Wednesday, April 9, 2014
For the 11th consecutive year, Genworth has released its national survey results for long-term care costs, including statistics for nursing home care, assisted living facility care, adult day health care, home health aide services, and homemaker services. The survey draws upon information from more than 14,800 providers in 440 regions nationwide.
Genworth's 2014 information is offered in several formats, including:
- Key Findings
- Full Report
- State-by-State Statistics (with an interactive map, including search-by-region function)
In addition, and not surprising given that Genworth is an insurance company, the website offers planning guidelines, explaining the role for long-term care insurance.
Thursday, April 3, 2014
That's a frequent paper topic proposal for students in my Elder Law course, and one that usually triggers a conversation about the potential for "ageism." I remind students it will be important to provide evidence in support of their proposals, and not simply recount anecdotes about bad older drivers.
But, in truth, there is plenty of data to identify risks associated with older driving, as suggested by Elder Law Attorney Robert Fleming on his great Blog, citing statistics from the Center for Disease Control about risks for "fatal" accidents over age 75. See "Driving, Aging and Dealing with Family Dynamics."
ElderLawGuy Jeff Marshall takes a very personal look at his own driving future on his Blog, and uses that moment of self reflection to also examine strategies for encouraging older drivers to give up the keys. Read "What to Do When Dad Shouldn't Be Driving."
This is another area of "social policy" where the laws are not uniform on how to intervene when the older driver refuses to stop driving or to make other appropriate adjustments in when and where to drive. Here is a link from the insurance industry's Claims Journal to a recent "State by State Look at Driving Rules for Older Drivers."
And, for a somewhat more theoretical approach to the topic, from University of Miami Law Professor Bruce Winick, the always thoughtful guru of the therapeutic jurisprudence movement, see "Aging, Driving and Public Health: A Therapeutic Jurisprudence Approach." Professor Winick proposes creation of community-based "safe driving centers," as a means of encouraging impaired drivers "voluntarily to cease or restrict their driving by offering inducements and alternative transportation solutions."
And of course, we have Professor Becky Morgan's preferred solution, the Jetsons' car that drives (and parks) itself. Read "New Study on Autonomous Cars."
Wednesday, April 2, 2014
Via the Alzheimer's Association:
We have known that women are the epicenter of Alzheimer's disease - making up the majority of both people living with the disease and caregivers. Not only are 3.2 million women living with Alzheimer's, women are also at the epicenter of caregiving for someone with the disease. The Alzheimer's Association's new 2014 Alzheimer's Disease Facts and Figures report shows women have a 1 in 6 chance of developing Alzheimer's, while men have a 1 in 11 chance. As real a concern as breast cancer is to women's health, women in their 60s are about twice as likely to develop Alzheimer's over the rest of their lives as they are to develop breast cancer.
A new Alzheimer's Association women's initiative has launched in conjunction with the Facts and Figures report. Realizing the impact Alzheimer's has on women - and the impact women can have when they work together - we ask women to share why their brain matters and how they can use it to end Alzheimer's at alz.org/mybrain.
University of Oklahoma Professor of Law Jonathan Barry Foreman writes on "Supporting the Oldest Old: The Role of Social Insurance, Pensions, and Financial Products," for the Elder Law Journal in 2014.
He points to "longevity risk," defined as the risk of outliving one's retirement savings, as "probably the greatest risk facing current and future retirees" in the U.S. As several recent studies demonstrate, such as those cited on the Elder Law Prof Blog here, here and here, many people are not adequately prepared in terms of finances for retirement.
In responding to this risk, Professor Foreman writes thoughtfully, proposing systemic alternatives, including expansion of Social Security and SSI for "the oldest old." Professor Foreman suggests 90 years of age as the starting point for that category. In addition he proposes greater incentives for public and private employers to promote annuities and other "lifetime income products" as components of employment-based retirement packages.
He concludes with a warning based on our national history of frequently failing to make significant changes in advance of a predictable crisis:
"Social insurance programs like Social Security, Supplemental Security Income, and Medicaid will certainly need to be expanded. Workers will also need to be encouraged to work longer and save more for their eventual retirements, and both workers and retirees should be encouraged to annuitize more of their retirement savings.
