The EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey (Consumer Engagement Survey) provides reliable national data on the growth of high-deductible plans and their impact on the behavior and attitudes of health care consumers with employment-based coverage or individually purchased coverage. It also looks broadly at consumer engagement and value-based health insurance design. Now in its 14th year, it is co-sponsored by the Employee Benefit Research Institute (EBRI) and Greenwald & Associates with support from six private organizations.
The 2018 survey was conducted online August 10‒23, using the Ipsos consumer panel. A total of 2,010 adults with private health insurance coverage through an employer, purchased directly from a carrier, or purchased through a government exchange participated in the survey. However, most survey participants (85 percent) received coverage through an employer. The data were weighted by gender, age, education, region, income, and race/ethnicity to reflect the actual proportions in the population ages 21–64 with private health-insurance coverage.
This Issue Brief identifies the key findings of the 2018 survey:
- HDHP enrollees have many characteristics equated with greater financial stability. HDHP enrollees have higher income and higher education than those enrolled in more traditional health coverage.HDHP enrollees are more likely than enrollees with more traditional health coverage to be employed full-time. Despite being slightly more likely to smoke, HDHP enrollees were more likely than enrollees in more traditional health coverage to report being in very good health.
- HDHP enrollees are more likely to seek cost information than traditional plan enrollees. More than one-third (39 percent) of HDHP enrollees versus 25 percent of traditional plan enrollees tried to find cost information in the last two years before receiving care.Among those who searched for information, HDHP enrollees were less likely than more traditional plan enrollees to have found such information.
- High-deductible health plan (HDHP) enrollees are more likely than traditional plan enrollees to exhibit cost-conscious behaviors. Those in a HDHP were more likely than those with traditional coverage to say that they had checked whether the plan would cover care or medication (55 percent HDHP vs. 41 percent traditional); checked the quality rating of a doctor or hospital before receiving care (41 percent HDHP vs. 33 percent traditional); asked for a generic drug instead of a brand name (41 percent HDHP vs. 32percent traditional); talked to their doctors about prescription options and costs (40 percent HDHP vs. 29 percent traditional); talked to their doctors about other treatment options and costs (37 percent HDHP vs. 31 percent traditional); asked a doctor to recommend less costly prescriptions (31 percent HDHP vs. 22 percent traditional); used an online cost-tracking tool provided by the health plan (25 percent HDHP vs. 14 percent traditional); or developed a budget to manage health care expenses (25 percent HDHP vs. 14 percent traditional).
- HDHP enrollees are more likely to delay care than traditional plan enrollees. HDHP enrollees were more likely to report that they delayed health care in the past year because of cost. One-third of HDHP enrollees reported delaying care, whereas 18 percent of traditional plan enrollees delayed care because of costs.
- HDHP enrollees are more likely to have and participate in wellness programs than traditional plan enrollees. HDHP enrollees were more likely than traditional plan enrollees to report that their employer offered them biometric screenings and were more likely to participate in such screenings. While they were also more likely to be offered reimbursement for all or part of fitness memberships, HDHP enrollees were less likely to report participating.
- HDHP enrollees are less likely than traditional plan enrollees to report that they do not have any major financial concerns. HDHP enrollees were more likely than traditional plan enrollees to report that they worry a lot about their finances and that debt is negatively impacting their ability to save for retirement.When it came to the top financial concerns, HDHP enrollees were more likely than traditional plan enrollees to report that they were concerned about not being able to retire when they want to, running out of money in retirement, not having enough money to cover out-of-pocket health care expenses not covered by insurance, and being laid off from work.Overall, a large majority of traditional plan and HDHP enrollees reported having major financial concerns.These findings may point to a broader correlation between financial wellness, plan design, and income that is not being captured by the survey findings.
