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My SciELO
Gac Sanit vol.34 n.3 Barcelona May./Jun. 2020 Epub Oct 13, 2020
http://dx.doi.org/10.1016/j.gaceta.2019.10.009
The use of health care services in the Great Recession: evaluating inequalities in the Spanish context
El uso de los servicios sanitarios durante la Gran Recesión: evaluación de las desigualdades en el contexto español
Raquel Sánchez-Recioa b , Juan Pablo Alonsob c , Isabel Aguilar-Palaciob d a *
aDepartamento de Fisiatría y Enfermería, Universidad de Zaragoza, Zaragoza, Spain.
bGrupo de Investigación en Servicios Sanitarios de Aragón (GRISSA) IIS Aragón, Zaragoza, Spain.
cDirección General de Salud Pública, Gobierno de Aragón, Zaragoza, Spain.
dDepartamento de Microbiología, Medicina Preventiva y Salud Pública, Universidad de Zaragoza, Zaragoza, Spain.
To analyse the effect of the Great Recession (2008) on primary care (PC) and secondary care (SC) inequalities in Spain.
Repeated cross-sectional study using Spanish Health Surveys from 2001 to 2017 (n = 139,566). Prevalence of PC and SC utilization were calculated standardized by age. Chi square tests for trend were conducted to explore the evolution. We performed logistic regression analyses adjusted by the Andersen's model of demand for care to explore inequalities prior to, during and following the recession. All the analyses were stratified by sex.
Healthcare use trends changed from a rapid increase in the pre-recession period to a plateau during the recession and a decrease in the post-recession period. Healthcare use was higher in women (PC: 15.8% to 32.5%; SC: 8.2% to 16.2%) than in men (PC: 11.3% to 24.1%; SC: 5.4% to 11.6%) and the gender gap increased. During the recession the likelihood of PC use was higher in disadvantaged groups, while SC had greater usage amongst more advantaged social groups. Inequalities in SC use increased during the recession and could not be attributed to factors of need.
Healthcare use trends changed as a result of the recession. There are socioeconomic inequalities in the use of PC and SC in Spain, which increased in secondary care, during the recession and in the post-recession period. It is necessary to take into account socioeconomic determinants in health planning, in order to achieve equity in healthcare services.
Keywords: Inequalities; Health care services; Recession; Economic crisis; Primary care; Secondary care
Analizar el efecto de la Gran Recesión en las desigualdades en el uso de atención primaria (AP) y atención especializada (AE) en España.
Análisis transversal repetido (Encuestas Nacionales de Salud 2001-2017; n = 139.566). Se calcularon las prevalencias de utilización estandarizadas por edad y se realizó el cálculo de tendencias para explorar la evolución. Se llevaron a cabo análisis de regresión logística ajustados por el Modelo de demanda asistencial de Andersen para estudiar las desigualdades en los periodos anterior, durante y posterior a la crisis. Todos los análisis se estratificaron por sexo.
La tendencia en la utilización de los servicios sanitarios pasó de un rápido incremento en el periodo anterior a la crisis a una estabilización durante la crisis y un posterior descenso. La utilización de los servicios sanitarios fue mayor en las mujeres (AP: 15,8% a 32,5%; AE: 8,2% a 16,2%) que en los hombres (AP: 11,3% a 24,1%; AE: 5,4% a 11,6%), aumentando las diferencias. Durante la crisis, la probabilidad de usar la AP fue mayor en los grupos más desfavorecidos, mientras que en la AE se observa la tendencia contraria. Las desigualdades en la AE aumentaron durante la recesión, pero ello no puede atribuirse a factores de necesidad.
La tendencia de la utilización de los servicios sanitarios cambió en la Gran Recesión. Existen desigualdades en la utilización de servicios sanitarios en España, que han aumentado en AE durante el periodo de crisis y poscrisis. Es necesario considerar los factores socioeconómicos en planificación sanitaria con el fin de lograr la equidad.
Palabras clave: Desigualdades; Servicios de salud; Recesión; Crisis económica; Atención primaria; Atención especializada
Health inequalities have their origin in the political, economic and social context of a society.1 These inequalities affect not only the health status of individuals and communities, but also the use of health care services. Several studies have demonstrated that health services utilization differs by social group. Primary care (PC) is mainly used by the lowest social classes, while secondary care (SC) utilization is more frequent in high classes.2-3 The existence of access barriers to health services, mainly in SC, such as increasing waiting times, lack of health literacy and reduction of available resources, are some of the main factors involved in the existence of a social gradient in the use of health care services.4-5
From 2008 to 2014 almost all European countries were affected by an economic recession.6 Public debt rose rapidly, as did unemployment.7 European governments implemented austerity policies in different areas, such as health care.6,8 This led to situations, such as having to decide in a family between spending on health care or food, prioritizing the latter.7-8 In Spain, one of the countries most affected by the Great Recession, austerity policies such as pharmaceutical co-payment or the closure of hospital beds, among others,7,9 were implemented to limit spending on health.7,9 This economic context had a direct and indirect impact on both health and the use of health systems, especially in some vulnerable groups10 such as ethnic minorities, children,11 the young and the elderly,2 among others.12 Now, it is widely asserted that the economic recession is over,13 but there remains doubt as to whether it has really ended or, on the contrary, the population has learned to live in a negative context.14 The population that became accustomed to living with fewer resources gave rise to the phenomenon of a group known as "the children of the crisis". The economic status and health of these people are adversely affected throughout their lives, aspects which worsen due to a lack of related governmental policies.5,15
Several studies have been carried out to analyze the effect of the Great Recession on the population's health.16-17 There are also some studies that explore the impact of economic recession on the use of health services.7,12,18 In this context, the objective of our study is to analyze the evolution of inequalities in health care service utilization in Spain and the impact of the Great Recession on these inequalities.
We used a repeated cross-sectional study design. Data were obtained from Spanish National Health Surveys (NHS) conducted in 2001, 2003, 2006, 2011, and 2017 and Spanish European Health Interview Survey (EHIS) in 2014. The economic recession period is split into three, with three surveys before (2001,2003, 2006), two during (2011, 2014) and one post-recession period (2017). NHS and EHIS are representative surveys, with a stratified multistage design. They were performed by means of personal interview among a non-institutionalized population from 15 years old. Therefore, in order to homogenize the sample in this study, only those over 16 were included in the analysis. Seasonal effect was avoided by including autumnal months in the sample collection.19-20 The methodology applied allows comparability between surveys. Sample sizes ranged from 21,067 in 2001, 22,575 in 2003, 29,478 in 2006, 20,884 in 2011, 22,659 in 2014 and 22,903 in 2017, with a total sample size of 139,566 subjects. The 2009 EHIS was not included in this study because of the different collection methods of some key variables, such as social class and level of education which made it incomparable with the other surveys. More information about data sources can be consulted in the reference section.21
Variables included in the study
To analyze healthcare utilization during the study period, two levels of healthcare services were considered: PC and SC, both in the private and public sector. To ascertain the use of PC, the following question was used: "In the last two weeks, have you consulted a family doctor for any problems, discomfort or illness?". Information about the use of SC was obtained from the question: "In the last four weeks, have you consulted a specialist doctor about any problems, discomfort or illness?".
In order to determine socioeconomic characteristics of the subjects, three variables were used: social class, educational level and employment status. These variables are the most commonly used in public health studies in order to identify health inequalities.22 Social class was obtained from the social class of the household's main supporter. It was classified into manual and non-manual, from the 2011 National Classification of Occupations.23 Educational level was classified into three categories according to the International Standard Classification of Education (ISCED)24 low (primary studies: ISCED 0-1), medium (secondary education: ISCED 2, 3, and 4), and high educational level (higher education and university studies, ISCED 5 and 6). Employment status was obtained through the profession or trade that the surveyed person performed in the last job, and was classified into five categories: workers (paid work), the unemployed, students, pensioners (retired persons and those who receive some kind of pension) and those doing unpaid household labor. Andersen's model originally included educational level in occupation as a component of predisposing characteristics, but it can also be considered as an influential enabling variable, as we have done in this study.
Finally, we included the variables of the Andersen's Model of Demand for care,25 a theoretical framework widely used to analyze health care service utilization.12 It classifies the determinants of healthcare use into three groups: predisposing factors (age and sex); factors of need (self-rated health, chronic disease/disorder, limitation of physical activity in the last 6 months and limitation during the last two weeks to perform everyday activities due to pain or any other symptom); and factors that facilitate access and use of health care (personal and/or family characteristics that may influence the use of health services: employment status, social class, educational level, marital status, tobacco consumption and health insurance model) (see Table I in online Appendix).
All the variables were collected in all surveys in the same way, which allows comparability across time.21 Included in the analyses were data regarding chronic diseases: high blood pressure, hypercholesterolemia, heart disease, bronchitis, stomach ulcer, allergy and depression, that had been collected in the six surveys.
First, a descriptive study of the socioeconomic characteristics of the sample was carried out. Prevalence with their 95% confidence intervals (95%CI) were calculated. Then, the estimated prevalence of healthcare services utilization (PC and SC) was calculated according to socioeconomic indicators. Trend analyses (chi-square for trend) were performed in order to observe the evolution of health services use during the study period. All the analyses were stratified by sex and standardized by age to guarantee data comparability, taking year 2001 as reference (first year of study). In order to facilitate readability, only the results of the first and last survey were presented.