While these kinds of solutions seem fairly predictable, the answers to two important policy questions have yet to be decided. First, how much will the government require the oldest old to save earlier in their lives? And second, how much will the government redistribute to benefit the oldest old? Unfortunately, if the history of the Social Security system is any indication, both government mandates and redistribution will be modest, and a significant portion of the oldest old will face their final years with inadequate economic resources."
Reading Professor Foreman's tightly focused paper suggests to me that there is, perhaps, a certain irony to all of this. The irony is that by not embracing systemic change, Americans are engaging in a form of financial roulette, betting we won't live long enough to care about the outcome of our gamble.
Wednesday, March 19, 2014
Every 67 seconds someone in the United States develops Alzheimer's disease. More than 5 million Americans are living with the disease. Learn the facts. Help wipe out Alzheimer's disease.
Saturday, January 18, 2014
New report from SSA's Office of Retirement and Disability Policy addresses SS, SSI participation rates by African Americans
African Americans: Description of Social Security and Supplemental Security Income Participation and Benefit Levels Using the American Community Survey
Patricia P. Martin and John L. Murphy
Research and Statistics Note No. 2014-01 (released January 2014)
Intro/summary: African Americans encounter significant economic disadvantages, making them a critical focus for social insurance programs. Examining how the African American population uses Old-Age, Survivors, and Disability Insurance (OASDI, or Social Security) benefits and Supplemental Security Income (SSI) payments clarifies the role these programs play in supporting at-risk populations.
Earlier research has explored various facets of the relationship between Social Security and African Americans. For instance, many studies investigate African Americans' low retirement benefit receipt rates relative to whites (Abbott 1977, 1980; Thompson 1975; Huntley 1979; Parsons 1980; Gibson 1987, 1991, 1994; Farley 1988; Hayward, Friedman, and Chen 1996; O'Rand 1996; Gendell and Siegel 1996; Choi 1997; Hendley and Bilimoria 1999; Gustman and Steinmeier 2004; Bridges and Choudhury 2007, 2009; Favreault 2010). Others examine the prominent role of children's benefits for African Americans (Newcomb 2003/2004; Tamborini, Cupito, and Shoffner 2011). This analysis contributes to that body of research by using a relatively new, publicly available, and comprehensive data source, the American Community Survey (ACS), to document the demographic and economic characteristics of African American OASDI beneficiaries and SSI recipients. It is designed to lay the groundwork for future detailed analyses of how African Americans interact with Social Security and related programs.
In this note, we first discuss the strengths of the ACS and the methodology of this analysis. Next, we present the demographic and economic characteristics of the African American population in the 2009 ACS. Then, we present ACS data on OASDI and SSI participation and benefit levels, comparing African American participants with overall participants in three age distributions: the full age range for which benefit statistics are available in the ACS (15 or older), working age (18–61), and retirement age (62 or older).
Wednesday, January 15, 2014
The Journals of Gerontology (Psychological Sciences and Social Sciences - Series B) for January 2014 arrived on my desk this week. It is a special issue on widowhood and bereavement. An opening editorial by Sociology Professor Gary R. Lee (Bowling Green State University) provides an enticing introduction to "Current Research on Widowhood: Devastation and Human Resilience." He begins:
"As of 2010, there were more than 14 million widowed persons in the U.S. population -- nearly 3 million men and well more than 11 million women (U.S. Bureau of Census, 2012 Table 57). About 13% of men and about 40% of women aged 65 and older, and 57% of women aged 75 and older, are widows. This is, of course, just a single snapshot in time; nearly half of the population necessarily experience widowhood during their lifetimes. The only ways to of avoiding it are to never marry, to divorce and never remarry, or to predecease your spouse....
Over the years, I have noted with interest how many articles on widowhood begin with a citation to Holmes and Rahe (1967) to the effect that widowhood is perhaps the most distressing and difficult experience of people's lives.... But some close scrutiny and some nuanced qualifications may be needed."
After outlining the array of articles in the special issue, Lee concludes:
"We know much more about the consequences of widowhood now than we did when Holmes and Rahe (1967) made their of-cited observations about its devastating effects. It does more than just make people sad; it changes their lives in fundamental ways. But the real story here may lie in the search for the ways in which widows and widowers manage to cope with the loss of their spouses and adjust to the new realities they must face."
The table of contents for the issue is available here.
