N/A Arizona 140 133 100 30 No 32 N/A Arkansas (2,3,4) (133) (200) 200 200 200 Yes 19 25 California (1) 200 133 100 100 No 56 86 Colorado (1,4) 133 133 100 37 Yes 39 N/A Connecticut 185 185 185 185 No 81 71 Delaware 185 133 100 100 No 31 N/A District of Columbia 185 133 100 37 No 37 N/A Florida (1) 185 133 100 100 No 28 28 Georgia 185 133 100 100 No 39 35 Hawaii 185 133 100 100 No 57 57 Idaho (4) 160 160 160 160 Yes 29 N/A Illinois 200 133 130 133 No 35 45 Indiana 150 133 100 100 No 27 N/A Iowa (4) 185 133 100 37 Yes 39 52 Kansas 150 133 100 100 No 40 44 Kentucky 185 133 100 46 No 49 28 Louisiana 133 133 100 17 No 18 N/A Maine 185 133 125 125 No 51 42 Maryland (2) 185 185 185 33 No 34 40 Massachusetts (1) 185 133 133 133 No 52 72 Michigan 185 150 150 150 No 45 52 Minnesota (3) 275 275 275 275 No 49 66 Mississippi 185 133 100 32 No 34 N/A Missouri 185 133 100 100 No 27 N/A Montana (4) 133 133 100 48 Yes 41 46 Nebraska 150 133 100 100 No 34 45 Nevada (4) 133 133 100 31 Yes 32 N/A New Hampshire 300 185 185 185 No 51 60 New Jersey (1) 185 133 133 133 No 41 52 New Mexico 185 185 185 185 No 36 N/A New York (1) 185 133 100 51 No 61 76 North Carolina 185 133 100 100 No 50 34 North Dakota (4) 133 133 100 100 Yes 40 47 Ohio 150 150 150 30 No 32 N/A Oklahoma 185 185 185 185 No 28 42 Oregon (4) 133 133 100 100 Yes 43 57 Pennsylvania (1) 185 133 100 37 No 39 43 Rhode Island (3,4) 250 250 250 250 Yes 51 69 South Carolina 185 150 150 150 No 18 N/A South Dakota 133 133 100 100 No 47 N/A Tennessee (3) 400 400 400 400 No 54 23 Texas (4) 185 133 100 17 Yes 17 25 Utah (4) 133 133 100 100 Yes 53 53 Vermont (3) (200) (225) 225 225 225 No 59 81 Virginia 133 133 100 100 No 22 33 Washington (185) (200) 200 200 200 No 50 62 West Virginia 150 133 100 100 No 24 27 Wisconsin 185 185 100 45 No 48 64 Wyoming (4) 133 133 100 52 Yes 55 N/A SOURCE: Center on Budget and Policy Priorities. 1998 and National Governors’ Association. 1996 and 1997. N/A: No medically needy programNote: The 1998 Federal poverty guideline for a family of three was $13,650; for Alaska $17,070 and Hawaii $15,700.(1) The state operates separate child health insurance programs for children not eligible for Medicaid. Such Programs may provide benefits similar to Medicaid or they may provide a limited benefits package and may include premiums and cost-sharing.(2) Children covered under Medicaid expansion programs in Arkansas and Maryland receive reduced benefits package pursuant to federal waivers.(3) The Medicaid programs in AR, MN, RI, TN, and VT may impose some cost-sharing-premiums and/or co-payments for some children pursuant to federal waivers.(4) The states noted count assets, in addition to income, in determining Medicaid eligibility for children; Utah does not consider assets for young children. An assets test in NOT required in Arkansas for its Medicaid expansion program.(5) The United States figure represents the median maximum AFDC payment level.