Secondly, to study the influence of socioeconomic factors on the use of healthcare services, logistic regression analyses, stratified by sex, were carried out. We pooled data into three periods: prerecession (2001, 2003 and 2006 surveys), recession (2011 and 2014 surveys) and post-recession (2017 survey). Although the economic recovery started in 2014,13 in this survey it has been considered as a "crisis year". This is because data collection in that year started in January,21 and because health spending, mainly for PC, did not increase for all the Autonomous Communities.26 Two models were employed: a first model (model 1) adjusted by age, and a second model (model 2) adjusted by the variables included in the Andersen's Model of Demand. The adjustment by Andersen's Model allowed isolation of the role of socioeconomic factors in the use of health care services, after controlling by characteristics that have been strongly associated with subject utilization. Finally, the C statistic (area under the ROC curve) was calculated to know the predictive capacity of the models, where 1 indicates perfect prediction and 0.5 indicate a low predictive capacity.
All the analyses were done using the weighting factors that each survey provided, to avoid errors associated with survey design or bias associated with no response. All tests were considered significant when p < 0.05. Analyses were performed with IBM SPSS Statistics 19®, Stata 14® and RStudio. Ethical approval was not required due to the public and anonymous characteristics of microdata.
Evolution of socioeconomic characteristics
Educational level improved from 2001 to 2017 in men and women, with an important increase in the number of people with medium studies (Table 1). High educational level decreased in men (35.1 vs. 26.5%), but increased in women (28.9% vs. 30.3%). Regarding employment status, an important increase in the prevalence of unemployment was observed in men (6.6% vs. 11.7%). In women, the most important changes were the significant increase in working women (32.1% vs. 44.2%) and the reduction of women whose main occupation was unpaid household labor (34.0% vs. 12.8%). Social class did not vary for the study period, with a majority of manual workers (60%).
Table 1. Percentage of Spanish population by social class, educational level and employment status with their 95% confidence interval (Spain, 2001-2017). Results standardized by age and weighted
2001% (95%CI)
p (χ2)
Men Social class Non-manual 36.5 (35.4-37.7) 37.1 (35.9-38.1) 0.70
Manual 63.5 (62.0-65.1) 62.9 (61.9-64.0) 0.70
Educational level Low 35.3 (34.2-36.5) 21.7 (21.0-22.5) <0.01
Medium 29.6 (28.6-30.7) 51.7 (50.1-52.7) <0.01
High 35.1 (33.9-36.2) 26.5 (25.6-27.5) <0.01
Employment status Working 57.3 (55.9-58.8) 51.7 (50.7-52.7) <0.01
Unemployed 6.6 (6.1-7.1) 11.7 (10.9-12.4) <0.01
Students 9.1 (8.5-9.7) 11.7 (10.9-12.5) <0.01
Pensioners 26.9 (25.9-28.1) 24.6 (24.2-25.1) <0.01
Unpaid Household Labor NE NE
Women Social class Non-manual 36.5 (35.6-37.4) 37.9 (36.9-38.9) 0.30
Unpaid Household labor 34.0 (33.2-34.8) 12.8 (121.2-13.4) <0.01
95%CI: 95% confidence interval; NE: not evaluable (low number of subjects).
Use of health care services
The use of PC and SC increased throughout the period analyzed, with a higher utilization in women. PC use (Fig. 1A) increased from 16.1 in 2001 to 30.1 in 2017 in women (slope 0.00999, p < 0.001). SC utilization (Fig. 1B) also increased from 8.2 to 15.4 in 2017 in women (slope: 0.00577; p < 0.001). This increase was not linear. There was an important increase in the use of PC and SC from 2001 to 2011, a plateau during the recession and a slow decrease, mainly for SC, in the post-recession period. This trend was similar for both sexes, with an increasing gap between women and men for both PC and SC levels of use.
Figure 1. Primary care (A) and specialized care (B) utilization (%) in Spain (2001-2017). Results standardized by age and stratified by sex
When the use of PC was analyzed by socioeconomic determinants (Table 2), it was observed that utilization doubled for the period 2001-2017 for all the categories considered. Some categories showed an even higher increase, such as in the PC utilization amongst men with high educational level (2001: 8.7, 95%CI: 7.410.1 vs. 2017: 23.4, 95%CI: 21.1-24.7) and students (men 2001: 1.4, 95%CI: 1.1-1.8 vs. 2017: 8.9, 95%CI: 2.5-15.4; women 2001: 4.8, 95%CI: 1.3-8.2 vs. 2017: 14.5, 95%CI: 8.1-20.9). In men, the gap in the use of PC between those of low and high educational level disappeared. On the other hand, the existing gap between male workers (2001: 9.5, 95%CI: 7.7-11.3 vs. 2017: 21.4, 95%CI: 18.9-23.9) and pensioners (2001: 20.8, 95%CI: 16.8-24.7 vs. 2017: 36.1, 95%CI: 29.3-42.9) increased. In women, the socioeconomic gap persisted between social classes and between those of low and high educational level. Regarding employment status, statistically significant differences were found among workers (2001: 13.5, 95%CI: 11.5-15.5 vs. 2017: 30.1, 95%CI: 26.8-33.2) and the rest of the categories, with the lowest utilization being in students (2001: 4.8, 95%CI: 1.3-8.2 vs. 2017: 14.5, 95%CI: 8.1-20.9) and the highest among pensioners (2001:18.7, 95%CI: 14.4-23.1 vs. 2017: 47.8, 95%CI: 39.0-56.6).
Table 2. Use of primary care and secondary care in men and women according to social class, educational level and employment status (Spain 2001-2017). Results standardized by age and weighted
Men Social class Non-manual 10.9 (9.8-12.0) 23.1 (20.9-25.1) 0.0088 <0.01 4.5 (3.8-5.2) 13.9 (12.3-15.6) 0.0061 <0.01
Manual 11.7 (10.8-12.5) 24.3 (23.3-25.3) 0.0078 <0.01 6.3 (5.6-6.9) 10.1 (9.4-10.8) 0.0031 <0.01
Educational level Low 13.5 (11.7-15.2) 26.3 (23.7-28.9) 0.0082 <0.01 6.3 (5.1-7.4) 9.6 (9.4-10.8) 0.0025 <0.01
Medium 10.4 (8.7-12.0) 23.6 (22.4-24.8) 0.0093 <0.01 7.4 (5.8-9.1) 10.8 (9.9-11.8) 0.0035 <0.01
High 8.7 (7.4-10.1) 23.4 (21.1-24.7) 0.0103 <0.01 4.7 (3.7-5.6) 12.4 (10.9-13.7) 0.0062 <0.01
Employment status Working 9.5 (7.7-11.3) 21.4 (18.9-23.9) 0.0095 <0.01 4.7 (3.8-5.7) 10.2 (8.1-12.2) 0.0049 <0.01
Unemployed 13.5 (10.5-16.5) 20.1 (18.1-23.6) 0.0046 <0.01 4.2 (2.7-5.7) 7.6 (5.8-9.4) 0.0006 0.31
Students 1.4 (1.1-1.8) 8.9 (2.5-15.4) 0.0045 <0.01 0.6 (0.4-0.8) 4.5 (1.0-9.2)) 0.0029 <0.01
Pensioners 20.8 (16.8-24.7) 36.1 (29.3-42.9) 0.0114 <0.01 6.2 (3.8-8.6) 23.4 (16.8-30.1) 0.0133 <0.01
Unpaid household labor NE NE NE NE
Women Social class Non-manual 14.7 (13.6-15.9) 23.7 (21.7-25.7) 0.0078 <0.01 7.4 (6.6-8.2) 17.4 (15.6-19.3) 0.0082 <0.01
Manual 17.1 (16.1-17.8) 32.1 (31.1-33.1) 0.0099 <0.01 8.5 (7.9-9.2) 14.9 (14.0-15.6) 0.0045 <0.01
Educational level Low 18.5 (16.7-20.3) 38.4 (34.9-42.1) 0.0122 <0.01 7.9 (6.7-9.1) 11.7 (9.7-13.6) 0.0038 <0.01
Medium 15.4 (13.7-17.1) 38.4 (34.9-42.1) 0.0114 <0.01 8.8 (7.4-10.1) 15.1 (14.1-16.2) 0.0054 <0.01
High 11.7 (8.5-12.1) 27.1 (25.2-28.9) 0.0112 <0.01 8.6 (7.1-10.1) 17.9 (16.3-19.4) 0.0077 <0.01
Employment status Working 13.5 (11.5-15.5) 30.1 (26.8-33.2) 0.0087 <0.01 8.9 (7.2-10.6) 18.1 (14.5-21.4) 0.0069 <0.01
Unemployed 17.1 (12.5-21.7) 31.5 (28.2-24.8) 0.0099 <0.01 7.3 (3.8-10.7) 15.4 (12.8-17.9) 0.0050 <0.01
Students 4.8 (1.3-8.2) 14.5 (8.1-20.9) 0.0048 <0.01 1.4 (1.1-1.8) 7.9 (2.5-13.3) 0.0033 <0.01
Pensioners 18.7 (14.4-23.1) 47.8 (39.0-56.6) 0.0175 <0.01 19.4 (10.6-28.2) 28.2 (21.9-34.5) 0.0072 <0.01
Unpaid household labor 17.1 (15.7-18.5) 32.1 (28.3-35.7) 0.0099 <0.01 9.4 (8.2-10.5) 11.5 (9.1-13.9) 0.0034 <0.01
SC utilization also increased from 2001 to 2017 (Table 2). This increase was more marked for male pensioners (2001: 6.2, 95%CI: 3.8-8.6 vs. 2017: 23.4, 95%CI: 16.8-30.1). With regard to educational level, men having a low educational level showed lower utilization of SC (2001: 6.3, 95%CI: 5.1-7.4, 2017: 9.6, 95%CI: 9.4-10.8) than those with middle and high educational level. Women with low educational level presented with a lower SC utilization than those with medium and high educational level, with an increasing educational gap. Regarding employment, pensioners showed the highest prevalence of SC utilization for both sexes (men 2017: 23.4, 95%CI: 16.8-30.1; women 2017: 28.2, 95%CI: 21.9-34.5).
In all groups studied and for both health care levels, with the only exception of unemployed men in SC (p = 0.31), trend analyses showed a statistically significant increase (p < 0.001).
Economic recession influence on the use of primary care and secondary care according to socioeconomic variables
Table 3 shows the influence of socioeconomic determinants in PC utilization before, during and after economic recession. In men before the recession, people with low and medium educational level had a higher probability of PC utilization, taking as reference those with high educational level. In the same way, unemployed people and pensioners showed a higher probability of PC utilization than workers. During the recession, manual workers (reference category: non-manual) and pensioners (reference category: workers) had a higher probability of PC use, independent of their level of need. For women, in the pre-recession period, there was a greater probability of using PC in manual workers than in non-manual, those with low and medium educational level (reference category: high studies), the unemployed and pensioners (reference category: workers). This employment effect was lost during the recession period. Regarding the post-recession period (2017), the pattern of PC use was similar to the previous period. In men, the probability of use was higher in pensioners than in workers. In women this association was also observed, as well as a higher likelihood of PC use in manual workers (reference category: non-manual), those doing unpaid household labor (reference category: workers) and women with a low educational level (reference category: high studies).
Table 3. Odds ratios and their 95% confidence intervals of primary care use by social class, educational level and employment status, stratified by sex. Comparison of the pre-recession (2001-2006), recession period (2011-2014), and post- recession period (2017)
Pre-recession period (2001-2006)
Recession period (2011-2014)
Post-recession (2017)
OR (95%CI)
Men Social class Non-manual Ref Ref Ref Ref Ref Ref
Manual 1.2 (1.1-1.3)a 1.1 (0.9-1.2) 1.1 (0.9-1.1) 1.2 (1.1-1.3)a 1.1 (0.9-1.3) 1.1 (0.9-1.2)
Educational level Low 1.7 (1.5-1.9)a 1.4 (1.2-1.6)a 1.3 (1.1-1.4)a 1.1 (0.9-1.3) 1.1 (0.8-1.2) 1.1 (0.9-1.2)
Medium 1.4 (1.2-1.5)a 1.3 (1.1-1.5)a 1.2 (1.1-1.3)a 1.1 (0.9-1.2) 1.1 (0.9-1.2) 0.9 (0.8-1.1)
High Ref. Ref. Ref. Ref. Ref. Ref.
Employment status Working Ref. Ref. Ref. Ref. Ref. Ref.
Unemployed 1.4 (1.2-1.6)a 1.5 (1.2-1.8)a 1.2 (1.1-1.3)a 1.1 (0.9-1.2) 1.2 (1.1-1.3)a 1.1 (0.9-1.3)
Students 0.7 (0.6-0.8)a 0.8 (0.6-1.2) 3.5 (3.2-3.8)a 1.2 (0.9-1.5) 0.9 (0.7-1.2) 1.1 (0.8-1.4)
Pensioners 3.1 (2.9-3.4)a 2.0 (1.7-2.3)a 1.2 (0.9-1.7) 1.4 (1.1-1.7)a 2.1 (1.8-2.4)a 1.5 (1.3-1.8)a
Unpaid Household labor NE NE NE NE NE NE
C statisticb 0.685 0.697 0.660 0.729 0.658 0.715
Women Social class Non-manual Ref. Ref. Ref. Ref. Ref. Ref.
Manual 1.2 (1.1-1.3)a 1.1 (1.1-1.2)a 1.2 (1.1-1.2)a 1.1 (1.0-1.3)a 1.4 (1.2-1.6)a 1.2 (1.1-1.4)a
Educational level Low 2.1 (1.9-2.3)a 1.6 (1.4-1.8)a 1.9 (1.7-2.1)a 1.4 (1.2-1.6)a 1.1 (0.9-1.2) 1.1 (0.9-1.2)
Medium 1.4 (1.3-1.5)a 1.3 (1.1-1.5)a 1.4 (1.3-1.5)a 1.2 (1.1-1.4) 1.4 (1.2-1.5)a 1.2 (1.1-1.3)a
Students 0.8 (0.7-0.9)a 0.9 (0.7-1.2) 1.9 (1.7-2.1)a 1.1 (0.8-1.2) 0.7 (0.6-0.9)a 0.8 (0.6-1.1)
Pensioners 1.8 (1.7-1.9)a 1.2 (1.1-1.3)a 1.4 (1.3-1.6)a 1.1 (0.9-1.2) 1.7 (1.4-1.9)a 1.5 (1.3-1.8)a
Unpaid household labor 1.3 (1.2-1.4)a 1.1 (0.9-1.2) 0.8 (0.7-0.9)a 1.1 (0.9-1.3) 1.3 (1.1-1.4)a 1.2 (1.1-1.3)a
95%CI: 95% confidence interval; NE: not evaluable (low number of subjects); OR: odds ratio; Ref.: reference category.
ap < 0.005.
bArea under the curve ROC.
Model 1 adjusted by age. Model 2 adjusted by age and by the variables of Andersen's Model for care (self-rated health, chronic disease/disorder, limitation of physical activity in the last 6 months and limitation during the last two weeks to perform usual activities due to pain or any other symptom, employment status, social class, educational level, marital status, tobacco consumption and health insurance model).
