The V-Chip and TV Ratings: Monitoring Children’s Access to TV Programming

To assist parents in supervising the television viewing habits of their children, the Communications Act of 1934 (as amended by the Telecommunications Act of 1996) requires that, as of January 1, 2000, new television sets with screens 13 inches or larger sold in the United States be equipped with a “V-chip” to control access to programming that parents find objectionable. Use of the V-chip is optional. In March 1998, the Federal Communications Commission (FCC) adopted the industry-developed ratings system to be used in conjunction with the V-chip. Congress and the FCC have continued monitoring implementation of the V-chip. Some are concerned that it is not effective in curbing the amount of TV violence viewed by children and want further legislation.

On August 31, 2009, the FCC released a report implementing the Child Safe Viewing Act of 2007. In the act, Congress had directed the FCC to examine “the existence and availability of advanced blocking technologies that are compatible with various communications devices or platforms.” Congress defined “advanced blocking technologies” as “technologies that can improve or enhance the ability of a parent to protect his or her child from any indecent or objectionable video or audio programming, as determined by such parent, that is transmitted through the use of wire, wireless, or radio communications.” Congress’s intent in adopting the act was to spur the development of the “next generation of parental control technology.” In a second inquiry issued in October 2009, the FCC is addressing additional issues it was unable to fully address based on its first inquiry.

There has been no action related to the V-Chip in the 112th Congress.

The V-Chip and TV Ratings: Monitoring Children's Access to TV Programming

August 25, 2011 (RL32729)

Summary

To assist parents in supervising the television viewing habits of their children, the Communications Act of 1934 (as amended by the Telecommunications Act of 1996) requires that, as of January 1, 2000, new television sets with screens 13 inches or larger sold in the United States be equipped with a "V-chip" to control access to programming that parents find objectionable. Use of the V-chip is optional. In March 1998, the Federal Communications Commission (FCC) adopted the industry-developed ratings system to be used in conjunction with the V-chip. Congress and the FCC have continued monitoring implementation of the V-chip. Some are concerned that it is not effective in curbing the amount of TV violence viewed by children and want further legislation.

On August 31, 2009, the FCC released a report implementing the Child Safe Viewing Act of 2007. In the act, Congress had directed the FCC to examine "the existence and availability of advanced blocking technologies that are compatible with various communications devices or platforms." Congress defined "advanced blocking technologies" as "technologies that can improve or enhance the ability of a parent to protect his or her child from any indecent or objectionable video or audio programming, as determined by such parent, that is transmitted through the use of wire, wireless, or radio communications." Congress's intent in adopting the act was to spur the development of the "next generation of parental control technology." In a second inquiry issued in October 2009, the FCC is addressing additional issues it was unable to fully address based on its first inquiry.

There has been no action related to the V-Chip in the 112th Congress.


The V-Chip and TV Ratings: Monitoring Children's Access to TV Programming

Background

Research published by the Kaiser Family Foundation (KFF) indicates that two-thirds of parents say they are "very" concerned that children in this country are being exposed to too much inappropriate content in the media, and a substantial proportion think sex (55%) and violence (43%) in the media contribute "a lot" to young people's behavior. Thirty-two percent of parents cite TV as the medium that concerns them the most, but the proportion who cite the Internet has increased over the past two years from 16% to 21%. Sixty-six percent of parents say they favor government regulations to limit the amount of sex and violence on TV during the early evening hours, a proportion that is virtually unchanged from 2004.1

Although exposure to inappropriate material has long been a concern to parents, only since the Telecommunications Act of 19962 has there been a nationwide effort to provide parents with a tool to control their children's television viewing—the V-chip.3 The V-chip, which reads an electronic code transmitted with the television signal (cable or broadcast),4 is used in conjunction with a television programming rating system. Using a remote control, parents can enter a password and then program into the television set which ratings are acceptable and which are unacceptable. The chip automatically blocks the display of any programs deemed unacceptable; use of the V-chip by parents is entirely optional.5

Since January 1, 2000, all new television sets with a picture screen 13 inches or greater sold in the United States have been required to be equipped with the V-chip.6 Additionally, some companies also offer devices that can work with non-V-chip TV sets.

