bls_0648_1940pt5.pdf

STUDY OF CONSUMER PURCHASES U R B A N TECH N ICAL SERIES

+

Family Expenditures in Selected Cities, 1935-36

VOLUME V

Medical Care

Bulletin T o^. 648

UNITED STATES DEPARTMENT OF LABOR B U R E A U OF LA B O R STATISTICS

in cooperation with the

W O R K S PROGRESS A D M IN IST R A T IO N

Digitized for FRASER http://fraser.stlouisfed.org/ Federal Reserve Bank of St. Louis

UNITED STATES DEPARTMENT OP LABOR

Frances Perkins, SecretaryB U R E A U O F L A B O R S T A T IS T IC S

I sador L u bin , C om m issionerS idney W . W ilcox

C h ief S ta tis tic ia nA . F . H in rich s

C h ief E conom istH ugh S. H anna

C h ief t E d itoria l and Research

STAFF FOR THE STUDY OF CONSUMER PURCHASES: URBAN SERIES

F aith M . W illia m s C hief f Cost of L ivin g D iv ision

A . D. H . K aplan D irector

B ernard B arton , Associate D irector M ildred P arten , Associate D irector, fo r Ta bu la tion Sam pling and Incom e Analysis

J . M . H adley , A ssociate D ir e c t o r , M ildred H artsough , Social A n alyst, Collection and Field Tabulations Expenditu re Analysis

A . C . R osander , Statistician, Ta b u la r Analysis


U N ITED STATES D E P AR TM E N T OF LABO RFrances Perkins, S ecre ta ry

B U R E A U OF L A B O R S T A T IS T IC S Isador Lubin , C om m ission er

in cooperation w ithW O R K S P R O G R E SS A D M IN IS T R A T IO N

+

Family Expenditures in Selected Cities, 1935-36

VOLUME V

Medical Care

Bulletin 648

U N IT E D S T A T E S

G O V E R N M E N T P R IN T IN G OFFICE

W A S H IN G T O N : 1940

S T U D Y OF C O N SU M E R PU R C H A SE S: U R B A N T E C H N IC A L SERIES

F or sale b y the Superintendent o f D ocum ents, W ashington, D . C. Price 30 cents


CONTENTS

PageP r e f a c e ______________________________________________________________________ v ii

Part I

E x p e n d it u r e s for M edical C are in R e l a tio n to I ncome [Prepared by Lenore A. Epstein]

C h a pt e r I. Family expenditures for medical care_____________________ 3C h a pt e r II. The components of the family medical care bill___________ 18C h a pt er III. The adequacy of spending for medical care________________ 44

L is t o f T e x t T a b le s

C h ap ter IT abl e 1. Percentage distribution of families in selected urban groups

according to the amount of expenditure for medical care, by incom e_________________________________________________ 4

2. Percentage of families reporting no expenditure for medicalcare or exp en d iture for m edicines, drugs, and m edical sup p lies only, for selected urban groups, by in co m e_____________ 9

3. Average expenditure per person for total medical care forselected urban groups, b y fam ily ty p e and in co m e_________ 13

C h ap ter I IT abl e 4. P ercen tage of to ta l exp en d itures for m edica l care a lloca ted to

services, m edicines and m edica l supplies, and h ea lth and accid en t insurance, a t selected incom e le v e ls________________ 19

5. Percentage increase in income and in expenditures for specifiedty p es of m edica l care over th e incom e range from $500- $1,000 to $2,500-$3,000, for w h ite fa m ilies_________________ 20

6. Percentage increase in income and in expenditures for specifiedtypes of medical care over a comparable income range, for white and Negro families in New York and Atlanta________ 25

7. Percentage distribution of total expenditures for medicalserv ices, for w h ite fam ilies in th e large and m id d le-sized cities, a t selected incom e le v e ls____________________________ 26

8. Percentage distribution of expenditures for medical services,for Negro families in New York and Atlanta, at selected income levels______________________________________________ 29

9. Percentage of families reporting any expense for a generalp h ysician or a sp ecia list other th an a d en tist or ocu list, for selected urban groups, b y in co m e_____________________________ 31

h i


I V CONTENTSPage

T a b l e 10. Percentage of families reporting expense for specified medical services and average expenditures for families reporting, for selected urban groups, at selected income levels___________ 34

11. Percentage of families reporting physicians services at officeand at home, average expense per family reporting, and average expense per visit, Chicago, by incom e_____________ 35

12. Percentage distribution of Chicago families by amount of usualfee for physicians visits at office and home, by incom e______ 37

13. Percentage of families reporting hospitalization, average expenseper family reporting, average number of days in the hospital, and average expense per day, Chicago, by incom e------------------ 39

14. Percentage of families reporting health and accident insuranceand average expenditures for families reporting, for selected urban groups, by incom e__________________________________ 43

Chapter IIIT a b l e 15. Average expenditure per person for medical care (exclusive of

dentistry, medicines, medical supplies, and eyeglasses) as a percentage of the estimated minimum cost per person of adequate medical care (exclusive of dentistry) when purchased on an individual basis at minimum fees, by incom e. _ 47

16. Average expenditure per person for medical care (exclusive ofdentistry, medicines, medical supplies, and eyeglasses) as a percentage of the estimated minimum cost per person of adequate medical care (exclusive of dentistry) when purchased on a group basis, by incom e________________________ 48

17. Average expenditure per person for medical care (exclusive ofdentistry, medicines, medical supplies, and eyeglasses) as a percentage of the estimated minimum cost per person of adequate medical care (exclusive of dentistry) when purchased on a group basis, East Central small cities, by family type and income___________________________________________ 49

18. Average expenditure per person for dental care as a percentageof the estim ated minimum cost per person of adequate dental care when purchased on a group basis, by incom e____ 50

L is t o f F i g u r e s

F ig u r e 1. Percentage of Chicago families reporting no expenditure forprofessional medical services, 1935-36______________________ 8

2. Family types for expenditure stu dy__________________________ 123. Relative change with income in family expenditures for medical

care, Denver and Providence, 1935-36______________________ 164. Distribution of expenditures for medical care among specified

categories, at selected income levels, Columbus and Portland, 1935-36___________________________________________________ 21

5. Distribution of expenditures for medical care among specifiedcategories, at selected income levels, Atlanta, 1935-36______ 24

6. Average expenditures per person for medical care, exclusive ofdentistry and medicines, Atlanta and Portland, 1935-36____ 46


CONTENTS VPart II

T a bu l a r Summary and A p p e n d ix e s[Jesse R. Wood, Jr., was in charge of the preparation of part II for publication]

T a b u l a r Su m m a r y : PageT a bl e 1. N u m b e r of F a m il ie s: Total number of nonrelief families

including husband and wife, both native born, eligible for the expenditure study in the areas covered; and number of families reporting on expenditures, by familytype, occupation, and income, in 1 year, 1935-36______ 54

T abl e 2. A d ju st e d I ncome a nd E x p e n d it u r e : Average adjusted income and total expenditure, by family type, occupation, and income, in 1 year, 1935-36__________________ 78

T a bl e 3. M edical C a r e : Percentage of families reporting expenditure for items of medical care and average amount of such expenditures, by family type and income, 1935-36__ 102

Supplement to Tabular SummaryT a b l e A. Median incomes and percentage distribution by income of

families represented by the expenditure data___________ 270B. Total family medical care expenditures as a percentage of

incom e________________________________________________ 271C. Average expenditures for all medical care, for services,

medicines and medical supplies, and health and accident insurance, at selected income levels_______________ 272

D. Percentage of total expenditures for medical care allocatedto services, medicines and medical supplies, and health and accident insurance, for white families in selected East Central cities, by family type, at selected income levels_________________________________________________ 273

E. Percentage of total expenditures for medical care allocatedto services, medicines and medical supplies, and health and accident insurance, Chicago, by occupation and incom e____________i ___________________________________ 274

F. Average number of visits to and from a general physicianand of days of hospitalization, for families reporting, Chicago, by occupation and incom e___________________ 275

G. Average number of visits to and from a general physicianand of days of hospitalization for families reporting, Chicago, by family type and incom e__________________ 276

H. Distribution of coefficients of variation in expenditures forgeneral physician, dentist, and medicines and drugs, Chicago_______________________________________________ 277


VI CONTENTSPage

A p p e n d i x A. Scope and method of the Study of Consumer Purchases:Urban Series___________________________________________ 279

The population covered:Cities studied__________________________________________________ 280N ativity groups________________________________________________ 280Income and occupational groups________________________________ 280Family type groups____________________________________________ 282Other eligibility requirements__________________________________ 282

Sampling procedures________________________________________________ 282Number of families from which expenditure data were secured-_ 285

Method of securing averages:Combinations of cities__________________________________________ 286Combinations of occupations and family ty p es__________________ 286The weighting process__________________________________________ 287

A p p e n d ix B. Classifications and definitions of terms Glossary_________ 289Ap p e n d ix C. Explanation of tables in Tabular Summary_______________ 295A p p e n d ix D. Facsimile of expenditure schedule_________________________ 299A p p e n d ix E. Analysis of variance_______________________________________ 305A p p e n d ix F. Communities included by the Bureau of Home Economics

in the Study of Consumer Purchases____________________ 309A p p e n d ix G. Cities included by Bureau of Labor Statistics in the Study

of Money Disbursements of Wage Earners and Clerical Workers________________________________________________ 311


PREFACE

Average annual expenditures for medical care during 1935-36, as reported to the United States Bureau of Labor Statistics in the Study of Consumer Purchases, were large enough to provide adequate medical care only among the few families with relatively high incomes.