For SC utilization (Table 4), unemployed men and pensioners had, in the pre-recession years, a higher probability of SC use than workers, being the only socioeconomic indicator with statistical differences after adjusting by the Andersen's Model. In women manual workers (ref. non-manual workers) and those doing unpaid household labor (ref. workers) showed a higher probability of SC use, while women with low educational level presented a lower likelihood of SC use than women with high level. During the recession period, inequalities increased for the use of SC, after adjusting for need. Manual workers (ref. non-manual workers) and those with a lower level of education (ref. high studies) showed a lower probability of utilization of SC, each having the same level of need. According to data observed in the post-recession period, association was similar to those observed for the recession period for both sexes.
Table 4. Odds ratios and their 95% confidence intervals of secondary care use by social class, educational level and employment status, stratified by sex. Comparison of the pre-recession (2001-2006), recession period (2011-2014) and post-recession period (2017)
Men Social class Non-manual Ref. Ref. Ref. Ref. Ref. Ref.
Manual 1.0 (0.9-1.1) 0.9 (0.8-1.1) 0.9 (0.8-0.9)a 0.8 (0.7-0.9)a 0.7 (0.6-0.8)a 0.7 (0.6-0.8)a
Educational level Low 1.2 (1.1-1.4)a 1.1 (0.9-1.3) 0.8 (0.7-0.9)a 0.8 (0.6-0.9)a 0.8 (0.6-0.9)a 0.7 (0.6-0.8)a
Medium 1.2 (1.1-1.4)a 1.2 (0.9-1.4) 0.9 (0.8-1.1) 0.8 (0.7-0.9)a 0.9 (0.7-1.1) 0.8 (0.7-0.9)a
Unemployed 1.8 (1.6-2.2)a 1.5 (1.2-2.0)a 0.9 (0.8-1.1)a 0.9 (0.7-1.1) 0.6 (0.7-1.2) 0.8 (0.7-1.1)
Students 0.8 (0.6-0.9)a 0.8 (0.4-1.3) 0.8 (0.7-0.9)a 1.4 (1.0-1.9)a 1.1 (0.8-1.3) 1.2 (0.9-1.7)
Pensioners 3.1 (2.8-3.4)a 1.8 (1.5-2.2)a 2.9 (2.6-3.2)a 1.7 (1.3-2.1)a 1.9 (1.5-2.3)a 1.3 (1.1-1.5)a
Educational level Low 1.2 (1.1-1.3)a 0.8 (0.7-0.9)a 0.9 (0.8-0.9)a 0.7 (0.6-0.8)a 0.7 (0.6-0.8)a 0.6 (0.5-0.7)a
Medium 1.0 (0.9-1.1) 0.9 (0.8-1.1) 0.9 (0.9-1.1) 0.8 (0.7-0.9)a 0.8 (0.7-0.9)a 0.8 (0.7-0.9)a
Unemployed 0.9 (0.8-1.1) 1.1 (0.8-1.2) 1.1 (0.9-1.2) 0.9 (0.8-1.1) 1.1 (0.9-1.2) 0.9 (0.8-1.1)
Students 0.5 (0.5-0.6)a 1.1 (0.8-1.6) 0.7 (0.6-0.8)a 1.3 (0.9-1.7) 0.6 (0.4-0.7)a 0.6 (0.5-0.8)a
Pensioners 1.6 (1.4-1.7)a 1.2 (0.9-1.4) 1.5 (1.3-1.6)a 0.9 (0.8-1.2) 1.4 (1.2-1.7)a 1.1 (0.9-1.3)
Unpaid household labor 1.2 (1.1-1.3)a 1.2 (1.1-1.4)a 1.2 (1.1-1.3)a 0.7 (0.6-0.8)a 1.1 (0.9-1.2) 0.8 (0.7-0.9)a
C statistic showed a fair explanatory capacity of the models developed. The regression models conducted for the recession period had greater explanatory power than pre and post-recession models. The explanatory capacity of the model was higher for men than for women, and similar for both health care levels. Full models are available in Tables II and III in online Appendix.
In Spain, from 2001 to 2017, there was a change in the use of health services. The increase observed in the pre-recession period led to a plateau during the recession and a decrease in the postrecession period, which was more marked in SC. This trend existed for both sexes, with a higher utilization in women and an increase in the gender gap. Socioeconomic differences in the use of PC and SC were observed for all the socioeconomic indicators used, and persisted even after adjusting for factors of need. These socioeconomic differences increased for SC during the recession period.
Spanish social structure improved for the period considered in terms of education. Nonetheless, unlike other surrounding countries,9 it has not been linked with a change in social class, which could be explained by different factors. First, Spain is one of The Organisation for Economic Co-operation and Development (OECD) countries where economic inequalities have increased more markedly in recent years, mainly because of unemployment and the lack of social policies to protect the most vulnerable groups.27 Other reasons may be related to the type of manufacturing work in Spain and the "brain drain" to other European countries with better job opportunities during the Great Recession. Because of that, the 2011 data reflected a negative migration balance with a significant migration rate amongst young Spanish workers with a high educational level.28
In relation to health care use patterns during the study period, our findings are consistent with the literature.11,29 The prevalence of health care utilization was higher in women, which has been justified by the social roles assumed by women and men. Women use health services not only to cover their own health needs, but also those of their family members. On the contrary, there are still men who consider that going to the doctor as negatively related to their masculinity.30-31 Authors29,32 have associated the increasing trend in health services utilization for various reasons. Firstly, the increase in SC may be due to changes in clinical practice. Lostao et al.33 related this with an increase in the rate of patient referral from general practitioners to specialist physicians. Secondly, this increase could be due to the worsening of health status and changes in the perception of health needs, mainly in the elderly. In this sense, some health indicators have worsened during this period, such as the deceleration of improvement in mortality rates since 2008, mainly in winter and in women, and increases in the prevalence of psychosocial stress.5
The plateau in the use of health services during the economic recession has also been found in other studies, and has been associated to an increased number of households that have given up or postponed medical care for financial reasons.12 In addition, other measures to control health care demand, such as an increase in waiting times, a reduction in service supply or in pharmaceutical co-payments34 could explain this trend.
There are socioeconomic inequalities in Spain in the use of healthcare services.10,29,34 The probability of PC use is higher for those in vulnerable socioeconomic conditions. Lostao et al.29,33 found that lower income categories used mainly PC, and Córdoba-Doña et al.35 observed a pro-low social class in the use of PC in Andalusia. These inequalities cannot be explained by health or sociodemographic characteristics. As we have observed for PC, after adjusting by the Andersen's Model, inequalities persist according to socioeconomic conditions, such as social class. This fact has been associated with different factors, such as low use of preventive services or low frequency of private health insurance, which forces disadvantage social classes to use PC.35 The characteristics of PC, in which access barriers are low and medical attention is supply on demand, could also impact the use of PC by disadvantaged people. With regard to the most advantaged groups, their high access to SC could be related with their better knowledge of the health system, as well as a higher use of private insurance.29 In contrast, the higher utilization observed amongst the unemployed for both sexes in the pre-recession period was lost during and after the recession. This reduction in use among low income groups has been attributed to a new pharmaceutical co-payment system as well as other measures. The pharmaceutical co-payment system led to difficulty for some in accessing certain medications that had been subsidized before the recession, and had been introduced due to difficulty in covering the cost of the previous arrangements.12,34,36
SC utilization was more frequent in people with positive socioeconomic indicators, and these inequalities increased during the recession period. People with medium and low educational level showed, during the economic recession, a lower probability of SC use than those with high education, even after adjusting for factors of need. In Spain, patients cannot use SC unless they are referred from PC.7 So, a deficit in health literacy amongst these educational groups could explain, at least partly, their lower utilization.6,29 Regarding social class, García-Subirats et al.12 reported that high social classes use SC with higher frequency than low social classes, as was observed in this study. This could be associated, also, to health literacy, which facilitates SC access to more advantaged social groups.
Finally, on both PC and SC, it is possible to observe a high probability of utilization by male pensioners during the recession that is not associated with factors of need. This result is consistent with other studies33-34 and has been related to a high frequency of health insurance plans in this group.
This study has some limitations associated with the use of health surveys as an information source, such as the inability to establish causality and the lack of temporality of the exposureeffect association. Health care use information was obtained from direct statements of those interviewed. However, health results obtained by survey are similar to those registered by electronic medical records.37 In addition, we could not use income level due to the high percentage of absent observations and the different criteria used among surveys. Instead of income, we have used three different socioeconomic indicators as proxies of socioeconomic level, which also provide different perspectives of the socioeconomic context. On the other hand, the surveys used are representative at a national level with a substantial sample available and a low number of absent values in the variables included (less than 5%).
The results of our study show that, in Spain, for the period 2001-2017, the use of healthcare services has increased, showing a plateau during the economic recession and a decrease when the recession ended. There are socioeconomic inequalities in the use of health services, with a higher use of PC by disadvantaged socioeconomic classes and a lower SC utilization. These inequalities increased for SC during the recession, and cannot be attributed to factors of need. Explaining the use of health care services based on socioeconomic indicators should be part of explanatory models in order to achieve health equity38 as well as to explore how these socioeconomic differences translate into different health results. Socioeconomic inequalities must be taken into account in order to control the effect of the subject's economic context on our health systems.
What is known about the topic?
The Great Recession in Spain led to an increase in the most vulnerable groups, because of the rapid rise in unemployment and the lack of social policies. In addition, there are social inequalities in the use of health services: low social classes mainly use primary care, while specialized care utilization is more frequent in high classes.
What does this study add to the literature?
Health care use trend have changed from a rapid increased in the pre-crisis to a plateau during the crisis and a decrease in the post-crisis period. Inequalities in health care use have increased for the crisis and post-crisis period mainly in Specialized Care. Explaining the use of health care services based on socioeconomic indicators should be part of explanatory models in order to achieve health equity.
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Supplementary data associated with this article can be found, in the online version, at doi: 10.1016/j.gaceta.2019.10.009.
Funding: This study was carried out with the financial support of the Grupo de Investigación en Servicios Sanitarios de Aragón (GRISSA) (B09-17R). This research group is funded by Gobierno de Aragón and Fondo Europeo de Desarrollo Regional(FEDER).
Received: June 21, 2019; Accepted: October 22, 2019; pub: January 28, 2020
* Corresponding author: iaguilar@unizar.es (I. Aguilar-Palacio).
Editor in charge
María-Victoria Zunzunegui.
The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.
Authorship contributions
R. Sánchez-Recio, J.P. Alonso-Pérez de Ágreda and I. Aguilar Palacio conceived and designed the study. R. Sánchez-Recio, J.P.Alonso-Pérez de Ágreda and I. Aguilar Palacio participated in the study, obtaining the data, interpreting the results, and writing and critically reviewing the manuscript. All signatories have approved the final version of the text.
© 2020 SESPAS
This is an open-access article distributed under the terms of the Creative Commons Attribution License