Appendix Table 2: Expansion Population Eligibility in State Medicaid Programs Operating Under Statewide Section 1115 Demonstration Waivers*State ExpansionPopulation FamilyIncomeRequire-ment ResourceRequire-ment CategoricalRequire-mentWaived Premium/Cost-Sharing EnrollmentCap Alabama Children aged 6-19 < 133% FPL N/A Change in income requirement No premium/cost-sharing No Women for 24 months post-partum^a < 133% FPL Pregnancy Arizona Children up to age 14 < 100% FPL N/A Change in income requirement $1-5 copay, depending on service. No copay for prescription drugs, prenatal care, EPSDT care, nursing facility services, and primary care visits not scheduled by the patient. No Pregnant women and infants < 140% FPL N/A Change in income requirement Arkansas Children up to age 19 < 200% FPL No resource test Change in income requirement $5 copay for prescriptions, $10 copay for outpatient services, percentage copay for hospital per diem No Delaware Low-income children and adults < 100% FPL N/A Changes income requirement for children, waives requirement of pregnancy, disability, or dependent children No premium/cost-sharing No Hawaii Low-income children and adults < 300% FPL < $2,000 for single person, < $3,000 for couple Changes income requirement for children, waives requirement of pregnancy, disability, or dependent children All persons (except pregnant women) making over 100% FPL pay 100% of medical, dental, and catastrophic care premiums. Sliding payment scale for children under 200% FPL. No Kentucky No eligibility expansion Maryland No eligibility expansion Massachusetts Low-income employed < 200% FPL No resource test Dependent child, pregnancy, disability Cost-sharing on a sliding scale based on income No Low-income unemployed < 133% FPL No resource test Dependent child, pregnancy, disability Unemployed persons receiving state or federal unemployment benefits < 400% FPL No resource test Dependent child, pregnancy, disability State ExpansionPopulation FamilyIncomeRequire-ment ResourceRequire-ment CategoricalRequire-mentWaived Premium/Cost-Sharing EnrollmentCap Minnesota Pregnant women and children up to age 19 < 275% FPL No resource test Changes income requirement Premiums range from 1.5 to 8.8% gross income, $4/month premium for families with children < 150% FPL, non-pregnant adults pay 10% of inpatient hospital costs with $1,000 maximum No Planned extension to low-income adults N/A N/A Dependent child, pregnancy, disability New Jersey Low-income individuals < 200% FPL < $7,500 for individual, < $15,000 per family Dependent child, pregnancy, disability Individuals with income below 200% FPL receive fully subsidized care; individuals with income below 300% FPL receive partially subsidized care. No Low-income individuals < 300% FPL < $7,500 resources for individual, < $15,000 per family New York Home Relief population N/A Dependent child, pregnancy, disability No premium/cost-sharing No Women for 24 months post-partum^a< 185% FPL Pregnancy Ohio No eligibility expansion Oklahoma No eligibility expansion Oregon Low-income children and adults < 100% FPL < $5,000 Dependent child, pregnancy, disability Cost-sharing on sliding scale for adult, non-pregnant new eligibles. No Rhode Island Pregnant women and children under age 8 < 250% FPL N/A Change in income requirement Individuals with family incomes between 185-250% FPL subject to cost-sharing requirements. No Women for 24 months post-partum^a < 250% FPL Pregnancy Tennessee Uninsurable individuals N/A No resource test Dependent child, pregnancy Individuals with family incomes > 100% FPL subject to cost-sharing requirements on sliding scale based on income. Enrollment capped at 1,775,000^b Persons ineligible for employer- or government-sponsored health plans No resource test Dependent child, pregnancy, disability Vermont Low-income children and adults < 150% FPL N/A Dependent child, pregnancy, disability No premium/cost-sharing *Based on data collected by the George Washington University Center for Health Policy Research. N/A indicates that this information was not clear based on the information reviewed.a. Only family planning services are covered under this extension.b. Tennessee does not cap enrollment of traditional eligibles meeting the state’s 1993 Medicaid eligibility criteria and uninsurable persons. The enrollment of uninsured persons is limited by the difference between 1,775,000 and the sum of traditional eligibles and uninsurable persons.

¹ Thomas Selden, Jessica Banthin, and Joel Cohen, “Medicaid’s Problem Children: Eligible but not Enrolled,” Health Affairs. May/June 1998: 192-200.

² Medicaid eligibility policy vis-a-vis the disabled and the elderly will be the focus of subsequent analyses.

³ See Lake Snell Perry & Associates, Barriers to Medi-Cal Enrollment and Ideas for Improving Enrollment: Findings from Eight Focus Groups with Parents of Potentially Eligible Children. Kaiser Family Foundation, September 1998.

⁴ See Kaiser Commission on Medicaid and the Uninsured, “Medicaid Eligibility and Enrollment Projects,” September 1998; Donna Cohen Ross, Child Health Outreach Handbook , Center on Budget and Policy Priorities, July, 1998; Sarah Shuptrine, Vicki Grant, and Genny McKenzie, Southern Regional Initiative to Improve Access to Benefits for Low-income Families with Children, Southern Institute on Children and Families, February 1998.