Development of the V-Chip Ratings System

The initial ratings system was developed during 1996 and 1997, but encountered criticism from within Congress as well as from groups such as the National Parent-Teacher Association. In response to those concerns, an expanded ratings system was adopted on July 10, 1997, and went into effect October 1, 1997.

Initial Ratings System

The first step in implementing the mandate of the law was to create a ratings system for television programs, analogous to the one developed and adopted for movies by the Motion Picture Association of America (MPAA) in 1968. The law urged the television industry to develop a voluntary ratings system acceptable to the FCC, and the rules for transmitting the rating, within one year of enactment. The ratings system is intended to convey information regarding sexual, violent or other indecent material about which parents should be informed before it is displayed to children, provided that nothing in the law should be construed to authorize any rating of video programming on the basis of its political or religious content.

After initial opposition, media and entertainment industry executives met with then-President Clinton on February 29, 1996, and agreed to develop the ratings system because of political pressure to do so. Many in the television industry were opposed to the V-chip, fearing that it would reduce viewership and reduce advertising revenues. They also questioned whether it violated the First Amendment. Industry executives said they would not challenge the law immediately, but left the option open should they deem it necessary.

Beginning in March 1996, a group of television industry executives7 under the leadership of Jack Valenti, then-president of the MPAA (and a leader in creating the movie ratings), met to develop a TV ratings system. On December 19, 1996, the group proposed six age-based ratings (TV-Y, TV-Y7, TV-G, TV-PG, TV-14 and TV-M), including text explanations of what each represented in terms of program content. In January 1997, the ratings began appearing in the upper left-hand corner of TV screens for 15 seconds at the beginning of programs, and were published in some television guides. Thus, the ratings system was used even before V-chips were installed in new TV sets.

Ratings are assigned to shows by the TV Parental Guidelines Monitoring Board. The board has a chairman and six members each from the broadcast television industry, the cable industry, and the program production community. The chairman also selects five non-industry members from the advocacy community, for a total of 24 members.

News shows and sports programming are not rated. Local broadcast affiliates may override the rating given a particular show and assign it another rating.

The Current "S-V-L-D" Ratings System

Critics of the initial ratings system argued that the ratings provided no information on why a particular program received a certain rating. Some advocated an "S-V-L" system (sex, violence, language) to indicate with letters why a program received a particular rating, possibly with a numeric indicator or jointly with an age-based rating. Another alternative was the Home Box Office/Showtime system of 10 ratings such as MV (mild violence), V (violence), and GV (graphic violence).

In response to the criticism, most of the television industry agreed to a revised ratings system (see box, below) on July 10, 1997, that went into effect October 1, 1997. The revised ratings system added designators to indicate whether a program received a particular rating because of sex (S), violence (V), language (L), or suggestive dialogue (D). A designator for fantasy violence (FV) was added for children's programming in the TV-Y7 category. On March 12, 1998, the FCC approved the revised ratings system, along with V-chip technical standards, and the effective date for installing them.8 The Appendix contains a description of the industry's revised TV ratings system.

In May 1999, the FCC created a V-chip Task Force, chaired by then-Commissioner Gloria Tristani. Among other things, the task force was charged with ensuring that the blocking technology was available and that ratings were being transmitted ("encoded") with TV programs; educating parents about V-chip; and gathering information on the availability, usage, and effectiveness of the V-chip. The task force issued several reports and surveys.9 A February 2000 task force survey found that most broadcast, cable, and premium cable networks, and syndicators, were transmitting ratings ("encoding") and those that were not either planned to do so in the near future or were exempt sports or news networks. Of the major broadcast and cable networks, only NBC and Black Entertainment Television do not use the S-V-L-D indicators, using the original ratings system instead.

Federal Communications Commission Action

On April 25, 2007, the FCC released a report on the "presentation of violent programming and its impact on children."10 In the report, the FCC—