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As a couples counselor, the most powerful thing you can do for the couples you work with is to teach them to be allies for one another. After all, they spend far more time with each other than they ever will with you.
Oppression 101
Overcoming oppression is one of the key things your clients need your help to do, yet they may not understand the ways they've been hurt and limited by oppression. That makes it all the more important that YOU understand it.
Feeling Stuck? Try Enlightenment!
Why should only a few people at the top of the spiritual pyramid have access to enlightenment? Enlightenment is for everyone! All you need to do is have high expectations for yourself and your clients, and follow a few simple steps.
Articles on Counseling and Coaching
Thinking for Yourself About What's Ethical
Following rules does not make a person ethical. Becoming truly ethical calls on you first to distinguish between real (proactive) ethics and cover-your-ass (defensive) ethics, and then to think for yourself about what's right.
Varieties of Change in Counseling Relationships
Like it or not, we keep changing. Counseling is about facilitating deliberate and desirable varieties of change. Knowing the differences between healing, growth, and liberation will make you a more effective change artist.
Don't Trust Your Feelings: Somatics and the Pre/Trans Fallacy
Somatics has helped the disembodied field of counseling to get back on the ground. Just because something is somatic, however, doesn't make it helpful. Integrating the body with other levels of human experience is the real goal.
Videos on Relationships
The Life Cycle of Relationships
Have you ever been in a relationship that's ended? Understanding the stages of the life cycle of relationships can help you make sense of why they end, and how to better enjoy each stage along the way.
The Other Safe Sex Conversation
The other safe sex conversation starts with an obvious, and yet not-so-simple, question. Once you start asking it, you'll wonder how you ever managed without it.
How to Flirt (with everything)
There's a secret to flirting. When you flirt, you suggest that there's a possibility around the corner, something exciting and good and mysterious that could happen. If you flirt this way with everything, everything flirts back!
Friendship 2.0
The original model of friendship seemed like some pretty good stuff until the upgrade came along! Friendship 2.0 makes a richer, more deeply satisfying kind of friendship possible! Three qualities characterize the deeper variety.
The Intimacy Equation
How do you create intimacy? It's not hard to do. I've distilled it down to a simple addition problem. Here's how to put two simple components together to perform profound relational arithmetic .
Your Partner Is Not
Who You Think They Are
You and your partner want different things. If you're assuming that you're just similar people with momentarily competing needs, you're missing something. Your partner is not who you think they are.
How To Be Attractive
Did you grow up learning that some people are just attractive and others just aren't? As it turns out, you become attractive when you become more and more yourself, when the full you-ness of you shines through to your outward form.
Getting Good at Getting Rejected
The path to an awesome life is paved with rejections. To practice asking for what you want, so that you keep getting better results, also means you'll get rejected a lot along the way. Since rejection is a necessary part of the process, you might as well get good at getting rejected.
How to Fulfill All Your Sexual Fantasies
Sexual fantasies reveal to us some of our deepest desires. Every last one of your sexual fantasies can be fulfilled. You just have to know what fulfilling them means, and it doesn't mean what you think it does.
How To Make Friends With Anyone
Here are three simple steps for making friends with anyone: 1.) Assume they want to be friends. 2.) Meet them where they're at. 3.) Shower them with love.
Deep Dating:
The New Rules For Creating Intimacy
Articles on Relationships
Why Men Are So Obsessed With Sex
Boys are conditioned to be men. This conditioning cuts us off from intimacy, our feelings, and our bodies. If sex is the only place we can access these parts of our humanity, we will continue to be obsessed with it.
6 Steps to Completing Relationships
All relationships end. We live in a culture that pours energy into beginning relationships well, but not into ending them well. It is possible, at the end of a relationship, to resolve everything in need of resolution.
Which do you prefer: conditional or unconditional love? Though unconditional love is what we ultimately need, conditional love seems to be what most of us seek most of the time. Are you ready to kick the conditional love habit?
Ending Jealousy Permanently
Naming Is Framing - Ending Jealousy Permanently (Part 1)
How would you like to no longer experience jealousy? Impossible, you say? How can we ever be free of our basic human emotions, you ask? Well, we can't. Fortunately, jealousy is not a basic human emotion. Part 1 of 6.
Deconstructing Suffering - Ending Jealousy Permanently (Part 2)
If you stop using the word "jealousy", and instead pay close attention to what's actually happening underneath the label, what do you notice? This is not an easy question to answer. It takes a kind of mad curiosity about your own experience to really notice what's going on.
The Loving Yourself Project - Ending Jealousy Permanently (Part 3)
Insecurity is learned. We internalize the belief that we are inadequate and act on it by being hard on ourselves. Like all the structures of meaning that keep suffering in place, it can be dismantled and replaced with something better. The Loving Yourself Project is a set of practices and beliefs to replace the ones that make up insecurity.
The Deepening Intimacy Project - Ending Jealousy Permanently (Part 4)
We fear there will not be enough love for us. Belief in the scarcity of intimacy has self-fulfilling consequences. The Deepening Intimacy Project is a set of practices and beliefs to replace the ones that make up scarcity.
The Enjoying Aloneness Project - Ending Jealousy Permanently (Part 5)
Loneliness is some hard core business. Codependency can be a helpful protection against feelings of loneliness, but it has some unfortunate side effects. The Enjoying Aloneness Project is a set of practices and beliefs to replace the ones that make up codependency.
The Loving What Is Project - Ending Jealousy Permanently (Part 6)
Do you ever feel like a victim, either of circumstances, or of what you think other people have done to you? The Loving What Is Project can help you practice accepting that what happens simply happens, and that change is inevitable.
Interchange Blog
Cheatsheets for Allies: Disrupting Internalized Sexism and Men's Oppression May 2, 2017 Steve Bearman
A User's Guide to the Mind: The Mind's Steering Wheel February 23, 2017 Steve Bearman
Deep Dating: The New Rules For Creating Intimacy June 20, 2016 Steve Bearman
Why Women Hurt Women: Understanding and Overcoming Internalized Sexism May 18, 2016 Steve Bearman
The Dangers of Oversimplicating October 8, 2015 Steve Bearman
© 2015 Interchange Counseling Institute. All rights reserved.


