FEATURES
HEALTH POLICY PERSPECTIVES
The ‘invisible hand’ and the market for dental care Marko Vujicic, PhD
I
n his classic The Wealth of Nations, economist and author Adam Smith famously described how allocating resources through free markets is the best way to achieve efficiency. He wrote that, in general, the “invisible hand” always will produce better outcomes than the visible hand of central planning, regulated prices or market quotas. Health economics, the discipline in which I was trained, applies the conceptual framework of economics to health care issues. Although there are many peculiarities in the market for health care services that make it different from other markets, the economic paradigm is still incredibly useful in helping to explain the outcomes we observe in various health care markets.
THE DENTAL MARKET: LOOKING BACKWARD
Let’s look at the market for dental care in the United States. The figure1-3 provides a highly aggregated snapshot of the supply of and demand for dental care services from 1993 through 2012. The number of practicing dentists per capita can
be thought of as a rough measure of the supply side of the dental care market. Inflation-adjusted dental spending per capita is a measure of how much dental care the population “buys” or consumes and serves as a rough measure of the demand for dental care. Demand for dental care, an economic concept, is not the same as the need for dental care, a clinical concept. U.S. dentists’ average inflation-adjusted earnings also are plotted on the figure. The supply of dentists, dental spending and dentists’ average earnings all have been converted to an index to allow for comparability, and the index has been set to equal 100 in 2008. When the data are considered in this way, they illustrate that the market for dental care has gone through three distinct periods over this time frame. From 1993 through 2002, dental care spending was growing steadily, at about 4 percent per year in real terms, whereas the supply of dentists was flat. With growing demand and flat supply, we see dentists’ earnings growing steadily during this period—as economic theory would have predicted. From about 2002 until the Great Recession, JADA 145(11)
dental spending grew at a much lower rate, about 2 percent per year. The supply of dentists remained flat and, as a result, dentists’ average earnings started to stagnate and began to decline. Beginning in 2008, market dynamics changed yet again. The supply of dentists began to increase. Dental spending remained flat, despite the economic recovery, and dentists’ average earnings continued to stagnate and actually declined. THE DENTAL MARKET: LOOKING FORWARD
These data confirm what is obvious to both economists and noneconomists: the interplay of demand for and supply of dental care has a significant impact on dentists’ earnings. The historical perspective is interesting and informative; however, the more interesting question for the dental community is what the three lines in the figure will look like going forward. Will dental spending return to historically high growth rates? Will the supply of dentists continue to rise? History tells us that answering these questions will provide considerable insight into the answer to a third question: how are dentists’ http://jada.ada.org
November 2014
1167
FEATURES
110
Demand Flat Supply Growing Income Declining
◆ ◆ ◆ ◆ ◆ ■ ■ ■ ■ ■ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ■ ■
90
■
■
■
■
■
◆
Supply of Dentists
■
Dental Care Spending
2012
2011
2010
2009
2008
2007
2006
2005
2004
Dentists’ Average Net Income
2003
2001
■
1999
■
1998
■
1997
■
1995
1993
60 ■
■
1996
70
■
■
2000
80
2002
100
Demand Growing Slowly Supply Flat Income Flat
Demand Growing Fast Supply Flat Income Growing Fast
1994
PERCENTAGE OF MARKET
120
YEAR Figure. Market dynamics in the dental care system. All values have been indexed to equal 100 in 2008. Sources: Average dentist net income data, Vujicic and colleagues1; dental care spending data, Wall and colleagues2; supply of dentists data, American Dental Association, Health Policy Institute.3
earnings likely to evolve in the near future? Let’s take dental spending first. A recent analysis shows that if current trends continue, the dental care sector will enter a “new normal” of flat per capita dental spending.4 In other words, the dental economy will not simply rebound with the economic recovery.4 The increased spending on dental care that is expected among older adults and children will not compensate for the expected decline among the working-age population. This analysis, however, does not take into account the potential impact of the Affordable Care Act (ACA). When the ACA was drafted, the intent was to expand dental insurance among children by making dental care an essential health benefit. For various complicated reasons, this “mandate” has been watered down, and the take-up of dental insurance within the health insurance marketplaces is well below 100 percent.5 In fact, on the basis of the most recent analysis available, the highest take-up rate is 36 percent in California.5 The ACA never was intended to include adult dental care as part of the individual mandate,
but recent analysis shows that there is interest, particularly among young adults, in purchasing dental insurance within the health insurance marketplaces.6 The expected expansion in coverage from the health insurance marketplaces pales in comparison with another aspect of the ACA: Medicaid expansion. A new analysis shows that up to 8.3 million adults will gain Medicaid dental benefits as a result of Medicaid expansion. This will reduce by up to 35 percent the number of low-income adults who do not have any form of dental coverage.7 In many states, the growth in the adult Medicaid population is significant, often a doubling or tripling of the number of enrollees.7 There obviously is much uncertainty in the market but, taken together, the best analyses suggest that demand for dental care, owing to expanded dental insurance coverage, is expected to grow among children, older adults and people receiving Medicaid benefits. Among people in the middle- to upper-income working-age population, demand is expected to continue to be sluggish if current trends continue.
