- Email: [email protected]
Report from the Washington Office
REPORT FROM THE WASHINGTON OFFICE A CLOSER EXAMINATION OF SOME NOTIONS GENERALLY RECOGNIZED AS SAFE
un f
-I. t seems appropriate, during this January pause between governments, to consider several commonly ac cepted beliefs, not to disavow but to scrutinize them. Just as the Food and Drug Administration decided a while back to look a little closer at foods and other substances on its so-called GRAS list (generally recognized as safe), let us examine a few notions generally recognized as true. —Big government is getting bigger, with a bloated bureaucracy of federal workers and skyrocketing spending on social programs. —Most people have some kind of health insurance protection. —Medicaid is doing next to nothing to improve the dental health of poor people.
BIGGER GOVERNMENT Government is getting bigger, by a myriad of measures. The budget gets larger every year without regard to whether Democrats or Republicans are in charge. By one informed estimate, if recent spending rates continue, the total cost of government in the United States will pass the $1 trillion level in 1982. Taxes keep rising. The Social Security withholding rate and the amount of earnings subject to with holding both increased as of Jan 1. The proliferating tentacles of red tape and regulation (October 1980 Washington Report), the growing number of federal grants programs, increasing activity in the courts and Congress, the sheer per vasiveness of government influence in our lives and livelihoods—all affirm the growth of government. But one way n o t to measure gov
ernment growth is by the size of the federal work force, a sometimes handy whipping boy for government exces ses. The plain truth is that federal em ployment leveled off in the 1970s, was held in check during the Carter Ad ministration, and probably will re main steady through the Reagan Ad ministration. The permanent federal work force actually has been shrink ing, not growing. In 1970 there were about 1,987,000 full-time permanent workers in the federal executive branch civilian work force, excluding the Postal Service, which is now an in dependent agency. As of September 1980, a decade later, there were 1,866,800 such workers. By a different measure, Figure 1 also shows a leveling off since 1970 of the to ta l federal civilian workforce of nearly 3 million persons. This larger group includes more than a half million Postal Service workers and other categories of full- and part-time personnel in the legislative and execu tive branches. The chart is from a re port on T he F e d e ra l R ole in the F e d e ra l S ystem : The Dynamics o f G ro w th , prepared by the Advisory Commission on Intergovernmental Relations, a bipartisan study group. The government civilian employ ment charts, Figures 2 and 3, are taken from the Special A n a ly s e s F is c a l Y e a r 1981 US Budget. What both docu ments clearly demonstrate is that the growth in government employment is occurring at the state and local levels, a growth obviously fueled to some ex tent by federal activity. But federal executive branch employment ac counts for just 2.8% of the civilian
'""nt
labor force, a decline from 3.8% in 1968; and the federal share of total government employment has declined significantly over the past three dec ades. The ratio of federal civilian em ployment to total population was pro jected by the 1981 budgettobel2.3 per thousand this year, which is the lowest ratio in 31 years. The highest ratio of federal employees to total population was in 1952 when it reached 16.3. The ratio declined and then peaked again in 1968 at 14.7. The ratio has been de clining slowly since 1968. At a Nov 6 news conference, Mr. Reagan indicated he would impose an immediate federal hiring freeze. Less than two weeks later, Reagan aides
1910
F ig l JADA, Vol. 102, January 1981
137
Fig 2
1951
1956
End of fiscal year
Fig 3
1976
1961
1981
Estimate
Executive branch
Government civilian employment at a p ercent of total civilian em ploym ent
S ta te and lo cal
Fed eral
1961
Fiscal years
said it wouldn’t happen, that any freeze would be slower and open to ex ceptions for certain types of workers. As for the proposition that public expenditures for social programs are soaring, it may be outdated. A recent Social Security report suggests that the dramatic growth in social welfare spending spurred by Lyndon Johnson’s Great Society peaked in the mid-1970s. For several years, govern ment spending at local, state, and fed eral levels has declined as a percentage of the Gross National Product, al though actual growth continues. With the growth rate down, it would take something like a national health in 138 ■ JADA, Vol. 102, January 1981
1966
Executive branch
surance or comprehensive welfare plan to speed it up again, according to some economists. The fiscal 1981 budget approved by the recent lame-duck session of Con gress offers further evidence of the topping-off trend. The budget in cludes a heavy emphasis on defense and cutbacks or slowdowns in the rate of growth for many of the social pro grams championed for years by Demo crats. For discretionary domestic programs—excluding welfare and other “entitlement” programs—the cuts amount to more than 15%. The Advisory Commission on Intergovernmental Relations found
that federal spending on domestic programs peaked in 1978 in terms of constant dollars, fell sharply the fol lowing year, and appears to have de clined again last year. In a report on S ig n ific a n t Features o f F is c a l Federalism, the ACIR also said com bined spending by local, state, and the federal governments is rising at a slower rate than the increase in popu lation. An intriguing set of statistics in the latest ACIR report would seem to indicate that the burden of govern ment spending on each and every American actually eased up a little under Jimmy Carter. Per capita spend ing by government began to decline
ÿ
Washington Report
in the last two years of the Carter pres idency, having peaked in 1978 at $1,065. In 1979, government spent $1,580 for each man, woman, and child, and per capita spending was ex pected to drop slightly to $1,540. All these figures are adjusted for inflation. By the same formula, according to the ACIR, governments spent $163 per person in 1929. The ACIR report shows a steady decline in federal domestic spending, both as a percent of Gross National Product and on a per capita, constant-dollar basis, although it continues to rise on a straight-dollar basis.
