Can Unpaid Medical Expenses Be Billed to Family Members

ABSTRACT

This chapter examines the economic impact of unpaid caregiving on family caregivers of older adults who need assist because of health or functional limitations and explores which caregivers are at greatest run a risk of astringent financial consequences. Workplace and authorities policies and programs designed to support caregivers and/or mitigate these effects are also discussed. Caregivers of older adults can endure pregnant financial consequences with respect to both direct out-of-pocket costs and long-term economical and retirement security. Spouses who are caregivers are especially at hazard. More half of today's caregivers are employed, yet current federal policy and virtually states' family get out is unpaid, making it hard for many employed caregivers, especially low-wage workers, to accept time off for caregiving.

National surveys show that many family unit caregivers of older adults study fiscal strain associated with their roles every bit caregivers (NAC and AARP Public Policy Institute, 2015b; Spillman et al., 2014; Wolff et al., 2016), suggesting that at that place are important economic furnishings of taking on the caregiving role. This chapter examines the economical impact of unpaid family caregiving on family members and friends who treat older adults with functional or cognitive limitations, or a serious health condition, and identifies which caregivers are at greatest risk of astringent financial consequences. Information technology also explores the intersection of caregiving and work by examining the effects of caregiving on working caregivers and employers and describes workplace and government policies and programs designed to support working caregivers.

The economic furnishings of family caregiving can be examined at private, family, and societal levels, including (1) reductions in available fiscal resource of the caregiver as a consequence of out-of-pocket expenses; (2) employment-related costs for the caregiver who must reduce piece of work hours, exit the labor force, and forego income, benefits, and career opportunities in order to provide care; (iii) employment-related costs to the employer who must replace workers who go out the labor strength or reduce hours; and (4) societal benefits that include the potential price savings to the formal health and long-term services and supports (LTSS) systems because of the care and support provided by family caregivers (Keating et al., 2014). The available research on these topics is limited and largely based on self-report data, studies that are as well short in duration to capture long-term economic bear upon prospectively, and researchers disagree about assumptions made in economic bear upon analyses (e.g., replacement price of a family unit caregiver) (Schulz and Martire, 2009).

Broad IMPACTS

Feelings of "financial strain" are a frequently used global measure of the economic costs of caregiving. For example, a contempo survey conducted by the National Alliance for Caregiving (NAC) and the AARP Public Policy Institute (2015b) asked caregivers nearly "financial strain" related to family caregiving. The survey plant that 36 percent of the caregivers of adults older than the age of fifty reported moderate to high levels of fiscal strain. Those caregivers most likely to study high levels were caregivers who live at a distance from the older care recipient, those with high levels of caregiving brunt, and those who report they are the "primary" caregiver. In a contempo analysis of the 2011 National Health and Aging Trends Written report (NHATS) and the National Study of Caregiving (NSOC)^ⁱ for adults age 65 and older, caregivers who provided substantial assistance with wellness intendance activities (including care coordination and medication management) were more likely to report financial difficulty (23.0 percent) compared to their counterparts providing some assistance (12.0 percentage) or no assist (6.7 percentage) (Wolff et al., 2016).

In 2011, nearly half (8.5 million of 17.7 1000000) of the nation's caregivers of older adults living at home or in residential care settings (other than nursing homes)^² provided care to loftier-need, older adults.^ⁱⁱⁱ As Figure 4-i illustrates, the caregivers who are helping older adults with the greatest needs are the near likely to study having financial bug. Nearly one-tertiary (31.3 per centum) of the caregivers (in NSOC) who helped significantly dumb persons—those with both dementia and the need for help with at to the lowest degree two personal intendance activities—reported having financial difficulties related to caregiving. In contrast, only sixteen.2 percent of the caregivers of individuals who needed help with fewer than two personal care activities and do not have dementia reported fiscal difficulties (i.e., the intendance recipients).

FIGURE 4-i

Percentage of caregivers reporting financial difficulties, past the intendance recipient'south dementia status and level of impairment. NOTES: Includes family caregivers of Medicare beneficiaries age 65 and older in the continental U.s. who resided in community (more...)

The caregiving literature consistently shows that caregivers of significantly impaired older adults are the near probable to endure economic furnishings (Butrica and Karamcheva, 2014; Jacobs et al., 2014; Langa et al., 2001; Lilly et al., 2007; NAC and AARP Public Policy Institute, 2015b; Van Houtven et al., 2013). The economical touch on of intensive caregiving is likely related to the many hours of care and supervision that this population requires and the costs of hiring aid. In a recent multivariate analysis of viii waves of the Health and Retirement Study (HRS), for case, Butrica and Karamcheva (2014) found that caregivers who helped with dressing, bathing, and eating provided almost three times the number of caregiving hours than caregivers who provided merely household help. They were also more than likely than household helpers to provide at least one,000 hours of assist annually.

Other researchers, using longitudinal data, suggest that caregiving for an older developed places the caregiver at fiscal run a risk over time. For example, Wakabayashi and Donato (2006) found that caregiving increases the likelihood that women feel poverty and/or reliance on public assist. Lee and Zurlo (2014) also found a positive association betwixt caregiving and lower income later in life. In their test of an 8-moving ridge longitudinal study, Butrica and Karamcheva (2014) constitute that caregiving was associated with both reduced labor force participation and reduced net worth of family caregivers when compared with not-caregivers. These are examples of some of the broad economic impacts of caregiving. The word below examines in greater detail specific types of economic impact on the caregiver.

OUT-OF-POCKET SPENDING

Out-of-pocket spending generally refers to the purchase of appurtenances and services on behalf of the person whom the caregiver is helping, including payment for medical/pharmaceutical co-pays, meals, transportation, and appurtenances and services. Data on the dollar value of out-of-pocket costs are limited. The available estimates are based on cocky-reports that use rather broad and vague definitions of what constitutes an out-of-pocket caregiving expense. Piddling is known most the extent to which older adults and their family caregivers share the costs. One 2007 telephone survey asked caregivers about a broad range of spending including medical expenses, food and meals, household appurtenances, travel costs, intendance recipient services (developed day services and dwelling house care), nursing domicile/assisted living costs, housing costs, caregiving services, home modifications, wear, medical equipment/supplies, and legal fees. The caregivers reported an average annual corporeality of $5,531; long-altitude caregivers had the highest average annual expenses ($viii,728) (Evercare and NAC, 2007). One in five caregivers reported that older adults' out-of-pocket medical costs were their highest expense. The 2011 NSOC found that eight pct of caregivers incurred more than $1,000 per twelvemonth in out-of-pocket caregiving costs—divers as spending on medications or medical care, Medicare or other insurance premiums or copay-ments, mobility and other assistive devices, abode modifications, and paid home wellness aides. For some caregivers these costs may mean drawing down avails, taking on debt, or foregoing treatment of their own health issues. Better data on economical effects of caregiving on the family caregiver are needed to provide an accurate moving picture of the magnitude and predictors of economic effects.