1168
November 2014
JADA 145(11) http://jada.ada.org
Now let’s turn to the supply side. The results of a new analysis that is based on sophisticated empirical modeling of inflows to and outflows from the dentist workforce show that the supply of dentists in the United States actually is expected to grow in the coming decades (B. Munson and M. Vujicic, unpublished data, August 2014). The analysis does not address whether tomorrow’s dentist workforce will be more or less likely to locate in certain areas (such as rural and underserved areas) or treat certain populations (for instance, people receiving Medicaid benefits, children, older adults), which is critical to the “shortage” debate. Further research is needed in this area. But at the most aggregate level, if dental spending remains sluggish and the supply of dentists continues to increase, history suggests that the “invisible hand” could produce a situation of stagnant dentist earnings in the coming years. CONCLUSIONS
Of course, there is a high degree of uncertainty in the future evolution of both demand for dental care and supply of dentists. Moreover, the
FEATURES
United States is not a single market. Like politics, economics is local. The American Dental Association Health Policy Institute will continue to analyze the best available data to monitor market trends in the dental care sector in the years ahead. ■ doi:10.14219/jada.2014.100 Disclosure. Dr. Vujicic did not report any disclosures. 1. Vujicic M, Munson B, Nasseh K. Despite economic recovery, dentist earnings remain flat. American Dental Association Health Policy Institute Research Brief. www.ada.org/ sections/professionalResources/pdfs/ HPRCBrief_1013_4.pdf. Accessed Oct. 3, 2014.
2. Wall T, Nasseh K, Vujicic M. U.S. dental spending remains flat through 2012. Health Policy Institute Research Brief. American Dental Association. January 2014. www.ada.org/ sections/professionalResources/pdfs/ HPRCBrief_0114_1.pdf. Accessed Oct. 3, 2014. 3. American Dental Association, Health Policy Institute. Dentist supply in the U.S.: 1993 to 2011. www.ada.org/en/science-research/ health-policy-institute/data-center/supply-ofdentists. Accessed Oct. 3, 2014. 4. Nasseh K, Vujicic M. Dental expenditure expected to grow at a much lower rate in the coming years. Health Policy Institute Research Brief. American Dental Association. August 2013. www.ada.org/~/media/ADA/Science%20 and%20Research/HPI/Files/HPIBrief_0813_1. ashx. Accessed Sept. 26, 2014. 5. Yarbrough C, Vujicic M, Nasseh K. Update: take-up of pediatric dental benefits in health insurance marketplaces still limited. Health
Policy Institute Research Brief. American Dental Association. May 2014. www.ada.org/~/ media/ADA/Science%20and%20Research/HPI/ Files/HPIBrief_0514_1.ashx. Accessed Sept. 26, 2014. 6. Vujicic M, Yarbrough C. Young adults most likely age group to purchase dental benefits in health insurance marketplaces. Health Policy Institute Research Brief. American Dental Association. August 2014. www.ada.org/~/ media/ADA/Science%20and%20Research/HPI/ Files/HPIBrief_0814_3.ashx. Accessed Sept. 26, 2014. 7. Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion. Health Policy Institute Research Brief. American Dental Association. February 2014. www.ada.org/ sections/professionalResources/pdfs/HPRCBrief_0214_1.pdf. Accessed Sept. 26, 2014.