Estimates of the cost of adequate care for an average group of families when paid for on an individual basis according to minimum fees place the average expenditure needed at $75.50 per person per year. In contrast, the data obtained by the Bureau of Labor Statistics in the Consumer Purchases Study shows that the per person expenditures of large-city families in the median income group average from $13 to $25. Insofar as these expenditures included fees for clinic visits, they did not cover the entire cost of the medical care received. Clinic service was received by a very small proportion of the families included in the investigation, however, and only a small proportion had any medical care for which they paid no fee.

The unmet health needs of a large proportion of the American population are today widely recognized. Likewise, the serious consequences of the uneven distribution of medical costs and the wage loss due to illness are the subject of serious consideration. In August 1935 the President appointed the Interdepartmental Committee to Coordinate Health and Welfare Activities, which, in turn, created a technical committee on medical care, made up of experts from the Federal agencies concerned. The report of this technical committee, presented at the National Health Conference held in July 1938, emphasized the deficiencies in the present health services, based upon findings of its own staff, on those of the National Health Survey, and of other responsible research agencies. Data collected in the National Health Survey and other national studies in the health field cover the prevalence and incidence of illness and the receipt of medical care in relation to various factors.

The Study of Consumer Purchases includes data on family expenditures for various types of medical service, for medicines and other medical supplies, and for health and accident insurance, but no correlative information in regard to the incidence of illness.

The present volume represents one of a number of bulletins covering expenditures for particular commodities and services. The results of the investigation are embodied in three series of bulletins, of which

VII


VIII PREFACEthe present constitutes a part of the third. The first series was concerned with an analysis of the distribution by income class, occupational group, family type, nativity, and home tenure, of families studied in selected communities in different parts of the country. Each volume in that series pertained to a specific geographic region. The second series comprised reports on expenditures for the main categories of family living by nonrelief native-born complete families in the same regions. The third series embodies separate reports on the constituent items in the more important consumption categories, assembling for the use of those people who are concerned with the original work materials, the data collected in all cities covered by the study.

The present study of family expenditures for medical care permits comparisons among different sections of the country, among communities of varying degrees of urbanization, and between white and Negro families in the same community. I t covers a wide range of family incomes, from those just above the relief level to incomes of more than $10,000. I t was planned, moreover, so as to supply a sample that would allow for comparison among different occupational groups and among families of varying composition.

The relation of income, family size and age composition, occupational classification, size of community, geographical location, and racial characteristics to average total expenditures for medical care, to the distribution of such expenditures among constituent categories, and to the proportion of families incurring such expenditures throws light on the relative urgency of different types of medical care as well as on the degree to which health needs are at present met among different groups of families. Data on the variation in expenditures for medical care among families classified in relatively homogeneous groups, moreover, may furnish a valuable guide to those concerned with health programs.

The study conducted by the Bureau of Labor Statistics was paralleled by a study of small-city, village, and farm families conducted by the Bureau of Home Economics of the United States Department of Agriculture. Both surveys, which together constitute the Study of Consumer Purchases, were administered under a grant of funds from the Works Progress Administration. The National Resources Committee and the Central Statistical Board cooperated in the Nation-wide study. The plans for the project were developed and the administration was coordinated by a technical committee composed of representatives of the following agencies: National Resources Committee, Hildegarde Kneeland, chairman; Bureau of Labor Statistics, Faith M. Williams; Bureau of Home Economics, Day Monroe; Works Progress Administration, Milton Forster; and Central Statistical Board, Samuel J. Dennis.


PREFACE IXIn view of the fact that a number of persons outside the Bureaus

regular staff took part in the investigation, the Bureau of Labor Statistics wishes to acknowledge the services of the following persons who served as regional or metropolitan directors of field work: Ruth Ayres, Le Roy Clements, Rachel S. Gallagher, Forest R. Hall, Sybil Loughead, Glenn W. Sutton, Margaret D. Thompson, Georges M. Weber, and Erika Hartmann Wulff.

Acknowledgment is also made to Frances W. Valentine, Jesse R. Wood, Jr., and William Loudon, who were in charge of computation and tables; Joseph A. Smith, in charge of machine tabulation; Dorothy McCamman who served as chief check editor; Frank Strohkarck, Marie Bloch, Ethel Cauman, Verna Mae Feuerhelm, Lenore A. Epstein, Trusten P. Lee, Mary Wiatt Chace, and Allan M. Winsor, who were in charge of editing and reviewing.

I sador Lubin,Commissioner oj Labor Statistics.

M ay 1939.


Part I

Expenditures for Medical Care in Relation to Income

1


Bulletin 7Vo. 648 (Vol. V) of the

United States Bureau of Labor Statistics

Fam ily E xpenditures in Selected C ities, 1935-36 MEDICAL CARE

Chapter I

Family Expenditures for Medical Care

In present-day American communities, there is a dual responsibility for the health of the population. Government agencies provide a basic safeguard by the operation and enforcement of sanitary measures, by direct relief allowances for the unemployed, by the institutionalization of the unfit, and, together with private philanthropic agencies, by the provision of medical services for those receiving relief or maintaining themselves on very small earnings. By and large, however, among self-sustaining families even at low income levels, the responsibility for meeting the expense of treatment and medical supplies necessitated by illness as well as of preventive care rests with the individual families.

Variations in medical care expenditures among families with similar income.The irregular and unpredictable incidence of illness results in wide variations from year to year in the expenditures of any one family for medical care, and in wide variations in the expenditures made during a single year, among families in the same economic group. Hence, any generalizations arising from a study of the average medical care expenditures 1 of the families covered by the Bureau of Labor Statistics in the Study of Consumer Purchases must be tempered by an understanding of the dispersion in the amounts spent.

There were some families in almost every income group that made no expenditures for medical care during the year of the survey, some that spent negligible amounts for medicine and drugs, while others expended several hundred dollars to meet the bills of surgeon or hospital. The prevalence of this situation throughout the country may be inferred from the data on the distribution of families by the

i While the term expenditure is used, it must be recognized that the figures reported include the full amounts incurred for medical care for members of the economic family during the year of the survey, whether or not they were actually paid.

3


4 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 - 3 6amount of their expenditures for medical care, presented in table 1 for white families in Chicago, 111.; Butte, Mont.; Pueblo, Colo.; and Atlanta, Ga.; and for Negro families in Atlanta.2 In the white group yi Chicago, there were some in all but one income class above $750 that spent at least $400 during the year for medical care. This was true of the families studied at all income levels above $1,250 in two relatively small cities in the Rocky Mountain area. Moreover, the expenditures of some families were far above $400.T a b l e 1 .Percentage distribution of families in selected urban groups according to the amount of expenditure for medical care, by income

CHICAGO: WHITE FAMILIES

Income class All,familiesNo expenditure reported

Under$10 $10-$19 $20-$39 $40-$59 $60-$79 $80-$99 $100-$199 $200-$299 $300-$399$400andover

$500-$749__________ 100 7 38 23 12 7 3 4 6$750-$999__________ 100 4 26 16 17 12 7 1 15 1 (*) 1$1,000-$1,249_ ____ 100 4 18 13 28 18 5 2 10 2 (*)$1,250-$1,499 _ _ _ 100 4 12 11 22 11' 10 7 22 (*) 1$1,500-$1,749_______ 100 2 12 12 19 12 11 9 18 2 1 2$1,750-$1,999_______ 100 1 9 4 20 15 14 6 26 2 3 (*)$2,000-$2,249_______ 100 1 8 8 14 16 13 11 20 3 4 2$2,250-$2,499_______ 100 3 3 8 14 15 11 8 21 10 4 3$2,500-$2,999_______ 100 (*) 2 3 13 13 13 15 24 9 4 4$3,000-$3,499_______ 100 1 4 4 10 13 10 11 30 6 7 4$3,500-$3,999_______ 100 2 2 5 9 10 13 12 27 10 4 6$4,000-$4,999_______ 100 1 3 1 7 8 9 11 25 18 6 11$5,000-$7,499_______ 100 2 1 6 3 6 6 9 25 18 8 16$7,500-$9,999 100 5 8 3 5 25 23 4 27$10,000 and over___ 100 7 18 11 18 22 9 15

BUTTE-PUEBLO: WHITE FAMILIES$250-$499 ______ 100 4 32 9 27 12 16$500-$749__________ 100 19 12 31 26 6 1 2 3$750-$999 __ ____ 100 3 10 19 17 12 8 11 17 2 1$1,000-$1,249_______ 100 9 18 24 17 8 3 14 2 5$1,250-$1,499_______ 100 (*) 5 11 16 12 17 10 21 4 1 3$1,500-$1,749_ ___ . 100 6 8 19 24 14 5 16 3 3 2$1,750-$1,999_______ 100 3 3 10 14 15 12 10 26 5 1 1$2,000-$2,249_______ 100 2 5 4 11 19 12 8 25 6 6 2$2,250-$2,499_______ 100 1 1 9 14 17 13 6 27 4 4 4$2,500-$2,999_______ 100 1 6 11 24 11 10 23 10 4$3,000-$3,499_______ 100 3 1 2 15 3 18 10 27 10 6 5$3,500-$3,999_______ 100 2 5 5 14 X i 8 18 16 10 4 4$4,000-$4,999_______ 100 8 3 5 6 5 3 39 7 5 19$5,000 and over____ 100 6 7 4 4 4 14 33 4 4 20

* Less than 1 percent.2 Two metropolitan communities, 6 large cities averaging 300,000 inhabitants, 14 middle-sized cities of

30,000 to 75,000, and 9 small cities of from 10,000 to 20,000 were included in the expenditure analysis by the Bureau of Labor Statistics. The Study was limited to native white families except in New York, Columbus, and the Southeastern cities, where a separate sample of native Negro families was taken. The expenditure survey covers only families which had not been on relief at any time during the schedule year. For list of communities, see pt. II, p. 280. For number of expenditure schedules analyzed for each tabulation unit, see pt. II, p. 285.