Out-of-pocket spending plays a significant part of financing for LTSS because insurance—public or private—is lacking for these services, including hiring direct care workers such every bit home wellness aides and personal intendance workers. In one national survey, ane in iv (25 percent) family caregivers said it was very hard to get affordable services in the older adult's community that would help with their care (NAC and AARP Public Policy Institute, 2015b). Out-of-pocket expenses for older adults who are not Medicaid eligible or do not have long-term care insurance must be covered past the older adult or their family. Medicare does not cover LTSS and Medicaid is only bachelor afterward people take become impoverished.

The wealthiest families may have funds to pay for supportive services but many middle-class families cannot afford the home- and customs-based services that volition enable their elders to remain at dwelling house and avoid even more expensive institutional care (Bookman and Kimbrel, 2011). In 2016 the cost of employing a home health aide total fourth dimension for i year was virtually $46,480 and apply of adult twenty-four hours services cost most $xviii,000. The median almanac cost for an assisted living facility was $43,539 in 2016; the median almanac toll for nursing abode care was $92,378 in 2016 (Genworth, 2016).

EMPLOYMENT-RELATED COSTS TO CAREGIVERS

Today'due south caregivers of older adults are much more likely to be employed than in the past. The NSOC found that approximately one-half of all caregivers to older adults were employed either part- or total-fourth dimension. Of those caregivers who worked, 69 per centum were employed at to the lowest degree 35 hours weekly. In 2011, half of the estimated 17.7 meg caregivers of older adults (8.vii million or 50.three percent) in the The states worked (encounter Figure 4-2). Depending on the care needs and the intensity of the caregiving function, a caregiver may have to make accommodations in guild to manage their caregiving responsibilities and their job. Researchers, advocates, and observers take raised concerns that the demands of caregiving can negatively bear upon caregivers' power to stay in the workforce and thus jeopardize their income, job security, personal retirement savings, eventual Social Security and retirement benefits, career opportunities, and overall long-term financial well-being (Arno et al., 2011; Feinberg and Choula, 2012; Lilly et al., 2007; Munnell et al., 2015; Reinhard et al., 2015; Skira, 2015; Van Houtven et al., 2013; Wakabayashi and Donato, 2006).

Figure 4-2

Employment status of family caregivers of older adults, by sex, co-residence, relationship, race, didactics, and household income. NOTES: Northward = 8.seven million (employed caregivers). Includes family unit caregivers of Medicare beneficiaries historic period 65 and older in the (more than...)

Other survey data (NAC and AARP Public Policy Institute, 2015a) suggest that the bulk (61 percent) of employed caregivers need to make some workplace accommodations such as coming in late to work or leaving early, taking time off to manage care situations, reducing work hours or level of responsibleness, and/or taking a go out of absenteeism. All of these accommodations accept potential costs associated with them for both the caregiver and the employer. If an employee has exhausted his/her paid time off or has no paid time off to brainstorm with, each hr of work lost due to caregiving activities bears a fiscal cost to the employee. Taking unpaid get out is expensive, as is cutting hours or taking a lower paying job with less responsibility. Not only does the caregiver have an immediate loss of income, his/her long-term economic condition may be affected due to lower retirement savings or benefits.

As Chapter ii describes, current trends betoken to higher rates of employment among caregivers in the future—especially for the wives and daughters of older adults (Rock, 2015). The U.South. Bureau of Labor Statistics projects that women'south participation in the labor strength will continue to increase during the same years they are most likely to be caregiving (Toossi, 2009). The per centum of women older than age 54 who work, for example, is expected to increase from 28.5 percent in 2012 to 35.ane percent in 2022. During the same period, the percentage of working women older than historic period 64—those nearly likely to be caring for a spouse—is expected to increment from 14.4 percent to 19.five percent. As women work outside the home to make ends meet and abound the economy, the demands and pressures of working families to residual work, caregiving, and other family responsibilities have grown (Feinberg, 2013).

Caregivers' employment rates are highly variable across important subgroups (Bauer and Sousa-Poza, 2015; Jacobs et al., 2014; Lilly et al., 2007; Van Houtven et al., 2013). The 2011 NSOC institute marked differences in employment between those caring for a spouse (24 percent) or a parent (more than 60 per centum).

Although many people await to work longer—primarily driven by financial considerations—family caregiving responsibilities tin can sometimes arrive the mode of continued employment (Feinberg, 2014). Surveys indicate a strong association between caregiving—especially high levels of caregiving—and reduced work for pay. One national survey found that ane in five (19 percent) retirees left the workforce earlier than planned because of the demand to intendance for an ill spouse or other family member (Helman et al., 2015). In the 2015 Caregiving in the U.S. survey (NAC and AARP Public Policy Institute, 2015a), working caregivers who quit their task or took early on retirement reported doing so in order to have more than fourth dimension with the person they were helping (39 percentage) or because their job did non provide flexible scheduling (34 per centum). Caregivers with loftier intendance hours provided to the older person reported that they left the job because they could not beget to hire a paid caregiver. Co-resident caregivers were near likely to brand income-related accommodations such equally cutting back work hours, taking a go out of absence, quitting a job, or taking early retirement. A contempo assay of NHATS and NSOC information revealed that working caregivers who provide high levels of assistance with health care activities were 3 times more than likely to experience work productivity loss^⁴ than caregivers who provided some or no help with health intendance (Wolff et al., 2016). Some inquiry has also examined how family caregiving affects a woman'south current and futurity employment situation and retirement security. One written report, using data from HRS, found that women who exit piece of work while caregiving may detect it hard to render to the labor force afterwards they finish providing care to a parent (Skira, 2015). A study past Arno and colleagues (2011) based on HRS longitudinal data examined the long-term economical furnishings on workers who either reduced their hours at work or left the workplace before total retirement age. The analysis found that income-related losses sustained past family caregivers ages 50 and older who get out the workforce to care for a parent are $303,880, on boilerplate, in lost income and benefits over a caregiver's lifetime.^{^five} More enquiry is needed to fully sympathise the factors influencing the working caregiver's productivity and decision to exit and later return to the workplace and whether there are strategies that could mitigate adverse economic effects.