Figure 23
Figure 13
Figure 7
H The To A FiD g ppendi ur H bb e P et igg te 5, enr rte rJob olle unde st ad x d it e — iff St ion s w re st aMe r a ta u e e l) nd nc s, b r; etor eho not t y he in c dPe do la only im v ost e np lop logy Ty a - c m cons e tp or d e tha , e a c20 ious t lik b udg H 18 eD ly b ................................ H e e tP to ha s h tb o vea ior m v offe a e is n on a rtg e ha e d c o the b ns H iom a D um ltH h c eP e tr ................................ rie a ce nr r e nga sc olle e re xpe g e e e nin s w m ns e g e e nt s b s (2 re , ut tne his 5 p w a rI e ely ss r r................................ e c ue te w m nt ic or B e H re ie D a lik fs H p P li erk ly e v esent s. 14 p ly to to ps fin arret ep ic rd or c ip ................. ings fr eta nt tte h ain t to tm he he y m 9
Figure 21
Paul Fronstin is director of the Health Research and Education Program at the Employee Benefit Research Institute
Consumer Engagement in Health Care: Findings From the 2018
Financial WellbFigur Figur e Figur Figur Figur ing, e 14 e 11 e 5 e 3 b e 9 y Plan Type, 2018
Figur Figur Figur e 19 e 16 e 1
Self-Reported Health Status, by Plan Type, 2018
Fronstin, Paul, and M. Christopher Roebuck. 2014a. "Brand-Name and Generic Prescription Drug Use After Adoption of
Marital Status, by Plan Type, 2018
d t ahe s w ela 201 yeell d( 8 Fi m t rE g a eB d ur dRI it ic e ion a /Gr 20 l c ae ) a l) . e r.e nw I n in t acld ont he & rp a A ast ss st, o y w ce ia hil atre e b s te he C con ayu su w se e m r of e e rm c os Eor nga te . lik g One eem ly-e ttnt hir o b in Hea de of offe HD lt rh C e Hd P r a e e rnr im e olle Su bur re v sem s r ey e(e p C nt or onsu tfor ed m fit de ene r la E y snga ing s club g ca er m m ee , en w m the b Sur erres v a hip, e s 18 y)
(EBRI). Edna Dretzka is senior R e dason irecto s r fof or he Particip althcar ae tin atg G in re Employ enwald e &r's Ass W oe clln iate es. ss Thi Progr s Iss am, ue Brief was written with
The findings presented in this Issue Brief were derived from the 2018 EBRI/Greenwald & Associates Consumer
(Percentage That Strongly or Somewhat Agree With Statement)
Tried Pr E e ase t miu o LeFin Employ n or D m g Ho th d Inc u iff Cos of Time se r icu e e Sou h t In ase r old lty of Fin Of f rs orma Jo ce f Income e Amo Cov r b of Cov s St W e tion n a r d e e tus g in lln d D Employ e g in b , is e rR ag y b ss tribu P a y He as e tin Pr Plan , t T alth b ogr gs e tion y rw s T Plan of Ca am, by Plan With o Plan ype , Y be y Plan T r ar , , e 10 or ype 2018 b Pr s Bef y , Plan ovi 2018 Tor ype Mor T dype e e T d , ype G e 2018 b e , Empl y Med t 2018 tin , 2018 g o Ca y ic e r al e es, , by
EBRI/Greenwald & Associates Consumer Engagement in Health
Traditional HDHP
a Full-Replacement, Consumer-Directed Health Plan With a Health Savings Account." EBRI Notes (Employee
Figure 6, Race Distribution, by Plan Type, 2018 ....................................................................................................... 9
Traditional HDHP
— jpus e ra tc e ov st nt udy e rof a d tq re a ua si dg it rtne io erna d of l p to the la prn e ov m inr p da e olle r tna ice ip tiona s d ate ed ll la yin suc y e re dp c re a h sent re a v ba e aila c tia v b us e le d e p aof rtog a crr ost e ag m a s ( s, c rdFi ing o gm ur tp he ea 18 r g ed r)ow . t o th o 42 fp e CrD cH ent Ps of and traH dD itiona HPs l he and atlthe h care
by Plan Type, 2018
a Ess nga istg ae nc me e nt from in He the a lt Ih nst Cia tut ree Sur ’s rv ee sea y, racn o h anli nd ne e dsu itor rvia ey l s tthaaff t s. exa Any mine vie s is ws e sue xpress s surreound d in t in hi gs r consu eporm t a erre - dtrhose iven of hea the lth ca autrhor e, s
35% Professionals and Work Fe acili r Earnin ties, Plan Comp gs and Type ar In e, d fla 2018 ttion o Sh, op 1988 pin – g 2019 for Other Types of
T T T T Tra ra ra ra rad d d d di i i i it t t t ti i i i io o o o on n n n nal al al al al H H H H HDHP DHP DHP DHP DHP
Bene 60fit % Research Institute) 35 (3). Traditional HDHP
th