HEALTH INSURANCE Consistently, the generalization that most people have some kind of protec tion against the costs of illness and disease, whether private insurance or the protection of some third party like Medicare or Medicaid, is found under scrutiny to be an inadequate gener alization. Government and private studies have shown that millions of persons lack any protection, and mil lions more have limited protection. This finding often is used to promote some type of national health insur ance. Still, many such studies lack the precision of a startling new statistical survey that found 26.6 million Ameri cans without any health insurance in 1977, or about 12.6% of the civilian population. The first of a series of re ports from a landmark National Health Care Expenditures Study also found important differences in insurance coverage by age, race, and place of res idence, though none by sex. “One sur prise of this study was the large number of persons who reported being uninsured,” said the National Center for Health Services Research, the gov ernment agency that launched this study, which also came up with some interesting dental data. It will take
years to evaluate fully the survey in formation. The survey interviewed some 37,000 people in 14,000 house holds and collected information from providers of health care services, em ployers, and insurance companies. It is said to be the most comprehensive analysis ever of domestic health care use and expenditures, intended both to offer insights on how Americans spend their health care dollars and to provide information to government agencies, legislative bodies, health professionals, and others concerned with the formulation of health policy. These other preliminary health in surance findings were reported: • Persons aged 18-24 were most likely to be without health insurance (21.9% of persons aged 18-24 are with out insurance coverage). • Persons 65 and older are least likely to be without some protection (only 4.3% lack insurance). • Non-white persons (18.1%) are more likely than white persons (11.7%) to be without insurance. • The fewer the years of education, the more likely a person is to be with out coverage. • When grouped by place of resi dence, the highest percentage of per sons without health insurance cover age was found in predominantly rural areas. • In most families, every family member had health insurance cover age, but 6% of families were entirely without coverage. These findings w ill sharpen the de bate on insurance legislation at a time when the Reagan government-inwaiting considers a voluntary health insurance plan for certain uninsurable persons preferred by the insurance in dustry, and when the political climate appears improved for Republican pro posals to stimulate competition for health insurance coverage.
MEDICAID DENTAL SERVICES M edicaid’s pittance for dental care is well documented. In 1978, only 2.1% of Medicaid benefit expenditures went for dental care. Medicaid spending on dental care for poor persons hovers around $400 m illion a year. Less well known is the impact of those few dol lars, in part because Medicaid keeps such inadequate program data. A t the same time it released the
health insurance information, the health research unit issued a separate report on dental visits and expendi tures that provided new information on dental care for poor children and Medicaid’s regional impact. For in stance, one breakout of information on all visits to dentists in which patients were charged a single fee (about twothirds of all visits), shows that Medicaid assumed the entire payment for as much as 11.3% of the visits by children 12 years of age or younger. Three-fourths of visits to dentists by white persons were paid entirely by the family, compared to 59% for non white persons. Medicaid paid for as much as 22.7% of the visits to dentists by non-white persons, as compared to only 4.8% for visits by whites, the re port said. However, of all visits paid o n ly by Medicaid, 74% were for white persons and 26% for all others. Private health insurance and Medicaid each paid for roughly one of every 1 0 dental visits in the West but for less than 3% in the South. Payments by Medicaid only also were relatively high in the Northeast (8.2%). Four tables of statistics provide further information from the dental survey. Following are selected high lights from those tables: Use o f d e n ta l services • Approximately 43% of the popu lation had at least one dental visit in 1977.