Figure iv-2 illustrates the employment rates by selected characteristics. These rates advise that factors that would predict the ability to continue working while providing care are related to higher education and income levels. Caregivers with a lower level of pedagogy or lower income are the least probable to be in the workforce and therefore are well-nigh at adventure of the economic losses outlined earlier.

COSTS TO EMPLOYERS

Much less is known nigh caregiving-related costs to employers. Employer- or concern-related costs may include the replacement costs for employees who quit due to their caregiving responsibilities, costs of absenteeism and workday interruptions, as well every bit direction and administrative costs based on the time supervisors spend on issues of employed caregivers. Some estimates suggest that the cost to U.Due south. businesses due to caregiving may exceed $29 to $33 billion per year, but these estimates should be viewed cautiously as they are based on quondam data and the studies make debatable assumptions in carrying out their assay (MetLife Mature Market Institute and NAC, 1997, 2006). Reliable information on the affect of eldercare on U.S. businesses are currently non available.

Some, primarily big, employers have invested resources in developing workplace programs for caregiving employees in an endeavor to support caregivers and retain workers. Anecdotal bear witness suggests that these programs may be well received and helpful to employed caregivers. All the same, information practice not exist to assess the effect of programs on employers or their return on investment. The few studies undertaken to explore these outcomes are largely dependent on cocky-reported data with the expected limitations (Gwyther and Matchar, 2015/2016; NAC and ReACT, 2012; Wagner et al., 2012). Only a few studies have been done to explore the small business concern surround (Matos and Galinsky, 2014; MetLife Mature Market place Institute and NAC, 2006). Yet, the topic of economic impact of family unit caregiving is an important one for both employers and caregivers who are employed. Every bit new workplace policies emerge it will exist important to assess employer acceptance, touch on business and industry, and benefit to the caregiver.

SOCIETAL BENEFITS

Family caregiving has the potential of substituting for formal wellness care services and the associated costs to Medicare and Medicaid in the form of reduced nursing home use and lower rates of home health care utilization (Charles and Sevak, 2005; Van Houtven and Norton, 2008). Both intervention and descriptive studies advise that under some circumstances cost savings tin exist achieved in the form of delayed institutionalization, reduced rehospitalizations, and lower home health service use. These studies are described in subsequent chapters on interventions with caregivers (see Chapter 5) and wellness care and LTSS (meet Chapter half dozen).

Some researchers estimate the societal do good of family caregiving past computing the replacement costs of the fourth dimension spent past family caregivers on tasks that someone else could perform (and assuming an hourly wage that would be paid in lieu of caregiving). Estimates of the economic value of unpaid care depend on which data sources are used and how caregiving is defined. Well-nigh studies apply survey information to estimate the number of family caregivers, the number of hours of care provided by caregivers, and the average wage of a home health aide (the replacement for the family caregiver). The Congressional Budget Office estimates that, in 2011, unpaid care provided by family caregivers to older adults was worth about $234 billion (CBO, 2013). However, estimating replacement costs is complex because not all caregivers are alike. For example, replacement costs for retired individuals would likely be different than replacement costs for younger caregivers in the workforce. In improver, equally noted by Skira (2015), existing static estimates are likely to underestimate the truthful toll because they practice not take into account dynamic wage and employment effects of elder parent care such equally leaving the labor strength permanently as a outcome of caregiving.

POLICIES AND PRACTICES THAT SUPPORT WORKING CAREGIVERS

Balancing work and caregiving responsibilities is a difficult chore fifty-fifty under the best of circumstances. A flexible workplace can back up employed caregivers with the time they demand to handle emergencies and routine matters such as dr.'s appointments. However, many family caregivers lack this flexibility and, for those who practice not have the option of taking time off with pay, balancing work and family responsibilities tin be nearly impossible. Employees may exist absent-minded from work for both planned and unplanned reasons. For example, taking a female parent to a scheduled md's appointment is a planned leave from piece of work. Going to the hospital to intendance for a father who has suffered a stroke is an case of unplanned leave that may happen due to an urgent and unexpected situation (Feinberg, 2013). The U.Due south. Department of Labor (DOL) (2015c) reports that xl percent of the private-sector workforce lacks access to any paid sick leave, while 70 per centum of workers who accept earnings in the bottom 25 percent of the wage scale in the United States lacks any paid time off.

Flexible Workplaces

Flexible workplaces may include flexibility about where work occurs, when work takes identify, and an selection to modify piece of work schedules co-ordinate to competing responsibilities. In 2014, President Obama signed a Presidential Memorandum that gave federal workers a right to request flexible working arrangements. Flexible workplaces are not only adept for the employees with caregiving responsibilities but benefit employers likewise. Studies suggest that flexible work policies reduce turnover and absenteeism among employees and may improve productivity (Council of Economic Advisors, 2010). Flexible work schedules specifically with respect to eldercare have not been studied.

Family and Medical Leave Policies

The federal Family and Medical Leave Human activity (FMLA) has been in place in the United States since 1993. The Act allows workers to take unpaid, task-protected leave to intendance for a worker's own health needs, to bond with a new child, or to intendance for a seriously ill family fellow member (child, parent, or spouse). FMLA only applies to governmental agencies and individual employers with more than than 50 employees. Eligibility for FMLA requires a worker to have been employed by the covered employer for at to the lowest degree 12 months and to take worked at least 1,250 hours. Up to 12 weeks of unpaid leave may be taken during any 12-month catamenia and employees must be able to render to their chore or equivalent with the aforementioned pay, benefits, and working conditions (Mayer, 2013). FMLA tin can be taken intermittently, over a 12-week period, or by working part time. In nearly states, the circumstances that ascertain a worker's right to FMLA are express to certain relationships: spouses, domestic partners, children, and parents. Many caregivers of older adults such every bit in-laws—daughters or sons—step-children, grandchildren, siblings, nieces and nephews, and other relatives are not eligible for the protection of FMLA. Overall xl percent of U.Southward. workers do not qualify for FMLA due to their family human relationship to the care recipient or because of the law's other restrictions (Klerman et al., 2014).

