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a Braceland Center for Mental Health and Aging, Institute of Living, Hartford Hospital's Mental Health Network, Hartford, CT, and Department of Medicine, University of Connecticut Health Center, Farmington
Correspondence: Leslie Curry, PhD, MPH, Director, Braceland Center for Mental Health and Aging, 400 Washington Street, Hartford, CT 06106. E-mail: lcurry{at}harthosp.org.
Laurence G. Branch, PhD
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Key Words: Long-term care financing • Nursing homes • Social norms
Medicaid, a federal-state means-tested health insurance program for the poor, is the largest single payor of nursing home services and other long-term care. In 1997, Medicaid financed 47% of the $83 billion in nursing home expenditures (Kaiser Commission on Medicaid and the Uninsured 1999
). Medicaid benefits are available only to those who meet specific income and asset standards set by each state and who are determined to be poor in accordance with these criteria. (In Connecticut, e.g., assets cannot exceed $1,600 for individuals and $2,400 for couples to qualify for Medicaid; a house is not counted as an asset in most instances.) Current federal and state laws prohibit the transfer of property or financial assets for the purpose of qualifying for Medicaid, if the transfer was done during the 36 months preceding the application for Medicaid.
Medicaid estate planning (MEP) involves legal and financial approaches to satisfying financial eligibility requirements for Medicaid coverage for nursing home care. More specifically, an individual's assets are sheltered with the intention of precluding consideration of such assets in determining Medicaid eligibility. Despite the continuing interest in understanding MEP and its impact on Medicaid expenditures, only a few empirical studies have quantified its magnitude and associated implications for the Medicaid program expenditures (General Accounting Office 1989, General Accounting Office 1993, General Accounting Office 1997; Office of the Inspector General 1989). Available evidence indicates that the incidence of MEP is low (Wiener 1996; Taylor et al. 1999), although some observers disagree (Moses 1990). There is wide variation in the level and nature of MEP activities across states because of state-specific legal, socioeconomic, and health service factors (Burwell and Crown 1996). On the whole, evidence regarding MEP prevalence is inconclusive and varies in terms of both methodology and findings. The disparate perceptions among elder law attorneys, Medicaid eligibility workers, and certified financial planners as to the magnitude of MEP (Walker, Robison, and Gruman 1998) suggest that it is essential to gather primary data from individual applicants and their families.
The limited research on MEP has examined outcomes (estimated magnitude and prevalence of transfers) rather than the process itself (timing and motivations behind decisions to transfer assets). No prospective longitudinal studies have assessed the relationship of individual expectations to the transfer of wealth for the purpose of accessing Medicaid. The Health and Retirement Study (HRS) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) study are the first two major national studies designed to gather the type of longitudinal data necessary to explore multiple aspects of health and family transitions and their impact on wealth transfer (Dunn and Phillips 1997; McGarry and Schoeni 1997; Soldo and Hill 1994). The AHEAD project will allow for tracking of episodes for Medicaid eligibility and how these episodes relate to health dynamics and intergenerational transfers. Future waves of the study will more closely examine asset transfers and relationships to family structure, perceptions of need and actual behavior. However, data are presently unavailable to address these questions (Soldo, Hurd, Rodgers, and Wallace 1997).
A variety of system-level factors may influence an individual's participation in Medicaid planning activities (Burwell 1991; Walker and Burwell 1998). Federal and state Medicaid eligibility policies have a strong influence on Medicaid planning, including the complexity of financial eligibility rules and requirements for impoverishment. Costs and quality of nursing home care are also important considerations. Estate recovery policies, which allow the government to retroactively recover costs that have been paid by the public on behalf of Medicaid long-term care recipients, are hypothesized to play a critical role in MEP. Evidence suggests there is great variability among states in applicable state law, financial impact, and implementation (Office of the Inspector General 1995; Sabatino and Wood 1996). Finally, the diligence with which local Medicaid eligibility offices enforce regulations may influence individual behaviors in Medicaid planning (Walker and Burwell 1998).