F A M I L Y E X P E N D I T U R E S F O R M E D I C A L C A R E 5Table 1. P e r c e n ta g e d i s t r ib u t io n o f f a m i l i e s i n s e le c te d u r b a n g r o u p s a c c o r d in g

to th e a m o u n t o f e x p e n d i tu r e f o r m e d ic a l c a r e , b y in c o m e ContinuedATLANTA: WHITE FAMILIES

Income class AllfamiliesNo expenditure reported

Under$10 $10-$19 $20-$39 $40-$59 $60-$79 $80-$99 $100-$199 $200-$299 $300-$399$400andover

$500-$749__________ 100 8 56 16 12 4 4$750-$999__________ 100 2 29 18 13 17 3 6 10 2$1,000-$1,249_______ 100 4 16 21 27 14 1 14 3$1,250-$1,499_______ 100 5 11 11 27 10 10 4 17 4 (*) 1$1,500-$1,749_______ 100 9 3 23 18 10 8 23 4 l 1$1,750-$1,999_______ 100 1 4 13 21 11 14 7 18 7 2 2$2,000-$2,249_______ 100 (*) 4 7 16 22 8 8 20 9 2 4$2,250-$2,499_______ 100 3 5 8 14 14 12 10 23 2 4 5$2,500-$2,999 _____ 100 2 4 10 11 10 12 25 14 5 7$3,000-$3,499_______ 100 i 4 5 6 9 17 10 27 9 6 6$3,500-$3,999_______ 100 4 9 8 10 4 13 8 19 4 14 7$4,000-$4,999 ___ _ 100 3 4 1 5 4 3 37 18 18 7$5,000-$7,499 ______ 100 1 1 6 5 7 2 20 19 17 22$7,500 and over____ 100 1 4 2 2 3 30 14 8 36ATLANTA: NEGRO FAMILIES

Under $250 ___ 100 29 25 24 3 13 6$250-$499 _____ 100 15 25 16 33 7 1 2 1$500-$749 100 4 20 12 20 28 11 3 2 (*)$750-$999 100 2 11 5 31 25 8 7 11 (*)$1,000-$1,249 100 12 3 26 23 16 6 13 1$1,250-$1,499 100 3 4 5 15 25 16 15 15 1 1$1,500-$1,749 100 7 12 13 7 18 17 17 3 6$1,750-$1,999 100 9 13 10 17 3 24 9 9 6$2,000-$2,249 _ _ 100 13 7 11 9 12 14 34$2,250-$2,499 _ . 100 7 13 7 13 7 8 45$2,500-$2,999 . 100 11 7 13 17 35 11 6$3,000-$3,499 100 8 46 46$3,500-$3,999 100 20 20 20 40$4,000 and over 100 10 20 70*Less than 1 percent.Incidence of illness at different income levels.The findings of

several recent studies all point to the inverse association of illness rates with economic status. Data collected from about 12,000 wageearning families in 10 cities in 1935 showed that among families classified as poor the disabling illness rate for a 3-month period was 23 percent higher than the illness rate of families classified as comfortable. 3

The findings of the Committee on the Costs of Medical Care, as to severity of illness, in a special study relating to approximately 6,500 wage earners (ages 15-64), are summarized in the followingtable:4

Annual family income:Under $1,250____$1,250-$1,999___$2,000-$2,999___$3,000 and over__

D a y s o f d is a b il i ty p e r d is a b lin g case p e r y e a r____ 24. 7____ 15. 4____ 13.9_____11. 2

3 Perrott, G. St. J., and Collens, S. D.: Relation of Sickness to Income and Income Change in 10 Surveyed Communities. Health and Depression Studies No. 1, Public Health Reports, vol. 50, No. 18 (May 1935). Reprint 1684.

4 Perrott, G. St. J.: The State of the Nations Health, Annals of the American Academy of Political and Social Science (November 1936), vol. 188, pp. 140-142.


6 F A M I L Y E X P E N D I T U R E S I N S E L E C T E D C I T I E S , 1 9 3 5 - 3 6Data collected in the National Health Survey, 1935-36, on the

annual frequency and severity of illnesses disabling for 1 week or longer as related to income (for 2,308,588 persons in 81 cities) are summarized as follows: 5

F r e q u e n c y r a te o f d is a b lin g i l l n e sse s p e r 1 ,0 0 0 p e r s o n sAnnual income and relief status: in a 1 2 -m o n th p e r io d

All incomes__________________________________________ 172Relief families________________________________________234Nonrelief families:

Under $1,000____________________________________ 174$1,000 to $1,999__________________________________ 155$2,000 to $2,999__________________________________ 150$3,000 and over__________________________________ 149

Changes with income in expenditures for medical care.Although the variation in expenditures for medical care shows little change over the entire income range, the proportion of families having small expenditures declines and the proportion spending large amounts increases at successively higher income levels. This shift is reflected in the rise in the average outlays from less than $50 among families with incomes below $1,000 in almost all the cities studied, to $70 or $80 at the $1,500 to $1,750 income level, and about $200 or more among those receiving incomes above $5,000.6

This tendency for average medical expenditures to increase with income, or ability to pay, which is a general characteristic of family spending habits, is in sharp contrast to the tendency for illness to strike more heavily the lower the average income of a group.

By and large, the increase in expenditures was proportional to the increase in family income.7 Although the medical care outlays of individual families varied from zero to 50 or even 100 percent of current income, average expenditures for medical care ranged irregularly between 3 and 6 percent of income, among families in the income groups between $1,000 and $5,000. Among families with incomes below $1,000, the proportion of income absorbed by expenditures for medical care in some city groups averaged substantially more than 6 percent and in some less than 3 percent. On the other hand, among families with incomes above $5,000, medical expendi-

5 See Preliminary Reports, The National Health Survey, Sickness and Medical Care Series, Bull. No. 2, Illness and Medical Care in Relation to Economic Status, National Institute of Health, U. S. Public Health Service, Washington, 1938, p. 2.

6 See pt. II, table 3, for all data on average expenditures for total medical care and constituent categories and on the percentage of families reporting. Averages and percentages are presented for all families at each income level and for families of each type group by income for 20 urban groups. Average expenditures are based on all families in a given group, whether or not they reported expenditures for a given category. Both averages and percentages are weighted by the frequency of families eligible to supply expenditure schedules in the constituent population groups. See pt. II, p. 286, for method of deriving averages and for weighting.

7 See supplement to Tabular Summary, table B. Family income, as defined in this report, includes money earnings, other money income, and nonomney income received in the form of housing, food, or fuel. It should be noted, however, that the income used as a basis of classifying families into different groups excluded nonmoney income obtained in the form of food and fuel, which was negligible for most families except at the lowest income levels. For data on total family income see pt. II, table 2.


FAMILY EXPENDITURES FOR MEDICAL CARE 7tures in most groups absorbed a somewhat smaller proportion of income.8

The steady increase at successive income levels in average expenditures for medical care reflects in varying degrees four factors: (1) The increasing proportion of families that made expenditures for services of one type or another; (2) the more frequent and extensive care obtained by those with successively higher incomes; (3) differences in the fees paid by families at different income levels; and (4) the relatively large proportion of families at the low income levels in certain cities that received some care without money expense. Available data on physicians* fees reported by families at different income levels and on the change with income in the amount of expenditures for given services, per family having such services, will be presented in chapter II.

A few nonrelief families studied at almost every income level, as noted above, reported no expenditure for any medical care during the year of the survey. The data in table 2 indicate that some families at almost every income level purchased drugs and medical supplies, but no professional medical services. At least one-third of the white families with incomes of $500 to $750 in Chicago and Atlanta, and one-quarter of those with incomes between $750 to $1,000 made no outlays for medical care or expenditures only for drugs and medical supplies other than eyeglasses. This was true of more than 1 in 10 of the Chicago families with incomes up to $1,750, and more than 1 in 20 of those in succeeding income groups up to $2,500. (See fig.1.) Among families in Butte and Pueblo, a somewhat smaller proportion of families had no expenditure for medical care or made outlays only for medicine and drugs. Among Negro families in Atlanta, the relation to income was somewhat less regular, perhaps because of the smaller number of families studied.9

In any given year, some families have no illnesses among their members, to be sure. Nevertheless, since expenditures for dental care and general physical examinations were included in the total whenever they had been made, it is surprising to find so many families in the middle and upper portion of the income scale which had no expenditures during an entire year for medical services of any kind. The high proportions in the lower income groups, among which the

8 Medical expenditures formed a slightly smaller proportion of total family expenditures than of family income among the low income groups, whose average total expenditures exceeded their average current incomes, and a slightly larger proportion of total expenditures than of income among the high income groups, which characteristically spent less than their incomes. For data on total expenditures or the total money value of current family living, see pt. II, table 2.