Care Surv ? HDHP en 70% ey roll ees are more likely to delay care than traditional plan enrollees. HDHP enrollees were
im plapn e actnr of olle the es. se W pla hil ne s on thetyhe w e bre eha no vior m or and e lik ae ttly itude to b s of e offe adr ult eds w heia th p lth r riis va kt e a ss he ea ssm lth e in nsu ts, ra H nc DH e P c o evnr erolle age e. s w Now ere in mitor s e 1 4 like ly
and should not 80% be ascribed to the officers, trustees, or ot Tradhe itionral sponsor HDHP s of EBRI, Employee Benefit Research Institute-
including the cost of insurance, the cost of care, satisfaction with health care, satisfaction with health care plans,
90% Services, by Plan Type, 2018
30% Tried to Find Cost Information Of Those Who Tried, Found Cost Information
Figure 7, Marital Status, by Plan Type, 2018 .......................................................................................................... 10
December 20, 2018 • No. 85% 468 *
120%
more likely to report that they delayed health care in the past year because of cost. One-third of HDHP
30%
y to ea re r, ptor his t p sa tudy rticipa wa ting s bain t sed he on m. a n Ot onlin herw eis su e, rv the eyr of e w 2a ,010 s no pd riff iva etre ely nc ins e in p urea dr taic dip ult as a tion gers 21 ates b -64 y p . la Tn ty he sa pe m for ple a w na ys of ratnhdeom ly
60%*
F E re r dons auc son attin, P s for ion a a nd ul, a choo Re nd sisea ng M. ra c C h Fun phr lais n, top d a nd (he EB Biom r sour RI Roe e- tri Ec c s RF) b e cruc s of ee, nk ino . gshe r20 the a 14 ltir h infor b . st"a Qua ffs. m lit a Nty e ion it of he . H The re E aB ltRI 201 h C nor a 8r e C E ons ABft Re um Ir- E Ae RF l d rop Enga ob ting bg iea es or m Fu ell nt t-a Re k Sur ep s p la ve cosit y e m wions e ant s , on High-
By Paul Fro 20ns % tin, Ph.D., Employee Benefit Research Institute, and Edna Dre 29%* tzka, Greenwald &
30% 40% 58%
Figur Traditie 18 onal HDHP 37%*
18.6%
You wanted to improve your health generally
50 60% % 68% 48%*
80% 3
enrolle 70% es re Yop uor wot rry e d ab od ut e yla our y ab ing ility to c a afr foe rd, rew tire he mer ne t as 18 percent of traditional plan enrollees delayed ca 43% re because of
26% 26%
50%
d ot rhe awrn fr typo D em e s of d Iuc psos w tible elln ’ onlin e Hss ea e lt p h P rp og an la ra en Wi m l of s. itnt h e ar ne Heta us lth Sa ers w vings A ho hac dc oun agre t: ed A tFi o vpea-rYte ica ipa r St teudy." in re sea EBR rI c h Iss su ue rv e By rs ie .f, no. The fin 40a 4l s ample
specific policy proposals. EBRI invites comment on Prem th ium is In r ce reas sea e rch. Worker Earnings Increases Overall Inflation
conducted within the Unit 65%ed States between Aug. 10 and Aug. 23, 2018, through a 15-minute internet 63% survey. The
Fi As gur soc e 8, iatPe re ssenc e of Children, by Plan Type, 2018 ................................................................................................ 10
18% 16.7% 72% Delayed Medical Care in Past Year Because of Costs, by Plan Type, 2018
25% 17.1% 24% 30%
52% 46%
Activity-based wellness challenges 25%
4
costs. Your health insurance premium costs were reduced if you participated
(Employee Benefit Research Institute). 35%
100% 23%
included 1,235 in a HDHP and 775 in a more traditional health plan. 34%
45 70% %
national or base sample was drawn fr 22%om Ipsos’ online panel of internet users who have agreed to participate in
25%
60% 39%
50 16 % %
14.7%
Consumer Engagement in Health Care: Findings From the 2018
40%
A number of questions were asked to gauge reasons for participating in wellness programs. Improving health was the
Suggested Citation: Paul Fronstin and Edna Dretzka. “Consumer Engagement in Health Care: Findings From the
40% 28%
Fi gure 9, Source of Coverage, by Plan Type, 2018 ................................................................ 27% ................................. 11
35%
You wanted to learn more about your health risks
research surveys. Over 1,000 ad Hult ealths a risk g ase ses 21 ssment-64 who had health insurance through an employer, purchased directly
40% 32%
21%
32%