FMLA is also not a truthful selection for low-income people who cannot afford to forego wages they would lose past taking it (Feinberg, 2013; Umberson and Montez, 2010). In a DOL-sponsored survey in 2011, 17 percentage of caregivers did not take leave considering they feared losing their job fifty-fifty though they were eligible for protected job leave, and 8 pct did not admission unpaid leave benefits because they were non eligible due to the relationship with the care recipient (Klerman et al. , 2014).

Although DOL has sponsored a series of surveys to track the implementation of FMLA, the bureau'south data drove is not detailed plenty to appraise the law's specific impact on caregivers of older adults. The nigh recent DOL survey indicates that, in 2012, xviii per centum of workers who took get out under FMLA did and so to care for a child, parent, or spouse with a serious wellness condition (Klerman et al., 2014). The survey did non distinguish amongst the unlike caregiver categories, so data on go out taken specifically for eldercare are not available.

Fourteen states including the District of Columbia take enacted legislation to extend FMLA to other family relationships, well-nigh often to domestic partners and parents-in-law but also including grandparents, grandchildren, and siblings. Six states have likewise expanded eligibility to some workers in smaller firms. Table 4-i lists the covered categories for each country.

TABLE 4-1

States with Expansions in Unpaid Family and Medical Leave.

Access to Paid Family Get out

The overwhelming majority of U.Due south. workers do not have admission to paid family unit or medical go out (Glynn, 2015). Co-ordinate to the National Compensation Survey, merely 12 percent of private-sector workers have admission to paid family unit leave benefits through their employers (BLS, 2015a). In this survey, lower-wage workers were less probable than college-wage workers to have access to paid family leave. Although paid family unit leave is not available to near workers, other forms of paid leave can support a working family caregiver. When employers provide paid time off, it can be in the grade of vacation days, sick leave, personal days, or as "PTO," paid fourth dimension off for any reason (Bishow, 2015; BLS, 2015a). Box 4-1 outlines culling paid leave options that may be available to employees. The form of exit benefits vary widely across occupations, type of worker, industries, institution size, and geographic areas. Nearly all full-time federal, country, and local regime employees are entitled to paid go out of some type (BLS, 2015a).

Table 4-ii shows the percentage of workers in wage categories without any paid leave. Equally can be seen, at that place is a articulate association between low wages and part-fourth dimension status and no paid go out options.

TABLE 4-two

Workers Without Employer-Paid Leave, by Average Wage Category and Weekly Work Hours, 2015.

State and Local Efforts to Expand Admission to Paid Leave for Family Caregivers

State governments provided the leadership in the development of the paid family and medical get out policies in place today. Connecticut was the first land to enact paid family leave for state employees in 1987. In 2004, California began the first paid family unit and medical leave programme in the nation (Wagner, 2006). Today states are again leading in the development of paid family unit leave programs. 4 states—California, New Bailiwick of jersey, New York, and Rhode Island—have enacted access to paid family and medical leave programs for new parents and caregivers of certain seriously ill family members. New York and Rhode Island incorporate job protection every bit a feature of their program. The iv programs share the following design characteristics:

Financed through an insurance model
Fully funded past worker payroll deductions
Provides fractional pay replacement for a finite menstruum of time
Covers caregivers of spouses, parents, and domestic partners (California, New York, and Rhode Island too include parents-in-law and grandparents; siblings are eligible only in California)
Uses an existing state infrastructure to finance and administer claims (i.e., Temporary Disability Insurance [TDI] agencies)

The almanac payroll deductions are designed to fully cover the program costs (Fiscal Policy Institute, 2014). Some evidence indicates that costs are low because programme utilization is low (Appelbaum and Milkman, 2011). Because New York's program was passed in 2016, information on the plan will not exist available until later on the program starts in 2018 (A Better Residue, 2016).

Impact of Paid Family Get out Programs on Caregivers of Older Adults

Determining the direct bear upon of these programs on caregivers of older adults is hard although the programs conspicuously offer some fiscal protection for those who can use them. The states collect some data on users merely not in enough detail to identify the ages or atmospheric condition of the older adults who receive care. In every state, the programs are used primarily by new parents for bonding with infants (Andrew Chang & Company, 2015; Bartel et al., 2014; EDD, 2014a,b, 2015; Milkman and Appelbaum, 2014; National Partnership for Women and Families, 2015; New Jersey Department of Labor and Workforce Development, 2015) (encounter Table iv-3). People caring for spouses or adult children caring for parents constitute about 6 to 10 percentage of claimants—presumably many of their care recipients are older adults. In New Jersey, 60 percent of family care claims in 2011 were made by employed caregivers aged 45 and older (Feinberg, 2013).

Tabular array iv-3

Characteristics of State Mandatory Paid Family and Medical Get out Programs.

Public awareness of the programs is a problem particularly with respect to eligibility for paid get out to treat seriously ill family unit members. In California, the individuals who are nearly likely to benefit from paid family leave are among those groups to the lowest degree likely to know about information technology (Andrew Chang & Company, 2015; Field Research Corporation and California Eye for Research on Women & Families, 2015). A survey conducted in late 2014, for instance, found that just 36 percent of California registered voters knew about the programme and its benefits; awareness was particularly low among ethnic minority groups (i.east., persons identifying as Latino, African American, or Asian American), individuals with no more than a high school teaching, depression-income households, and women (Field Inquiry Corporation and California Middle for Inquiry on Women & Families, 2015). A New Jersey poll found that lx percent of the public did not know about the family caregiving do good (White et al., 2013). Some workers may not use available paid family get out considering the benefit does not guarantee job security, or considering they cannot beget to take the time off because the paid leave benefit covers simply partial wage replacement.

In 2014, the California legislature funded a public education and outreach campaign that including focused market place enquiry on the linguistic and cultural issues that may affect awareness and utilise of family leave benefits. Focus group discussions—structured to examine the perspectives of eligible Armenian, Chinese, Filipino, Latino, LGBTQ Californians, Panjabi, and Vietnamese—revealed significant challenges in communicating information virtually paid family exit (Andrew Chang & Company, 2015).