It's a walkway in Ravnica that's used by people of all guilds. It even has different guild symbols in the pillars!
In fact, if you look closely, you can see that people from multiple guilds are actually walking on the promenade right now! This person is definitely from the Izzet League.
And over on the left, there's someone from the Rakdos Cult talking to someone from the Selesnya Conclave!


Kinda off-topic, I just read that FAQ about the smithing update. Hopefully it means they ARE going to release something to make high level smithing better, they just wanted this supposedly better training method first. They might need to adjust exp rates since I heard addy plates with SC hammers is still better and cheaper. Although, this has the benefit, from what I've seen, of being way way less of a grind.
Penguins were already in the sheep disguise in Lumbridge before the quest started. Had to use some creative license for the story and couldn't exactly tear the sheep from Lumbridge, now could I?
Kinda off-topic, I just read that FAQ about the smithing update. Hopefully it means they ARE going to release something to make high level smithing better, they just wanted this supposedly better training method first.
Save that comment because in the next year or two it might happen... keep your fingers crossed.
Not sure how Jagex can do this and keep player versus player interactions. And if Jagex set an NPC up as the house, they'd probably do something boneheaded like give it no edge.
i first know is ms-dos, then win3.1, not sure what the specs that time.
around 2001, my father buy us a pc(iirc cpu is 133 or 266mhz) and my sister subscribe dial-up. and because of dam slow pc , my cousin can only recommand me to play RS. every in order to start the game, it need to DL quite some time(need to re DL everytime got updates until 100%, this show how much better than it is now, roughly 5% can login and play).
the first time i enter game is to press F1 to get better performance(reduce graphic quality and blank every 2 row).
because of slow pc and internet, i play very few, so i miss out all rares that i can get that time. i remember the highest skill is mining, which i tried very hard to lvl up mining to 40 in order to wield and use rune pickaxe. then later my old pc spoil and i get a new P4 1.6ghz with riva tnt64 graphic card.
but shortly after that RS2 become public, and i was shock to login and need to 'makeover' myself again and to see that i lost my items in classic because items cannot co-exist in both. that time there are many ppl wanted jagex to let them get back their items from RS2. so Jagex make a deal that it is 1 way shot for anyone who want it. that time i almost want, but thinking that RS2 is partial 3D is cool although. and that time i started to play few more hours per weeks.
since each time technology power is double, my pc that always low end, there is always lag. so it explain my total levels after 10 years.
it can still go on and on and on, but this should cover about the first 3 years of RS.
The game has changed indeed. What's your objective in Runescape (as in everyone who bothers to read my post and care to put a reply to it)? I wonder.
So, all melee weapons are overpowered, at least.