  • found that on balance, research provides strong evidence that exposure to violence in the media can increase aggressive behavior in children, at least in the short term;
  • noted that although viewer-initiated blocking and mandatory ratings would impose lesser burdens on protected speech, skepticism remains that they will fully serve the government's interests in promoting parental supervision and protecting the well-being of minors;
  • stated that the V-chip is of limited effectiveness in protecting children from violent television content;
  • observed that cable operator-provided advanced parental controls do not appear to be available on a sufficient number of cable-connected television sets to be considered an effective solution at this time;
  • stated that further action to enable viewer-initiated blocking of violent television content would serve the government's interests in protecting the well-being of children and facilitating parental supervision and would be reasonably likely to be upheld as constitutional;
  • found that studies and surveys demonstrate that the voluntary TV ratings system is of limited effectiveness in protecting children from violent television content;
  • stated that Congress could develop an appropriate definition of excessively violent programming, but such language needs to be narrowly tailored and in conformance with judicial precedent;
  • suggested that industry could on its own initiative commit itself to reducing the amount of excessively violent programming viewed by children (e.g., broadcasters could adopt a family hour at the beginning of prime time, during which they decline to air violent content);
  • observed that multichannel video programming providers (MVPDs) could provide consumers greater choice in how they purchase their programming so that they could avoid violent programming. (e.g., an a la carte regime would enable viewers to buy their television channels individually or in smaller bundles); and
  • found that Congress could implement a time channeling solution and/or mandate some other form of consumer choice in obtaining video programming, such as the provision by MVPDs of video channels provided on family tiers or on an a la carte basis (e.g., channel blocking and reimbursement).

On March 2, 2009, the FCC adopted and released a Notice of Inquiry (NOI) to implement the Child Safe Viewing Act of 2007. The Child Safe Viewing Act directed the FCC to initiate a proceeding within 90 days after the date of enactment to examine "the existence and availability of advanced blocking technologies that are compatible with various communications devices or platforms." Congress defined "advanced blocking technologies" as "technologies that can improve or enhance the ability of a parent to protect his or her child from any indecent or objectionable video or audio programming, as determined by such parent, that is transmitted through the use of wire, wireless, or radio communications." Congress's intent in adopting the act was to spur the development of the "next generation of parental control technology." In conducting this proceeding, the FCC will examine blocking technologies that may be appropriate across a wide variety of distribution platforms and devices, can filter language based upon information in closed captioning, can operate independently of pre-assigned ratings, and may be effective in enhancing a parent's ability to protect his or her child from indecent or objectionable programming, as determined by the parent. The NOI covered not only broadcast, cable, and satellite television, but also wireless devices, non-networked devices, and Internet content.

The FCC released its report based on the NOI on August 29, 2009.11 In the report, the FCC concluded that a market exists for advanced blocking technologies and other parental empowerment tools, although data is lacking in certain key areas, such as awareness and usage levels, which warrant further study. Educational programs to increase awareness of parental control technologies have the potential to accelerate the rate of development, deployment, and adoption of these technologies. Parental control technologies vary greatly among media platforms, and even among different providers within the same media platform, with respect to various criteria. While there are technologies in existence for each media platform, there is not currently a universal parental control technology that works across media platforms. To explore these issues and how to maximize benefits and minimize harms to children, the FCC issued a second NOI exploring these issues and others relating to protecting children and empowering parents in the digital age on October 23, 2009.12

In the second NOI, the FCC asked to what extent children were using electronic media, the benefits and risks this presents, and the ways in which parents, teachers, and children can help reap the benefits while minimizing the risks of using these technologies. The FCC also recognized that a wealth of academic research and studies exist on these issues and asked commenters to identify additional data and studies, and to indicate where further study is needed. The NOI additionally seeks comment about the effectiveness of media literacy efforts in enabling children to enjoy the benefits of media while minimizing the potential harms. The NOI recognizes that other federal agencies are addressing similar issues, at least with respect to online safety, and asks what the FCC can do to assist with these efforts. No report has been released as a result of this NOI, but since the beginning of 2011, there have been renewed discussions at the FCC over possibly updating the ratings system using this proceeding as a vehicle.13

Congressional Action—111th and 112th Congress

There was no legislative action on the V-Chip in the 111th Congress and no legislative action thus far in the 112th Congress.

Congressional Action—110th Congress

On December 2, 2008, then-President Bush signed into law the "Child Safe Viewing Act of 2007."14 This law was originally introduced by Senator Mark Pryor and, as discussed above, requires the FCC to examine the existence and availability of advanced blocking technologies that parents could use across a variety of communications devices or platforms.