Impact of Paid Family Leave Programs on Employers

Almost of the published reports on employers' response to their country's mandated paid leave programme draw from small surveys and structured, in-depth interviews with selected employers. Nigh employers appear to take adapted to the mandates although some report additional costs. A 2010 survey of California employers found that nearly 90 percent of employers reported either a positive or no noticeable issue on productivity, profitability, or employee turnover (Appelbaum and Milkman, 2011). In-depth interviews with 18 New Jersey employers iv years after the first of the program found largely positive responses (Lerner and Appelbaum, 2014). The surveyed employers represented businesses with as few as 26 employees and as many as 36,000 employees. All respondents had at to the lowest degree one employee who submitted a merits for paid family unit leave. Some employers said it improved morale and led to only small-scale to moderate increases in paperwork. Nonetheless, 2 of the 18 employers said the mandate led to lower profitability.

Prospects for New State and Local Paid Family Leave Programs

California, New Jersey, New York, and Rhode Island have been able to limit the cost of implementing paid family go out past using existing TDI country agencies. These states have extended TDI programs to provide a partial wage replacement benefit to employees caring for a relative with an illness (Feinberg, 2013; New York State Legislature, 2016). In April 2016, California expanded its paid family leave law to include more low-income workers and to provide higher pay to workers while on leave (effective in 2018). Only one other land—Hawaii—has the aforementioned TDI infrastructure but it does not have a paid family exit program (National Partnership for Women and Families, 2015).^{^six} Washington State—which does not have a TDI program—enacted paid family leave in 2007 but has yet to implement it due to lack of start-up funds (Glynn, 2015). Table 4-3 displays the characteristics of land mandatory paid family and medical exit programs.

Additional insights into other approaches for the design and implementation of paid family medical go out programs may be forthcoming from DOL. Since 2014, DOL has awarded more than $2 million in grants to 12 states and localities to either evaluate their existing programs or to conduct feasibility studies to encourage their evolution. The grantees are California; the District of Columbia; Massachusetts; Montana; Montgomery Canton, Maryland; New Hampshire; New York City; Rhode Island; Tennessee; Vermont; and Washington land (DOL, 2015b). Recently DOL appear the 3rd circular of $1 million in grants. Importantly, in this circular of paid go out analysis grants, DOL is encouraging states/localities to study issues related to eldercare. DOL volition award up to iii points to applications that touch on paid family leave for workers with eldercare responsibilities (DOL, 2016).

Access to Mandatory Paid Sick Exit

5 states—California, Connecticut, Massachusetts, Oregon, and Vermont—have recently enacted paid sick go out laws affecting the employees of all or a large portion of the respective state's employers. The policies, described in Table 4-4, have important implications for employed caregivers because they stipulate that workers have access to paid sick time when caring for certain ill family members. Earned sick day policies differ from paid family and medical go out policies. Public policies covering sick days at piece of work generally cover a limited number of paid days off per year (typically between three and 9 days, depending on land or locality) with full wage replacement (Reinhard and Feinberg, 2015). California has the nearly expansive definition of eligible family unit members; it includes spouses, domestic partners, parents, parents-in-police, grandparents, and siblings. Connecticut covers spouses simply. The Massachusetts statute—a result of a 2014 ballot initiative—allows time off for workers taking family unit members to a medical appointment.

TABLE iv-4

Characteristics of State Mandatory Paid Ill Leave Laws.

Employers in a growing number of major metropolitan areas are too subject to local paid sick leave mandates (National Partnership for Women and Families, 2015; Reyes, 2016). These include Eugene and Portland, Oregon; New York City; the San Francisco Bay Area; Los Angeles; Montgomery County, Maryland; Philadelphia and Pittsburgh; Seattle and Tacoma; Washington, DC; and nine New Bailiwick of jersey cities.^⁷

Federal workers and contractors also have access to sick leave. In January 2015, the White Firm issued a Presidential Memorandum directing federal agencies to advance up to 6 weeks of paid ill leave for federal employees to treat sick family members, including spouses and parents (White House Office of the Press Secretary, 2015a). In September 2015, the President signed an Executive Social club requiring federal contractors to offer their employees upwards to seven days of paid sick leave annually, including paid get out allowing employees to care for ill family members (White House Office of the Press Secretary, 2015b).

Caregiving and Social Security Benefits

Because Social Security benefits are based on ane's earnings history, caregivers who cut their work hours or withdraw from the workforce will ultimately receive lower Social Security payments. Social Security caregiving credits have been proposed as one style to reduce the bear upon of foregone wages on hereafter benefits (Estes et al., 2012; Morris, 2007; White-Means and Rubin, 2009). In its simplest form, a Social Security credit plan would prospectively credit eligible caregivers with a defined level of deemed wages upwards to a specified fourth dimension period. White-Means and Rubin (2009), for example, accept proposed that total-time caregivers receive upwardly to 4 years of Social Security work credits equal to the individual's average wage or self-employment income during the previous 3 years. The caregiver's eligibility would require certification past a physician as to the care recipient'south level of need. Using 2008 estimates, the analysts projected that married caregivers who used the credit for the full 4 years would run into a lifetime increment in Social Security benefits of $8,448 and single caregivers would receive $thirteen,632 more than.

The costs of developing and administering a Social Security caregiver credit plan have not been fully explored. The direct cost of the credits would depend on several variables such as eligibility criteria (e.thou., spouses, adult children, or others), the maximum number of creditable years, and the method used to calculate individual payments (Jankowski, 2011). The evolution and management of an infrastructure to administer the plan would also have costs.

Job Bigotry

Some employed caregivers of older adults may be subject to workplace bigotry considering of their caregiving responsibilities (Bornstein, 2012; Calvert, 2010; Calvert et al., 2014; EEOC, 2007, 2009; Williams et al., 2012). Family responsibleness discrimination (FRD), also chosen caregiver bigotry, is employment discrimination against someone based on his or her family caregiving responsibilities and the assumption that workers with family obligations are not undecayed or less productive than their peers (Calvert, 2015). The issue can be emotionally draining and costly to the working caregiver. Appendix Thou includes the stories of two workers who reported experiencing job bigotry as a event of their family caregiving responsibilities.

FRD commonly results from unexamined assumptions about how an employee volition or should deed. For example, a supervisor may assume that a woman will not be as attentive or committed an employee afterward she advises her supervisor of her demand to take periodic time off to care for her ill married man. FRD occurs when caregivers—regardless of their piece of work functioning—are rejected for rent, denied a promotion, demoted, harassed, terminated, or subjected to schedule changes that force the employee to quit (Calvert, 2010). 1 recent national study found that 5 percent of working caregivers historic period 65 or older had ever received a warning about their performance or omnipresence as a result of caregiving (NAC and AARP Public Policy Institute, 2015b).