November 1, 2010 — The National Committee for Quality Assurance (NCQA) announced in October that the Palmer Academic Health Center and the Campus Health Center clinics on Palmer College of Chiropractic Davenport, Iowa campus have received recognition from the Back Pain Recognition Program (BPRP) for providing superior care to clinic patients suffering from low back pain.
According to the NCQA registry, these Palmer clinics and their respective faculty clinicians are the only healthcare facilities and providers in Iowa to receive BPRP recognition.
The Back Pain Recognition Program was designed to improve the quality of care to the nearly 30 million Americans who experience low back pain, by motivating healthcare providers to deliver high-quality care and service.
To receive recognition, the two on-campus Palmer Chiropractic Clinics were required to pass a rigorous, comprehensive review of several key clinical measures demonstrating quality healthcare delivery and service. These measures include appropriate imaging for acute back pain, recommendations for exercise and attention to health risk factors, among many others.
Back pain is among the most common ailments in America. Each year, nearly one in nine Americans experience pain severe enough to impair their usual daily activities.
Treatment costs total approximately $91 billion a year and back pain accounts for 25 percent of all workers' compensation claims.


1. Ignore opening and dosing money and financial institution balances showing in receipts and funds account.
2. Get rid of all objects of capital receipts and funds.
three. Verify earnings of the related yr by deducting from the entire receipts the earnings acquired on account of earlier and future years and by including the earnings accrued due within the yr however not acquired and earnings acquired within the earlier yr however referring to this yr.
four. Verify expenditure of the related interval by deducting expenditure each referring to previous interval and succeeding interval from the entire funds and by including the expenditure excellent on the finish and expenditure pay as you go to start with.
5. Make changes, as per further info, akin to depreciation, unhealthy money owed and so forth., if any.
6. The earnings and expenditure account, when balanced, will disclose surplus (if the credit score facet is greater) or deficit (if the debit facet is greater). If surplus i.e. extra on earnings over expenditure add it to the capital or accrued fund. Nonetheless, if deficit i.e., extra of expenditure over earnings deduct it from the capital or accrued fund.
"Receipt" means whole money acquired through the present yr. However "earnings" means whole earnings earned for the present yr.
1. Any money acquired in considered receipt.
2. It isn't confined to any accounting yr. In different phrases, it could embrace money acquired for any year-past, current or future.
three. It might be of each capital and income nature.
four. In case of receipt, money will increase equal to quantity of receipt.
5. An merchandise cannot be referred to as "receipt" except equal amount of money acquired.
6. It's recorded on debit facet of money ebook.
7. It isn't included in ultimate accounts. In different phrases, it isn't thought-about in figuring out the results of concern.
1. Any money acquired mayor is probably not considered earnings. Money acquired for present yr is regarded solely as earnings.
2. It's confined to present accounting yr solely.
three. It's of income nature solely.
four. In case of earnings money could not improve equal to the quantity of earnings.
5. An merchandise could also be "earnings", regardless that money has not been acquired.
6. It's credited to earnings and expenditure account.
7. It have to be thought-about in ultimate accounts.
Cost means whole money paid through the present yr. However expenditure means whole bills incurred for the present yr solely.
1. Any money paid in considered funds.
2. It isn't confined to any accounting yr, i.e. it could embrace money paid for any year-past, current or future.
four. In case of fee, money decreases equal to quantity of fee.
5. An merchandise cannot be referred to as "fee" except equal amount of money is paid.
6. It's recorded on credit score facet of money ebook, i.e. credited to money account.
1. Any money paid mayor is probably not considered expenditure.
four. Money mayor could not lower equal to the quantity of expenditure.
5. An merchandise could also be "expenditure" regardless that money has not been paid.
6. It's debited to earnings and expenditure account.
GEICO Careers – How Can I Pass The GEICO Employment Test?
© TermLifeInsurance7.com. 2009-2017. All right reserved.


IPTC creates and maintains sets of concepts – called a controlled vocabulary or a taxonomy – to be assigned as metadata values to news objects like text, photographs, graphics, audio and video files and streams. This allows for a consistent coding of news metadata across news providers and over the course of time – that's the reason why we call them IPTC NewsCodes.
What can NewsCodes be used for?
For the news industry – but also far beyond – it is a strict requirement being able to assert something about the content of a news item, to apply so called metadata. This could be achieved either by free-text human language (e.g. by a headline or a caption) or by codes, NewsCodes. Codes have the advantage that they can be easily shared among users and as each code requires an explicit and comprehensive definition not only the codes but also their semantics can be shared among users. Further NewsCodes are language agnostic, thus the code is the same for describing content in different languages, only the definition of the code should be translated to help with understanding its semantics.
Why so many different sets of NewsCodes?
As the world is only one single big object all codes could be put into a single vocabulary. But such a vocabulary cannot be managed in an efficient way. For that reason the IPTC decided to group concepts of the same type in a specific controlled vocabulary. Each vocabulary has a description of its scope.
Can NewsCodes be used free of charge?
Yes, they can. Any NewsCode provided by the IPTC can be used at any stage of a news workflow without any royalty fee. But if one includes IPTC NewsCodes into an application the intellectual property and the copyright of the IPTC must be explicitly included.
How to view and retrieve NewsCodes?