The Senate and the House of Representatives each held one hearing on issues related to the V-Chip during the 110th Congress:

  • The Senate Committee on Commerce, Science, and Transportation held a hearing, "Impact of Media Violence on Children," on June 26, 2007.15 The hearing focused on issues related to the impact of violent television programming on children, including issues raised by the FCC report, "Violent Television Programming And Its Impact On Children."
  • The House Committee on Energy and Commerce Subcommittee on Telecommunications and the Internet held a hearing, "Images Kids See on the Screen," on June 22, 2007.16 The hearing included discussion of advertising for junk food aimed at children and on the inability of the V-chip to screen out undesirable advertising.

Effectiveness of the V-Chip

From 1998 through 2007, the Kaiser Family Foundation (KFF) conducted research into the impact of media violence on children and the effectiveness of the V-chip and television ratings as tools for parents to control access to undesirable television content.17 In the Foundation's most recent report, published in June 2007, two-thirds of parents say they are "very" concerned that children in this country are being exposed to too much inappropriate content in the media, and a substantial proportion think sex (55%) and violence (43%) in the media contribute "a lot" to young people's behavior. Thirty-two percent of parents cite TV as the medium that concerns them the most, but the proportion who cite the Internet has increased over the past two years from 16% to 21%. Sixty-six percent of parents say they favor government regulations to limit the amount of sex and violence on TV during the early evening hours, a proportion that is virtually unchanged from 2004.18

Overall, the parents interviewed for the study stated that they were more concerned about inappropriate content on TV than in other media: 32% said TV concerned them most, compared to 21% who said the Internet, 9% movies, 7% music, and 8% video games. Half (50%) of all parents said they have used the TV ratings to help guide their children's viewing, including slightly more than one in four (28%) who said they use them "often."19

Furthermore, the study revealed that while use of the V-chip has increased substantially since 2001, when 7% of all parents said they used it, it remains modest at just 15% of all parents, or about four in 10 (42%) of those who have a V-chip in their television and know it. Nearly two-thirds (61%) of parents who have used the V-chip said they found it "very" useful.20

Other significant findings reported included:

  • After being read arguments on both sides of the issue, nearly two-thirds of parents (63%) said they favored new regulations to limit the amount of sex and violence in TV shows during the early evening hours, when children were most likely to be watching (35% are opposed).21
  • A majority (55%) of parents said ratings should be displayed more prominently and 57% said they would rather keep the current rating systems than switch to a single rating for TV, movies, video games, and music (34% favor the single rating).22
  • When read the competing arguments for subjecting cable TV to the same content standards as broadcasters, half of all parents (52%) said that cable should be treated the same, while 43% said it should not.23
  • Most parents who have used the TV ratings said they found them either "very" (38%) or "somewhat" (50%) useful.24
  • About half (52%) of all parents said most TV shows are rated accurately, while about four in ten (39%) said most are not.25
  • Many parents do not understand what the various ratings guidelines mean. For example, 28% of parents of young children (2-6 years old) knew what the rating TV-Y7 meant (directed to children age 7 and older) while 13% thought it meant the opposite (directed to children under 7); and only 12% knew that the rating FV ("fantasy violence") is related to violent content, while 8% thought it meant "family viewing."26

In releasing the survey results, Vicky Rideout, vice president and director of the Kaiser Family Foundation's Program for the Study of Entertainment Media and Health, commented, "While many parents have used the ratings or the V-chip, too many still don't know what the ratings mean or even that their TV includes a V-chip."27

A number of groups conducted research and published opinion pieces questioning the usefulness and/or legality of the V-chip and the ratings system after the 1996 Telecommunications Act was enacted (e.g., the Progress and Freedom Foundation, the American Civil Liberties Union, Cato Institute, Morality in Media). Since that time, opposition has waned and even the controversies over inappropriate content being broadcast live did not renew it. Further, while the V-chip and the ratings system can block objectionable or indecent programming when used in tandem, since the incidents were broadcast "live" and did not have ratings that would have blocked them, neither the V-chip nor the ratings system would have been effective in either case. Therefore, some could claim that the V-chip and the ratings system, while useful tools in many cases, remain unreliable tools for parents because they cannot guarantee all objectionable content will be blocked.

Issues for Congress

In the Child Safe Viewing Act, Congress addressed most of the issues that have been raised by various interest groups about the V-chip. However, the issue that appears not to be able to be addressed through legislation, which is to educate parents and make them aware of the tools available to them, still remains.