9 It should be noted that the percentages of families reporting any expenditures for medical care shown in pt. II, table 3, column 2, exaggerate the prevalence of spending for medical care, particularly among low income families, in so far as expenditures for medical care imply purchase of care by physicians or of hospital and other services. The data on the proportions of families in selected units that had expenditures for medicines and medical supplies only, presented in the accompanying table 2, indicate the probable bi^s in the figures in pt. II, table 3.

150667 40-----2


ooPERCENTAGE OF CHICAGO FAMILIES REPORTING NO EXPENDITURE

FOR PROFESSIONAL MEDICAL SERVICES IN ONE YEAR, 1935-1936

U. S. BUREAU OF LABOR STATISTICS

FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5-3 6


FAMILY EXPENDITURES FOR MEDICAL CARE 9frequency and severity of illness has been found in other studies to be greatest, adds further evidence to that obtained from the National Health Survey and other studies as to the pressing need for a broad health program.T a b l e 2 . Percentage of families reporting no expenditure for medical care or expenditure for medicines, drugs, and medical supplies 1 only, for selected urban groups, by income

Income class

Chicago: White families Butte-Pueblo: White familiesAtlanta

White families Negro familiesNo expenditure or expenditure formedicinesanddrugsonly

No expenditure formedicalcare

Expenditureformedicinesanddrugsonly

No expenditure or expenditure formedicinesanddrugsonly









Under $250__ (2) (2) (2) (2) (2) (2) (2) (2) (2) 46 29 17$250-499_____ (2) (2) (2) 25 4 21 00 (2) (2) 30 15 15$500-$749____ 33 7 26 18 18 42 8 34 17 4 13$750-$999____ 25 4 21 14 3 11 25 2 23 12 2 10$1,000-$1, 249__ 14 4 10 6 6 12 4 8 11 11$1,250-$1,499_ _ 13 4 9 7 (*) 7 6 5 1 5 3 2$1,500-$1, 749__ 11 2 9 7 7 5 5 4 4$1,750-$1,999_. 6 1 5 8 3 5 5 1 4 22 9 13$2,000-$2,249_ _ 6 1 5 7 2 5 5 (*) 5 12 12$2,250-$2,499_. 7 3 4 4 1 3 11 3 8 7 7$2,50O-$2,999_ _ 2 (*) 2 3 3 3 3$3,000-$3,499__ 4 1 3 5 3 2 4 1 3$3,500-$3,999_ _ 5 2 3 8 2 6 11 4 7$4,000-$4,999_ _ 4 1 3 7 7 2 2 10 (6) 5 10$5,000-$7,499_ _ 3 2 1 3 10 00 3 10 3 3 (6) (6) (6)$7,500-$9,999__ 5 5 00 (3) 00 41 41 (*) (0 () (*>$10,000 andover__ 00 (3) 00 W (*) (*) (6) (

10 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 -3 6the middle portions of the income range. It is probable that some of these families received no more than routine health treatments while others received extensive care and even hospitalization. Among high income families it is probable that the medical treatment received without money expense represented in many cases a professional courtesy to medical men. I t is not known how frequently free care was interpreted to include, for example, physical examination of children in school.

Insofar as attention is centered on the effect of differences in income on spending for medical care, the relative frequency of families in different income groups is of no concern. If the data are to be interpreted in terms of community living, however, it is of extreme importance that the income distribution be kept in mind. The nonrelief white families containing husband and wife, both native bom, to which the study of expenditures was limited in most communities,10 constitute the most favorably situated population group. Half of these families in the middle-sized and small cities covered in the Urban Series of the Consumer Purchases Study had incomes below a point that ranged from $1,355 to $1,675. In the large and metropolitan cities the level below which half these families were found varied from $1,600 in Providence to slightly over $2,100 in New York. Nonrelief Negro families containing husband and wife, both native born, had considerably lower incomes.11

At most, 1 in 14 of the Chicago families studied at each income level above $1,750 made no expenditure for medical services. The families in the five preceding income groups, however, which very frequently reported no such expenditure, comprise almost one-half the Chicago families represented by the consumption data. Similarly, the Negro families in Atlanta in the three income groups below $750 constitute over one-half the Negro families covered in the expenditure study in that city. No expenditures for medical services were reported by 46 percent of the Negro families covered in this city with incomes below $250, by 30 percent of those having incomes of $250 to $500, and 17 percent of those with incomes of $500 to $750.

10 The purpose of these qualifications was to eliminate as far as possible factors of economic stress, broken family ties, and alien customs, which might tend to obscure the relationship to family expenditure patterns of income, occupation, family composition, degree of urbanization, and geographical locality. Since native white families greatly outnumber all other racial and national groups in most cities, it seemed wise to confine the restricted resources available for the survey to a study of the expenditures of this relatively homogeneous group. A separate sample of Negro families was taken in the Southeastern cities covered, where Negroes make up at least one-third of the population, and in New York and Columbus, in order that the influence of racial characteristics might be analyzed separately.

11 See supplement to Tabular Summary, table A, for the median incomes and a percentage distribution by income of the families represented by the data on consumer expenditures. The average incomes of foreign born families are generally below those of native born families in the same community. Similarly, broken families receive lower incomes, on the average, than families containing both husband and wife. For detailed discussion of the income distribution of foreign born and incomplete families, see U. S. Bureau of Labor Statistics Bulletins 642 through 647 and 649, Family Income an d Expenditure, Washington* 1939, vol. I.


FAMILY EXPENDITURES FOR MEDICAL CARE 11F actors other th a n in co m e th a t affect average ex p en d itu re s f o r m e d ic a l

care.While the increase in average expenditures at succeeding income levels is inversely related to the frequency and severity of illness, average expenditures of families with similar incomes might reasonably be expected to vary with the following characteristics: Family size and age composition, since they are related to the frequency and severity of illness; the occupational classification of a family, since disease and accident rates vary widely with occupation;12 community of residence, since both service fees and health needs may vary with city size and geographical locality; and racial characteristics, since the occupational distribution and the level of living is different for white and Negro families with similar incomes.13 The effect of these five factors on average total medical care expenditures will be discussed briefly before examining the components of the family medical care bill.

M e d ic a l care expen se a s re la ted to f a m i l y s iz e a n d age c o m p o s itio n . Neither family size nor the proportion of family members under and over 16 years of age appears to have any consistent bearing on total family expenditures for medical care at given income levels.14 Data analyzed by the Bureau of Labor Statistics from the Study of Consumer Purchases throw no light, however, on the customary expense of medical care for the very young or the very old, among whom illness rates reach a maximum.

12 The following nine major hazards of employment are now recognized: (1) Abnormalities of temperature; (2) compressed air; (3) dampness; (4) defective illumination; (5) dust; (6) infections; (7) radiant energy; (8) repeated motion, pressure, or shock; and (9) poisons. See U. S. Bureau of Labor Statistics Bulletin 582, Occupation Hazards and Diagnostic Signs, Washington, 1933, for detailed list of occupations affected by such hazards.

13 See U. S. Bureau of Labor Statistics Bulletins 643, 644, 647, Family Income and Expenditure, Washington, 1939, vol. II.

H White families in Chicago, Columbus, and the East Central middle-sized and small cities, and Negro families in Atlanta were classified into seven family types, shown pictorially in fig. 2, on the basis of the number and age of members other than the husband and wife, as follows:

I No other persons (families of two).II One child under 16 (families of three).

III Two children under 16 (families of four).IV One person 16 or over and one or no other person, regardless of age (families of three or four).V One child under 16, one person 16 or over, and one or two others, regardless of age (families of

five or six.).VI Three or four children under 16 (families of five or six).

VII One child under 16, and 4 or 5 others, regardless of age (families of seven or eight).In the expenditure analysis for other tabulation units, families classified in only the first five types were included and families of types II and III, and IV and V, respectively, were combined. In general, therefore, the analysis of family type differences in this report will be confined to those units where the data were presented for seven family types.

When average expenditures for medical care are compared for families of each type within each occupational group at given income levels for families in Chicago and the East Central cities, no significant differences are found. See U. S. Bureau of Labor Statistics Bulletins 642 and 644, Family Income and Expenditure Washington, 1939, vol. II, Supplement to Tabular Summary, table B, and appendix D.

When an analysis of variance is applied to data on medical care expenditures for families in the six large and six middle-sized city units, it appears that differences in family type, as defined in the Study of Consumer Purchases, were not an important factor contributing to the total variation in such expenditures. See appendix E.