From the White House's Rose Garden, President Bush advocates for the Emergency Economic Stabilization Act of 2008 as a response to the 2008 housing crash.
A short time ago, the House of Representatives passed a bill that is essential to helping America's economy weather the financial crisis. The Senate passed the same legislation on Wednesday night. And when Congress sends me the final bill, I'm going to sign it into law.
There were moments this week when some thought the federal government could not rise to the challenge. But thanks to the hard work of members of both parties in both Houses -- and a spirit of cooperation between Capitol Hill and my administration -- we completed this bill in a timely manner. I'm especially grateful for the contributions of Speaker Nancy Pelosi, Minority Leader John Boehner, Majority Leader Steny Hoyer, Minority Whip Roy Blunt, Chairman Barney Frank, Ranking Member Spencer Bachus.
By coming together on this legislation, we have acted boldly to help prevent the crisis on Wall Street from becoming a crisis in communities across our country. We have shown the world that the United States of America will stabilize our financial markets and maintain a leading role in the global economy.
A major problem in our financial system is that banks have restricted the flow of credit to businesses and consumers; many of the assets these banks are holding have lost value. The legislation Congress passed today addresses this problem head on by providing a variety of new tools to the government -- such as allowing us to purchase some of the troubled assets, and creating a new government insurance program that will guarantee the value of others. The bill also ensures that these new programs are carried out in a way that protects taxpayers. It prevents failed executives from receiving windfalls from taxpayers' dollars. It establishes a bipartisan board to oversee the plan's implementation.
Taken together, these steps represent decisive action to ease the credit crunch that is now threatening our economy. With a smoother flow of credit, more businesses will be able to stock their shelves and meet their payrolls. More families will be able to get loans for cars and homes and college education. More state and local governments will be able to fund basic services.
The bill includes other provisions to help American consumers and businesses. It includes tax incentives for businesses to invest and create jobs. It temporarily expands federal insurance for bank and credit union deposits from $100,000 to $250,000 -- a vital safeguard for consumers and small businesses. It provides families with relief from the Alternative Minimum Tax, which would otherwise increase taxes for 26 million taxpayers by an average of $2,200.
I know some Americans have concerns about this legislation, especially about the government's role and the bill's cost. As a strong supporter of free enterprise, I believe government intervention should occur only when necessary. In this situation, action is clearly necessary. And ultimately, the cost -- ultimately, the cost to taxpayers will be far less than the initial outlay. See, the government will purchase troubled assets and once the market recovers, it is likely that many of the assets will go up in value. And over time, Americans should expect that much -- if not all -- of the tax dollars we invest will be paid back.
Americans should also expect that it will take some time for this legislation to have its full impact on our economy. Exercising the authorities in this bill in a responsible way will require a careful analysis and deliberation. This will be done as expeditiously as possible, but it cannot be accomplished overnight. We'll take the time necessary to design an effective program that achieves its objectives -- and does not waste taxpayer dollars.
Our economy continues to face serious challenges. This morning, we learned that America lost jobs again in September -- disappointing news that underscores the urgency of the bill that Congress passed today. It will take more time and determined effort to get through this difficult period. But with confidence and leadership and bipartisan cooperation, we'll overcome the challenges we face, return our nation to a path of growth, and job creation, and long-term economic prosperity. Thank you.


text:
Many Charters Not Reporting English-Learners, GAO Finds
By Lesli A. Maxwell — August 15, 2013 2 min read
This post was written by Katie Ash and first published on Charters & Choice.
A recent report from the Government Accountability Office has found that over a third of charter schools in 2010-11 did not report the number of English-language learners in their data collections for the federal government.
About 37 percent of the data collected from charter schools left the field where the number of ELL students was to be recorded blank, the GAO found. And while a blank field could mean that the charter did not have any ELL students, because of the high number of blank fields, the GAO suspects that it is a result of nonreporting instead.
The GAO includes a chart that details the percentage of charter schools, broken down by state, that left the ELL field blank. (Click to enlarge.)
One reason that many charters left the field blank could be definitional, the GAO concludes. The field used to determine the number of ELLs in charter schools asked schools for the number of students enrolled in "English language instruction educational programs." The word "program" was not adequately defined, the report says, which could have led to some of the schools not reporting a number for that field.
However, the field for the number of ELLs in charter schools was not the only field left blank, the GAO says. In fact, some of the charter schools missing ELL counts were also missing data on math and/or reading performance, as well as graduation data, suggesting a broader reporting problem among charter schools.
The GAO report recommends that the U.S. Department of Education conduct a systemic evaluation of data-reporting practices in charter schools to determine the extent to which nonreporting by charter schools happens and to explore the underlying reasons for the nonreporting.
In response, the Education Department said it was putting together a comprehensive directory of all charter schools in the United States, which would help determine the extent of the problem. But the GAO believes that "these efforts are not designed to provide a clear picture of the extent of nor reasons for charter school nonreporting," the report says.
U.S. Reps. George Miller, D-Calif., and Raul Grijalva, D-Ariz., released a letter addressed to U.S. Secretary of Education Arne Duncan urging him to put forward some concrete steps to improve the quality of data from charter schools.
"It is imperative that [the Education Department] have reliable and accurate data for all public schools, LEAs, and states in fulfilling our mission to equitably serve all children and families," the letter states.
Nina Rees, the president and CEO of the National Alliance for Public Charter Schools, and Greg Richmond, the CEO of the National Association of Charter School Authorizers, released a joint statement about the report. The statement notes that the GAO did not find that charters were serving ELLs inadequately and calls on charter schools to work with their state education departments to provide appropriate data.
"We hope that all schools—public charter or traditional public—will take reporting requirements seriously and follow the letter of the law," the statement says.
Lesli A. Maxwell
Managing Editor, Education Week
Lesli Maxwell is managing editor. She also writes The Savvy Principal newsletter.
A version of this news article first appeared in the Learning the Language blog.
School Choice & Charters Letter to the Editor Are NOLA Charters a Mixed Bag?


The newly crowned Let'Er Buck Car Wash is now open and to celebrate, they're offering free car washes.
We are proud to announce the Grand Opening of LEB II in Casper, WY! To celebrate we are providing free washes from now until February 8th at our new wash in Casper. Come on by and check us out.


Pax6 is the best described member of the paired box (Pax) family of genes encoding tissue-specific transcription factors. The Pax6 protein contains paired box and homeobox domains with DNA-binding activities, and a Pro/Ser/Thr-rich C-terminal domain with transactivation function. Pax6 is a transcription regulator important in the development of the eyes and other sensory organs, the nervous system, and other homologous tissues derived from the ectoderm. Pancreatic development also depends on Pax6, and Pax6 is used as a marker for pancreatic endoderm when inducing differentiation of stem cells.
Expressed in E. coli and purified using IMAC column purification.
Storage: Store at -80 °C.
Size: 22.8 kDa (AA 1-209).
Each Lot has been verified to meet quality specifications in accordance with testing guidelines. We will replace the product if it does not conform to specifications. Product guaranteed for 6 months from date of purchase if stored as directed. This product must not be resold without written permission from Primorigen Biosciences.


Intermittent rain on a Sunday morning. Spring emerging in the countryside. Kim comes along for the sightseeing, conditioned on accompanying her for some shopping a bit later.
From his recent travels, Herman sends along this iPhone sighting of one of our favorite Porsches of the current generation.


Join us for a Walkabout in downtown Spartanburg (destination to be determined). We will get together and talk a bit about Weegee (Arthur Fellig, the original street photographer) and what he did to make street photography the thing that it is now. After a discussion on street photography, ethics and courtesy, we can start. Each person will be issued 2 rolls of Black and White film before we go off shooting. Afterwards, the completed rolls will be picked up for film developing, scanned and printed into a personalized 6×6 photo book. You will then be entered into a photo contest to win.
Train Day is an event for kids of all ages who love trains. The museum and caboose will be open to the public. See artifacts of the railroading, textile, and peach industries from the Spartanburg area. Learn about the Advanced Train Control System. Operate Thomas the Tank layout, enjoy bounce house rides on a trackless train. New this year is a train and airhorn trailer.


text:
Q: Scanner + System.in stop condition I'm reading a file with Scanner + System.in. My command in Linux looks like:
cat -A test.txt | java -jar test.jar

I'm reading input like:
Scanner input = new Scanner(System.in);

    while (input.hasNextLine())
    {
        String log_line = input.nextLine();
    }

The question is.. How I can stop reading when the end of file is reached?

A: The problem is that System.in never "ends", i.e. EOF is never sent to the stream, so hasNextLine() after the last line is blocking waiting for more data.
The solution is to pass the file name to your app, than you open FileInputStream(filePath) and use it in Scanner constructor.