According the 2004 KFF Study, parents also indicated that they would like to see the ratings displayed more prominently to make it easier to notice them. Such findings are consistent with a lack of wide-spread usage or even awareness of the V-chip. Specifically, as noted above, the 2004 KFF study indicated that even after years of being available, only 42% of parents who have a V-chip and are aware of it actually use it. However, of the parents that had used the V-chip, 89% found it "somewhat" to "very" useful.28 Those figures would indicate that increased knowledge of the V-chip would substantially increase parents' perceptions of control over their children's television viewing.

One of the easiest approaches to increasing the use of the V-chip may likely be to step up parental awareness programs through, for example, public service announcements on television, educational materials on the FCC website, and possibly public service advertisements in print media. Additionally, such educational materials could be made available on congressional member websites for constituents to download. Such actions would not require any new legislation or additional work by the ratings board or related entities; however, some initially may require funding.

Related Reading

Other Reports and Documents

"The Perils of Mandatory Parental Controls and Restrictive Defaults," Progress and Freedom Foundation, April 2008, http://www.pff.org/issues-pubs/pops/pop15.4defaultdanger.pdf.

"Parents, Media, and Public Policy: A Kaiser Family Foundation Survey," Kaiser Family Foundation, Fall 2004, http://www.kff.org/entmedia/entmedia092304pkg.cfm.

"V-chip Frequently Asked Questions," Children Now, http://www.childrennow.org/media/vchip/vchip-faq.html.

"Summary of Focus Group Research on Media Ratings Systems," A Study Commissioned by PSV Ratings, Inc., Spring 2003, http://www.independentratings.org/Parents_Views.pdf.

Websites

Federal Communications Commission V-chip Information, http://www.fcc.gov/vchip/.

Appendix. U.S. Television Industry's Revised TV Ratings System

 

TV-Y All Children
This program is designed to be appropriate for all children. Whether animated or live-action, the themes and elements in this program are specifically designed for a very young audience, including children from ages 2-6. This program is not expected to frighten younger children.

 

TV-Y7 Directed to Older Children
This program is designed for children age 7 and above. It may be more appropriate for children who have acquired the developmental skills needed to distinguish between make-believe and reality. Themes and elements in this program may include mild fantasy or comedic violence, or may frighten children under the age of 7. Therefore, parents may wish to consider the suitability of this program for their very young children.

 

TV-Y7-FV Directed to Older Children-Fantasy Violence
For those programs where fantasy violence may be more intense or more combative than other programs in the TV-Y7 category, such programs will be designated TV-Y7-FV.

 

TV-G General Audience
Most parents would find this program appropriate for all ages. Although this rating does not signify a program designed specifically for children, most parents may let younger children watch this program unattended. It contains little or no violence, no strong language and little or no sexual dialogue or situations.

 

TV-PG Parental Guidance Suggested
This program contains material that parents may find unsuitable for younger children. Many parents may want to watch it with their younger children. The theme itself may call for parental guidance and/or the program contains one or more of the following: moderate violence (V), some sexual situations (S), infrequent coarse language (L), or some suggestive dialogue (D).

 

TV-14 Parents Strongly Cautioned
This program contains some material that many parents would find unsuitable for children under 14 years of age. Parents are strongly urged to exercise greater care in monitoring this program and are cautioned against letting children under the age of 14 watch unattended. This program contains one or more of the following: intense violence (V), intense sexual situations (S), strong coarse language (L), or intensely suggestive dialogue (D).

 

TV-MA Mature Audience Only
This program is specifically designed to be viewed by adults and therefore may be unsuitable for children under 17. This program contains one or more of the following: graphic violence (V), explicit sexual activity (S), or crude indecent language (L).

Footnotes

1.

Kaiser Family Foundation, "Parents, Children & Media, June 2007," http://kaiserfamilyfoundation.org/entmedia/upload/7638.pdf (KFF Study), p. 3.

2.

Telecommunications Act of 1996, P.L. 104-104, February 8, 1996, available at http://www.fcc.gov/Reports/1934new.pdf. The 1996 act amended the Communications Act of 1934 (47 U.S.C. 101, et seq.), updating some existing sections and adding new sections to account for new technologies. One such addition to the law was to mandate the inclusion of a computer chip in new television sets to allow parents more control over the programming viewed by their children (47 U.S.C. 303 (x)). The 1934 act, as amended by the 1996 act, is available at http://www.fcc.gov/Reports/tcom1996.pdf.