Individual- and social-level factors that may motivate Medicaid planning have not been examined empirically. However, relevant considerations such as moral hazard, welfare aversion, and bequest motives in the context of long-term care have been explored, primarily in the economics literature. Moral hazard occurs when the existence of a given entity (such as public payment for health care) creates perverse incentives that lead to unintended or undesirable effects. Because most long-term care is provided by family, lower nursing home costs may encourage families to abandon caregiving at taxpayers' expense. The results of one study suggest there is no moral hazard for nursing home care (Reschovsky 1998). Qualifying for Medicaid does not appear to be a major reason for creating trusts; rather, factors significantly related to trust formation include wealth, White race, and higher education (Taylor, Sloan, and Norton 1999). Evidence on welfare aversion suggests people go to great lengths to avoid becoming recipients of Medicaid, even receiving transfer payments from children or liquidating housing assets (Crown, Burwell, and Alecxih 1994; Norton 1995).
Protection of a family estate to ensure inheritance for the children has been described as a central value in our society (Hill 1995; Kane 1996; Langbein 1991; Moody 1995) and may be a primary motivation for MEP (Walker, Gruman, and Robison 1999). Bequest motives to explain intergenerational transfers have been described through altruism (McGarry and Schoeni 1995) and exchange models (Cox 1987). Empirical evidence as to the relative contribution of each is mixed. Altruism and parental concern for children has been most commonly proposed, although some research on bequest motives and patterns challenges this notion (Laitner and Juster 1996; Tachibanaki 1994; Wilhelm 1996). Exchange theory models maintain that transfers are a form of exchange based on a risk-sharing arrangement in which parents transfer assets and expect support from children if they live longer than expected (Cox 1987). Finally, the notion of generativity has been offered as a motivation for bequests (Alexander, Rubenstein, Goodman, and Luborsky 1991). No theoretical framework for MEP has been proposed in the literature.
This research was a direct outgrowth of previous quantitative and qualitative work examining the prevalence, magnitude, and policy responses to MEP from the perspectives of lawyers, financial planners, and policymakers (Walker and Burwell 1998; Walker et al. 1998, Walker et al. 1999). These studies raised new questions about individual-level and system-level motivations for MEP. In the research reported here, we sought to examine MEP from a perspective not yet explored—that of older individuals and their caregivers living in the community, who may be planning for how to finance nursing home care in the future.
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) or confirmatory (Miles and Huberman 1994) in nature. Investigators commonly use focus groups to discover more about a topic for which understanding is limited (Stewart and Shamdasani 1990) and that involves personal and social constructs (Kuzel 1999). Eighteen focus groups of 5–12 members each were conducted. Groups were stratified on the basis of race/ethnicity/socioeconomic status (SES), previous use of nursing home and/or home care services, and caregiver status (see Table 1 ). These strata were developed on the basis of a priori evidence that suggests such factors may play a role in MEP.
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). For this study, it was important to have group members share an experience to facilitate exchange of views, strengthen the group interviewing process, and achieve compatibility among group members (Morse 1995). Hence, we used the homogeneous method to enhance discussions about responsibility for financing long-term care generally and MEP specifically. Each group was uniform with regard to race/ethnicity and experience with long-term care (i.e., all White or all African American; all using, not using, or caregivers). SES levels were somewhat mixed in three groups, again because such data were not included in the screening process in advance of the session. The sessions were approximately 1.5 h in length and were conducted in locations both familiar and accessible to participants. A monetary incentive of $25 per person was provided. The study was approved by the Institutional Review Board of Hartford Hospital.
Instrumentation
A series of 11 guiding questions with structured probes was developed by a multidisciplinary team, including a sociologist, an anthropologist, an epidemiologist, two state policymakers, and two gerontologists. The guide was also reviewed by a panel of long-term care consumers and advocates for comprehensibility and scope (the Connecticut Lifelong Care Community Advisory Board). The team designed the questions to stimulate discussion on (a) individual plans to pay for nursing home care, (b) attitudes toward government and familial responsibilities in paying for nursing home care, (c) views on MEP, and (d) attitudes toward rights to material legacy and inheritance. This report of findings focuses on the discussions most germane to MEP. Additionally, to characterize the groups, we asked participants to complete a seven-item structured questionnaire gathering sociodemographic information. Questions included age, gender, marital status, education, living arrangements, monthly household income, and total assets. No personal identifiers were used, because data were to be reported in the aggregate (by focus group), and anonymity was promised.
