Costs, Use, and Access to Care

---

AHRQ's research indicates that more than 6 million U.S. children ages birth to 17 were uninsured all year in 2006. Obtaining adequate access to care and maintaining a usual source of care are special challenges for these young people and their families. There also are significant racial and ethnic differences in children's access to health care that cannot be explained by insurance and socioeconomic factors alone.

---

Access to care may be compromised for low-income children affected by hunger and unstable housing.

Researchers examined data on 12,746 children living in households with incomes less than 200 percent of the Federal poverty line (less than $40,000 for a family of four in 2006). They found that nearly 30 percent of the children suffered from housing instability (inability of family to pay mortgage or rent and utility bills) and 39 percent from food insecurity (worry about running out of food and not having money to buy more, having reduced portions, and/or skipping meals). Nearly 12 percent of children with housing instability had no usual source of care, and 36 percent had used the ED for routine care. Food insecurity was independently associated with postponed medical care and prescriptions. Ma, Gee, and Kushel, Ambul Pediatr 8(3):50-57, 2008 (AHRQ Grant HS11415).

More than 2 million children with insured parents are uninsured.

According to this study, some 2.3 million children a year, mostly from low-to moderate-income families, have no health care coverage to pay for preventive or other health care needs, even though at least one of their parents is insured. These children account for one-fourth of the estimated 9 million children in the United States who currently are uninsured. DeVoe, Tillotson, and Wallace, JAMA 300(10):1904-1913, 2008 (AHRQ Grant HS16181).

Racial/ethnic differences exist in children's health insurance coverage.

Researchers used Medical Expenditure Panel Survey data to examine variations in health insurance coverage among children from different racial/ethnic groups. They found that certain characteristics—such as poverty, parent education level, family structure, and immigration-related factors—accounted for 70 percent or more of the coverage differences among white, black, and Hispanic children. Pylypchuk and Selden, J Health Econ 27(4):1109-1128, 2008 (AHRQ Publication No. 08R068)* (Intramural).

Gaps in children's health insurance often result in unmet health care needs.

Researchers analyzed survey results from 2,681 families with children enrolled in Oregon's food stamp program at the end of January 2005 and found that one-fourth of the children had coverage gaps during the 12 months preceding the survey. The gaps were less than 6 months (17.5 percent), 6 to 12 months (1.5 percent), and more than 12 months (3.1 percent); nearly 4 percent of the children never had health insurance. Study results showed that the longer the insurance gap, the higher the chance of a child having an unmet need for care, including medical or dental care, prescriptions, not having a regular provider, and delays in urgent care. DeVoe, Graham, Krois, et al., Ambul Pediatr 8(2):129-134, 2008 (AHRQ Grants HS14645, HS16181).

Gap between charges and payments for ED pediatric visits has widened.

This study found that payments for pediatric ED visits that did not result in hospitalization did not keep pace with charges between 1996 and 2003, falling from 63 percent to 48 percent of charges during that time period. This decline occurred in all payer groups, including public (Medicaid, SCHIP), private, and uninsured. For all years, Medicaid/SCHIP had the lowest reimbursement rates, declining to 35 percent of charges in 2003. Pediatric visits accounted for one in every four ED visits; 54 percent of children's ED visits were privately insured, 33 percent were covered by Medicaid/SCHIP, and 12 percent were uninsured. Hsia, MacIsaac, Palmer, and Baker, Acad Emerg Med 15:347-354, 2008 (AHRQ Grant HS13920).

Health insurance coverage varies substantially among children of different racial/ethnic groups.

Researchers examined 2004-2005 Medical Expenditure Panel Survey data to learn how much a given characteristic contributes to coverage differences among children. They found observable characteristics such as poverty, parent educational level, family structure (for black children), and immigration-related factors (for Hispanic children) account for 70 percent or more of the coverage differences among white, black, and Hispanic children. The most important immigration-related factor for Hispanic children was the disproportionate prevalence of native-born children with noncitizen parents. These results suggest that lower coverage rates among minority children are due to the fact that uninsurance is concentrated among poor children who happen to be minorities. Pylypchuk and Selden, J Health Econ 27(4):1109-1128, 2008 (AHRQ Publication No. 08R068)* (Intramural).

Minority children are much less likely than white children to receive specialized therapies.