Friday, January 10, 2014
The earliest signs of dementia are often subtle. It can be tempting and easy to brush them off as merely the signs of fatigue or being overwhelmed. Ironically, at the other end of the spectrum, advanced dementia, it may also be easy to jump to conclusions, believing one diagnosis fits all forms of dementia. The modern assumption is probably most often Alzheimer's, while in earlier decades the label might have been simply "senility."
I often ask a medical or gerontology professional with expertise in the various forms of dementia, including Lewy-Body Disease, Frontotemporal Dementia (FTD), Parkinson's related dementia, vascular dementia, as well as Alzheimer's, to speak to my elder law classes. The lectures are fascinating (okay, also a little frightening). But often, near the near the end of a class discussion, a student will ask, "if there is no cure for dementia, does diagnosis of the source really matter?"
A family's search for answers suggests there are may be very good reasons to pursue a definitive diagnosis, even if the ultimate answer is possible only after the death of a loved one impacted by disease. The Ruhrig Family in central Pennsylvania was perplexed by the symptoms and rapid progress of confusion for the patriarch of their family. Sixty-six year old Weston Ruhrig passed away less than a year after the family first began seeing signs of confusion:
"The 6-2, 210-pounder was up by 7 a.m. daily ... seemed always on the move. In June , he conducted a charity auction for United Cerebral Palsy of Central Pennsylvania, just as he had since 1987. He seemed normal.
But his family began noticing odd behavior. Ruhrig became withdrawn. He continually locked doors, sometimes locking out his wife after she had gone to the yard or garage during daylight. Ruhrig was known for harping on people to turn off lights to save electricity. Now he switched on lights for no reason and left the room.
By September , his family had persuaded him to see his family doctor. The doctor found no medical problems but referred him to a neurologist. Ruhrig felt nothing was wrong. In November, the neurologist gave Ruhrig cognitive tests. Ruhrig named the president and recalled facts including his wife’s birth date. But he couldn’t correctly state her age or calculate it. Still, he joked during the visit."
As carefully detailed by Patriot News writer David Wenner, eventually doctors suggested the problem was Alzheimer's. But the family, contrasting their father's symptoms with those of others they knew with more traditional presentations of Alzheimer's related dementia, persisted in seeking a more precise diagnosis. An MRI was viewed as normal. Another test was a spinal tap. Unfortunately, Mr. Ruhrig died suddenly in December 2013, after a fall that led to a rapid decline.
The diagnosis occurred after his death, based on the results of the spinal fluid analysis: Creutzfeldt-Jakob Disease, a very rare variation of the family of diseases associated with "Mad Cow" and "chronic wasting" in deer, but a form that is not considered to be caused by eating or handling contaminated meat. Deterioration associated with the condition is rapid, usually leading to death within a year, and the cause of the disease is currently unknown, and there are no cures.
But the courage of the family in pursuing and talking about the diagnosis could help others, as better understanding of the various forms and causes of dementia should help the larger community of physicians, epidemiologists and other experts chart the frontiers of dementia. Heredity, life-style, diet, viruses, environmental impacts -- with the help of families, all of these factors and others might better be understood in the search for causes and solutions for the different forms of dementia.
For more, read "Hampton Township Man Dies of Mysterious Disease Sometimes Associated with Mad Cow and Chronic Wasting." Thanks to my colleague, Professor Laurel Terry, for pointing me to this interesting local article.
Tuesday, December 31, 2013
The Consumer Financial Protection Bureau (CFPB) has issued preliminary results on its evaluation of "pre-dispute arbitration provisions," used in many contracts for consumer financial service products, such as credit cards, checking accounts or pay-day loans. Congress commanded the study as part of the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010.
Consumers probably end up viewing these clauses as triggering "mandatory" arbitration, in that consumers typically "consent" by signing agreements without any real understanding of the implications. The report summarizes both pro and con arguments on the use of pre-dispute arbitration provisions.
The study makes strong use of academic research, including recent work by Peter Rutledge (University of Georgia Law) and Christopher Drahozal (Kansas Law), Jean Sternlight (UNLV Law), and my own colleague and friend, Nancy Welsh (Penn State Law).
Much of the CFPB report focuses on what it calls the "front end" of arbitration issues, identifying a host of arbitration-related factors addressed in corporate contracts, such as opt-out rights, arbitrator selection, limits on recoverable damages, time limits for claims, and allocation of costs.