A: It seems that problem is -A option, not Your java code (it works correctly on plain files):
$ echo -e "foo\nbar" | java -jar Test.jar
foo
bar
$

Maybe test.txt contains some non-printable chars that Scanner can't handle...

redpajama_set_name: RedPajamaStackExchange


* Tank Cleaning Supercargo Services for Chemical Tankers, Product.
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* Tank Cleaning advice and recommended tank cleaning procedure.
We Provide experienced Riding squads for tank cleaning purposes at very economical rates.
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* We provide professional tank cleaning supervision on a 24 hour basis. We have supervisors on Stand-by ready to join vessels world-wide. Highly qualified tank cleaning supervisors, with many years of experience. Ensure fast and efficient cargo change over-thereby saving time and money. Minimises the risk of being rejected for next cargo. Experience with typical problem areas in tanks. Avoid problems with special cargo change overs that are rarely/seldom performed.
* Attractive Cost/Benefit on Tank Cleaning Supervision Being rejected by the surveyor a few hours before taking the next clean Cargo is bad business. In that connection an investment in a professional Tank Cleaning Supervision will save you a lot of money and help you keep focus on the main business.
When it comes to chemical tank cleaning due to a special cargo changeover, like changing from for instance heavy instance Heavy Fuel oil to Light Marine Gas Oil or other CPP cargoes, we have experienced that many officers and crewmembers have Very little experience.
Tough market competition demands high focus on other operations than tank cleaning from officers and crewmembers onboard Focus on cargo operations systems, loading and discharging the cargoes and being efficient when sailing vessels from port to port.
Special cargo changeover does not take place often and therefore nobody onboard should be blamed for their lack of experience. Actually we often see the most qualified officers calling for supervision as they previously have experienced the benefit of professional assistance – and the difference it makes.
In that kind of Chemical tank cleanings it is necessary to get the cargo tanks and cargo pipe line systems cleaned properly, fast and in time The experienced Supervisor secures that the cleaning is carried out in the right way, using the right equipment and in the quickest possible time to secure that the vessel for sure will be passed by the surveyor as suitable for loading the next clean cargo.
When considering whether supervision is necessary or not, it should be calculated that the costs of having supervisor onboard during such costs of having a supervisor onboard during such special tank cleaning operations at sea in most cases are less than the costs of just half a days delay of the vessel. A serious delay is certain if she is rejected by the surveyor as knot being completely suitable for the next cargo and additional cleaning must be done first.


WeddingWire World 2016 tickets are now on sale, and we are excited to officially announce our first round of top rated speakers – all back by popular demand!
Join us February 9-11th, 2016 in Washington, DC for three days of top education to grow your business. Don't miss out on your chance to participate in all the new presentations, networking opportunities, and fun surprises we have in store!
Check out the WeddingWire World 2016 website and announcement blog post for more details and additional confirmed speakers. Plus check back soon for new speaker announcements, agenda updates and more!
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« Attention DJs: Don't Miss The 2015 Las Vegas DJ Show!


text:
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You always have the choice to experience our sites without personalized advertising based on your web browsing activity by visiting the DAA's Consumer Choice page, the NAI's website, and/or the EU online choices page, from each of your browsers or devices. To avoid personalized advertising based on your mobile app activity, you can install the DAA's AppChoices app here. You can find much more information about your privacy choices in our privacy policy. Even if you choose not to have your activity tracked by third parties for advertising services, you will still see non-personalized ads on our sites and applications.
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- Richard Morgan
Richard Morgan
Kyle Cheromcha @cheromcha
Kyle is the West Coast Editor for The Drive. He recently relocated from New York to Los Angeles, and he still can't figure out how anyone gets any work done out here.
There are no do-overs in life, and few things exemplify that more than the Plymouth Prowler. The nouveaux hot rod was supposed to be a daring sequel to the howlin' Dodge Viper when it launched with great fanfare in 1997. It was one of the wildest designs to ever sneak past the bean counters at a major manufacturer—and saddled with a gutless V-6, it never had a chance. The Prowler stumbled out of the gate. Four years later, Plymouth was dead.
That's the real tragedy of the Plymouth Prowler. History is littered with the husks of good cars felled by a few bad decisions, but the Prowler is confounding in how close it came to greatness. The hard part of building a modern homage to a Thirties hot rod shouldn't be deciding whether or not to stick a giant engine in there. That's a non-negotiable. Why go 95 percent of the way with a wild exterior, then give it a V-6 from a Dodge Intrepid and call it a day?
More from TheDrive
It's one of history's great mistakes. And it's finally being fixed at a small shop in Tusla, Oklahoma, where they're making the world's first Hellcat-swapped Plymouth Prowler. The six-person team at Brand New Muscle Car is known for cranking out beautiful continuation Yenko Camaros, Eleanor Mustangs, and bringing all manner of midcentury American classics back to life. The Prowler was never high on their list, but when a valued client asked about building one with a modern V-8, it seemed like worthy challenge.
"We've done some oddball stuff before, so it wasn't out of our realm. But it's definitely the most outrageous thing yet," Richard Morgan, head of Brand New Muscle Car's mechanical department, told The Drive. "We're talking 700 plus horsepower in this thing."
The year-and-a-half process, periodically hinted at on their Facebook page, has been far more involved than your average swap. In addition to its wimpy 253-horsepower engine, the Plymouth Prowler also featured a curiously fragile rear transaxle setup that's been known to crumble in the face of a massive power bump. That wouldn't have been a big problem as the project was first conceived: a car show cruiser with a third-generation Hemi and a dummy blower sitting on top.
But the build took a hard turn last fall when Mopar unveiled a crate version of the famed 6.2-liter supercharged Hellcat engine, which puts out 707 horsepower and 650 pound-feet of torque. Ordering one was a no-brainer; getting it to fit in the Prowler's narrow nose required extensive modifications to the headers, fuel and cooling systems, as well as a completely custom radiator. But the block itself slips in there with surprising ease and all ancillary systems like air conditioning and power steering will work as intended. As Morgan put it, "Now it has enough power to hurt itself."
As everything started to come together this summer, the client authorized converting the Prowler to a traditional RWD layout with a new, stronger transmission attached directly to the back of the motor—in this case, a two-speed Powerglide often used in drag cars. Meanwhile, the rear axle will be replaced with a Getrag limited-slip differential and sticks from a 2013 Dodge Challenger SRT8. Morgan said that with a few tweaks to the firewall, there's actually plenty of room behind the dashboard to put the gearbox up front.
Tight fit. - Richard Morgan
Tight fit. Richard Morgan
For now, the plan is to retain the original interior in all its plastic glory, right down to the stock shifter. The Prowler Purple Metallic paint job and original alloy wheels will also remain untouched, making it something of a sleeper (if that can be said about a car that looks like this regardless). The only hint that this Prowler is a truly sinister one will be a different hood, since the supercharger pokes up through the stock clearance by about an inch. Brand New Muscle Car hasn't settled on a final design for the accommodating scoop. Oh, and the unfortunate front bumpers are also going.
Those mechanical changes should make the Prowler strong enough to handle the fire within. Morgan estimates the Hellcat engine adds about 260 pounds up front, which he partly offset by seating the block as far back as possible and moving the battery to the trunk. With a new curb weight of around 3,100 lbs, Morgan told us it some napkin math has the thing running a quarter mile in the 9's at 160 mph. He's not sure the wheels would actually hook up properly, or if the Prowler's aero is designed to handle those speeds, but he's confident that the end result will be a mid-ten-second car "all day."
Of course, it will never see an NHRA-sanctioned drag race, since it's still a convertible with zero rollover protection. Morgan said they discussed adding a rollcage but opted against it because it would require a complete teardown. Plus, even with a two-speed transmission, the Hellcat Prowler is being built as a potential daily driver rather than a drag strip star. A 3.06 rear axle ratio means it'll be able to cruise down the highway without working itself to death, Koni shocks will help keep everything settled, and the fully-functional interior will make it as livable as a late-90's Chrysler product can be.
As it sits now, Morgan plans to have the car done in time to display at this year's SEMA show in December. There are still a few kinks to work out between the Hellcat's computer and the factory instrument panel, but things are progressing. With parts arriving this week, the rear axle surgery is imminent—soon after that, everything will be hooked up for the first test drive. The world is this close to finally seeing what the Prowler was supposed to be from the beginning. And Morgan? He's not worried.
"I've been thinking about this for eight months. I've got three backup plans for everything," he said. "Next week, we're really gonna see what we're dealing with."
Rest assured, we'll be watching. It's not every day you get a do-over like this.
The man is ready. - Richard Morgan
The man is ready. Richard Morgan
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