Researchers used Medical Expenditure Panel Survey data to examine therapy use for children and found that 3.8 percent of children who are age 18 or younger obtain specialized therapies from the health care system, including physical, occupational, and speech therapy or home health services. Children most likely to use specialized therapies tended to be males (60 percent), white children (81 percent), and children with a chronic condition (39 percent). Kuhlthau, Hill, Fluet, et al., Dev Neurorehabil 11(2):115-123, 2008 (AHRQ Grant HS13757).

Costs and use of care are higher for children in families with intimate partner violence.

According to this study, children of women who are or have been abused by their partners seek more mental and other health care than children of mothers who aren't abused. Researchers compared health care use and costs of 760 children of mothers with no history of abuse and 631 children of mothers with a history of abuse over an 11-year period. Health care use and costs were significantly greater for mental health services, primary care visits and costs (15 percent higher), and laboratory costs for children of abused mothers than for other children. Rivara, Anderson, Fishman, et al., Pediatrics 120:1270-1277, 2007 (AHRQ Grant HS10909).

Children with private insurance have better access to specialty care than other children.

Researchers reviewed 30 studies on the relationship between access to specialty care and insurance coverage and found that children with private insurance have better access to such care than those who have public coverage or no insurance. Although children insured by Medicaid or SCHIP have better access to specialty care than uninsured children, their access to specialists is worse and their specialists are less likely to be board-certified compared with privately insured children. Skinner and Mayer, BMC Health Serv Res 7, 2007; online at www.biomedcentral.com (AHRQ Grant T32 HS00032).

Concerns about SCHIP expansions crowding out private insurance are not borne out in New York.

Concern that middle-class families might be using SCHIP when they could have private insurance for their children was a major point of contention in Federal SCHIP reauthorization. However, this study of New York State SCHIP families showed that crowd-out of private insurance due to expanded SCHIP eligibility is rare (7.1 percent of 2,644 new SCHIP enrollees). More than 60 percent of the new enrollees had been uninsured for a year or more, and a third had never had any insurance before SCHIP. Shone, Lantz, Dick, et al., Health Serv Res 43(1, Part II):419-434, 2008 (AHRQ Grant HS10450).

Hospital costs for preterm and low birthweight infants are very high.

According to hospital discharge data from the 2001 Nationwide Inpatient Sample, 8 percent of infants were born premature or low birthweight that year. Their hospital stays accounted for nearly half (47 percent) of infant hospitalization costs in 2001. The true costs of caring for these vulnerable infants are actually higher because the study data did not account for physician fees, rehabilitation, outpatient expenses, and the mother's hospital costs. Russell, Green, Steiner, et al., Pediatrics 120, 2007; online at www.pediatrics.org (AHRQ Publication No. 07-R066)* (Intramural).

Access to care improves for adolescents following SCHIP enrollment.

Researchers interviewed adolescents who were new SCHIP enrollees and their parents shortly after enrollment and 1 year later. Enrollment in SCHIP was associated with greater access to a usual source of care; increased use of preventive care, specialty care, and prescription medicines; and fewer unmet care needs. SCHIP also seemed to eliminate previous racial disparities in care access. The researchers note that there is still room for improvement, as 40 percent of adolescents reported that there were still some unmet health care needs even after SCHIP enrollment. Klein, Shone, Szilagyi, et al., Pediatrics 119(4), 2007; online at www.pediatrics.org (AHRQ Grant HS10450).

Despite increases in SCHIP enrollment, over 5 million eligible children remain uninsured.

Since expansion of SCHIP enrollment criteria in 2001, the number of uninsured U.S. children has significantly decreased. Yet 5.5 million children who are eligible for SCHIP remain uninsured, according to this study. The authors examine how various expansions and cuts in SCHIP would affect the eligibility and overage of the Nation's children. They note that eligible but uninsured children are among the Nation's most disadvantaged, are disproportionately minority, and are more likely than average to live with a single parent or no parent. Hudson and Selden, Health Aff 26(5), 2007; online at www.healthaffairs.org (AHRQ Publication No. 07R078)* (Intramural).

Many underinsured children are not getting needed vaccines due to current U.S vaccine financing system.