Reading between the lines of the report's preliminary findings, it seems to me to support the view that companies use arbitration as a procedural barrier to consumer challenges, including class actions. At the same time, statistics cited in the report suggest that companies may dispense with arbitration when pursuing collection from defaulting consumers, instead filing suits in small claims courts (the CFPB will address federal and other state court claims in the future).
This seems consistent with what I observed during my 10+ years with Penn State Law's Elder Protection Clinic, where we frequently represented older clients on debt claims. Many of these claims were "old" debts, where our clients had been making minimum payments for years, but were no longer able to keep up with the payments after retirement, particularly if also confronted with new debt from medical crises. I don't recall any of the collection cases being initiated by arbitration. By filing in court, the companies seemed to hope for a low-cost route to default judgments.
The New York Times cites the CFPB study in a recent editorial, calling for a change in laws to permit consumers an effective legal tool when needed to challenge certain corporate practices, pointing out that:
"In disputes over financial products — involving, say, excessive fees, inflated loan balances, faulty credit reporting, or fraud and discrimination — the damages at stake may be significant for an individual but not enough to warrant the cost of a legal challenge unless grouped in a class action. Forced arbitration also fosters abuse, since there is no check on wrongdoing that takes small amounts of money from potentially millions of customers."
The CFPB notes that its December 2013 findings will be followed by a more complete report, expected in 2014.
Sunday, December 29, 2013
Washington Post reporters Peter Whoriskey and Dan Keating use more than ten years of data from California to provide a detailed portrait of hospice, with national implications, concluding that providers are pursuing "healthier" patients to increase their margin. While acknowledging the importance of Medicare-supported hospice for individuals legitimately diagnosed with less than six months to live, the Washington Post article uses survival rates to suggest manipulation of the diagnosis for financial gain:
"[T]he survival rates at AseraCare are emblematic of a problem facing Medicare, which has created a financial incentive for hospice companies to find patients well before death. Medicare pays a hospice about $150 a day per patient for routine care, regardless of whether the company sends a nurse or any other worker out on that day. That means healthier patients, who generally need less help and live longer, yield more profits.
The trend toward longer stays on hospice care may be costing Medicare billions of dollars a year. In 2011, nearly 60 percent of Medicare’s hospice expenditure of $13.8 billion went toward patients who stay on hospice care longer than six months, MedPAC, the Medicare watchdog group created by Congress, has reported."
For the full Washington Post story, itemizing factors contributing to misuse of hospice, see "Hospice Firms Drain Millions from Medicare."
Wednesday, December 18, 2013
A study released in December by the Stanford Center on Longevity addresses one of my frequent concerns. Reports on elder abuse, particularly those on financial abuse and exploitation, routinely include a statement to the effect that "X number of financial fraud cases were examined during the year" but that that more time/money/energy should be devoted to addressing the problem "because X plus Y number of cases exist" but are unreported. There is rarely any explanation for the prediction. While I accept that there is likely to be underreporting, don't we need better measurement tools than intuition?
In "The Scope of the Problem: An Overview of Fraud Prevelance Measurement," Stanford researchers address exactly this issue. "'Without accurate and reliable estimates of fraud,' wrote Martha Deevy, director of the Financial Security Division at the Stanford Center on Longevity, 'it is difficult to understand what works or does not work to protect victims from harm.'" The problem may be not just underreporting, but "underadmitting," especially for victims of elder abuse.
The Stanford report illustrates how analysis of recent sources and methodology can explain variations in predictions, thus also helping to design better tools for the future, including better surveys. For example, they point to the 2011 study of elder abuse in New York State by Lachs & Berman, "notable as a comprehensive endeavor that used multiple sources of data and collaboration among community, governmental, and academic partners to get a sense of the 'big picture' problem."
Thanks to my colleague, Laurel Terry, for sharing this report. Laurel and Howard are the justifiably proud parents of a Stanford sophomore.
Thursday, December 12, 2013
From the University of Michigan Retirement Research Center, a paper on "Older Adult Debt and Financial Frailty" by Annamaria Lusardi (George Washington Univ. of Business) and Olivia Mitchell (Wharton, Univ. of Penn.). The authors compare data from three different time periods to analyze older persons' debt, debt management practices and corresponding potential for financial insecurity. Key findings include:
- Older Americans now on the verge of retirement are more likely to have substantial debt than in the past. "Median debt for those age 56-61 has more than quadrupled, from about $6,200 in 1992 to $28,300 in 2008 (in 2012 dollars)."