• Persons with at least one visit averaged three visits per person. • Females had more dental visits and were more likely to have a dental visit than males. • Whites had more dental visits and were almost twice as likely to have a dental visit than all others. • The number of dental visits per person with visits increased with fam ily income, as did the likelihood of having a dental visit. • Persons living in large urban areas (SMSAs) were more likely to have a dental visit than persons in other areas. Charges and sources o f p a y m e n t f o r dental services • The average charge per dental visit was lowest for children under 6 years, compared to other age groups. It was $48 for the entire population. • The average charge was the same for males and females. JADA, Vol. 102, January 1981 ■ 139
• The average charge was highest for whites, for persons in families with incomes over $18,000, in the West, for persons with more than 13 years of education, and in urban areas (SMSAs). • Dental visits without, charge (in prepaid group practice settings or free from provider) accounted for approx imately 4.7% of all visits. Charity care represented much the smaller propor tion of that category. • The family paid the highest pro portion of the average charge (95%) for dental visits for persons 65 years or older. • Medicaid paid the highest pro portion of the average charge (14%) per dental visit for children less than 6 years. • A greater proportion of the aver age charge per dental visit was paid by the family for visits by white persons. • Medicaid paid on average 23% of the charge for visits for those other than white. • The average proportion paid by Medicaid per dental visit was highest in the West. • The average proportion paid by
the family decreased with the educa tion of the family head. • The pattern of sources of payment for dental visits is similar in urban and more rural areas.
O ut-of-pocket expense for dental ser vices • Children 6 to 18 years were most likely to have no out-of-pocket ex pense for dental visits. • More than 8 million persons (3.9% of the population) had out-ofpocket expenses of more than $1,000 for dental care. • Persons 55 to 64 years were most likely to have out-of-pocket expense of more than $1,000 for dental care com pared to other age groups (6.1%). • Persons in the West were most likely to have no out-of-pocket ex pense for dental visits compared to other regions. Annual expenses and sources o f pay m ent fo r dental services • Average annual expenses for den tal visits were highest for persons 6 to 18 years ($179 compared to $143 for all those with dental expenses). • Average annual expenses for den
tal visits were highest for whites, for those in high-income families, in the Northeast and West, for persons in more highly educated families, and for persons living in urban areas. • Medicaid paid the largest percent of annual expenses for dental care for children under 6 years old (11.4%). • Persons 65 and older had the largest proportion (93.5%) of annual expenses for dental care paid by the family. • Overall, the proportion of annual expenses for dental care paid by the family was 79.7%. It was highest for whites, persons in the South, and in rural areas. • Private health insurance paid a substantially lower share of expenses (4.1%) for dental care for persons 65 years or older than for all persons (16.8%). • Private health insurance paid a lower share of expenses for dental care for persons in the lowest family in come group, in the lowest education group, in the South, and in the more rural (non-SMSA) areas. This column was prepared by Craig Palmer, pub lic information counsel, ADA Washington Office.
THE PRESIDENTS Each m onth, T h e Journal prints the picture of a past president of the A m erican Dental A ssociation with a brief biography and a few historical highlights of his presidential year. The series began in February 1979 w ith the first president and is continuing in chronological order.
John N a th a n C rouse 1884 - 1885 Doctor Crouse, of Chicago, was elected 24th president of the Association at the 1884 meeting at Saratoga Springs, NY. Doctor Crouse received the DDS degree from the Pennsylvania College of Dental Surgery in 1867. He served as president of the Illinois and Chicago dental societies and of the National (Southern) Dental Association. Doctor Crouse was the founder and president of the Dental Protective Association and publisher of the D e n ta l D igest. He was born in Pennsylvania in 1842 and died in 1914. Grover Cleveland, Democrat, was elected president in 1884, defeating James G. Blaine, Republican. The Meridian Conference in Washington, with 25 na tions represented, agreed on the “normal day.” The Washington monument was completed. The Apache Indians under Chief Geronimo took to the war path in Arizona and New Mexico.