Responses to evidence of FRD take been varied. No federal statutes or regulations specifically prohibit FRD. Some states and localities take enacted laws that protect workers with family responsibilities as a specific group or form from discrimination—but the protections are sometimes express to childcare responsibilities (Reinhard et al., 2014; Williams et al., 2012). In January 2016, the Mayor of New York City signed legislation expanding the protections of the urban center's Man Rights law confronting employment discrimination to include caregivers of a minor child or an private with a disability. The law adds "caregiver status" as an boosted protected category for which employment discrimination is prohibited (McHone, 2016).

In 2007, the Equal Employment Opportunity Committee (EEOC) issued a report on FRD, Enforcement Guidance: Unlawful Disparate Treatment of Workers with Caregiving Responsibilities (EEOC, 2007). While the study acknowledges that federal equal employment opportunity laws practice not prohibit bigotry against caregivers, it articulates the circumstances in which employment decisions affecting a caregiver might unlawfully discriminate on the basis of Title Vii of the Civil Rights Act^⁸or the Americans with Disabilities Human action.^⁹ Further guidance is provided in an EEOC best practices guide for employers (EEOC, 2009). Although the EEOC efforts are valuable, the bureau's communication does not acquit the weight of regulation nor does information technology have authority over FMLA and other statutes outside of the agency's jurisdiction.

The magnitude of the touch on of FRD on family caregivers of older adults is not known; most reported cases relate to pregnancy and parenthood. The Center for WorkLife Law, which tracks litigated cases of FRD cases decided by courts, agencies, and arbitrators, has compiled a dataset of more than 4,400 cases dating from 1996 to 2015 (Calvert, 2016). Overall, 11 percent of the cases were related to caregiving for crumbling relatives. The report author suggests that considering FRD cases are identified primarily through publicly bachelor courtroom rulings, they may be a small fraction of the total number of actual cases.

PRIVATE EMPLOYER INITIATIVES

More than thirty years ago, employee surveys began to heighten concerns among big employers and organized labor nearly the challenges faced past workers with caregiving responsibilities (Labor Project for Working Families, 1999; Travelers Insurance Companies, 1985). An ofttimes cited Fortune magazine survey found that even some CEOs reported they did not believe they could manage their own jobs if they had to care for a parent (Fortune Magazine and John Hancock Fiscal Services, 1989). In response, large employers began to provide workplace programs to back up workers and mitigate the affect of caregiving on employees' temporary or permanent departures, lower productivity, absenteeism, coming to work tardily or leaving early, accidents or mistakes, and wellness bug (Galinsky and Stein, 1990; GAO, 1994; Wagner et al., 2012). The 2014 Society for Homo Resource Direction (SHRM) survey of employers estimates that 5 per centum of employers provide eldercare referral services, 1 percent geriatric counseling and 1 percent eldercare in-habitation assessments (Matos and Galinsky, 2014). There is petty empirical show virtually outcomes of the workplace programs and the extent to which they either aid the employee with caregiving responsibilities or mitigate piece of work–family conflicts. Early inquiry supports the idea that many employees do not experience comfy bringing a family issue into the workplace and may, every bit a event, not utilise available programs (Wagner and Chase, 1994). However, in that location is evidence every bit discussed earlier, that workplace flexibility supports those employees with eldercare responsibilities. The three eldercare workplace programs shown in Box 4-2 were selected as examples because of their successes over time (Fannie Mae and Duke Academy) and the thoughtfulness and careful planning that went in to the newly adult Emory University programme. The university used consultants and studied both the campus needs and the resources in the community in their planning.

BOX 4-2

Three Noteworthy Eldercare Workplace Programs.

CONCLUSIONS

The committee'due south key findings and conclusions are described in item in Box 4-3. In summary, the commission concludes that family caregiving of older adults poses substantial financial risks for some caregivers. Although the relevant testify is based primarily on caregivers' self-reports, research consistently shows that family caregivers of older adults with significant physical and cerebral impairments (and associated behavioral symptoms) are at the greatest take a chance of economic harm. This risk is especially true for low-income caregivers (and families) with express financial resources, caregivers who reside with or live far from the older adult who needs intendance, and caregivers with limited or no access to paid leave benefits (if they are employed).

BOX iv-3

Key Findings and Conclusions: Economic Bear on of Family Caregiving.

Some caregivers cut dorsum on paid piece of work hours or leave the workforce altogether to care for an older adult. As a issue, they lose income and may receive reduced Social Security and other retirement benefits. They may likewise incur significant out-of-pocket expenses to pay for help and other caregiving expenses. There is also some evidence of increasing job-related bigotry confronting workers with eldercare responsibilities.

Caregiving of older adults has substantial implications for the workplace. Today's family caregivers of older adults are more than likely to be in the workforce than always earlier—more than half are employed either part- or full-time. Moreover, the cohort of Americans about likely to intendance for older adults—women historic period 55 and older—are expected to participate in the workforce at increasing rates.

Federal policies provide petty protection to many employed caregivers in these circumstances. For instance, daughters- and sons-in-law, stepchildren, grandchildren, nieces and nephews, and siblings of older adults are non eligible for FMLA's unpaid leave or chore protections for family leave. Low-wage and office-time workers are peculiarly vulnerable because they cannot afford to accept unpaid get out and their employers are less probable to offer paid fourth dimension off. A handful of states and local governments have taken activeness to clinch admission to some course of paid family unit or sick exit. However, much remains to exist learned about how these efforts have specifically affected caregivers of older adults or their employers.

The impact of family caregiving on employers has non been well studied. Some large employers have established programs to support workers with eldercare responsibilities. Unfortunately, in that location is little empirical evidence about the costs and outcomes of workplace programs or the extent to which they help working caregivers juggle their caregiving and job responsibilities. Data and inquiry are clearly needed to learn how to effectively support working caregivers of older adults through workplace leave benefits, protections from job discrimination, or other approaches.