⁵ Congressional Budget Office, Behind the Numbers: An Explanation of CBO’s January 1997 Medicaid Baseline, April 1997, p. 7.

⁶ For detailed state-by-state data on the number and type of beneficiaries covered, see David Liska, Brian Bruen, Alina Salganicoff, Peter Long, and Bethany Kessler, Medicaid Expenditures and Beneficiaries: National and State Profiles and Trends, 1990-1995, Third Edition, Kaiser Commission on the Future of Medicaid, November 1997.

⁷ Statement of Bruce C. Vladeck, Administrator, Health Care Financing Administration, “1998 Budget for Medicaid and Medicare Part B” presented to the House Commerce Committee, Subcommittee on Health and Environment, February 12, 1997.

⁸Choices Under the New State Child Health Insurance Program: What Factors Shape Cost and Coverage? Kaiser Commission on Medicaid and the Uninsured, January 1998.

⁹MCH Update: State Medicaid Coverage of Pregnant Women and Children, National Governors’ Association, September 1997, www.nga.org.

¹⁰ See David Super, Sharon Parrott, Susan Steinmetz, Cindy Mann, The New Welfare Law, Center on Budget and Policy Priorities, August 14, 1996, http://www.cbpp.org.

¹¹ For a discussion of eligibility rules relating to two-parent families, see Jocelyn Guyer and Cindy Mann, Taking the Next Step: States Can Now Take Advantage of Federal Medicaid Matching Funds to Expand Health Care Coverage to Low-Income Working Parents, Center on Budget and Policy Priorities, July 1998, www.cbpp.org.

¹² 63 Fed. Reg. 42270 (August 7, 1998.)

¹³ Jeff Harris and Jane Horvath, The Administrative Impact of the Medicaid Eligibility Resource Test, Kaiser Commission on the Future of Medicaid, April 1993.

¹⁴ Marilyn Moon, The Urban Institute, Asset Limits and Medicaid, Kaiser Commission on the Future of Medicaid, April 1993.

¹⁵ See Leighton Ku and Bethany Kessler, The Number and Cost of Immigrants on Medicaid: National and State Estimates, Urban Institute, December 1997. For a discussion of the impact of the welfare law changes on elderly legal immigrants, see Robert B. Friedland and Veena Pankaj, Welfare Reform and Elderly Legal Immigrants, Henry J. Kaiser Family Foundation, July, 1997. For a review of the options remaining to states with respect to coverage of this population through either federally-funded or state-funded programs, see Kelly Carmody, State Options to Assist Legal Immigrants Ineligible for Federal Benefits, Center on Budget and Policy Priorities, February 1998, http://www.cbpp.org.

¹⁶ Sara Rosenbaum, Medicaid and Migrant Farmworker Families: Analysis of Barriers and Recommendations for Change, National Association of Community Health Centers, 1991.

¹⁷ Guyer and Mann. July 1998.

¹⁸www.hcfa.gov/init/chip-map.cfm

¹⁹ Guyer and Mann. July 1998.

²⁰ For a summary of the expansion populations covered by some states under section 1115 waivers, see Sara Rosenbaum and Julie Darnell, Statewide Medicaid Managed Care Demonstrations under Section 1115 of the Social Security Act: A Review of the Waiver Applications, Letters of Approval, and Special Terms and Conditions, Kaiser Commission on the Future of Medicaid, May 1997.

²¹ Under section 1931 of the Social Security Act, States have the option of liberalizing their financial eligibility standards for adults in one-parent and certain two-parent families by adopting “less restrictive” income or resource methodologies. They do not, however, have the option to liberalize the non-financial eligibility rules. In order to receive federal Medicaid matching funds for the coverage of childless non-disabled adults who do not meet these family composition requirements, states must obtain a waiver from the Secretary of HHS under section 1115.

²² Schoen, C., B. Lyons, D. Rowland et al, “Insurance Matters for Low-Income Adults: Results from a Five-State Survey” Health Affairs, Sept/Oct 1997.

²³ Selden, Banthin, and Cohen, May/June 1998.