12 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 -3 6

Fig. 2

FAMILY TYPES FOR EXPENDITURE STUDY

TYPE VI TYPE VII

^ MEMBERS REQUIRED FOR TYPE

MEMBER REQUIRED FOR TYPE, BUT AGE ALTERNATIVE

o

MEMBER OPTIONAL FOR TYPE

AGE ALTERNATIVE

U. S. BUREAU O f LABOR STATISTICS


FAMILY EXPENDITURES FOR MEDICAL CARE 13Per person expenditures for medical care are inversely related to

family size, as shown in table 3.16 Chicago families containing seven or eight members, for example, spent as much as $18 per member, on the average, only when they had incomes of $3,000 and more, while Chicago families containing only husband and wife, or husband, wife, and one child under 16 spent at least $18 per member, on the average, whenever their incomes exceeded $750.T a b l e 3 .Average expenditure per person for total medical care for selected urban groups, by family type and income

Income classFamily type 1

I II III IV V VI VIICHICAGO: WHITE FAMILIES

$750-$999____________________ $17. 80 $20.00 $9. 30 $13.00 $12.90 $6.10 $7.00$1,000-$l, 249________________ 18. 70 22.40 8.70 10.40 4.30 8.20 7.20$1, 250-$l, 499________________ 28. 80 25. 80 12. 30 15.80 7.20 11.80 4.80$1, 500-$l, 749________________ 29. 30 29.30 25.50 29.30 8.60 10.60 4.80$1, 750-$l, 999________________ 36.40 26.00 19.40 23. 90 10.30 20.40 12.10$2, 000-$2,249________________ 59. 80 26.80 22.40 19.40 17.20 20.00 12.70$2, 250-$2,499________________ 61.10 44. 30 25.00 25.50 17.70 25.80 8.90$2, 500-$2,999________________ 55.60 37.30 28.90 34.10 24.40 21.00 12.70$3, 000-$3,499________________ 55. 20 57.10 31.30 34.60 23.10 21.90 22.90$3, 500-$3,999________________ 57.90 73. 80 26. 30 33.80 33.60 32.50 18.30$4, 000-$4,999________________ 102. 30 58.90 42.30 62.10 33.10 28.40 24.10$5, 000-$7,499________________ 84.00 92.90 69. 30 67.60 34.00 35.80 54.90$7, 500-$9,999________________ 149.60 120.50 54.60 77.60 59.30 36.60 31.80COLUMBUS: WHITE FAMILIES

$750-$999_______ ____________ $20.10 $10.60 $9.20 $15.10 $6.40 $2.10$1, 000-$l, 249________________ 14.50 14.50 9.20 11.90 11.30 10.60$1, 250-$l, 499________________ 33.90 18.00 15.40 22.10 4.90 13.00$1, 500-$l, 749________________ 35.90 19.20 15.80 25.20 15. 80 11.40$1, 750-$l, 999________________ 30. 90 20.80 23.00 22.10 9.70 13.60$2, 000-$2,249________________ 55.80 30.30 24.00 20.60 16.20 18.70$2, 250-$2, 499________________ 51.90 29. 90 30.40 27.90 17.30 17.10$2, 500-$2,999________________ 44.10 27.00 34.50 50.20 15.40 23.10$3, 000-$3, 499________________ 88. 60 29.00 40.40 26.30 22.10 13.30$3, 500-$3,999________________ 37.60 39.10 23.50 32.40 23.50 33.80$4,000-$4,999________________ 88. 60 34.60 33.60 43.10 32.00 25.50$5,000-$7,499________________ 101. 00 69.30 40.10 42.30 34.70 (t)

$2.

10.10.19.17.22.3.75.EAST CENTRAL MIDDLE-SIZED CITIES: WHITE FAMILIES

$500-$749____________________ $10. 70 $7.00 $6.90 $3.90 $2.40 $10. 30 $4.20$750-$999____________________ 15. 80 14.10 7.30 6.90 3.60 5.20 3.30$1, 000-$l, 249________________ 18.10 16.00 11.10 11.00 9.10 8.40 4.40$1, 250-$l, 499________________ 36. 50 19.10 14.20 18.40 7.20 14.10 5.80$1, 500-$l, 749________________ 21.40 28.50 16.70 24.90 12.50 11.20 6.50$1, 750-$l, 999________________ 41.30 46.80 15.60 14.50 13. 30 9.40 10.50$2,000-$2, 249________________ 31.90 19.60 20.90 24.20 15.80 15.00 16.70$2, 250-$2,499________________ 51. 80 35. 90 19.50 14. 50 10.30 16.00 11.60$2, 500-$2,999________________ 39.20 26. 30 36. 70 23.90 12. 60 30.20 13.00$3,000-$3,499________________ 51.60 58. 70 20.10 48.60 14.60 20.80 11.00$3, 500-$3,999________________ 67.10 35. 60 12.50 43.10 27.60 14.50 (t)$4,000-$4,999________________ 46. 30 81.50 13. 30 35.20 18.90 16.90 (t)1 The 7 family types are distinguished on the basis of the number and age of members other than husband and wife, as follows:

I. No other persons (families of 2).II. 1 child under 16 (families of 3).III. 2 children under 16 (families of 4).IV. 1 person 16 or over and 1 or no other person, regardless of age (families of 3 or 4).V. 1 child under 16, 1 person 16 or over, and 1 or 2 others, regardless of age (families of 5 or 6).VI. 3 or 4 children under 16 (families of 5 or 6).VII. 1 child under 16, and 4 or 5 others, regardless of age (families of 7 or 8). t Fewer than 3 cases.15 For average number of persons per family, see Bureau of Labor Statistics Bull. 648, vol. I ll , part II,

table 1-A.

ggg3

ggg

gg 1

' SSg

SSgg

gSSg

g 1

I ggg

ggc?

gSg

ggg


14 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 - 3 6Occupational differences in medical care expense.Occupational

classification appears to have slightly more influence than family size on family expenditures for medical care, at given income levels.16 Families of self-employed professional and business workers tended to spend less than families in wage-earner, clerical, or salaried business and professional groups. This is fairly clear when family size differences are eliminated, and the data are combined for families with incomes between $1,250 and $2,500 in all the large and middle-sized cities studied.17 Since the principal earners in many of the independent professional families were themselves physicians or dentists, the members of their families doubtless received much care within the home, as well as complimentary services from other members of the medical profession. In Chicago, families of wage-earner and clerical workers tended to have larger average medical care expenditures than those in the business and professional group in the same income classes. Moreover, at almost all comparable income levels, the proportion of Chicago families spending $50 or less on medical care was smaller among the former than among the latter. In general, however, occupational variations in family expenditures for medical care were small and by no means entirely consistent.18

Regional differences in medical care expense.The native white self- sustaining urban families studied in New England and the East Central area generally spent less for medical care during the year 1935-36 than did similar families living in the Southeast or west of the Mississippi. I t is pot possible to say whether or not this regional difference would obtain in other years, although for the year of the survey it is clearly defined.19 When the comparison is based on the average expenditures of families with incomes of $1,250 to $2,500 in the large and middle-sized cities combined, with families of given type and occupation similarly distributed for each urban group, expenditures in the Rocky Mountain region stand out as highest. Families in the Pacific Northwest and the Southeast appear to have spent the

18 The occupational classification of a family was determined by the occupational group from which it derived the major portion of its earnings during the year of the survey, whether that portion was contributed by one or more family members. By and large the occupational classification was determined by the earnings of the principal earner, who, in turn, was usually the husband. For number of occupational groups distinguished in cities of varying size and for different racial groups, see pt. II, p. 286.

17 See appendix D.18 See U. S. Bureau of Labor Statistics Bulletins 642-647 and 649, Family Income and Expenditure,

Washington, 1939, vol. II, ch. VII.19 Comparisons among families at given income levels in different cities may be made without regard to

differences in the size and age composition of the population or in the occupational distribution of the families. All factors which differ are then considered a part of the regional or city-size differences observed. Another approach to the problem required that the populations compared shall be qualitatively and quantitatively alike, that is, only data for the same family type, occupational, and income groups be included, and that each group must contain equal proportions of the total number of families in each city. Any differences which can then be observed may be assumed to be true regional or city-size differences. Because of time limitations, the latter type of analysis has been made only in respect to total family expenditures for medical care and only for white families in the large and middle-sized cities included in the survey.


FAMILY EXPENDITURES FOR MEDICAL CARE 15next largest amounts, followed in sequence by families in the West Central, East Central, and New England regions.20

Comparison at each comparable level over the income range likewise shows medical care expenditures to be lowest in New England and the East Central area. On this basis, no consistent differences appear among the remaining four regions in the case of the large cities. As among the middle-sized cities, however, average medical care expenditures were clearly highest in the Pacific Northwest, with Butte and Pueblo in the Rocky Mountain area ranking next in order.

Differences in the average expenditures for medical care by families in the Northeast and the West are illustrated in figure 3. The lines in the chart marking the upper range of expenditures emphasize the wide variation in outlays by individual families from the average for the group that is characteristic of medical care expenditures. The lower limit of expenditure with few exceptions falls along the zero line. I t will be noted that while the average expenditures of Denver families consistently exceeded those of Providence families the maximum expenditure at any income level was as frequently reported by a family in Providence as by a family in Denver. The light diagonal line indicates the slope which the lines would have taken if expenditures had increased in the same proportion as income. Thus, it is clear that average expenditures for medical care in both Denver and Providence increase slightly more rapidly than income over the lower portion of the income range, and slightly more slowly over the upper portion. Maximum expenditures, on the other hand, increase considerably less rapidly than income.

Size oj city differences in medical care expense.During 1935-36 families living in the small communities covered in this report (ranging in size from 11,000 to 19,000) generally spent for medical care as much as, if not slightly more than, families with similar incomes in metropolitan cities in the same area.21 When average expenditures are compared for families in metropolitan New York, in Providence, in New Britain and Haverhill combined, and in four small New England cities, it appears that average outlays were generally largest in the last named unit. Similarly, the medical care expenditures of families in five small cities in Pennsylvania, Indiana, and Illinois averaged higher than the expenditures of families in Chicago, Columbus, and the East Central middle-sized cities. In both regions, however, expenditures of families living in the metropolises tended to be next largest. Moreover, at the income levels between $3,000 and $5,000

20 See appendix D .A test of differences in expenditures for medical care between large and middle-sized cities, based on

averages adjusted to a standardized population, for all large cities combined and all middle-sized cities combined, was not significant. (See appendix D.) City-size comparisons will be limited throughout this report to the East Central and Northeast areas where the Bureau of Labor Statistics covered communities representing four degrees of urbanization. Data for cities of the four sizes are comparable at the income levels between $500 and $3,000.