140 ■ JADA, Vol. 102, January 1981
un f
-I. t seems appropriate, during this January pause between governments, to consider several commonly ac cepted beliefs, not to disavow but to scrutinize them. Just as the Food and Drug Administration decided a while back to look a little closer at foods and other substances on its so-called GRAS list (generally recognized as safe), let us examine a few notions generally recognized as true. —Big government is getting bigger, with a bloated bureaucracy of federal workers and skyrocketing spending on social programs. —Most people have some kind of health insurance protection. —Medicaid is doing next to nothing to improve the dental health of poor people.
BIGGER GOVERNMENT Government is getting bigger, by a myriad of measures. The budget gets larger every year without regard to whether Democrats or Republicans are in charge. By one informed estimate, if recent spending rates continue, the total cost of government in the United States will pass the $1 trillion level in 1982. Taxes keep rising. The Social Security withholding rate and the amount of earnings subject to with holding both increased as of Jan 1. The proliferating tentacles of red tape and regulation (October 1980 Washington Report), the growing number of federal grants programs, increasing activity in the courts and Congress, the sheer per vasiveness of government influence in our lives and livelihoods—all affirm the growth of government. But one way n o t to measure gov
ernment growth is by the size of the federal work force, a sometimes handy whipping boy for government exces ses. The plain truth is that federal em ployment leveled off in the 1970s, was held in check during the Carter Ad ministration, and probably will re main steady through the Reagan Ad ministration. The permanent federal work force actually has been shrink ing, not growing. In 1970 there were about 1,987,000 full-time permanent workers in the federal executive branch civilian work force, excluding the Postal Service, which is now an in dependent agency. As of September 1980, a decade later, there were 1,866,800 such workers. By a different measure, Figure 1 also shows a leveling off since 1970 of the to ta l federal civilian workforce of nearly 3 million persons. This larger group includes more than a half million Postal Service workers and other categories of full- and part-time personnel in the legislative and execu tive branches. The chart is from a re port on T he F e d e ra l R ole in the F e d e ra l S ystem : The Dynamics o f G ro w th , prepared by the Advisory Commission on Intergovernmental Relations, a bipartisan study group. The government civilian employ ment charts, Figures 2 and 3, are taken from the Special A n a ly s e s F is c a l Y e a r 1981 US Budget. What both docu ments clearly demonstrate is that the growth in government employment is occurring at the state and local levels, a growth obviously fueled to some ex tent by federal activity. But federal executive branch employment ac counts for just 2.8% of the civilian
'""nt
labor force, a decline from 3.8% in 1968; and the federal share of total government employment has declined significantly over the past three dec ades. The ratio of federal civilian em ployment to total population was pro jected by the 1981 budgettobel2.3 per thousand this year, which is the lowest ratio in 31 years. The highest ratio of federal employees to total population was in 1952 when it reached 16.3. The ratio declined and then peaked again in 1968 at 14.7. The ratio has been de clining slowly since 1968. At a Nov 6 news conference, Mr. Reagan indicated he would impose an immediate federal hiring freeze. Less than two weeks later, Reagan aides
1910
F ig l JADA, Vol. 102, January 1981
137
Fig 2
1951
1956
End of fiscal year
Fig 3
1976
1961
1981
Estimate
Executive branch
Government civilian employment at a p ercent of total civilian em ploym ent
S ta te and lo cal
Fed eral
1961
Fiscal years
said it wouldn’t happen, that any freeze would be slower and open to ex ceptions for certain types of workers. As for the proposition that public expenditures for social programs are soaring, it may be outdated. A recent Social Security report suggests that the dramatic growth in social welfare spending spurred by Lyndon Johnson’s Great Society peaked in the mid-1970s. For several years, govern ment spending at local, state, and fed eral levels has declined as a percentage of the Gross National Product, al though actual growth continues. With the growth rate down, it would take something like a national health in 138 ■ JADA, Vol. 102, January 1981
1966
Executive branch
surance or comprehensive welfare plan to speed it up again, according to some economists. The fiscal 1981 budget approved by the recent lame-duck session of Con gress offers further evidence of the topping-off trend. The budget in cludes a heavy emphasis on defense and cutbacks or slowdowns in the rate of growth for many of the social pro grams championed for years by Demo crats. For discretionary domestic programs—excluding welfare and other “entitlement” programs—the cuts amount to more than 15%. The Advisory Commission on Intergovernmental Relations found
that federal spending on domestic programs peaked in 1978 in terms of constant dollars, fell sharply the fol lowing year, and appears to have de clined again last year. In a report on S ig n ific a n t Features o f F is c a l Federalism, the ACIR also said com bined spending by local, state, and the federal governments is rising at a slower rate than the increase in popu lation. An intriguing set of statistics in the latest ACIR report would seem to indicate that the burden of govern ment spending on each and every American actually eased up a little under Jimmy Carter. Per capita spend ing by government began to decline
ÿ
Washington Report
in the last two years of the Carter pres idency, having peaked in 1978 at $1,065. In 1979, government spent $1,580 for each man, woman, and child, and per capita spending was ex pected to drop slightly to $1,540. All these figures are adjusted for inflation. By the same formula, according to the ACIR, governments spent $163 per person in 1929. The ACIR report shows a steady decline in federal domestic spending, both as a percent of Gross National Product and on a per capita, constant-dollar basis, although it continues to rise on a straight-dollar basis.