? HDHP en 14% rollees are more likely to have and participate in welln 21% es 33%s * program 53% s than traditional plan
Fronstin, Paul. 20 60% 15. "Sources of Health Insurance Coverage: A Look at Changes Between 2013 and 2014 from the
20% 34%
20 The top 18 rre e E am B son ( RI ainde /Gr Fie rg e ur of nw et his a 21 ld )I. & ss A A ue no ss B oc the rie iarft e ris e s C aout son ons lin tum ha edt ea r sc s follow Eonga redg highly e s. me The nt w in Hea a ne s c xtonv sect lth C e 20% nie ion p 19% arn ec Sur e re tsen o ve w tys d he .” rE if eB fe tRI he re nc Ie ss m eue s in t ploy Bre ie he ef , w cno. h or ak ra e 468 c dt. e There ristics of
EBRI/Greenwald & Associates Consumer Engagement in Health
You worry a lot about your finances
Introduc50 tion % 12.1%
from a carrie 80 r, %or purchased through a government exchange were drawn randomly from the Ipsos sample for this
40% 31% 38%
20%
17% It was convenient to participate where you work 60%*
March 2014 and 2015 Current Population Su 11.2% rvey." EBRI Issue Brief, no. 419 25% (Employee Benefit Research
enro 35ll %ees. HDHP enrollees were more likely than traditional plan enrollees to report that their employer
12% 32%
Tobacco-free pledge or smoking cessation program
indiv Fi we gr ur eidua eno 10st l, s e a Cthoi nr istolle ic ce a lld of y in t si Hg ernif a alt dih P c ita iona nt la n, dl he iff be ya r e P ltnc la h p n Ty es b lans p y ep a, nd la 20 n 18 H ty Dp ................................ H eP , sw . it The h one follow exce ing ption sect ................................ — ion th HDHe Pn p enr re olle sent es w s diff e ............................. re er e m nor ce es in a likely tt t ith uadn e s 11
(Employee B30 ene % fit Research Institute, December 13, 2018).
17% 30%
30% 50%
10.1% 10.1% 17%
Care Survey
E ba m se ploy sam me pnt le- . bThi ased s sa he ma plle th b we ane s st fit ra s a tifi re ed t he by m ge os nde t crom , am geon , re for gion, m of inc he om alteh insu , and rraanc cee . in t he United States. In 2017, 167.4
Institute). 62%*
15% 32%
offered them biometric screenings and were more likely to participate in such screenings. While they were also
40% You wanted to maintain your current health status
15 30 10 % % %
t arnd adit bion eha av l p ior las b n e ynr polle la 14% n t ey s pte o . n The ote tla ha st t se the cir tio he n p alrte h ins sentur s fin anc de ings r prem ela ium ted s w to ould fina nc haiv ae l w be ee llbe n hig ing he and r ha pd la tn ty heyp not e.
29% 1
32%
27%* 27%
30% 13%*
m illion individuals under a Cou ge ns e65 ling 8.0% , o r or stre s6 s m 1.7 74% anage * pm e er nc tent of 8.1% that population, had employment-based health benefits. In nearly
15 60% %
40% 7.5% 29%
Fi gure 11, Length of Time Covered by Health Plan, by Plan Typ 13% e, 2018 ...................................................................... 12
Copyrigm ht In ore form likely a to tio be n :offe Thi re s r d e rp eim ortb is ur seme copyrn ight t for ed a b ll or y the pa E rtm of p loy fitne eess B em ne em fitb Re ersh sea ips rc,h I HD ns HtP it u etnr e olle (EBe RI s w ). e Itr e m le ay ss b lik e ely
By Paul Fronstin, Ph.D., Employee Benefit Research Institute, and Edna Dretzka, Greenwald &
Your health insurance premium costs would have been increased if you had not 17% 57%
participated in t 8%he emp19% loyer’s wellness program 7.3% . 6.9%
13%
To examine t 25 he % issues mentioned above, the sample was divided into two groups: those with a high-deductible health
Fronstin, Pa 25ul, a % 20% nd M. Christopher Roebuck. 2016. "The Impact of an HSA-Eligible Health Plan on Health Care Services
22%*
You feel financially secure 6.3% 31%*
every year between 2008 and 20 par15 ticip, atep dremium increases have exc 6.1% eeded 6.1% worker-ea 6.1% rnings inc 22% reases and inflation (Figure
30%
6.1% 6.1%
to report participating 16% . 20%
used without permission but citation of the source is required. 5.5%
Associates Financial wellness resources 60%
30%
Use 10 a 6% % nd Spending by Worker Income." EBRI Issue Brief, no.425 (Employee Benefit Research Institut 2e).