3.

Although commonly believed to be short for "violence," the V in V-chip is actually short for "ViewControl," the name given by the inventor of the device. See "V-Chip Technology Invented by Professor Tim Collings," available at http://www.tri-vision.ca/documents/Collings%20As%20Inventor.pdf. See also, "The History of Invention," available at http://www.cbc.ca/kids/general/the-lab/history-of-invention/vchip.html.

4.

The ratings data are sent on line 21 of the Vertical Blanking Interval found in the National Television System Committee (NTSC) signals used for U.S. television broadcasting.

5.

This report focuses on the use of the V-chip and the ratings system as a tool to assist parents in selecting appropriate television programming for their children. However, both the V-chip and the ratings system can be used by a wide range of viewers, from individuals who, themselves, do not wish to view content they find objectionable to individuals who may be babysitting on an intermittent basis in their homes. Further, the V-chip and the television ratings are closely related to another issue—that of broadcast indecency and how to define and enforce the appropriate use of the public airwaves by the television media. That issue is discussed in greater detail in CRS Report RL32222, Regulation of Broadcast Indecency: Background and Legal Analysis, by [author name scrubbed].

6.

47 U.S.C. 303(x).

7.

The group included the national broadcast networks; independent, affiliated and public television stations; cable programmers; producers and distributors of cable programming; entertainment and movie studios; and members of the guilds representing writers, directors, producers and actors.

8.

As of January 1, 2000, all new television sets with a picture screen 13 inches or greater sold in the United States must be equipped with the V-chip.

9.

See http://www.fcc.gov/vchip.

10.

In the Matter of Violent Television Programming and its Impact on Children (FCC 04-175, MB Docket 04-261), Notice of Inquiry (NOI), Adopted July 15, 2004; Released July 28, 2004. The NOI is available at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-07-50A1.pdf.

11.

In the Matter of Implementation of the Child Safe Viewing Act; Examination of Parental Control Technologies for Video or Audio Programming, Notice of Inquiry, MB Docket No. 09-26, FCC 09-69, August 31, 2009, online at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-09-69A1.doc.

12.

In the Matter of Empowering Parents and Protecting Children in an Evolving Media Landscape, Notice of Inquiry, MB Docket No. 09-194, FCC 09-94, October 23, 2009, online at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-09-94A1.pdf.

13.

"FCC Explores Improved TV Ratings, V-Chip," by David Hatch, National Journal, February 28, 2011, online at http://www.nationaljournal.com/domesticpolicy/fcc-explores-improved-tv-ratings-v-chip-20110225.

14.

S. 602 (see also S.Rept. 110-268).

15.

The hearing webpage containing witness statements and the archived video is at http://commerce.senate.gov/public/index.cfm?FuseAction=Hearings.Hearing&Hearing_ID=1879. See also, Broadcasting & Cable, "TV Hammered In Violence Hearing," by John Eggerton, June 26, 2007. Available at http://www.broadcastingcable.com/article/CA6455579.html.

16.

The hearing webpage containing witness statements and the archived video is at http://energycommerce.house.gov/cmte_mtgs/110-ti-hrg.062207.ImagesKidsSEE.shtml. See also, Broadcasting & Cable, "Markey Calls V-chip Limited Success," by John Eggerton, June 22, 2007. Available at http://www.broadcastingcable.com/article/CA6454591.html.

17.

See Kaiser Family Foundation, Program on Study of Entertainment Media & Health: Television/Video, http://www.kff.org/entmedia/tv.cfm.

18.

KFF Study, p. 3.

19.

KFF Study, p. 8.

20.

KFF Study, p. 7.

21.

KFF Study, p. 8.

22.

Ibid.

23.

Ibid.

24.

KFF Study, p. 5.

25.

Ibid.

26.

KFF Study, p. 6.

27.

KFF News Release, "Parents Favor New Limits on TV Content in Early Evening Hours; Half of Parents Say Cable TV Should Adhere to Same Standards as Broadcast TV; Use of the V-Chip is Up," September 23, 2004. Available at http://www.kff.org/entmedia/entmedia092304nr.cfm.

28.

KFF Study, p. 7.