Statement of Ownership, Management, and Circulation $OO3HULRGLFDOV3XEOLFDWLRQV([FHSW5HTXHVWHU3XEOLFDWLRQV 1. Publication Title: The Journal of the American Dental Association; 2. Publication Number: 0002-8177; 3. Filing Date: October 1, 2014; 4. Issue Frequency: Monthly; 5. Number of Issues Published Annually: 12; 6. Annual Subscription Price: Members-$25, Non-Members-$173, Institutions-$205; 7. Complete Mailing Address of Known Office of Publication (Not printer) (Street, city, county, state, and ZIP+4®): 211 East Chicago Avenue; Chicago, IL 60611-2678, Contact Person :Jill Philbin, Telephone (Include area code): 312-440-2518; 8. Complete Mailing Address of Headquarters or General Business Office of Publisher (Not printer): 211 East Chicago Avenue; Chicago, IL 60611-2678; 9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor (Do not leave blank), Publisher (Name and complete mailing address): Michael D. Springer, Managing Vice President, and Publisher, 211 East Chicago Avenue; Chicago, IL 60611-2678; Editor (Name and complete mailing address): James Berry, Associate Publisher, Editorial, 211 East Chicago Avenue; Chicago, IL 60611-2678; Managing Editor (Name and complete mailing address): This title does not exist; 10. Owner (Do not leave blank. If the publication is owned by a corporation, give the name and address of the corporation immediately followed by the names and addresses of all stockholders owning or holding 1 percent or more of the total amount of stock. If not owned by a corporation, give the names and addresses of the individual owners. If owned by a partnership or other unincorporated firm, give its name and address as well as those of each individual owner. If the publication is published by a nonprofit organization, give its name and address.): Full Name, American Dental Association, Complete Mailing Address, 211 East Chicago Avenue, Chicago, IL 60611-2678: 11. Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities. If none, check box: NONE; 12. Tax Status (For completion by nonprofit organizations authorized to mail at nonprofit rates) (Checkone) The purpose, function,and nonprofit status of this organization and the exempt status for federal income tax purposes: Has Not Changed During Preceding 12 Months; 13. Publication Title: The Journal of the American Dental Association; 14. Issue Date for Circulation Data: June, 2014 15. Extent and Nature of Circulation Average No. Copies Each Issue During Preceding 12 Months No. Copies of Single Issue Published Nearest to Filing Date a. Total Number of Copies (Net press run) 153,059 156,788 b. Paid Circulation (By Mail and Outside the Mail) (1) Mailed Outside-County Paid Subscriptions Stated on PS Form 3541 (Include paid 121,863 125,490 distribution above nominal rate, advertiser’s proof copies, and exchange copies) (2) Mailed In-County Paid Subscriptions Stated on PS Form 3541 (Include paid distribution 0 0 above nominal rate, advertiser’s proof copies, and exchange copies) (3) Paid Distribution Outside the Mails Including Sales Through Dealers and Carriers, 0 0 Street Vendors, Counter Sales, and Other Paid Distribution Outside USPS® (4) Paid Distribution by Other Classes of Mail Through the USPS (e.g. First-Class Mail®) 0 0 c. Total Paid Distribution (Sum of 15b (1), (2), (3), and (4)) 121,863 125,490 d. Free or Nominal Rate Distribution (By Mail and Outside the Mail) (1) Free or Nominal Rate Outside-County Copies Iincluded on PS Form 3541 28,896 29,173 (2) Free or Nominal Rate In-County Copies Included on PS Form 3541 0 0 (3) Free or Nominal Rate Copies Mailed at Other Classes Through the USPS (e.g. First-Class Mail) 0 0 (4) Free or Nominal Rate Distribution Outside the Mail (Carriers or other means) 150 0 e. Total Free or Nominal Rate Distribution (Sum of 15d (1), (2), (3) and (4) 29,046 29,173 f. Total Distribution (Sum of 15c and 15e) 150,909 154,663 g. Copies not Distributed (See Instructions to Publishers #4 (page #3)) 2,150 2,125 h. Total (Sum of 15f and g) 153,059 156,788 i. Percent Paid (15c divided by 15f times 100) 81% 81% 16. Publication of Statement of Ownership; If the publication is a general publication, publication of this statement is required. Will be printed in the November, 2014 issue of this publication. 17. Signature and Title of Editor, Publisher, Business Manager, or Owner Senior Vice President, Business and Publishing Date: October 1, 2014 I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties).