²⁴ See Alina Salganicoff and Patricia Seliger Keenan, Child Health Facts: National and State Profiles of Coverage, Kaiser Commission on Medicaid and Uninsured, January 1998. Return to top

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Part 2

Even when insurance is offered to low-wage workers, its costs to these workers may be substantial, and, for some, a barrier to coverage. In 1996, workers had to contribute an average of $1,615 per year for family coverage, or about 30% of the total premium.⁵ Thus, a worker who earned $10 an hour in 1996, with annual wages of about $20,000, would have had to spend 8% of earnings to buy family coverage.* A worker who earned just $7 an hour would have had to spend 12% of earnings on health insurance.

* Annual earnings are estimated based on 40 weekly hours worked and 50 weeks of work per year.

Despite substantial costs, the large majority of low-wage workers take up insurance when it is available to them. High-wage workers, though, are more likely than low-wage workers to participate in employer plans. In 1996, 76% of workers who earned less than $7 an hour participated in employer plans to which they had access (either through their own employer or through a family member’s employer), compared to 94% of workers who earned more than $15 per hour [Figure 6].⁶

These data do not provide much support for the view that low-income families lack coverage because they are turning down coverage that is available to them. Although high-wage workers are more likely to take up insurance, the limited impact of participation differences for low-wage workers is apparent in the following example. If low-wage workers increased their participation in any job-based plan offered to them from the current rate, 76 percent, to a rate comparable to that of high-wage workers, 94 percent, their coverage rate would only increase from 42 to 51 percent, still far below the rates found among higher wage workers.* In other words, closing the gap in participation would not close the gap in coverage between high-wage and low-wage workers. The primary reason low-income families lack coverage is not failure to participate, it is because they work for employers who do not offer them health benefits.

The Decline in Employer Coverage

The limits to employer coverage, especially for low-wage workers, are widely recognized. The deterioration of that coverage–again, especially for low-wage workers–is a pattern of even greater concern.

Between 1987 and 1996, the proportion of Americans under age 65 with employer coverage declined from 69.2% to 64%. Although partially offset by an increase in the proportion of the nonelderly population with Medicaid coverage (mostly for children), the proportion of the population without insurance grew from 14.8% in 1987 to 17.7% in 1996 [Figure 7].

* The coverage rate is equal to the participation rate multiplied by the proportion of workers with access to health coverage. Assuming access remains unchanged and 55% of low wage workers have access to employment-related health benefits, the coverage rate would increase from 42% (76% * 55%) to 51% (94% * 55%) if participation rates rose.

These changes in coverage–the drop in employer coverage and the rise in Medicaid– were most pronounced between 1988 and 1993. Since 1993, the deterioration in employer coverage appears to have stabilized, remaining at about 64 percent,⁷ while the Medicaid coverage rate dropped from 12.7% in 1993 to 12.1% in 1996, and the proportion of uninsured Americans under age 65 continued to rise, despite economic growth and relatively low unemployment.

Although the deterioration of employer coverage has affected workers and families across all income levels, the impact has varied with income, with near-poor and modest income families showing the greater losses. From 1988 to 1993, the rate of employer coverage for the near-poor (with incomes between 100-199% of poverty) fell seven percentage points–from 50.9% to 43.9% [Figure 8]. Among individuals in families with incomes between 200 and 399% of poverty, the coverage rate fell from about 77.8 to 72.3 percent, and for those in families with incomes above 400% of poverty, the proportion with employer coverage dropped from 86.0% to 82.4 percent.⁸

Table 1 illustrates the same phenomenon over a longer period of time, focusing on workers differentiated by a variety of characteristics. Looking first at wages, coverage rates declined across all wage levels, but the drop in coverage was concentrated among low-wage workers. Coverage for workers in the bottom fifth of the wage distribution dropped 13 percentage points from 40% in 1979 to 27% in 1993. That drop is much larger than for workers in the top fifth of the wage distribution. The top wage earners were unaffected by the coverage declines in the early 1980s, but saw a small decline (of 3 percentage points) between 1988 and 1993. The fall in coverage by education level follows a similar pattern: large declines among less educated workers, with some decline in coverage in the most educated groups. Coverage rates fell more among men than women, and although employer coverage declined similarly among blacks and whites, Hispanics suffered a much larger drop.