16 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 - 3 6

Fig. 3RELATIVE CHANGE WITH INCOME

IN FAMILY EXPENDITURES FOR MEDICAL CARE DENVER AND PROVIDENCE, 1935-1936

NONRELIEF W HITE FA M ILIES INCLUDING HUSBAND AND W IFE BOTH NATIVE BORN

ANNUAL EXPENDITURE ANNUAL EXPENDITURE(in Dollars )

FAMILY EXPENDITURES FOR MEDICAL CARE 17metropolitan families consistently spent more for medical care than did families in this income range in the large or middle-sized cities in the same geographic area.

Differences between racial groups in medical care expense.In the Southeastern cities Negro families with incomes below $1,750 or $2,000 (representing the great majority of all Negro families) had higher average total expenditures for medical care than white families with similar incomes, but at higher levels white families generally spent larger amounts. In Columbus there were no consistent differences between white and Negro families at given income levels, while in New York City the expenditures of white families were higher at each income level above $1,000. Thus, it appears that racial differences per se have no bearing on average total expenditures for medical care. Negro families in Atlanta, moreover, consistently spent more than Negro families with similar incomes in Columbus, and they, in turn, had larger expenditures than Negroes in New York City.

Thus far, attention has been directed only to average total expenditures for medical care. Similarities and differences among families in different groups have been pointed out, but without regard to the varying ways in which the amounts were spent. I t may be, for example, that while the total expenditures of families of different size are remarkably similar, the apportionment of these expenditures varies with family size. The regional and city-size differences in expenditures may be a reflection of different emphasis in distributing expenditures for medical care. In the following chapter, therefore, the apportionment of the average total expenditures for medical care will be discussed.


Chapter II

Components of the Family Medical Care Bill

Family expenditures for medical care fall into three distinct categories: Expenditures for care by physicians, dentists, oculists, and other specialists, and for hospital, nursing, other special services; expenditures for medicines, drugs, eyeglasses, medical supplies, and appliances; and expenditures for health and accident insurance.

Some 2 to 3 million people in the United States at present obtain all or an important part of their medical care through voluntary arrangements which embody the insurance principle. Some of these people hold health and accident policies in regular insurance companies which indemnify against medical expenditures. The majority of them, however, purchase some or all of their medical care through a cooperative arrangement; that is, in return for a fixed amount paid periodically they are entitled to specified medical services. A greater number of persons carry insurance against the risk of loss of income due to temporary disability.22 The families canvassed by the Bureau of Labor Statistics in the Study of Consumer Purchases were not asked to estimate the value of care supplied directly by an insurance company, an employer, or a benefit organization, under the terms of an insurance or benefit plan. (Such care was not, however, considered free.) When a family member received a cash benefit under the terms of a health or an accident insurance policy, the amount was added to current money income and any expenditure incurred for care during illness was entered under the appropriate medical expense item. Large average outlays for health and accident insurance and relatively small outlays for services for any group of families are, therefore, not to be considered entirely compensatory in terms of the adequacy of medical care expenditures.

Apportionment of Medical Care Expenditures Among ThreeMajor Categories

Small as are the medical care expenditures of families with incomes between $500 to $1,000, from 17 to 35 percent of the average amounts spent by white families in the different cities surveyed (that is, from $5 to $13) goes for drugs, medicines, medical appliances, and eyeglasses. (See table 4, and Supplement to Tabular Summary, table C.) Three to nine percent of the total is generally paid out in premiums for health and accident insurance. Thus, for care by physicians, dentists, oculists, and other specialists, as well as for hospital and other special health services, there remains, on the average, 60 to 80 percent of total medical expenditures, or about $20 to $30. *

22 See Louis S. Reed, Health Insurance, New York, 1937, ch. XII. 18


T a b l e 4. P e r c e n ta g e o f to ta l e x p e n d i tu r e s f o r m e d ic a l c a re a l lo c a te d to s e r v ic e s , m e d ic in e s a n d m e d ic a l s u p p l i e s ,l a n d h e a lth a n d a c c id e n tin s u r a n c e , a t se le c te d in c o m e levels

Income class$500-$999 $1,500-$1,999 $2,500-$2,999 $5,000 and over

City and color Average total expenditures formedicalcare

Percentage distribution of the total among Average total expendi- tures formedicalcare

Percentage distribution of the total among Average total expendi- tures formedicalcare

Percentage distribution of the total among Average total expenditures formedicalcare

Percentage distribution of the total among

ServicesMedicines and medical supplies

Health and accident insuranceServices

Medicines and medical supplies





Health and accident insurance

W h ite f a m il ie s Metropolises:New York_________ $19.10 66 27 7 $78.70 77 20 3 $117.90 76 19 5 $384. 70 81 10 9Chicago. __________ 39.50 81 18 1 78.20 77 17 6 117.10 75 19 6 241. 60 77 15 8Large cities:Providence.. _ _ _ 29.10 68 24 8 70.80 79 15 6 92.80 74 16 10 229.90 77 14 9Columbus.._ . . . . 40.20 73 21 6 69.50 75 19 6 122. 30 80 14 6 186. 70 77 14 9Atlanta________ _. 30. 50 62 35 3 83.20 71 24 5 162. 50 73 21 6 465. 60 85 11 4Omaha-Council Bluffs. 54.10 75 17 8 75.40 65 21 14 110. 40 66 20 14 234.10 71 13 16Denver.._ _________ 37.00 69 28 3 107.40 74 18 8 120. 40 70 18 12 266.10 72 16 12Portland . . . _______ 38. 50 71 23 6 81.60 74 16 10 122. 50 72 18 10 339. 70 81 10 9Middle-sized cities:New E n g la n d ..____ 28.60 65 28 7 97. 60 78 18 4 81. 20 77 20 3 116. 60 77 17 6East Central. ______ 28. 50 64 27 9 72.50 73 19 8 93.00 72 17 11 132.10 72 18 10Southeast_______ _ 40.00 65 29 6 82.00 68 26 6 90.60 68 26 6 204. 60 69 23 8West Central. ___ 36. 60 74 18 8 84.90 69 20 11 103. 50 68 19 13 230.00 76 12 12Rocky Mountain._. 54. 50 62 24 14 88.20 66 24 10 103. 30 66 21 13 193. 50 62 19 19Pacific Northwest___ 43.10 64 25 11 102. 40 67 18 15 110.10 66 16 18 216.00 65 12 23Small cities:New England______ 43.00 72 20 8 79.80 74 17 9 81.60 74 19 7 * 160. 30 2 73 214 2 13East Central________ 31.20 67 20 13 80.00 61 18 21 144.30 69 16 15 2149.60 2 69 2 14 217

N e g r o f a m il ie s Large cities:New York__ ____ _ 25.00 78 18 4 55.20 71 20 9 80.30 73 19 8 2 108. 70 2 87 2 12 21Columbus__________ 35. 70 42 13 45 78.10 68 14 18 41.90 49 28 23 (3) (3) (3) (3)Atlanta____________ 42.30 19 14 67 91.20 40 22 38 117. 50 51 15 34 2 134.10 2 60 2 15 2 25Middle-sized cities:Southeast__________ 43.30 30 16 54 87.40 37 19 44 161. 60 48 16 36 0 (3) (3) (3)

CO1 Includes eyeglasses. 2 Data are combined for families with incomes of $3,000 and more. 3 Expenditure schedules not taken for families at this income level.

COMPONENTS OF THE FAMILY MEDICAL CARE BILL


20 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 - 3 6Drugs and medical supplies tend to absorb a somewhat smaller

proportion of the average total expenditures for medical care among families at successively higher income levels. Even the white families with incomes of $5,000 and more, however, spent in this manner $20 to $50, or 10 to more than 20 percent of their total outlay for medical care. On the other hand, payments for services and for health and accident insurance increased somewhat in relative importance among white families in most cities. The shift over the income range in the apportionment of medical expenditures among three major categories was, however, less marked than might have been expected. (See fig. 4.)