- Housing purchased with small down payments and subject to large mortgages are key reasons for higher debt for Boomer retirees.
- Income, level of education, marriage status, race, number of children, health, were also factors identified as affecting risk of financial insecurity after retirement.
One sentence that particularly stood out: "Baby Boomers are more likely to have engaged in expensive borrowing practices."
Wednesday, October 30, 2013
At the LeadingAge annual meeting in Dallas, earlier this week, I attended a round table session hosted by representatives of the Elder Justice Working Group (EJWG), a component of the Elder Justice Coordinating Council (EJCC). The two presenters sought response from the audience, which included individuals from CCRCs, nursing homes, senior housing authorities and other providers of senior living or senior care, to the EJCC's Principles for Action (developed from 9 proposals of the EJWG) aimed at improving national awareness and response to elder abuse, neglect and exploitation.
Here are the first 3 of 9 Principles:
"1. Support the investigations and prosecution of elder abuse, neglect and financial exploitation cases,
2. Support and protect elder victims by improving identification of elder abuse and enhancing response and outreach to victims.
3. Develop a national Adult Protective Services system based upon standardized data collection and a core set of service provision standards and best practices."
For addtional information on recommended federal action, including the other 6 principles, see details reported at the most recent, September meeting of the EJCC.
Our LeadingAge roundtable session focused on practical concerns, including the frustrations felt by some in the room in reporting suspected abuse at a local level, but seeing no response.
I was struck by the very diverse makeup of the individuals choosing to attend a session on elder abuse, both in terms of race and geography, drawing from Maine to Hawaii -- and on to Guam, and thus strongly supporting the EJCC's concerns about nationalized data collection and the need for standardized reporting.
Tuesday, October 22, 2013
With a hat tip to Professor Laurel Terry for sharing this NPR-linked post from Robert Krulwich, check out stats on how American men and woman compare to those in other developed countries in terms of "surviving" to old age. Here's an excerpt, commenting on the trend:
"In 2011, the National Institutes of Health issued a report that tried to make sense of it all. Right away, they found our weak spot. 'U.S. women have relatively high mortality rates at the younger older ages,' they said, which means when women hit their 55th birthdays, for the next almost 20 years, roughly 55 to 75, they will die more often than women in comparable countries. Americans get more lung disease, more heart disease, more diabetes. If Americans reach 75, they get competitive again, but that early old age is where we lose ground. American men showed pretty much the same weakness at roughly the same times.
The authors declared themselves puzzled. 'The relatively poor performance of the United States," they wrote, is "perhaps all the more surprising in light of the fact that the United States spends far more on health care than any other nation in the world, both absolutely and as a percentage of gross national product.'
Tuesday, October 1, 2013
Sweden is the best place in the world to be old and Afghanistan the worst, according to a UN-backed global study. The Global AgeWatch Index examined the quality of life of the elderly in 91 countries. It warns that many countries do not have adequate support in place for their ageing populations. By 2050, older people will outnumber children under 15 for the first time, with most of the elderly in developing countries, it said. The Global AgeWatch Index was complied by the UN Population Fund and advocacy group HelpAge International, and released to mark the UN's Day of Older Persons. Researchers used 13 different indicators - including income and employment, health provision, education, and environment - in what they said was the first study of kind to be conducted on a global scale. The study's authors say countries across the world face an ongoing challenge from the rapidly ageing global population.
Friday, September 27, 2013
Despite modest gains in the economy in 2012, national poverty rates remain virtually unchanged from last year. However, a new study highlights one group that has unexpectedly fallen deeper into poverty: elderly women. Among women 65 and older, the ‘extreme poverty’ rate rose 18% in 2012. Extreme poverty is defined as an annual income of $5,500 or less for older individuals living by themselves. “The cause has to be something that hits elderly individuals particularly hard,” said Kate Gallagher Robbins, a senior policy analyst at the National Women’s Law Center, who conducted the study. ”We also know that poverty for elderly men and women was statistically unchanged so we are talking about a group of individuals who went from being poor to extremely poor.”