Table 1

Change in Private Sector Employer-Provided Health Insurance Coverage, Wage and Salary Workers, 1979-1993

Health Insurance Coverage Percentage Point Change

Group*

1979

1988

1993

1979-93

All Workers

71%

69%

64%

-7

Wage (by wage fifth)

Lowest

40

32

27

-13

Second

66

62

59

-7

Middle

79

76

71

-8

Fourth

87

83

80

-7

Top

90

90

87

-3

Gender

Men

76

74

68

-8

Women

61

62

58

-3

Race

White

72

71

66

-6

Black

66

64

61

-5

Hispanic

63

56

47

-16

Education

Less Than High School

63

55

45

-18

High School Graduate

70

67

62

-8

Some College

72

68

63

-9

College

81

82

75

-6

More Than College

80

85

79

-1 *Private wage and salary workers ages 18 to 64, with at least 20 weekly hours and 26 weeks of work. Source: Mishel, Bernstein and Schmitt, 1997.

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Part 3

What Explains the Coverage Decline?

Rapidly rising health care costs-or, more precisely, employers’ responses to costs-have contributed to the widespread erosion of employer coverage. As employers have shifted costs to workers, participation has dropped. Low-wage workers have been disproportionately affected by rising costs, losing access to coverage as well as finding participation more difficult. Their problems have been exacerbated by structural changes in labor markets, which have weakened the tie between jobs and health insurance.⁹

Constrained Employer Spending. A key factor behind the decline in employer coverage has been the rapid rise in health care costs. The cost of health insurance grew rapidly in the 1980s and early 1990s, far exceeding the growth in consumer prices generally. Between 1988 and 1996, the average premium for family coverage rose 9.8% per year, the premium for individual coverage increased 7.5% per year, while prices overall increased about 4% annually.¹⁰

Employers’ primary response to rapidly rising health care costs has not been to drop health care coverage for full-time workers. However, employers have constrained spending by requiring workers to pay a larger share of health insurance premiums, by tightening eligibility requirements for part-time workers (whose coverage has long been restricted) and, increasingly, in recent years, by replacing regular full-time employees with part-time and contingent workers.¹¹

Workers’ average monthly contributions for single and family coverage rose steadily between 1988 and 1996 as workers paid a larger share of higher premiums.¹² In fact, as shown in Figure 9, workers’ contributions rose more rapidly than premiums as employers shifted more of the costs of health insurance to workers, especially for non-family coverage. While average premiums for non-family coverage rose an average of 7.5% per year between 1988 and 1996, employees’ contributions rose much more rapidly–increasing by 18.3% per year.¹³

As employers have shifted costs to workers, some workers have dropped coverage, while those who have kept coverage are paying more. As shown in Figure 10, the proportion of workers participating in employer plans to which they had access fell from 93% in 1987 to 89% in 1996. Access to employer coverage was basically unchanged over this period–about 82 percent. Although the fact remains that most (about 70 percent) of the working uninsured lack access to coverage, the decline in coverage between 1987 and 1996 mostly reflects a drop in participation.¹⁴

This overall pattern obscures a worsening of access, as well as participation, for low-wage workers. Although participation rates have dropped most rapidly for the lowest wage workers, access to employer coverage has also declined for these workers. For example, among workers earning more than $15 per hour, the proportion with access to employer coverage increased from 92% in 1987 to 96% in 1996. In contrast, the proportion of low-wage workers (those earning less than $7 per hour) with access to employer coverage declined 5 percentage points over this same time period, from 60% to 55% [Table 2]. The large drop in coverage rates for the lowest wages workers is thus explained by a combination of declining participation and a decline in employer offerings.

Changes in Low-wage Labor Markets. For low-wage workers, costs and employer cost containment are not the only factors producing this deterioration. Structural changes in labor markets, that have occurred throughout the 1980s and 1990s, have contributed to the decline in coverage.

The main change in the labor market over the past two decades has been the widespread deterioration of wages, especially for those workers who initially had low wages, were without a college degree, were in blue collar or service occupations, or were in younger age brackets.¹⁵ From 1989 to 1996, the real hourly wage of the typical (median) worker fell 5.2%, while the wages of high-wage workers (90th percentile) increased 0.4%, and wages for low-wage workers (20th percentile) declined by 2.3%. Among low-wage men, the wage declines were even greater. Wages for low-wage men fell 6.4% between 1989-96.¹⁶ That is, wages for workers at the middle and at the bottom of the pay scale have not only failed to keep up with health care costs, they have declined in real terms. The large drop in participation rates for the lowest wage workers is understandable in light of the deterioration in wages for these workers. Employer actions that have led to coverage declines for all workers have thus had a disproportionate effect on the lowest wage workers.