Newly recommended vaccines for children and adolescents have nearly doubled in the past 5 years, boosting the cost to fully vaccinate a child in the public sector from $155 in 1995 to $1,170 in 2007. Childhood vaccines in the United States are financed by a patchwork of public and private sources, resulting in many underinsured children being unable to receive publicly purchased vaccines in either private practices or public health clinics, according to this study. The researchers conducted a national survey of State immunization program managers in 2006 and found that only 34 percent of States had a health insurance mandate requiring insurers to cover currently recommended vaccines for children and adolescents. Lee, Santoli, Hannan, et al., JAMA 298(6):638-643, 2007 (AHRQ Grant HS13908).

Caregivers of children with special health care needs say Medicaid provides better care access than traditional plans.

Caregivers of children with special health care needs in Washington, DC, rated a partially capitated Medicaid managed care plan better than a traditional fee-for-service (FFS) plan in providing these children with access to care. Case management and care coordination services of the Medicaid plan probably account for its higher ratings, according to the researchers. Each special needs child enrolled in the plan was assigned a case manager, who scheduled appointments, arranged for transportation, and facilitated the services the child received from primary care doctors, specialists, and the public school system. Also, the Medicaid plan reimbursed pediatricians and specialists at twice the rate of the FFS plan. Mitchell and Gaskin, Med Care 45(2):146-153, 2007 (AHRQ Grant HS10912).

Children sometimes must travel great distances to see a subspecialist.

Although most U.S. children live within an hour's drive of a pediatric subspecialist, such care is less widely available in certain regions and for certain subspecialties. According to this study, the average distance to a subspecialist ranged from 15 miles for neonatology to 78 miles for pediatric sports medicine. Fewer than one-half of hospital referral regions had a provider for 7 of 16 pediatric subspecialties, suggesting that the supply of pediatric subspecialties is inadequate, pediatric subspecialists are distributed inequitably, or the market for pediatric subspecialists exceeds the hospital referral regions. Mayer, Pediatrics 118(6):2313-2321, 2006 (AHRQ Grant HS13309).

Children with special health care needs benefit from Medicaid managed care programs.

According to this study, children with special health care needs who have disabilities and are enrolled in Medicaid programs that have a managed care option, including case management services, have better access to care and receipt of occupational and physical therapy at school, compared with those in Medicaid fee-for-service (FFS) plans. The researchers evaluated use of speech, occupational, and physical therapy by children with special health care needs who were enrolled in the managed care or FFS plans of the District of Columbia Medicaid program that serviced only children with disabilities. Schuster, Mitchell, and Gaskin, Health Care Financ Rev 28(4):109-123, 2007 (AHRQ Grant HS10912).

Children with special health care needs report improved health care after SCHIP enrollment.

Researchers compared access to care and quality of care 1 year before and 1 year after enrollment in SCHIP for children with special health care needs. Based on parental report, 17 percent of 2,290 children enrolled in New York's SCHIP in 2001-2002 had special health care needs. SCHIP enrollment was generally associated with improved access to care, better continuity of care, and fewer unmet care needs. Szilagyi, Shone, Klein, et al., Ambulatory Pediatr 7(1):10-17, 2007 (AHRQ Grant HS10450).

Many adolescents newly enrolled in SCHIP have "catch up" health care needs.

According to this study, nearly 75 percent of adolescents in Florida and New York who were new SCHIP enrollees had been without health insurance the previous year. One in five had at least one serious illness or disability, with impoverished minority youth most at risk for health problems. The quality of care received prior to SCHIP enrollment was suboptimal, and States may need to enhance outreach to older adolescents and design programs and benefits to meet their substantial health care needs, according to the researchers. Klein, Shenkman, Brach, et al., J Health Care Poor Underserved 17:789-807, 2006 (AHRQ Publication No. 07R032) (Intramural).

Researchers use a county-level measure of urban influence to examine children's health care use, expenditures, coverage, and quality of care.

This analysis of data from the 2002 Medical Expenditure Panel Survey and 2002 Nationwide Sample and State Inpatient Databases found that greater percentages of children in large metropolitan (metro) counties were Hispanic or black, compared with children in small metro and large and small rural counties. Small rural areas had a greater percentage of children in fair or poor health, and they were more likely to have a hospital stay and emergency department use than children in large metro areas. Children in large metro counties had longer average hospital stays and higher hospital charges per day, compared with all other children. Chevarley, Owens, Zodet, et al., Ambulatory Pediatr 6(5):241-264, 2006 (AHRQ Publication No. 06R079)* (Intramural). See also Dougherty, Simpson, and McCormick, Ambulatory Pediatr 6(5):265-267, 2006 (AHRQ Publication No. 06-R080)* (Intramural).