JADA 145(11)
http://jada.ada.org
November 2014
1169
HEALTH POLICY PERSPECTIVES
The ‘invisible hand’ and the market for dental care Marko Vujicic, PhD
I
n his classic The Wealth of Nations, economist and author Adam Smith famously described how allocating resources through free markets is the best way to achieve efficiency. He wrote that, in general, the “invisible hand” always will produce better outcomes than the visible hand of central planning, regulated prices or market quotas. Health economics, the discipline in which I was trained, applies the conceptual framework of economics to health care issues. Although there are many peculiarities in the market for health care services that make it different from other markets, the economic paradigm is still incredibly useful in helping to explain the outcomes we observe in various health care markets.
THE DENTAL MARKET: LOOKING BACKWARD
Let’s look at the market for dental care in the United States. The figure1-3 provides a highly aggregated snapshot of the supply of and demand for dental care services from 1993 through 2012. The number of practicing dentists per capita can
be thought of as a rough measure of the supply side of the dental care market. Inflation-adjusted dental spending per capita is a measure of how much dental care the population “buys” or consumes and serves as a rough measure of the demand for dental care. Demand for dental care, an economic concept, is not the same as the need for dental care, a clinical concept. U.S. dentists’ average inflation-adjusted earnings also are plotted on the figure. The supply of dentists, dental spending and dentists’ average earnings all have been converted to an index to allow for comparability, and the index has been set to equal 100 in 2008. When the data are considered in this way, they illustrate that the market for dental care has gone through three distinct periods over this time frame. From 1993 through 2002, dental care spending was growing steadily, at about 4 percent per year in real terms, whereas the supply of dentists was flat. With growing demand and flat supply, we see dentists’ earnings growing steadily during this period—as economic theory would have predicted. From about 2002 until the Great Recession, JADA 145(11)
dental spending grew at a much lower rate, about 2 percent per year. The supply of dentists remained flat and, as a result, dentists’ average earnings started to stagnate and began to decline. Beginning in 2008, market dynamics changed yet again. The supply of dentists began to increase. Dental spending remained flat, despite the economic recovery, and dentists’ average earnings continued to stagnate and actually declined. THE DENTAL MARKET: LOOKING FORWARD
These data confirm what is obvious to both economists and noneconomists: the interplay of demand for and supply of dental care has a significant impact on dentists’ earnings. The historical perspective is interesting and informative; however, the more interesting question for the dental community is what the three lines in the figure will look like going forward. Will dental spending return to historically high growth rates? Will the supply of dentists continue to rise? History tells us that answering these questions will provide considerable insight into the answer to a third question: how are dentists’ http://jada.ada.org
November 2014
1167
FEATURES
110
Demand Flat Supply Growing Income Declining
◆ ◆ ◆ ◆ ◆ ■ ■ ■ ■ ■ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ■ ■
90
■
■
■
■
■
◆
Supply of Dentists
■
Dental Care Spending
2012
2011
2010
2009
2008
2007
2006
2005
2004
Dentists’ Average Net Income
2003
2001
■
1999
■
1998
■
1997
■
1995
1993
60 ■
■
1996
70
■
■
2000
80
2002
100
Demand Growing Slowly Supply Flat Income Flat
Demand Growing Fast Supply Flat Income Growing Fast
1994
PERCENTAGE OF MARKET
120
YEAR Figure. Market dynamics in the dental care system. All values have been indexed to equal 100 in 2008. Sources: Average dentist net income data, Vujicic and colleagues1; dental care spending data, Wall and colleagues2; supply of dentists data, American Dental Association, Health Policy Institute.3
earnings likely to evolve in the near future? Let’s take dental spending first. A recent analysis shows that if current trends continue, the dental care sector will enter a “new normal” of flat per capita dental spending.4 In other words, the dental economy will not simply rebound with the economic recovery.4 The increased spending on dental care that is expected among older adults and children will not compensate for the expected decline among the working-age population. This analysis, however, does not take into account the potential impact of the Affordable Care Act (ACA). When the ACA was drafted, the intent was to expand dental insurance among children by making dental care an essential health benefit. For various complicated reasons, this “mandate” has been watered down, and the take-up of dental insurance within the health insurance marketplaces is well below 100 percent.5 In fact, on the basis of the most recent analysis available, the highest take-up rate is 36 percent in California.5 The ACA never was intended to include adult dental care as part of the individual mandate,
but recent analysis shows that there is interest, particularly among young adults, in purchasing dental insurance within the health insurance marketplaces.6 The expected expansion in coverage from the health insurance marketplaces pales in comparison with another aspect of the ACA: Medicaid expansion. A new analysis shows that up to 8.3 million adults will gain Medicaid dental benefits as a result of Medicaid expansion. This will reduce by up to 35 percent the number of low-income adults who do not have any form of dental coverage.7 In many states, the growth in the adult Medicaid population is significant, often a doubling or tripling of the number of enrollees.7 There obviously is much uncertainty in the market but, taken together, the best analyses suggest that demand for dental care, owing to expanded dental insurance coverage, is expected to grow among children, older adults and people receiving Medicaid benefits. Among people in the middle- to upper-income working-age population, demand is expected to continue to be sluggish if current trends continue.