plan (HDHP)20 a %nd those with traditional health coverage. Individuals were assigned to the 28% HD * HP group if they had a
19% 22% p
20% 22%
1). Overall, health insurance premiums have increased twice as much as worker earnings during that pe4.4% riod.
Figure 12, Smoking Behavior, b Yoy u w P ela re on Ty ffered in pce en, tiv 20 e p18 rizes t ................................ o participate ................................ 4.1% ...................................... 12
10%
17%
9% 29% 3.8%
Who Is E 40 nr % olled in HDHPs?
2.5% 3.9% 3.6%
15%
20%
deductible of at least $1,350 for individual coverage or $2,700 for family coverage. 15%
20% 4% 2.1% 18%
16%*
10% 8% 2.6%
Report Ava Reil im a bbil ursem it en y t : fo r T all hoir s r pare t op f or fitnets sis cl ua b m vea mil ba ers b hle ip on the internet at www.ebri.org 2.4%
? HDHP en 20 Y% ou earner do fun lldees s for y ou a r F re SA o les r oths er fun lik d ely to he7% lp th paya mn ed tr ical a exp d eit nseio s, ifnal plan enrollees 15% to report th 2.1% at they do not have any
15% 6% 18%
23%*
Fronstin, Paul, Mart 6% in J. Sepulveda, and 6% 9% M. Christopher Roe 9%buck. 2013a. "Medication Utilization and Adherence in a
Financial Wellbeing by Plan Type 9%
6% 6%
The 2018 Consumer Engagement Survey found a number of similarities and diff 20% erences between HDHP enrollees and
10% you participated
7%
Fi Wg hil uree t13 he, gSe aplf - bRe etw por eetn p ed r H ee m aium lth St inc atr ues, b ases y P ala nd n Ty wor pk ee , r20 -ea 1r8nin ................................ gs increases has nar ................................ row 41%ed more recently, .................... it has not 13
5% 2%
9%
major financial concerns. HDHP enrollees were more lik 10%ely than t 9%raditional plan enrollees to report that
De5% bt is negatively impacting your ab 4% ility to save for retirement
Health Savings Account-Eligible Plan." A T Am erA ican J G ourL naA l of N MaC nag Eed Care 19 (12): e400-e407.
10% 25%
10% 7%
14% 3%
The t The hose g 20 re oup 18 nrolle C w ons Fre 10 20 it d% % h e s in m um et m rin ae ar d or r sit /gE ion e unga e st t ra sa pl eg d ak he e it em rs iona a ae lt bont h ul he t hcSur eov alt 7% a he av ltr ne h cov da w y g 7% ee inc llne inc se slude rlude age d. d a H indiv ra Dng HP idua e e of nrls q olle ue the st as ha tions had v e te o highe itb he etrt eno rr inc unde do ed muc re st ta a ible nd nd highe t or he a fin dre a e d nc d uc uc ia tible a l w tion th e tllbe hata ing w n as of
2018 Consumer Engagement in Health Care Survey Underwrite2% rs
You were required to participate by your employer 6%39% 48%*
stopped employers from seeking ways to manage health care cost increases. One 23% 2% of * the more notable 2% trends has been
15% 1% 19% 4%
0% 4%
they 0% worry a lot about their finances and that debt is negatively impacting their ability to save for retirement.