REFERENCES

Appelbaum East, Milkman R. Leaves that pay: Employer and worker experiences with paid family leave in California. Washington, DC: Center for Economic and Policy Research; 2011. [November 22, 2015]. http://www.cepr.internet/publications/reports/leaves-that-pay.
Arno P, Viola D, Shi Q. The MetLife Report of Caregiving Costs to Working Caregivers: Double jeopardy for infant boomers caring for their parents. Westport, CT: MetLife Mature Market Constitute; Center for Long-Term Intendance Research and Policy, New York Medical College; and National Alliance for Caregiving; 2011. [February 12, 2016]. http://www.caregiving.org/wp-content/uploads/2011/06/mmi-caregiving-costs-working-caregivers.pdf.
Bauer JM, Sousa-Poza A. Impacts of informal caregiving on caregiver employment, health, and family. Journal of Population Ageing. 2015;8(3):113–145.
Bookman A, Kimbrel D. Families and elder care in the twenty-first century. The Future of Children. 2011;21(2):117–140. [PubMed: 22013631]
Bornstein S. Work, family unit, and discrimination at the bottom of the ladder. Georgetown Periodical on Poverty Constabulary Policy. 2012;19(one):i–42.
Calvert CT. Family responsibilities discrimination: Litigation update 2010. San Francisco, CA: The Center for WorkLife Police force; 2010.
Calvert CT. Family unit responsibilities discrimination. Washington, DC: 2015. [January xvi, 2015]. (Presentation to the Committee on Family Caregiving for Older Adults).
Calvert CT. Caregivers in the workplace: Family responsibilities bigotry litigation update 2016. San Francisco, CA: The Middle for Worklife Law; 2016. [May 19, 2016]. http://www.worklifelaw.org/pubs/FRDupdate2016.pdf.
Calvert CT, Williams JC, Phelan G. Family responsibilities bigotry. Arlington, VA: Bloomberg BNA; 2014.
CBO (Congressional Budget Part). Ascension demand for long-term services and supports for elderly people. Washington, DC: Congressional Budget Part; 2013.
Charles KK, Sevak P. Tin family caregiving substitute for nursing home intendance? Journal of Health Economic science. 2005;24(vi):1174–1190. [PubMed: 15979742]
Connecticut Department of Labor. Guidance from the Connecticut Department of Labor regarding Connecticut General Statutes §§ 31-57r – 31-57w – paid sick leave. 2014. [December 22, 2015]. https://www.ctdol.state.ct.us/wgwkstnd/SickLeaveGuidance.pdf.
EEOC (Equal Employment Opportunity Commission). Enforcement guidance: Unlawful disparate treatment of workers with caregiving responsibilities. Washington, DC: 2007. [July 2, 2015]. http://www.eeoc.gov/policy/docs/caregiving.html.
Feinberg LF. Keeping up with the times: Supporting family caregivers with workplace go out policies. Washington, DC: AARP Public Policy Institute; 2013.
Feinberg LF. Recognizing and supporting family caregivers: The time has come. Public Policy & Aging Report. 2014;24(two):65–69.
Feinberg L, Choula R. Understanding the impact of family caregiving on piece of work. Washington, DC: AARP Public Policy Institute; 2012.
Field Research Corporation, and California Center for Research on Women & Families. A survey of California registered voters near the country's paid family unit leave programme. San Francisco, CA: 2015. [December 29, 2015]. http://www.field.com/fieldpollonline/subscribers/Rls2494.pdf.
Fiscal Policy Found. Reform of New York's Temporary Inability Insurance program and provision of family unit go out: Estimated costs of proposed legislation. Albany, NY: Financial Policy Plant; 2014.
Fortune Magazine and John Hancock Financial Services. Corporate and employee response to caring for the elderly: A national survey of U.S. companies and the workforce. New York: Fortune Mag and John Hancock Financial Services; 1989.
Galinsky E, Stein PJ. The touch on of man resources policies on employees: Balancing work/family life. Journal of Family Issues. 1990;eleven(4):368–383.
GAO (Authorities Accountability Office). Long term care: Private sector elder intendance could yield multiple benefits. Washington, DC: Government Accountability Office; 1994.
Gwyther LP, Matchar BG. The Duke employee elder intendance consultation: Meeting employees where they are. Journal of the American Social club on Aging. 2015/2016;39(iv):105–108.
Jankowski J. Caregiver credits in France, Deutschland, and Sweden: Lessons for the The states. Social Security Bulletin. 2011;71:61–77. [PubMed: 22191285]
Kasper JD, Freedman VA. Findings from the 1st round of the National Health and Crumbling Trends Study (NHATS): Introduction to a special issue. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences. 2014;69(7):S1–S7. [PubMed: 25342818]
Keating NC, Fast JE, Lero DS, Lucas SJ, Eales J. A taxonomy of the economic costs of family care to adults. The Journal of the Economic science of Ageing. 2014;3:11–20.
Klerman JA, Daley 1000, Pozniak A. Family and medical get out in 2012: Technical report (2014 revision). Cambridge, MA: Abt Associates; 2014.
Labor Project for Working Families. Bargaining for elderberry care. Berkeley, CA: Labor Project for Working Families; 1999.
Langa KM, Chernew ME, Kabeto MU, Regula Herzog A, Ofstedal MB, Willis RJ, Wallace RB, Mucha LM, Straus WL, Fendrick AM. National estimates of the quantity and cost of informal caregiving for the elderly with dementia. Journal of General Internal Medicine. 2001;sixteen(eleven):770–778. [PMC gratuitous article: PMC1495283] [PubMed: 11722692]
Lee Y, Zurlo KA. Spousal caregiving and fiscal strain among middle-aged and older adults. International Journal of Homo Development. 2014;79(4):302–321. [PubMed: 25888536]
Lilly MB, Laporte A, Coyte PC. Labor market place work and habitation care's unpaid caregivers: A systematic review of labor force participation rates, predictors of labor market withdrawal, and hours of work. Milbank Quarterly. 2007;85(4):641–690. [PMC free commodity: PMC2690351] [PubMed: 18070333]
Matos K. Paid time off, vacations, sick days and short-term caregiving in the United States: 2014 National Study of Employers. New York: Families and Work Institute, Guild for Human Resource Direction, and When Work Works; 2015. [March 16, 2015]. http://familiesandwork.org/downloads/paid-exit-nse.pdf.
Mayer Grand. The Family and Medical Leave Act (FMLA): Policy issues. Washington, DC: Congressional Research Service; 2013.
MetLife Mature Market Establish and NAC (National Brotherhood for Caregiving). The MetLife Written report of Employer Costs for Working Caregivers. 1997. [December 4, 2015]. (Based on data from Family unit Caregiving in the U.South.: Findings from a national survey). http://www.geckosystems.com/downloads/empcosts.pdf.
MetLife Mature Market Institute and NAC. The MetLife Caregiving Price Written report: Productivity losses to U.South. business organisation. Westport, CT: MetLife Mature Market Institute and NAC; 2006.
Milkman R, Appelbaum Due east. What works for workers: Public policies and innovative strategies for low-wage workers. Luce South, Luff J, McCartin JA, Milkman R, editors. New York: Russell Sage Foundation; 2014. pp. 305–328. (Depression-wage workers and paid family leave: The California experience).
Morris JL. Explaining the elderly feminization of poverty: An analysis of retirement benefits, health care benefits, and elder care-giving. Notre Dame Journal of Law, Ethics & Public Policy. 2007;21(two):571–607.
NAC (National Brotherhood for Caregiving) and AARP Public Policy Institute. Caregiving in the U.Southward. Washington, DC: NAC and AARP Public Policy Institute; 2015a.
NAC and AARP Public Policy Institute. Caregivers of older adults: A focused look at those caring for someone age 50+ Washington, DC: NAC and AARP Public Policy Institute; 2015b.
New Bailiwick of jersey Department of the Treasury. New Jersey Family Leave Act and Family and Medical Go out Act of 1993: Frequently Asked Questions and Answers. Employers' Pensions and Benefits Administration Manual (EPBAM); 2016. [August sixteen, 2016]. http://world wide web.state.nj.us/treasury/pensions/epbam/boosted/fmla-qa.htm.
Reinhard Due south, Feinberg LF. Family caregiving in the new normal. Gaugler JE, Kane RL, editors. London, UK: Academic Press; 2015. pp. 291–304. (The escalating complexity of family unit caregiving: Meeting the challenge).
Reinhard SC, Kassner E, Houser A, Ujvari K, Mollica R, Hendrickson L. Raising expectations: A state scorecard on long-term services and supports for older adults, people with physical disabilities, and family unit caregivers. Washington, DC: AARP, The Republic Fund, and The Scan Foundation; 2014. [April 8, 2015]. http://www.aarp.org/content/dam/aarp/inquiry/public_policy_institute/ltc/2014/raising-expectations-2014-AARP-ppi-ltc.
Reinhard SC, Feinberg LF, Choula R, Houser A. Valuing the invaluable: 2015 update. Washington, DC: AARP Public Policy Institute; 2015.
Rhode Island Section of Labor and Training. Launching the Rhode Island Temporary Caregiver Insurance plan (TCI): Employee experiences 1 year later. Providence, RI: 2015.
Schulz R, Martire LM. Aging and work: Issues and implications in a irresolute mural. Baltimore, Physician: Johns Hopkins University Press; 2009. pp. 35–50. (Caregiving and employment).
Skira MM. Dynamic wage and employment effects of elder parent care. International Economic Review. 2015;56(1):63–93.
Stone RI. Family unit caregiving in the new normal. Gaugler JE, Kane RL, editors. London, UK: Academies Press; 2015. pp. 57–78. (Factors affecting the futurity of family unit caregiving in the United States).
Toossi Thousand. Labor strength projections to 2018: Older workers staying more active. Washington, DC: Bureau of Labor Statistics; 2009.
Travelers Insurance Companies. The Travelers Employee Caregiver Survey: A survey on caregiving responsibilities of Travelers employees for older Americans. Hartford, CT: The Travelers; 1985.
Umberson D, Montez JK. Social relationships and health a flashpoint for wellness policy. Periodical of Health and Social Beliefs. 2010;51(ane Suppl):S54–S66. [PMC free article: PMC3150158] [PubMed: 20943583]
Van Houtven CH, Norton EC. Informal intendance and Medicare expenditures: Testing for heterogeneous treatment effects. Journal of Health Economics. 2008;27(1):134–156. [PubMed: 17462764]
Van Houtven CH, Coe NB, Skira MM. The result of informal care on piece of work and wages. Periodical of Health Economics. 2013;32(1):240–252. [PubMed: 23220459]
Wagner DL. Families, work, and an crumbling population: Developing a formula that works for the workers. Journal of Aging and Social Policy. 2006;18(iii):115–125. [PubMed: 17135098]
Wagner DL, Hunt One thousand. The use of workplace eldercare programs by employed caregivers. Inquiry on Crumbling. 1994;16(1):69–84.
Wakabayashi C, Donato KM. Does caregiving increase poverty amid women in later life? Evidence from the Health and Retirement Survey. Periodical of Health and Social Beliefs. 2006;47(3):258–274. [PubMed: 17066776]
White K, Houser 50, Nisbet Due east. Policy in activity: New Jersey'due south Family unit Leave Insurance program at age three. New Brunswick, NJ: Rutgers Center for Women and Work; 2013. [December 29, 2015]. http://smlr.rutgers.edu/CWW-report-FLI-at-historic period-three.
Wolff J, Spillman B, Freedman V, Kasper J. A national profile of family and unpaid caregivers who assist older adults with health care activities. JAMA Internal Medicine. 2016;176(three):372–379. [PMC free article: PMC4802361] [PubMed: 26882031]