1168
November 2014
JADA 145(11) http://jada.ada.org
Now let’s turn to the supply side. The results of a new analysis that is based on sophisticated empirical modeling of inflows to and outflows from the dentist workforce show that the supply of dentists in the United States actually is expected to grow in the coming decades (B. Munson and M. Vujicic, unpublished data, August 2014). The analysis does not address whether tomorrow’s dentist workforce will be more or less likely to locate in certain areas (such as rural and underserved areas) or treat certain populations (for instance, people receiving Medicaid benefits, children, older adults), which is critical to the “shortage” debate. Further research is needed in this area. But at the most aggregate level, if dental spending remains sluggish and the supply of dentists continues to increase, history suggests that the “invisible hand” could produce a situation of stagnant dentist earnings in the coming years. CONCLUSIONS
Of course, there is a high degree of uncertainty in the future evolution of both demand for dental care and supply of dentists. Moreover, the
FEATURES
United States is not a single market. Like politics, economics is local. The American Dental Association Health Policy Institute will continue to analyze the best available data to monitor market trends in the dental care sector in the years ahead. ■ doi:10.14219/jada.2014.100 Disclosure. Dr. Vujicic did not report any disclosures. 1. Vujicic M, Munson B, Nasseh K. Despite economic recovery, dentist earnings remain flat. American Dental Association Health Policy Institute Research Brief. www.ada.org/ sections/professionalResources/pdfs/ HPRCBrief_1013_4.pdf. Accessed Oct. 3, 2014.
2. Wall T, Nasseh K, Vujicic M. U.S. dental spending remains flat through 2012. Health Policy Institute Research Brief. American Dental Association. January 2014. www.ada.org/ sections/professionalResources/pdfs/ HPRCBrief_0114_1.pdf. Accessed Oct. 3, 2014. 3. American Dental Association, Health Policy Institute. Dentist supply in the U.S.: 1993 to 2011. www.ada.org/en/science-research/ health-policy-institute/data-center/supply-ofdentists. Accessed Oct. 3, 2014. 4. Nasseh K, Vujicic M. Dental expenditure expected to grow at a much lower rate in the coming years. Health Policy Institute Research Brief. American Dental Association. August 2013. www.ada.org/~/media/ADA/Science%20 and%20Research/HPI/Files/HPIBrief_0813_1. ashx. Accessed Sept. 26, 2014. 5. Yarbrough C, Vujicic M, Nasseh K. Update: take-up of pediatric dental benefits in health insurance marketplaces still limited. Health
Policy Institute Research Brief. American Dental Association. May 2014. www.ada.org/~/ media/ADA/Science%20and%20Research/HPI/ Files/HPIBrief_0514_1.ashx. Accessed Sept. 26, 2014. 6. Vujicic M, Yarbrough C. Young adults most likely age group to purchase dental benefits in health insurance marketplaces. Health Policy Institute Research Brief. American Dental Association. August 2014. www.ada.org/~/ media/ADA/Science%20and%20Research/HPI/ Files/HPIBrief_0814_3.ashx. Accessed Sept. 26, 2014. 7. Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion. Health Policy Institute Research Brief. American Dental Association. February 2014. www.ada.org/ sections/professionalResources/pdfs/HPRCBrief_0214_1.pdf. Accessed Sept. 26, 2014.