The extreme poverty rate for elderly women ticked up to 3.1% in 2012 from 2.6% in 2011. An additional 135,000 elderly women became categorized as extremely poor, bringing the total number of elderly women in extreme poverty to 733,000. Sixty-two percent of elderly women in this group are white, non-Hispanic, 16% are Hispanic, 17% are black, 4% are Asian and 2% are Native American.
The National Women’s Law Center is currently exploring potential reasons for the sudden increase.
“One factor might be cuts in recent years to Social Security Administration funding which may be making applications for [Supplemental Security Income] more difficult,” Robbins wrote in an email to MSNBC.com. “Without Social Security, almost 15.3 million more elderly individuals would have been poor in 2012, yet many policy makers are debating switching the cost-of-living adjustment to the chained CPI which will reduce the value of benefits for current beneficiaries. Clearly these data show that making such cuts would be unconscionable.”
Another cause for the rise in the extreme poverty rate for this group may have to do with unemployment insurance benefits. Since older workers are more likely to be unemployed for longer periods of time, the likelihood that their unemployment insurance benefits expired, or even cut, between 2011 and 2012 is high.
Wednesday, September 18, 2013
In the United States alone, some 23,000 people die each year from infections casued by bacteria that are resistent to antibiotics. That's just one important statistic from the report released this week by the Centers for Disease Control and Prevention (CDC). Antibiotic resistant infections can affect any age, but why is this also a major "elder" issue? Becaue nursing homes and hospitals -- and their residents or patients -- are on the front lines of the battle with resistaint strains. For more on the chilling history and the CDC's call for action, see here.
The CDC website is a great source for information on Healthy and Safe Aging, including video segments useful to spark class discussions.
Update: The CDC report and measures to control overuse of antibiotics will be the topic of a panel discussion on The Diane Rehm Show on public radio on September 18, 2013.
Friday, August 30, 2013
NBC's Today Show featured Edythe Kirchmaier, who at 105+, uses her humor and upbeat personality to banter with talk show hosts and interviewers. She redefines the meaning of "spry," recently passing the test to renew her driver's license, after more than 85 years without so much as a parking ticket, much less a driving violation. Best of all, she's celebrating 40 years of volunteer service at Direct Relief International, calling it her second home.
Edythe is an important part of the national economy. Seniors contribute huge numbers of volunteer hours, with rates of older volunteers increasing over the last several years. One study reports:
"The proportion of older adults who volunteer 100 or more hours a year is 46 percent higher today than in 1974. Today, 46.1 percent of older adults volunteer 100 or more hours a year while 31.6 percent of older adults volunteered 100 or more hours in 1974."
Wednesday, August 28, 2013
The first day of class, I give my students the U.S. Census Bureau's "Global Aging Quiz". It's a great way to get them thinking about the kinds of issues raised by demographic aging. I use the quiz to provide a context for my introduction to elder law (Chapter 1 of my casebook)...and to get them used to the idea of interactive discussion and participation. It works--kind of.
Access the quiz via U.S. Census Bureau (Kinsella, et al.) An Aging World (2009) (pp. 5-6).
Wednesday, August 21, 2013
Since my 2010 Fulbright sabbatical in Northern Ireland, I've become more attuned to research resources outside of the U.S. That's what sabbaticals should do, right? Broaden our professional horizons!
One of the sites I find useful is the International Longevity Centre in the U.K., which is known as a think-tank seeking to impact policy on longevity, ageing and population change. Plus, it is always fun to try to remember where I am on the U.S./Britain "divide" on proper spelling of key terms such as aging or ageing!Here are a few interesting statistics featured in the ILC's recent “Factpack”:
- At 12.2 million, the number of pensioners in the UK is equivalent to the combined populations of Finland, Latvia, Lithuania and Estonia.
- One third of babies born in 2012 in the UK are expected to survive to celebrate their 100th birthday.
- Health Life Expectancy at birth is 63.5 years for men and 65.7 for women. Increase in life expectancy is currently outstripping the increase in HLE.
- Spending on long-term care is projected to rise by around £14bn by 2061/62.
- In June 2013 there were over 1 million workers over the age of 65 in the UK – the highest since records began.
- 28% of those aged 75 and over have internet access in their home. 3% of over 75s own a smart phone.
How would statistics compare in your state or country? Feel free to add your comment below.