i: The prevalence data presented in this report describe primarily from NHATS and NSOC, unless noted otherwise. Run across Chapter 2 and Appendix E for boosted information nearly the surveys and the commission's methods in analyzing them.
2: NSOC includes caregivers of older adults living in any type of residential care setting other than a nursing home. Residential care settings include assisted or independent living facilities, personal care and group dwelling house settings, standing care retirement communities, and other settings (Kasper and Freedman, 2014).
3: See Affiliate 2 for additional statistics describing the caregiver population.
four: "Work productivity loss" in this research was a composite variable based on measures of absenteeism (missed hours of work because of caregiving in relation to typical hours worked) and presenteeism (negative issue of caregiving on productivity when at work) (Wolff et al., 2016).
5: In this study, the estimates range from a total of $283,716 for men to $324,044 for women, or $303,880 on average. The average figure breaks downwardly every bit follows: $115,900 in lost wages, $137,980 in lost Social Security benefits, and conservatively $fifty,000 in lost pension benefits.
half-dozen: Puerto Rico also has a TDI program.
7: The New Bailiwick of jersey cities are Bloomfield, Due east Orange, Irvington, Bailiwick of jersey Urban center, Montclair, Newark, Passaic, Paterson, and Trenton.
eight: Public Law 88-352.
ix: Public Constabulary 101-336.

myerssnack1984.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/books/NBK396402/