Data Analysis
We made an audiotape for each session to allow for clarification of points and preparation of transcripts for analysis. Recorded data were formatted as a single transcript per session and imported into QSR NUD*IST 4.0 software for sorting, coding, and analysis. The code structure was reviewed twice by the research team and an external expert (Research Talk) for verification. Refinements were made at each review and during the analysis process on the basis of interpretative observations (Crabtree and Miller 1999). As transcripts were coded, recurrent themes were noted and text was clustered under these themes in accordance with the constant comparative method (Glaser and Strauss 1967) until no new themes emerged.
Systematic, verifiable analysis of the focus groups was accomplished through a number of strategies, including consistent use of the discussion guide, audiotaping and independent professional preparation of the transcripts, standardized coding and analysis of the data, and creation of an analysis audit trail to document analytic decisions (Kirk and Miller 1986; Miles and Huberman 1994).
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Losing Control of Assets
One of the issues consistently identified was the fear of losing control of one's assets. This concern was expressed among groups across each of the SES levels, as well as experience with long-term care groups. In some cases, the concern was general in nature, whereas in others it was clearly related to the potential that the child in control of the assets might exercise poor judgment.
Well, it's kind of a scary thing to take a large portion of whatever funds you have available and give them to somebody else, even if it's one of your children whom you trust. It's still kind of scary. It's hard to do. You work all your life to establish some kind of financial security and suddenly it's out the window.
If you leave this money over to your children, sometimes children can be very selfish. They take the money and spend it and now not only does your child not have the money but now you're penniless.
Medicaid Stigma.—Discussions surrounding the Medicaid program evoked passionate responses from participants in many of the groups about the stigma associated with receiving benefits. These comments were not probed for by moderators, but rather emerged as a significant subtext to the conversations. In groups where the dynamic was positive and members felt most comfortable, those receiving welfare benefits were candid about effects on their self-esteem. Two of the high-SES groups were characterized by a strong social conscience among members, who also made observations about the impact of Medicaid stigma.
There were a number of very candid exchanges among participants presently enrolled in a Medicaid-sponsored home care program and in the low-SES groups. Typically, the issue of stigma was raised during discussions about Medicaid and individual responsibility for paying for care. Some group members responded to such conversations by explaining their use of welfare benefits. While the more vocal participants expressed the negative effects of welfare on their self-esteem and sense of pride, others quietly nodded in agreement.
To begin with, when you ask for help from the government you absolutely need it because nobody likes to be thrown a bone, nobody.
It kind of belittles you. [And] It's the last resort. [In reply] It's your pride, naturally.
You feel degraded, I guess that's what it is.
It gives you kind of a funny feeling. [In reply] I think the same thing. I mean, nobody wants to get stuff for free.
In several of the high-SES groups, more philosophical observations were offered. Although less poignant, the comments are still reflective of social norms around impoverishment and stigma of accessing services through a welfare-based program.
To be forced to reduce your financial holdings in order to get Medicaid is destructive to the spirit of the individual who has to get rid of the money.
That notion, that you are totally at the mercy of the government subsidy of Medicaid, is more negative than those who built the law thought about.
I think anytime you are dependent on anything, dependency breeds rage. You don't get Medicaid unless your resources are down below $2,000 or something like that. That's probably a need that the country has but it is not a healthy state somehow. [In reply] It's terrible.
Nearly all of the focus groups addressed the issue of whether Medicaid status influenced the quality of care provided to a beneficiary. There was strong consensus that individuals covered by Medicaid received a poorer quality of nursing home care, particularly if the caregiver was aware of the person's payment source. A number of groups raised the issue that an individual receiving Medicaid may not feel entitled to or comfortable with asking for certain services.
When you think about the fact that perhaps the Medicaid care might not be as good as if you paid for it yourself, so in that instance [who participated in MEP], somebody's getting their just desserts. I just have a feeling that if you paid for something you might get a little better care than if you were strictly state supported.
If you have a low income you can't demand anything.
We get what we pay for. Suppose we have 25 and another person will pay 100, they get better care. This is what I am trying to say.
Well, I also think that if someone else is paying you don't have the right to ask for certain things. You feel that it's not coming to you. [In reply] Whereas if you are paying for it you feel it's your right to have it because you paid for it.
Extensive discussion occurred in three of the moderate-SES groups about disclosure of Medicaid status to health care providers, with several participants arguing that no one other than the nursing home's accounting office should be aware of an individual's method of paying for care. Comments illustrated concern for privacy, as well as concerns about lesser quality of care for Medicaid recipients.