Statement of Ownership, Management, and Circulation $OO3HULRGLFDOV3XEOLFDWLRQV([FHSW5HTXHVWHU3XEOLFDWLRQV 1. Publication Title: The Journal of the American Dental Association; 2. Publication Number: 0002-8177; 3. Filing Date: October 1, 2014; 4. Issue Frequency: Monthly; 5. Number of Issues Published Annually: 12; 6. Annual Subscription Price: Members-$25, Non-Members-$173, Institutions-$205; 7. Complete Mailing Address of Known Office of Publication (Not printer) (Street, city, county, state, and ZIP+4®): 211 East Chicago Avenue; Chicago, IL 60611-2678, Contact Person :Jill Philbin, Telephone (Include area code): 312-440-2518; 8. Complete Mailing Address of Headquarters or General Business Office of Publisher (Not printer): 211 East Chicago Avenue; Chicago, IL 60611-2678; 9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor (Do not leave blank), Publisher (Name and complete mailing address): Michael D. Springer, Managing Vice President, and Publisher, 211 East Chicago Avenue; Chicago, IL 60611-2678; Editor (Name and complete mailing address): James Berry, Associate Publisher, Editorial, 211 East Chicago Avenue; Chicago, IL 60611-2678; Managing Editor (Name and complete mailing address): This title does not exist; 10. Owner (Do not leave blank. If the publication is owned by a corporation, give the name and address of the corporation immediately followed by the names and addresses of all stockholders owning or holding 1 percent or more of the total amount of stock. If not owned by a corporation, give the names and addresses of the individual owners. If owned by a partnership or other unincorporated firm, give its name and address as well as those of each individual owner. If the publication is published by a nonprofit organization, give its name and address.): Full Name, American Dental Association, Complete Mailing Address, 211 East Chicago Avenue, Chicago, IL 60611-2678: 11. Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities. If none, check box: NONE; 12. Tax Status (For completion by nonprofit organizations authorized to mail at nonprofit rates) (Checkone) The purpose, function,and nonprofit status of this organization and the exempt status for federal income tax purposes: Has Not Changed During Preceding 12 Months; 13. Publication Title: The Journal of the American Dental Association; 14. Issue Date for Circulation Data: June, 2014 15. Extent and Nature of Circulation Average No. Copies Each Issue During Preceding 12 Months No. Copies of Single Issue Published Nearest to Filing Date a. Total Number of Copies (Net press run) 153,059 156,788 b. Paid Circulation (By Mail and Outside the Mail) (1) Mailed Outside-County Paid Subscriptions Stated on PS Form 3541 (Include paid 121,863 125,490 distribution above nominal rate, advertiser’s proof copies, and exchange copies) (2) Mailed In-County Paid Subscriptions Stated on PS Form 3541 (Include paid distribution 0 0 above nominal rate, advertiser’s proof copies, and exchange copies) (3) Paid Distribution Outside the Mails Including Sales Through Dealers and Carriers, 0 0 Street Vendors, Counter Sales, and Other Paid Distribution Outside USPS® (4) Paid Distribution by Other Classes of Mail Through the USPS (e.g. First-Class Mail®) 0 0 c. Total Paid Distribution (Sum of 15b (1), (2), (3), and (4)) 121,863 125,490 d. Free or Nominal Rate Distribution (By Mail and Outside the Mail) (1) Free or Nominal Rate Outside-County Copies Iincluded on PS Form 3541 28,896 29,173 (2) Free or Nominal Rate In-County Copies Included on PS Form 3541 0 0 (3) Free or Nominal Rate Copies Mailed at Other Classes Through the USPS (e.g. First-Class Mail) 0 0 (4) Free or Nominal Rate Distribution Outside the Mail (Carriers or other means) 150 0 e. Total Free or Nominal Rate Distribution (Sum of 15d (1), (2), (3) and (4) 29,046 29,173 f. Total Distribution (Sum of 15c and 15e) 150,909 154,663 g. Copies not Distributed (See Instructions to Publishers #4 (page #3)) 2,150 2,125 h. Total (Sum of 15f and g) 153,059 156,788 i. Percent Paid (15c divided by 15f times 100) 81% 81% 16. Publication of Statement of Ownership; If the publication is a general publication, publication of this statement is required. Will be printed in the November, 2014 issue of this publication. 17. Signature and Title of Editor, Publisher, Business Manager, or Owner Senior Vice President, Business and Publishing Date: October 1, 2014 I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties).
JADA 145(11)
http://jada.ada.org
November 2014
1169