The average expenditures for all medical care and for the three major components of the medical care bill are compared in table 5 for white families in 16 urban groups over a range that begins with families having incomes of $500 to $1,000 and ends with those receiving $2,500 to $3,000. Except in Chicago and the West Central cities, the percentage increase in service expenditures, the largest of the components, was greater than that in total expenditures for medical care or in outlays for medicines and medical supplies. Among some urban groups the increase in health and accident insurance payments was more rapid than that in services, and among others, less rapid.T a b l e 5 . P e r c e n ta g e in c r e a s e i n in c o m e a n d i n e x p e n d i tu r e s f o r s p e c i f ie d t y p e s

o f m e d ic a l c a re o v er th e in c o m e r a n g e f r o m $ 5 0 0 - $ 1 ,0 0 0 to $ 2 ,5 0 0 - $ 3 ,0 0 0 , f o r w h ite f a m i l i e s

City and region Income Totalmedicalcare ServicesMedicines and medical supplies

Health and accident insuranceMetropolises:New York. _ __________________ ___ _ __ 224 517 614 339 293Chicago. _ ______________________ _ __ _ _ 223 196 173 223 1, 600

283Large cities:Providence_______ ____ _ ___ 231 219 250 111Columbus______ _____ __________ __ 231 204 233 103 217Atlanta_________ _ __ __ _________ _ _ 236 433 531 216 870Omaha-Council Bluffs. _______ _____ _ 220 104 80 147 241Denver_________ ___________________ _ _ 229 225 232 106 1,117Portland_________ __ _ __ __ ________ 230 218 224 151 430Middle-sized cities:New E n g la n d ..___ ______ _ _ _ _ 220 184 235 103 38East Central ____ _ ____ ___ ______ 232 226 267 110 285Southeast. _ __ _____ ____ _________ 235 126 138 103 121West Central _ __ _ _ _ _ ._ _ __ 249 183 156 208 376Rocky Mountain _ _ __ _______ _ __ _ _ 237 90 103 65 74Pacific Northwest __________ _ ___ 219 155 161 67 333Small cities:New England _ _ _________________ 220 90 96 85 69East Central__________________ ________ 236 361 378 281 407

The percentage increases in expenditures by families in different urban groups are directly comparable since the average incomes of families in the $500 to $1,000 and $2,500 to $3,000 income classes, respectively, were very similar. The relatively great increases in expenditures for medical care among white families in New York and Atlanta therefore require explanation. In the case of New York,


COMPONENTS OF THE FAMILY MEDICAL CARE BILL 21

Fig. 4

DISTRIBUTION OF EXPENDITURES FOR MEDICAL CARE AMONG SPECIFIED CATEGORIES

AT SELECTED INCOME LEVELSCOLUMBUS AND PORTLAND, 1935-1936

NONRELIEF WHITE FA M IL IE S INCLUDING HUSBAND AND W IFE BOTH NATIVE BORN

COLUMBUSINCOME CLASS ( In D o lla rs )

500AND UNDER

1000

1500AND UNDER 2000

2500AND UNDER3000

5000AND

OVER

PERCENTAGE0 20 40 60 80 100

INCOME CLASS( In D o lla rs )

500ANDUNDER

1000

1500ANDUNDER

2000

2500ANDUNDER3000

5000AND

OVER

PORTLAND

0 20 40 60 80 100PERCENTAGE

SERVICESGENERAL PHYSICIAN DENTISTOTHER SERVICES

MEDICINES AND MEDICAL SUPPLIES HEALTH AND ACCIDENT INSURANCE

U. S. BUREAU DF LABOR STATISTICS


22 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 -3 6the increase is largely attributable to the extremely low average expense (only $19) of families with incomes between $500 and $1,000, which in turn reflects the fact that about two-thirds of the families spent less than $20 for all medical care. Only one of the families in this group spent more than $100. New York City has medical facilities that are probably among the best in the country even in relation to the needs of its great population. There are many hospitals and medical agencies in the city which furnish free service to families which can demonstrate their need therefor. In general, however, these hospitals and clinics adjust their fees in accordance with what they can ascertain of the familys financial status, and most families which are not on relief are charged at least a nominal fee. If the medical care expenditures of this low income group in New York had been as large as those of Chicago families with similar incomes, the percentage increase in expenditures over the selected income range would have been approximately the same as in Chicago. In the case of Atlanta, on the other hand, the sharp increase is attributable primarily to the high average expense of families with incomes of $2,500 to $3,000. Over one-fourth of these families spent more than $200 during the year for medical care, and approximately one-eighth of the latter families spent over $500 to meet the bills of physicians, specialists, and hospitals.

The size of white families appears to have no significant bearing on the apportionment of medical expenditures.23 The occupation from which a family derives the major portion of its earnings, however, appears to have some influence on the share of the average medical outlays allotted to the three major types of health expenditures.24 In Chicago, families of independent professional workers, among whom were many physicians and dentists, at most income levels spent a smaller portion of the total for services than did families in other occupational groups, probably because of the prevalence of courtesy service for families of men in the medical profession. Wage- earner families, on the other hand, generally spent more than other families for health and accident insurance, while families classified in the business group tended to make relatively the smallest expenditures for insurance. The position of wage-earner families in this respect doubtless reflects the prevalence of health and accident insurance plans operated by labor unions as well as the operation of contributory health and accident insurance in some factories.25

The geographic area in which a family lives appears to influence in some measure the relative medical expenditures of the three general

23 See supplement to Tabular Summary, table D.24 See supplement to Tabular Summary, table E. Data on expenditures for specified types of medical

care by occupational group and income are available only for Chicago.28 When an employer deducted from earnings for health or accident insurance, such amounts were entered

as insurance payments and were also added to earnings.


COMPONENTS OF THE FAMILY MEDICAL CARE BILL 23types under discussion. Outlays for services were relatively least important for families at given income levels in the Rocky Mountain and West Central regions, as among the large cities, and in the Rocky Mountain and Pacific Northwest regions, as among the middle-sized cities. Families in the Southeast tended to spend a larger share of their medical expenditures for medicines, drugs, and supplies than did families in other regions. In general, regional differences in patterning were less marked in the case of the large than of the middle- sized cities, perhaps because the availability of medical facilities varies more markedly among communities in the 30,000 to 75,000 population range than among cities of 250,000 to 300,000.

The relative distribution of medical expenditures was similar for families in cities in the four size-of-city groups in the North Atlantic and East Central areas. In the East Central region, however, health and accident insurance payments were inversely related to city size, with families in the five small cities covered clearly spending the largest amounts in this manner. Moreover, differences between the average insurance payments reported by families in the small cities and by those in Chicago were so great that when the average expenditures for medical care other than for insurance are compared, it appears that Chicago families generally spent more than the small-city families with comparable incomes, while the reverse is true when total expenditures for medical care are considered.

More striking differences in the distribution of medical expenditures are found between white and Negro families at given income levels in the Southeast than between white families at opposite ends of the income scale. Negro families in Atlanta and the Southeastern middle- sized cities at the income levels up to $2,000 paid out more, on the average, for health and accident insurance than they spent for al] medical services, drugs, and supplies. (See fig. 5.) Thus, white families consistently spent more for services and medicines than did Negro families with similar incomes. Negro families in Columbus likewise spent a larger share of their medical care allotment for health and accident insurance than did Columbus white families, but the differences were less striking than in the Southeastern cities. And in New York the pattern of spending for medical care was not very different for white and Negro families.

When average expenditures by white and Negro families in both New York and Atlanta are compared over an income range beginning with the group having incomes between $500 and $1,000, and ending with those with an average income of approximately $4,000, racial differences are very marked. (See table 6.) The increase in average outlays for all medical care is more than twice as rapid among white as among Negro families in both cities, but the increase in expendi-

15066740----- 3


24 FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5 -3 6

Fig. 5

DISTRIBUTION OF EXPENDITURES FOR MEDICAL CARE AMONG SPECIFIED CATEGORIES

AT SELECTED INCOME LEVELSATLANTA, 1935-1936

N O NREUEF FA M ILIES INCLUDING HUSBAND AND WIFE BOTH NATIVE BORN

WHITE FAMILIESINCOME CLASS (In Dollars)

500AND UNDER

1000

1500ANOUNDER

2000

2500AND UNDER3000

PERCENTAGE

INCOME CLASS (In Dollars)

500AND UNDER

1000

1500AND UNDER

2000

2500ANDUNDER3000

NEGRO FAMILIES

o 20 40 60 80 100PERCENTAGE

SERVICESGENERAL PHYSICIAN DENTISTOTHER SERVICES

U. S. BUREAU OF LABOR STATISTICS

%//A MEDICINES AND MEDICAL SUPPLIES E H HEALTH AND ACCIDENT INSURANCE


COMPONENTS OF THE FAMILY MEDICAL CARE BILL 25tures for services is relatively greater among whites than among Negroes in New York, while the reverse is true in Atlanta. As would be expected, differences in the percentage increase in insurance payments are particularly striking.

T a b l e 6 . P e r c e n ta g e in c r e a s e in in c o m e a n d i n e x p e n d i tu r e s f o r s p e c i f ie d t y p e s o f m e d ic a l c a re over a c o m p a r a b le in c o m e r a n g e f f o r w h ite a n d N e g r o f a m i l i e s in N e w Y o r k a n d A t la n ta

City and color group Income Totalmedicalcare ServicesMedicines and medical supplies

Health and accident insuranceNew York:White families _ _ ___ __ _ _ __ 370 826 1,004387 451 58617Negro families _ __ ________ _ - 337 333 193Atlanta:White families ______ _ __________ 405 506 646 209 1,01017Negro families ___ _____ _____ ____ 439 217 899 245

1 Average expenditures of families with incomes between $500 and $1,000 are compared with the average expenditures of those having incomes that averaged about $4,000. Incomes averaged approximately $4,000 for all the Negro families studied in New York and Atlanta that had incomes of $3,000 or more and for all white families studied in these cities in the income classes between $3,500 and $5,000.MEDICAL SERVICES

Care of the teeth and treatment by medical specialists other than dentists and oculists appears to be a luxury for most urban American families. Average expenditures for such services were very small for the families with incomes of $500 to $1,000 in most of the cities covered by the Bureau of Labor Statistics in the Study of Consumer Purchases, but they mounted rapidly among families in the upper portion of the income scale.