SCHIP programs increase access to care for previously uninsured children.

A study of children in Georgia and Alabama who were either uninsured or lost Medicaid eligibility increased their use of office visits and well-child care once they were enrolled in SCHIP. Children in SCHIP programs that used a primary care case management system used more well-child care and less emergency care, while children in SCHIP programs that had a fee-for-service structure used more specialty care. Other factors also affected use of care, including personal characteristics (e.g., race, sex, age), community-level poverty, and health care provider proximity. Bronstein, Adams, and Florence, Health Care Financ Rev 27(4):44-51, 2006 (AHRQ Grant HS10435).

Medical injuries among children result in longer hospital stays and higher charges.

This study found that 3.4 percent of children hospitalized between 2000 and 2002 in Wisconsin suffered a medical injury while in the hospital. These injuries were due to problems with medications, procedures, and medical devices. Injured children had a longer hospital stay (0.5 day) and higher charges ($1,614) than children who were not injured. The study involved more than 318,000 children admitted to 1 of 134 Wisconsin hospitals between 2000 and 2002. Meurer, Yang, Guse, et al., Quality Safety Health Care 15:202-207, 2006 (AHRQ Grant HS11893).

Immunocompromised children who acquire fungal infections have higher costs, longer hospital stays, and an elevated risk of death.

Some children's immune systems are compromised by diseases such as cancer or treatments such as bone marrow transplantation. During 2000, 0.5 percent of hospitalized immunocompromised children developed invasive aspergillosis (IA), the most common fungal infection to strike immunocompromised children. Nearly one in five (18 percent) of the children died in the hospital; children with cancer and IA had a 13.5 percent higher risk of dying in the hospital than children who had cancer but were not infected with IA. Median length of stay was over five times as long for immunocompromised children with IA (16 days) as for children who were not infected with IA (3 days), and their total hospital charges were also five times as high ($49,309 vs. $9,035). Zaoutis, Heydon, Chu, et al., Pediatrics 117:711-716, 2006 (AHRQ Grant HS10399).

Uninsured children's access to care is affected by the availability and capacity of the local safety net.

Researchers examined data on a nationally representative sample of more than 2,600 children aged 2 to 17 who were uninsured for at least 1 year during 1996 to 2000. They found that 60 percent of uninsured children did not visit a physician's office during the year, and more than half had no care from a provider of any type in an office-based setting. Uninsured children in rural areas were more likely to make physician visits if they lived closer to a safety net provider or in an area with a larger supply of primary care physicians. Although proximity to safety net providers was not found to be a determinant of access to care among uninsured urban children, the researchers caution that other factors affecting accessibility to care (e.g., availability of public transportation, ER crowding) were not measured and may influence the services that urban uninsured children receive. Gresenz, Rogowski, and Escarce, Pediatrics 117:509-517, 2006 (AHRQ Grant HS10770).

Non-English-speaking parents report better care and access for their children when interpreters are present during doctor visits.

Hispanic and Asian/Pacific Islander parents who always use an interpreter when their child has an outpatient medical visit report enhanced care access and quality, compared with parents who don't always use interpreters. They also report better service from their health plan when compared with parents who do not use interpreters. Morales, Elliott, Weech-Maldonado, and Hays, Med Care Res Rev 63(1):110-128, 2006 (AHRQ Grant HS09204).

Having health insurance coverage greatly increases children's access to care and use of services.

Researchers pooled 1996-2002 data from the Medical Expenditure Panel Survey (MEPS) to estimate the impact of insurance coverage on children's access to and use of care. Like other researchers, they found that public and private coverage were both associated with large increases in care access and use. The large differences between public and private coverage were reduced (and often reversed) when the researchers accounted for other characteristics of children and their families that could affect health care access and use. Selden and Hudson, Medical Care 44(5 Suppl):19-26, 2006 (AHRQ Publication No. OM-06-0074, for single copies of the journal)* (Intramural).

Medicaid primary care case management reduces children's access to primary and preventive care.