HEALTH INSURANCE Consistently, the generalization that most people have some kind of protec tion against the costs of illness and disease, whether private insurance or the protection of some third party like Medicare or Medicaid, is found under scrutiny to be an inadequate gener alization. Government and private studies have shown that millions of persons lack any protection, and mil lions more have limited protection. This finding often is used to promote some type of national health insur ance. Still, many such studies lack the precision of a startling new statistical survey that found 26.6 million Ameri cans without any health insurance in 1977, or about 12.6% of the civilian population. The first of a series of re ports from a landmark National Health Care Expenditures Study also found important differences in insurance coverage by age, race, and place of res idence, though none by sex. “One sur prise of this study was the large number of persons who reported being uninsured,” said the National Center for Health Services Research, the gov ernment agency that launched this study, which also came up with some interesting dental data. It will take
years to evaluate fully the survey in formation. The survey interviewed some 37,000 people in 14,000 house holds and collected information from providers of health care services, em ployers, and insurance companies. It is said to be the most comprehensive analysis ever of domestic health care use and expenditures, intended both to offer insights on how Americans spend their health care dollars and to provide information to government agencies, legislative bodies, health professionals, and others concerned with the formulation of health policy. These other preliminary health in surance findings were reported: • Persons aged 18-24 were most likely to be without health insurance (21.9% of persons aged 18-24 are with out insurance coverage). • Persons 65 and older are least likely to be without some protection (only 4.3% lack insurance). • Non-white persons (18.1%) are more likely than white persons (11.7%) to be without insurance. • The fewer the years of education, the more likely a person is to be with out coverage. • When grouped by place of resi dence, the highest percentage of per sons without health insurance cover age was found in predominantly rural areas. • In most families, every family member had health insurance cover age, but 6% of families were entirely without coverage. These findings w ill sharpen the de bate on insurance legislation at a time when the Reagan government-inwaiting considers a voluntary health insurance plan for certain uninsurable persons preferred by the insurance in dustry, and when the political climate appears improved for Republican pro posals to stimulate competition for health insurance coverage.
MEDICAID DENTAL SERVICES M edicaid’s pittance for dental care is well documented. In 1978, only 2.1% of Medicaid benefit expenditures went for dental care. Medicaid spending on dental care for poor persons hovers around $400 m illion a year. Less well known is the impact of those few dol lars, in part because Medicaid keeps such inadequate program data. A t the same time it released the
health insurance information, the health research unit issued a separate report on dental visits and expendi tures that provided new information on dental care for poor children and Medicaid’s regional impact. For in stance, one breakout of information on all visits to dentists in which patients were charged a single fee (about twothirds of all visits), shows that Medicaid assumed the entire payment for as much as 11.3% of the visits by children 12 years of age or younger. Three-fourths of visits to dentists by white persons were paid entirely by the family, compared to 59% for non white persons. Medicaid paid for as much as 22.7% of the visits to dentists by non-white persons, as compared to only 4.8% for visits by whites, the re port said. However, of all visits paid o n ly by Medicaid, 74% were for white persons and 26% for all others. Private health insurance and Medicaid each paid for roughly one of every 1 0 dental visits in the West but for less than 3% in the South. Payments by Medicaid only also were relatively high in the Northeast (8.2%). Four tables of statistics provide further information from the dental survey. Following are selected high lights from those tables: Use o f d e n ta l services • Approximately 43% of the popu lation had at least one dental visit in 1977.