Table 2 Change in Access, Family Take-up and Coverage, by Wage1987-1996 Wage Level 1987 1996 Change 1987-96

Coverage $15 87 90 +3

Access to Employer Coverage* $15 92 96 +4

Family Take-Up Rate** $15 94 94 0 * Percent of workers with access to job-based insurance through their own employer or a family member s employer.** Percent of workers with access to job-based insurance who are actually covered by it.Source: Cooper and Schone, 1997.

The decline in access for low-wage workers also is rooted in structural labor market changes. Shifts in employment to low-paying sectors may account for most of this decline in access. As jobs have shifted from high-paying industries like manufacturing to low-paying sectors like retail trade and services, health insurance coverage has declined.¹⁷ In addition, the proportion of the workforce in “nontraditional” work arrangements–such as regular part-time work, contingent work, and self-employment–has grown in the past decade. The expansion of employment in these jobs is not large enough to explain much of the decline in coverage; nevertheless, since these jobs are less likely to come with health insurance benefits, the expansion of nontraditional work has contributed to the overall decline in coverage.¹⁸

Conclusion

Over the past decade, there has been a decline in employment-based health insurance coverage. The fall in coverage is a widespread phenomenon that goes beyond low-income families. However, often overlooked is that low-wage workers and low-income families–who started out at a disadvantage, with low rates of coverage–have borne the brunt of the decline. The gap in coverage between low-wage and high-wage workers has grown between 1987 and 1996 because the decline in coverage has been greatest for low-wage workers. Although Medicaid plays an important role in providing insurance coverage for many low-income families, including working families, Medicaid’s eligibility levels are constrained. Workers without children are, for the most part, precluded from coverage. Beyond Medicaid’s reach, therefore, many low-income working families are likely to be uninsured.

This paper was prepared for the Kaiser Commission on Medicaid and the Uninsured by Ellen O’Brien and Judith Feder, Institute for Health Care Research and Policy, Georgetown University.

Notes

¹ In this Issue Paper, we rely on Current Population Survey estimates of employer health coverage and trends. Estimates of the proportion of families with various sources of insurance by income level are based on the Urban Institute’s TRIM-II model, which produces a different total estimate because it adjusts for the undercount of Medicaid beneficiaries in the CPS.

² Workers ages 21-64 who are not self-employed.

³ The tax treatment of employment-based health insurance provides an incentive for employers to provide compensation to workers in the form of health coverage rather than in the form of wages subject to current taxation. The tax preference that the exclusion provides is substantial and has resulted in widespread access to health coverage. Yet, despite this fact–as this Paper describes–coverage rates for the lowest wage workers have traditionally been quite low and have declined significantly in the past two decades. The specific provisions of the exclusion provide a partial explanation. To qualify for the exclusion of employer-provided health coverage, employers’ health plans do not need to cover all workers. Although the tax code requires “non-discrimination”–a self-insured health plan may not discriminate in favor of highly compensated individuals as to ability to participate–employees who have not completed three years of service, those under age 25, and part-time or seasonal employees may be excluded from consideration. Moreover, insured health plans, as opposed to self-insured plans, are generally not subject to non-discrimination rules.

⁴ According to the Employee Benefits Supplement to the Current Population Survey, 51 million of the nearly 89 million private wage and salary workers in 1993 (or about 57% of private industry workers) had health care coverage through their employer. Of the 38 million workers without such coverage, about 50% were in firms that did not offer coverage, and 40% were in firms that offered benefits to at least some employees. (Information on whether the employer sponsored a health plan was not available for the remaining 10% of workers). See tabulations of the CPS Employee Benefits Supplement in U.S. Department of Labor. Report on the American Workforce (Washington, DC: GPO, 1995).

⁵ Based on an average premium for family coverage of $5,349 in 1996. KPMG Peat Marwick data cited in AFL-CIO, Paying More and Losing Ground: How Employer Cost-Shifting is Eroding Coverage of Working Families (Washington, DC: AFL-CIO,1998), p. 16.