Primary care case management (PCCM) programs reimburse providers on a fee-for-service basis. However, they assign Medicaid patients to gatekeeper providers who must make specific referrals for specialty, emergency, and inpatient care. This arrangement resulted in disruptions in established patterns of care use in Alabama and Georgia and had an unexpected negative effect on children, especially minority children, according to this study. PCCM was associated with lower use of primary care for all children (except for white children) in urban Georgia and reduced preventive care for white children in urban Alabama and for black and white children in urban Georgia. Implementation of PCCM without fee increases may affect provider decisions about Medicaid participation and ultimately may reduce provider availability, note the researchers. Adams, Bronstein, and Florence, Med Care Res Rev 63(1):58-87, 2006 (AHRQ Grant HS10435).

Nearly one-quarter of Latino children living in the United States lack health insurance.

Despite State Medicaid programs for the poor and the State Children's Health Insurance Program (SCHIP), more than 8 million U.S. children are uninsured. Latino children, in particular, are likely to be uninsured. This study found that nearly one-quarter (3 million) Latino children lack health insurance. Even in States where all low-income children are eligible for health insurance, current SCHIP and Medicaid outreach and enrollment efforts are not reaching many uninsured Latino children. Major obstacles to enrollment of these children include lack of knowledge about the application process and eligibility, language barriers, family mobility, and misinformation from insurance representatives. Flores, Abreu, Brown, and Tomany-Korman, Ambulatory Pediatr 5(6):332-340, 2005 (AHRQ Grant HS11305).

Researchers examine factors that affect children's primary care experiences.

This study found that having a regular provider and obtaining needed care have a greater impact on children's primary care experiences than having health insurance. After accounting for other factors that affect the primary care experience—such as the parent's language and the mother's education level—gaining or losing insurance during the 1-year study period did not have a significant effect on primary care experiences. Gaining a regular physician also did not have a significant effect on primary care experiences, but losing a regular physician was associated with much lower parental satisfaction scores. Seid and Stevens, Health Services Res 40(6):1758-1780, 2005 (AHRQ grant HS10317).

SCHIP decreases uninsurance among children from low-income families.

During the period 1996-2002, SCHIP significantly increased public insurance for poor children, from 21.5 percent in 1996 to 26.3 percent in 2002. During the same period, uninsurance declined for this group by more than 3 percentage points, from 16.4 percent to 13.1 percent. Further study is needed to quantify the potential benefits to these children and their families from lower premiums and out-of-pocket expenditures, as well as improved access to care. Hudson, Selden, and Banthin, Inquiry 42:232-254, 2005 (AHRQ Publication No. 06-R018)* (Intramural).

Expanding public health insurance for children lessens the financial burden on low-income families.

Expansions in public health insurance programs (e.g., Medicaid, SCHIP) between 1980 and 2000 have reduced out-of-pocket medical expenses for low-income families, according to this study. The researchers compared out-of-pocket health care expenditures and the associated financial burden for children aged 0 to 18 in six poverty level groups. They found that out-of-pocket expenses and financial burden decreased for all groups studied, ranging from a reduction of 36.5 percent for those below 100 percent of the Federal poverty level to 46.7 percent for those at or above 300 percent (four times the Federal poverty level). Wong, Galbraith, Kim, and Newacheck, Arch Pediatr Adolesc Med 159:1008-1013, 2005 (AHRQ Grant HS11662).

Researchers examine methods for predicting Medicaid child health expenditures.

In this study, researchers found that models with either pharmacy-based or diagnosis-based risk adjustment improved the prediction of Medicaid child health expenditures compared with demographic models without risk adjustment. They used Medicaid claims data from the mid-1990s for children in three States who were not covered by managed care. Kuhlthau, Ferris, Davis, et al., Med Care 43(11):1155-1159, 2005 (AHRQ Grant HS10152).

Premium subsidy programs can help low-income families obtain health insurance.

A growing number of States have begun to explore the use of premium subsidy programs to help low-income families purchase health insurance through the workplace or private plans. Three studies examined the benefits and difficulties encountered in several of these programs. The studies are part of AHRQ's Child Health Insurance Research Initiative (CHIRI™). The first study examined the factors that led parents to choose Oregon's premium subsidy program over SCHIP to cover their children and compared the children's experiences with regard to access, use of services, and satisfaction. The second study found that SCHIP can improve care for vulnerable children and reduce racial/ethnic disparities in health care. The third study found that families have difficulty shifting to Medicaid primary care case management programs, which limit the providers enrollees can use for routine care. Mitchell, Haber, and Hoover, Health Aff 24(5):1344-1355, 2005 (AHRQ grant HS10463); Shone, Dick, Klein, et al., Pediatrics 115(6), 2005; online at www.pediatrics.org (AHRQ Grant HS10465); and Bronstein, Adams, Florence, et al., Health Care Financ Rev 26(4):95-107, 2005 (AHRQ Grant HS10435).