The average amounts spent for dental care generally ranged from $2 to $8 at the low income levels, and generally rose to at least 10 times as much among families with incomes of $5,000 and more. Since the services of other specialists are required in part at least because of emergency situations, the average amounts reported are somewhat less regular, varying from a few cents to $6 among low income families in different cities. The absolute increase with income in average expenditures for medical specialists reflects the present-day specialization in the field of medicine and the growing tendency on the part of some families with the ability to pay to rely not on the family physician, but on the pediatrician, the dermatologist, the allergist, the internist, the orthopedist, the gynecologist, or the ear, nose, and throat specialist, as the case requires. The importance of expenditures for diagnosis and treatment by specialists, in relation to expenditures for all medical services, increases less regularly, however, and, at least above the $1,500 income level, less rapidly than might have been expected. (See table 7.) This confirms the assumption that a considerable part of these expenditures were for care that was emergency in nature.


T a b l e 7. P e r c e n ta g e d i s t r ib u t io n o f to ta l e x p e n d itu r e s f o r m e d ic a l s e r v ic e s , f o r w h ite f a m i l i e s i n th e la rg e a n d m id d le - s i z e d c i t i e s , a t se lec tedin c o m e levels

fcO

Income classServices $500-$999 $1,500-$1,999 $2,500-$2,999

$5,000andover$500-$999 $1,500-$1,999 $2,500-$2,999

$5,000andover$500-$999 $1,500-$1,999 $2,500-$2,999

$5,000andover$500-$999 $1,500-$1,999 $2,500-$2,999

$5,000andoverProvidence Columbus Atlanta Omaha-Council Bluffs

General physician ______ __ ____ 53 35 40 26 51 46 36 30 59 49 47 30 50 40 42 2815 23 24 32 10 20 20 29 22 19 19 19 14 26 23 412 1 4 1 1 1 1 1 4 3 2 1 1 2 3 310 11 15 13 3 9 8 15 1 9 8 13 14 12 7 1516 26 11 13 34 19 31 11 9 13 15 16 17 13 15 10Private nurse ________ _____ ___ _____ 1 1 2 11 C ) 1 1 2 6 3 2 6 18 (*) 4 1 4 1Other services1 __ . _ _ _ ______ 3 3 4 4 4 2 8 2 5 3 3 6 6 2Average expenditures for all services------- $19. 70 $55.60 $69.00 $176.30 $29.30 $52.10 $97. 50 $144.30 $18.90 $59. 20 $119.30 $393.30 $40.60 $49.10 $72.90 $165.90

Denver Portland New England middle-sized cities East Central middle-sized citiesGeneral physician_______ _ _ _____ _ 54 51 43 41 45 41 38 23 47 32 35 25 58 45 40 37Dentist - ____________ ____________ 19 19 30 33 28 30 29 24 26 14 37 52 23 20 29 28Oculist __- __________ ____________ C ) 3 2 1 2 1 2 1 1 3 1 1 (*) 1 1 3 2Other specialist_____ _ __ ________ 11 9 6 4 7 10 3 6 10 14 23 8 8 10 5Hospital _______ ____ _____ - 20 11 10 10 19 12 9 13 12 38 9 8 17 10 17Private nurse _______ _________ 1 3 5 (*) 3 2 7 32 2 2 () 4 3 5 8Other services1 ____ __ ___ 4 5 4 3 6 6 4 4 3 2 6 3 3Average expenditures for all services_____ $25. 40 $80.10 $84. 40 $190. 70 $27. 20 $60. 70 $88.00 $277. 20 $18.60 $76.40 $62.30 $89. 30 $18.20 $52. 80 $66.80 $95.60

Southeast middle-sized cities West Central middle-sized cities Rocky Mountain middle-sized cities Pacific Northwest middle-sized citiesGeneral physician _ _ ____________ _ 58 55 49 34 55 48 36 40 44 46 29 29 40 27 31 24Dentist _ _ _ _________________ 11 19 23 23 14 24 40 18 18 25 41 29 30 26 45 54Oculist _____ - ____ _____________ (*) 9 1 1 1 1 1 3 1 2 4 1 4 1 1 3 1Other specialist _____ ________ _ ___ 9 7 4 5 7 11 10 2 7 14 15 13 20 4 11Hospital _ ______ ________ ____ 18 10 9 19 14 12 4 7 30 11 8 7 7 13 8 5Private nurse ______ _ _____________ 2 1 4 14 4 5 5 20 (*) 4 2 3 11 1 7 5 2Other services C _ __ ______ ________ 7 5 7 5 7 3 1 4 5 4 5 8 6 4 3Average expenditures for all services_____ $26.10 $55.40 $62.00 $141.00 $27. 20 $59.00 $69. 70 $174.30 $33.90 $58.10 $68. 70 $119. 20 $27. 70 $68. 20 $72.20 $140.10

1 Includes expenditures for visiting nurse, examinations and tests, clinic visits, fees for anaesthetist, operating room, health or infirmary fees paid for a member of the economic family attending school or college, and other services. *Less than 1 percent.

FAMILY EXPENDITURES IN SELECTED CITIES, 19 3 5-3 6


COMPONENTS OF THE FAMILY MEDICAL CARE BILL 27Outlays for hospitalization,26 except for obstetrical cases, reflect

emergency situations to an even greater extent. Hence, it is not surprising that such expenditures vary irregularly in relative importance among different groups of families, with no clear relationship to income.

The very small average amounts spent for private nurses whether in the hospital or at home, by families at all except the very highest income levels indicate that private nursing, like dental and other specialized care, is a luxury that most families cannot afford. The amount of care received from visiting nurses is difficult to estimate. The average amounts spent for this type of care were very small; this may indicate that the families studied made little use of such services, or it may reflect the fact that many of the families received such care without expense or at a nominal charge.

Average expenditures for clinic visits were extremely small. As in the case of visiting nurses, however, this may be accounted for either by negligible use of such services, free clinical care, or nominal charges.

Examinations and tests likewise took a negligible proportion of expenditures for medical services. I t is recognized that relatively few persons have annual health examinations as a preventive measure, and it is probable that expenditures for diagnostic tests in the case of illness were frequently included with expenditures for the physician, specialist, or for hospital care.

The outlays of all families with incomes of $500 to $1,000 for oculists7 care never averaged as much as $1. Even when combined with expenditures for eyeglasses they seldom averaged as much as $3 for the year, among the low income families.27

The general practitioner, or family physician, still plays a predominant role in meeting family health needs. A larger share of every dollar spent for medical services goes for care by a general physician than for any other type of medical service, except among the relatively few families at the very high income levels, which tend to spend larger amounts for dental care. (See fig. 4.) Very roughly, one-half the average expenditures for services, or $10 to $20, is paid out to the general practitioner by families with incomes between $500 and $1,000. At least among families with incomes below $3,000, physicians7 fees account for more than one-third of the total for services, and even among families with incomes of $5,000 and more, as much as three- tenths. The increase with income in expenditures of this type is

26 In addition to expense for hospital room or bed, the fees for physician, examinations, use of operating room, and medicines and supplies were included under the heading of hospital expense in cases where the family found it impossible to separate the various items.

27 Expenditures for eyeglasses are in this report generally included under expenditures for medicine and medical supplies although they include the charge for an eye examination given by the person from whom glasses were purchased and frequently conceal the fee for an optometrists examination ostensibly offered as a free service with the purchase of eyeglasses.


28 FAMILY EXPENDITURES IN SELECTED CITIES, 1 9 3 5 - 3 6nevertheless relatively slow, generally less than for any other important type of medical service, reflecting the irreducible minimum of expenditure for low income families and the tendency for the very high income families to turn to specialists.

When expenditures for the general practitioner and the specialist are considered in combination, as representing the major portion of nonhospitalized care during illness, it appears that they have somewhat less relative importance at the high than at the low income levels. The relative decline is in general slight, however, and the combined expenditures commonly account for at least two-fifths of all medical service expenditures, amounting to more than outlays for dental care even among families with incomes of $5,000 and more.

In the foregoing discussion, an attempt has been made to generalize from data collected from families of different composition and occupational classification, as well as from families living in cities of different size and in different sections of the country. The patterns suggested are by no means always sharply defined; the tendencies indicated, by no means uniform for every group. The similarities, however, are far more striking than the differences. Two exceptions must nevertheless be noted. Negro families in the Southeast devoted a substantially larger share of expenditures for medical services to the general practitioner than did white families. (See fig. 5.) Negro families in New York, on the other hand, spent a remarkably large proportion of their medical service expenditures for dental care, averaging more than two-fifths of the total for services at the low as well as at the high income levels. Among white families, it is probable that the inconsistencies in the patterning of expenditures for medical services reflect the chance fluctuations characteristic of small samples rather than significant differences between groups.

The distribution of expenditures for medical services, averaged for all families, is an indicator both of the adequacy of and also of the relative importance attached to various types of service by different groups of the families. Data on the proportions of families that made expenditures for each type of service is another such measure.

Families reporting expenditures for specified types of service.Among white families in the lower income classes in all cities except those in the Pacific Northwest, a larger proportion reported expenditures for office visits to a general physician than for any other type of medical service.28 There was a very moderate tendency for these proportions to increase over the income range. In general, however, among white families at any income level in all cities, including those in the Northwest, no less than two in five families and no more than two in three reported office visits to a physician during the year of the survey.

28 If a family was unable to allocate expenditures for physician between home and office visits, the expense was divided equally between the two.

Digitized for FRASER ht

bls_0648_1940pt5.pdf

Documents

e d s t

e n t p r

u r e s

pt e r

e r pu r c h

t o f t e x t t

t e sg o v e r n

secretaryb u r e