⁶ These are “family take-up rates.” They measure the proportion of workers who take-up any employer plan available to them — through their own employer or through a family member’s employer. Workers’ participation rates in their own employer plans are lower (63% of the lowest wage workers and 85% of the highest wage workers participated in own employer plans they were offered) since some workers turn down their employer’s plan and choose to be covered under a family member’s plan.

⁷ Because of changes to the survey beginning with the March 1995 CPS, however, the estimates of employer coverage rates for 1994-96 are not comparable to data for prior years. The observed increase in employer coverage rates may be an artifact of changes in the survey questions.

⁸ John Holahan, Colin Winterbottom, and Shruti Rajan, “A Shifting Picture of Health Insurance Coverage,” Health Affairs 14(Winter 1995): 253-264.

⁹ On the more rapid drop in coverage for less educated workers see Peter Gottschalk, Trends in Wages and Health Insurance Status of Less Educated Workers. Menlo Park, CA: The Henry J. Kaiser Family Foundation; and Sherry Glied and Mark Stabile, “Graduation to Health Insurance Coverage: 1981-1996,” Working Paper 6276. (Cambridge, MA: National Bureau of Economic Research, 1997). Other studies of the decline in employer coverage include: Richard Kronick, “Health Insurance 1979-1989: The Frayed Connection between Employment and Insurance,” Inquiry 28(Winter 1991): 318-332; Deborah Chollet, “Employer-Based Health Insurance in a Changing Workforce,” Health Affairs 13(Spring 1, 1994): 315-26; Gregory Acs, “Trends in Health Insurance Coverage Between 1988 and 1991,” Inquiry 32(Spring 1995): 102-110; and Stephen Long and Joel Rogers, “Do Shifts Toward Service Industries, Part-time Work, and Self-Employment Explain the Rising Uninsured Rate?” Inquiry 32(Spring 1995): 111-117; and Paul Fronstin and Sarah Snider, “An Examination of the Decline in Employer Sponsored Health Insurance Between 1988 and 1993,” Inquiry 33(Winter 1996/1997): 317-325.

¹⁰ Data from KPMG Peat Marwick and Health Insurance Association of America, cited in General Accounting Office. “Private Health Insurance: Continued Erosion of Coverage Linked to Cost Pressures.” GAO/HEHS-97-122 (Washington, DC: GPO, 1997).

¹¹ See Arne Kalleberg, Edith Rassell, and Ken Hudson, et. al., Nonstandard Work, Substandard Jobs (Washington, DC: Economic Policy Institute, 1997) and Thomas Rice, Nadereh Pourat, Rebecka Levan, et. al., “Trends in Job-Based Health Insurance Coverage.” (Los Angeles, CA: UCLA Center for Health Policy Research, June 1998).

¹² The total nonfederal employer premium contribution fell from 85.1% to 83.9% between 1990 and 1996. In 1996 alone, this 1.2-percentage-point decrease in the employer’s share would represent a cost-shift of $3.6 billion to employees enrolled in employer-sponsored health plans. See Katherine R. Levit, Helen C. Lazenby, Bradley R. Braden, et. al. “National Health Spending Trends in 1996,” Health Affairs 17(January/February 1998), p. 46.

¹³ KPMG Peat Marwick data for 1991-1996 and HIAA data for 1988-1990 cited in AFL-CIO, “Paying More and Losing Ground: How Employer Cost-Shifting is Eroding Coverage of Working Families” (Washington, DC: AFL-CIO,1998), p. 16.

¹⁴ Philip Cooper and Barbara Schone. “More Offers, Fewer Takers for Employment Based Health Insurance: 1987 and 1996,” Health Affairs 16(November/December 1997): 142-149.

¹⁵ Lawrence Mishel, Jared Bernstein, and John Schmitt. The State of Working America, 1996-97 (Armonk, NY: M.E. Sharpe, 1997), p. 139.

¹⁶ Lawrence Mishel, Jared Bernstein, and John Scmitt. “Finally Real Wage Gains.” Issue Brief #127, July 17, 1998. Washington, DC: Economic Policy Institute.

¹⁷ See especially Chollet (1994).

¹⁸ See Arne Kalleberg, Edith Rassell, and Ken Hudson, et. al., Nonstandard Work, Substandard Jobs (Washington, DC: Economic Policy Institute, 1997). Return to top

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