Certain features of managed care increase access to specialists for low-income children with chronic illnesses.

This study linked certain features of managed care—having more in-network pediatricians and offering financial incentives for meeting quality of care standards—with greater access to specialty care for low-income children with chronic conditions. The study involved 2,333 children with conditions such as asthma, diabetes, and cystic fibrosis who were enrolled in an SCHIP program. The study also identified disparities in access to care; overall, black children were only half as likely as white children to receive specialty care. Shenkman, Tian, Nackashi, and Schatz, Pediatrics 115(6):1547-1554, 2005 (AHRQ Grant HS09949).

Improving access and quality for low-income and minority children may require more than expanding coverage.

Although low-income children account for nearly 40 percent of the U.S. child population, only about one-quarter of total pediatric medical expenditures are for these children. Access and quality challenges for these children include: problems in accessing necessary care, difficulty in getting referrals for specialty care, and lack of effective communication with physicians and other care providers. Regardless of income, black children had lower health care use and expenditures than white children, according to these researchers. Simpson, Owens, Zodet, et al., Ambul Pediatr 5(1):6-44, 2005 (AHRQ Publication No. 05-R048)* (Intramural).

One in five Latino children in the United States is uninsured.

This study examined the use of bilingual community-based case managers to assist Latino children with public insurance enrollment in two Boston-area communities. Children aged 18 and younger were divided into two groups: one group received help from trained case managers, and the other group (control) received traditional Medicaid and SCHIP outreach and enrollment. The researchers found that 96 percent of children in the intervention group enrolled in either Medicaid or SCHIP between May 2002 and September 2003, compared with 57 percent of children in the control group. Flores, Abreu, Chaisson, et al., Pediatrics 116(6):1433-1441, 2005 (AHRQ Grant HS11305).

Rollbacks in SCHIP will not save money.

High enrollment and reduced Federal allocations for SCHIP have led a number of States to begin reversing the expansion in public coverage for children. However, this study by AHRQ researchers found that rollbacks in SCHIP will not save much money. The net cost of SCHIP—both to States and to the Federal Government—is substantially less than the average spending per enrollee would suggest, according to the researchers. They conducted a variety of simulations and found that budgetary data greatly overstate the true net costs of SCHIP and consequently the potential savings from rollbacks to reduce enrollment. Selden and Hudson, Inquiry 42:16-28, 2005 (AHRQ Publication No. 05-R063)* (Intramural).

Children of working poor parents continue to be at a disadvantage for health care access and use.

Researchers used data from the 2001 California Health Interview Survey to compare health insurance coverage, access to care, and use of health care services for three groups of children: the working poor, nonworking poor, and nonpoor. They found that despite public health insurance, children from poor working families in California were less likely to be insured than other poor and nonpoor children in 2001. Children of the working poor also were more likely to be Latino and less likely to be black or Asian, more likely to be undocumented, and more likely to live in two-parent or larger households. Guendelman, Angulo, and Oman, Med Care 43(1):68-78, 2005 (AHRQ Grant HS13411).

Children with special needs use more health services and have higher costs than other children.

Children who have special health care needs (CSHCN) require more and /or more complex care than other children. This study found that in 2000, CSHCN had three times the health care expenditures of other children ($2,099 vs. $628). Although CSHCN made up less than 16 percent of U.S. children, they accounted for 42 percent of total medical costs and 52.5 percent of children's hospital days in 2000. Also, CSHCN used five times as many prescription drugs and substantially more home health care days than other children. Newacheck and Kim, Arch Pediatr Adolesc Med 159:10-17, 2005 (AHRQ/HRSA cooperative agreement). See also: Jaffee, Liu, Canty-Mitchell, et al., Psychiatr Serv 56(1):63-69, 2005 (AHRQ Grant HS10453).

Return to Contents
Proceed to Next Section