Whether you pay for it by yourself or you are on Medicaid, you should still get the same care.
I don't think it should make any difference how you are treated. The dollar is being paid. The person doing the work don't [sic] know where the dollar is coming from.
I would imagine that if a nurse's aide is coming to help you and they know you are on Title 19 they would probably push you aside a little bit. If you have a lot of money you [sic] are going to be good to them.
Morality of MEP.
Views regarding the morality of MEP dominated discussions, most often in the moderate- and high-SES groups. The majority of comments indicated that participants believed MEP, as they understood it, is inappropriate and immoral. This opposition generally reflected notions of fairness and equity as well as individual responsibility in paying for nursing home care.
I think it's immoral to try and get rid of all your money out there before you go to a nursing home. Somehow, that isn't right.
I think that, personally, [MEP] lacks integrity. To impoverish yourself so you will be on the backs of the taxpayers, to me, is wrong.
Here you are a millionaire but yet taxpayers have to pay for you to be in a nursing home. Who do you feel sorry for, the person who has $20,000 and you took it or the person who has $20 million and doesn't pay anything?
However, there were several exchanges in which focus group members argued that MEP is acceptable in some circumstances. A few group members contended that the present long-term care financing system encourages (and even necessitates) such behavior. Those comments typically emerged from groups who were of moderate SES and/or were caregivers experiencing the burden of paying for an extended nursing home stay for a spouse or parent.
If the law requires impoverishment, then to divest oneself of assets in order to achieve what is required is made wrong by the passage of a law. Whether it is wrong in a philosophical sense is another question altogether. There are as many opinions as there are people.
Then if you have nothing then you go on Title 19, the best thing in the world that can happen to you.
It seems unethical if it is a wealthy person somehow. I make an exception, if it is middle class or less, I consider it ethical somehow. I am not sure why I make that distinction.
Incentives for MEP
Two themes emerged from the focus group data that represent incentives to participate in MEP. First, there was high concordance across all groups as to the importance of avoiding total impoverishment associated with prolonged nursing home stays. Personal tales of a catastrophic long-term care event that wiped out life savings clearly resonated with focus group members. Second, the significance of protecting spouses living in the community was underscored in many group discussions. Current community spouse protection regulations under Medicaid were either misunderstood or viewed as inadequate by participants. Those focus group members (primarily in caregiver groups) who expressed concerns about their future well-being did so in the context of arguing that MEP is a reasonable course for a community spouse to take.
Protection Against Total Impoverishment
The importance of protecting against total impoverishment was raised in discussions, primarily in the moderate- and high-SES groups. As participants talked about the Medicaid program and its financial eligibility standards, there was general agreement that such standards are severe. In many of the groups, members shared personal accounts about someone who had been made destitute in paying for nursing home care before qualifying for Medicaid. Response to these reports was uniformly negative, generating statements about the need to provide a "decent" lifestyle for those supported by a government program.
I think our government has a responsibility to us that they don't get us down to zero dollars, that they leave us with enough money to function in a normal existence. We should have some sort of an index that says at so many dollars we are not going to extract any more from you and let the person live a normal life.
If it [Medicaid] requires divesting oneself of his entire estate, that is a little extreme the way it is now but it seems to me that the program could be worked out that would [complement] individuals to avoid complete discharge of their estate.
The importance in American society of bequests and other forms of legacy was echoed in each of the focus groups. The general notion of leaving an estate for the next generation was espoused by some participants. Although they were not specifically asked about the home, some groups spoke specifically of the significance of passing on the family homestead.
First and foremost, you don't want to give up your home. [In reply] That's a big thing—giving up your home.
I think the home should be kept sacred.
There was one group member, with whom several others agreed, who felt differently about the preservation of the family home, suggesting that expectations must change in the current social and economic environment:
That sentimental attachment to your home and things that are customary is one of the chronic afflictions of older age and has to be overcome.
Spousal Protection.
The caregiver groups offered a unique and important perspective on the role of MEP in providing protection to the spouse living in the community. Several persons candidly shared their experience in financing a nursing home stay for their spouse and described their fears about the implications for their own future. Comments reflected a limited understanding of current Medicaid policy related to spouses.
I don't think they are hiding it. I think what they are doing in many cases is trying to protect themselves like we were talking about the husband or wife gets sick and the other one is saying okay I'll pay the bills. But you wonder. I am paying the bill down at the home and I wonder what is going to happen when my time comes because I am going down fast. That is what you worry about.