2%*
2%* 2% 2%
1%* 25% 1% 0.3%*
b elow current 0% HDHP thresholds. 0.2%
Fi su t hose grur vee ye 14 rnr espond , olle Trd ie 5% d in m e nt to s. or Find e W te rC a fou o dst iti nd ona Infor som l he ma e at lt ion in dh cov ifferee P nc r aa s eg ts in fina eTw . N o eY ae r na lc yria s B 30 l w epe for ellbe rc ee ing G nte tof tb ing yH p DC la H a n ty P re e , nr p be y olle . P C la eonfide n Ty s had p e nc a , e hous 20 th 18 ae t ....................... hold indiv inc idua om ls ew of ill 14
Excellent Very Good Go 13% od Fair or Poor
the movement toward increasing deductibles. Between 2007 and 2018, the percentage of individuals under age 65
13%
Fronstin, Paul, M 0% 0% artin J. Sepulv Yoe u w dan at, eda tnd o addM. ress aC sph er cifis ic h top ealth he prorb le Roe m buck. 2013b. "Consumer-Directed Health Plans Reduce The
0% Married On Liv -in site g wi clinic th Partner Divorced or Separated Widowed Never Married
When it -2% came to the top financial concerns, HDHP enrollees were more likely than traditional plan enrollees to
0% 16%
-1.1%
This survey was made possible by funding support from the following 14% organizations: Benefit Wallet, Blue Cross and Blue
0% 10% 20% 30% 40% 50% 60% 70%
$1 hav 50 e ,00 enoug 0 orh mone more, Em y c p om loy to edp l Fu iv a Ow ll T e re n im c d Jo eom bwit for h 17 p Emt pa loyb el dy Pe ar in r rt c Te imnt e et ira Sp em om uong se e U 'snt n Job em e pd loy nr id ed onot llee v s in mor aDire ryH ct o b m From y e mp e a Ila ke nt srr un ty ra and ce itp Co ion e m p(a an Fi l h yg Reu tired eraelt h cov 22). Pu be Sim licr E a xch gila e an Ot r ge ( hly eFi r, gtur he e p 3) er . c e Nnt ea argly e
The EBRI/Greenwa Leld ss Tha &n A Onss e Ye oar ciates C 1 t ons o 2 Yum ears er Engag 3 te o 4 m Ye ear n st in Healt 5 t h C o 9 Ya ear re s Survey 10 Y(eC aron s or su More mer Eng Don ag 't e Kn m owent Survey)
< $20,000 $20,000 - $30,000 - $40,000 - $50,000 - $70,000 - $100,000 - $150,000 or Declined
enrolled L in hig ong0% 0% -h Te -d re m d uc Use tible Of O heut alt ph p atie la nn t s (H PhyD siH ciP as n Vi ) (p si la ts A ns nd with d Pree sc druc ipttible ion D s of rugs." at le H ast ea $ lt1,35 h Aff0 for airs 32 indi (6) vidua : 11l 2c6 o-v 1134. erage and
10%
Source: EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey, 2018.
repor -4% t that they were concerned about not being 0% able 5% to re 10 tir %e w 15he % n th 20% ey 25 w % an 30 t %to,35 r% unni 40ng % out 45% of 50% money in
Shield Association, HealthEquity, Inc., National Rural Electric Cooperative Association, Prudential Financial, Inc., and
Fi Be gcur aus e 15 e t, he Ea b se ase or So sa D urce: m iffp ic EBRI/ le ul t( Greenwald y n a of $2 tion 9,999 Finding a & l s Asso am ciates C $3 post 9,999 le Co ) nI inc sume nfor lude r Eng m $49,999 a ag dt em ion f only ent in or 275 Health $6 Me 9,999 indiv d Care ica Su l C idua rvey $9 ar , 9,999 l 2 e s in a 0, 18C . om n p $1 H a 49,999 D reH dP t, o aShop n o Mo ve re p ring samfor ple Ot of he indiv r Ty idu pea s of ls was
Easier Traditional 0% About the Sa5% me 10% 15% Difficult20% H 25 DHP % 30 Un % able to An35 sw % er 40%
r one epor -ha ting lf (4 th 5 p at e the rc So e y u n rce: w t)or EBRI/ of ryH Greenwald a DbH out P e t nr & he Asso olle ir ciates a eb s iliha Co ty nd sume t o a a r cEng ff olle o ag rd g em e r ent edte i inrg Health erm ee e nt Care and aSu nd a rvnot ey th , 2a he 0t 1 8tr .he 27 y p fe ee rc l fina ent ha ncia ve lly a secu gradrua e d te id sc not hool vad ry e g brye e
p rovides reliable Trad nat iti ion onala = l d heal ath ta p la on n with n the o g ded row uctibtle h o or