• Persons with at least one visit averaged three visits per person. • Females had more dental visits and were more likely to have a dental visit than males. • Whites had more dental visits and were almost twice as likely to have a dental visit than all others. • The number of dental visits per person with visits increased with fam ily income, as did the likelihood of having a dental visit. • Persons living in large urban areas (SMSAs) were more likely to have a dental visit than persons in other areas. Charges and sources o f p a y m e n t f o r dental services • The average charge per dental visit was lowest for children under 6 years, compared to other age groups. It was $48 for the entire population. • The average charge was the same for males and females. JADA, Vol. 102, January 1981 ■ 139
• The average charge was highest for whites, for persons in families with incomes over $18,000, in the West, for persons with more than 13 years of education, and in urban areas (SMSAs). • Dental visits without, charge (in prepaid group practice settings or free from provider) accounted for approx imately 4.7% of all visits. Charity care represented much the smaller propor tion of that category. • The family paid the highest pro portion of the average charge (95%) for dental visits for persons 65 years or older. • Medicaid paid the highest pro portion of the average charge (14%) per dental visit for children less than 6 years. • A greater proportion of the aver age charge per dental visit was paid by the family for visits by white persons. • Medicaid paid on average 23% of the charge for visits for those other than white. • The average proportion paid by Medicaid per dental visit was highest in the West. • The average proportion paid by
the family decreased with the educa tion of the family head. • The pattern of sources of payment for dental visits is similar in urban and more rural areas.
O ut-of-pocket expense for dental ser vices • Children 6 to 18 years were most likely to have no out-of-pocket ex pense for dental visits. • More than 8 million persons (3.9% of the population) had out-ofpocket expenses of more than $1,000 for dental care. • Persons 55 to 64 years were most likely to have out-of-pocket expense of more than $1,000 for dental care com pared to other age groups (6.1%). • Persons in the West were most likely to have no out-of-pocket ex pense for dental visits compared to other regions. Annual expenses and sources o f pay m ent fo r dental services • Average annual expenses for den tal visits were highest for persons 6 to 18 years ($179 compared to $143 for all those with dental expenses). • Average annual expenses for den
tal visits were highest for whites, for those in high-income families, in the Northeast and West, for persons in more highly educated families, and for persons living in urban areas. • Medicaid paid the largest percent of annual expenses for dental care for children under 6 years old (11.4%). • Persons 65 and older had the largest proportion (93.5%) of annual expenses for dental care paid by the family. • Overall, the proportion of annual expenses for dental care paid by the family was 79.7%. It was highest for whites, persons in the South, and in rural areas. • Private health insurance paid a substantially lower share of expenses (4.1%) for dental care for persons 65 years or older than for all persons (16.8%). • Private health insurance paid a lower share of expenses for dental care for persons in the lowest family in come group, in the lowest education group, in the South, and in the more rural (non-SMSA) areas. This column was prepared by Craig Palmer, pub lic information counsel, ADA Washington Office.
THE PRESIDENTS Each m onth, T h e Journal prints the picture of a past president of the A m erican Dental A ssociation with a brief biography and a few historical highlights of his presidential year. The series began in February 1979 w ith the first president and is continuing in chronological order.
John N a th a n C rouse 1884 - 1885 Doctor Crouse, of Chicago, was elected 24th president of the Association at the 1884 meeting at Saratoga Springs, NY. Doctor Crouse received the DDS degree from the Pennsylvania College of Dental Surgery in 1867. He served as president of the Illinois and Chicago dental societies and of the National (Southern) Dental Association. Doctor Crouse was the founder and president of the Dental Protective Association and publisher of the D e n ta l D igest. He was born in Pennsylvania in 1842 and died in 1914. Grover Cleveland, Democrat, was elected president in 1884, defeating James G. Blaine, Republican. The Meridian Conference in Washington, with 25 na tions represented, agreed on the “normal day.” The Washington monument was completed. The Apache Indians under Chief Geronimo took to the war path in Arizona and New Mexico.
140 ■ JADA, Vol. 102, January 1981