I don't think you should be allowed to divest totally. My concern is when there is a surviving spouse benefit. If the wealth was considered your home I don't think the surviving spouse that can remain in the home should divest of that estate.
I am concerned about myself right now because if my wife lives, she could live another 20 years or so and uses up all of these funds, and they come and grab the rest that I have for myself, I got nothing.
Variation in Access to and Awareness of MEP
There was commentary in most moderate- and high-SES groups that MEP was feasible or appropriate only for select individuals, particularly those with a substantial amount of assets. Several participants argued, however, that persons with very high assets should not be concerned with protecting such assets through MEP, because they can pay privately for services in settings other than a nursing home (such as a continuing care retirement community).
The problem is if you need the assets in order to live then you can't part with them and still afford to live your life. You need the income from the assets. So it's a Catch-22.
If you have a million dollars you should be living good and taking care of your own house and don't be worried about spending down. Why would I want to leave my kids something so I could live in a decrepit place, a convalescent home on Title 19?
It was also observed that those participating in MEP had access to essential informational resources, such as elder law attorneys or financial resources. These comments emerged primarily from the moderate- and low-SES groups.
I had a friend whose wife was in there and they were paying and then he went to the attorney and he said now buy a new car, fix the roof on your house, and he did everything for his benefit to get his money down and then go on Medicaid. So there are ways and means, unfortunately for some people and others don't have that.
I know people who have done it. One lady's son was a judge... Everything went to her son and then she became ill and this [sic] the taxpayers picked up the tab and this happens to people who have the knowledge that they can do it.
Sure I've heard of it [MEP]. It's what rich people do.
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; General Accounting Office 1993). Although primary data about MEP are challenging to gather, the perspectives of individuals and families involved in Medicaid planning are essential to fully characterize system-level, social, and individual factors relevant to MEP (Walker and Burwell 1998). In this study, individuals presently using long-term care services, individuals anticipating using services, and family caregivers identified potential disincentives and incentives for MEP. Findings have relevance for both policy and research regarding MEP.
Implications for Policy
Focus group members offered impassioned statements that the present model—using a means-tested program to ensure access to nursing home care—is not humane public policy and is contradictory to social norms of caring for vulnerable citizens. Participants also reported that impoverishment requirements may increase interest in MEP. One policy option identified by some groups is to increase the amount of assets that individuals can retain and still qualify for Medicaid benefits. Simulations of the cost of raising the asset test for Medicaid nursing home benefits estimated that the fiscal impact of raising the limit (to $12,000, $20,000, or $30,000) would be relatively minor (Crown et al. 1994). Others produced similar estimates of moderate impact on Medicaid expenditures, projecting the number of days covered by Medicaid would increase only slightly if the asset limits were raised (Norton 1995). A change in policy to increase retainable asset amounts might reduce fear of total impoverishment due to the need for nursing home care as well as minimize economic incentives to participate in MEP.
A second finding indicated that ensuring the well-being of a spouse of an institutionalized individual is a major concern, particularly among the caregiving groups. The Medicare Catastrophic Coverage Act of 1988 contained provisions regarding asset transfers and included protections for the community-dwelling spouse. Although there has been general consensus on spousal protections in theory, there is less agreement on the scope and intent of such protections (Moody 1995). Some suggest that Medicaid has been expanded from a welfare program to address the needs of the middle class as well (Dobris 1989; Kapp 1997; Taylor et al. 1999). Others observe that federal and state policy relies on Medicaid as a safety net for nursing home care, yet regulations also endorse a parallel system that may facilitate broader access to Medicaid benefits for long-term care coverage (Wiener, Illston, and Hanley 1994). This conflicting policy is echoed in the public perceptions of morality and necessity of MEP as reported by older adults and their families in this study.
The subjective norms and individual attitudes raise questions about the effectiveness of regulations in shaping individual behavior and defining social expectations around financing nursing home care. Researchers in one study attempted to quantify the administrative costs of enforcing the complex MEP regulations, and found them to be substantial (Harris and Horvath 1992). Concern about compliance with regulations was raised in just one group (moderate SES, White, non–service users). Many of the members reported having met with an estate planning attorney and seemed to feel quite confident in his or her ability to comply with regulations and assist them in planning to finance future nursing home care. At least for those in this study, regulation did not appear not to play a major role in influencing individual MEP behavior. A thorough examination of the costs of developing, implementing, and enforcing MEP regulations is critical in estimating the overall impact of MEP on State Medicaid budgets (Walker et al. 1998).
Implications for Research
Efforts to estimate the magnitude of MEP have been impeded by the sensitivity of the issue and methodological challenges in gathering primary data from individuals. Although study participants were not explicitly asked whether they had transferred assets, many shared freely about their plans and actions in this regard. They also spoke with candor about their fears of needing nursing home care in the future, the strain of certain family dynamics and expectations of others, and feelings of shame associated with receiving welfare benefits. This study demonstrates the efficacy of focus group methodology, especially in the early phases of a research effort, to identify key facets of a phenomenon through an inductive approach.
Research aimed at understanding individual motivations for MEP requires preliminary data about potential influencing factors. Accordingly, in this study we set out to advance the research agenda by exploring the entire scope of considerations relevant to people's thinking about MEP. Certain of these factors, such as bequest motivations, avoidance of impoverishment, and perceived risk of needing nursing home care, have been previously hypothesized to play a role in MEP behaviors, although they have not been examined in any depth. Further attention should be directed toward understanding the role of potential influences (including norms of wealth transfer and responsibility for providing nursing home care) on individual decisions regarding long-term care financing generally and MEP specifically. A second important area of inquiry is the contrasting perceptions of morality and necessity of MEP among those who have participated in MEP and those who have not. Although it is likely to be extremely challenging for researchers to recruit individuals who will report having transferred assets to qualify for Medicaid, working with elder law attorneys or certified financial planners to identify clients and using a methodology that effectively assures confidentiality may be useful.
Findings should be considered in light of three general limitations of the study. Using focus groups to explore a potentially sensitive topic may have led to purposeful nonresponse or to misrepresentation of participant actions or views. The group dynamic was seen as critical to examining social norms, yet it posed challenges in terms of ensuring that participants' views were articulated honestly and completely. Moderators were trained to observe group interactions and wherever possible to minimize dynamics that may have constrained participation. In addition to moderator intervention, transcripts were analyzed to identify recurrent bias or dominance of a particular participant. The transcript reviews indicated that although the degree of participation certainly varied among members, more dominant individuals did not appear to significantly influence the nature of information shared by others.
Second, the composition of the groups may have been biased by the omission of important informants. Although "saturation" was achieved and it is quite likely that all major themes were elicited from focus group participants, there are several notable sources of potential bias in the sample. Groups recruited through institutions were drawn from two assisted living environments and two adult day care centers. In addition, all individuals were willing and able to participate in a focus group. It is possible that those who had experience with MEP were hesitant about discussing those activities and declined participation.
A final limitation of the study is the fact that it was conducted in a single state. Although the particular state is one believed to be among the most active in MEP, the generalizability of this study is constrained by the fact that it was conducted in only one state. The very nature of MEP dictates that the research must take into account state-specific regulatory, socioeconomic, and service delivery factors (Burwell and Crown 1995). For example, individuals living in states with aggressive enforcement of MEP regulations might be more likely to identify regulations as an influencing factor on MEP behavior.
Despite these limitations, the study makes several contributions to the evolving research agenda on MEP. Previous research has examined perspectives of elder law attorneys, certified financial planners, Medicaid policymakers, and eligibility workers regarding the magnitude and prevalence of MEP (Walker et al. 1998, Walker et al. 1999). In this study we addressed a void in the existing empirical literature regarding MEP. The large-scale, longitudinal AHEAD study presently underway will measure the nature and structure of wealth transfer, but no research has examined individual motivations for MEP. In this qualitative, exploratory study, we identify the primary individual- and social-level factors related to asset transfer for Medicaid qualification. Focus group methodology, well suited for exploratory research, generated discussion about participants' experiences with and beliefs about long-term care financing generally and MEP specifically. The transcriptions of discussions reveal how individuals conceive of, and talk about, MEP. Although large-scale surveys will be necessary for researchers to examine potential associations more rigorously, the study of social norms through such an approach is challenging. Exploratory approaches to identify normative considerations from the perspective of individuals who may pursue MEP can inform the development of a theoretical framework, hypotheses, and instrumentation for future studies.
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Received for publication May 5, 2000. Accepted for publication August 23, 2000.
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