The Latest Bureaucratic Nonsense from Government Regulators7.30.14 10:30 am
Foust has slammed his opponent, Republican Del. Barbara Comstock, for her opposition to expansion. He has spoken of the need to “make health care available to 400,000 Virginians,” insisting it is “the right thing to do.”
Foust’s wife, Dr. Marilyn Jerome, practices with Foxhall OB/GYN in northwest Washington, D.C. Six of its physicians made Washingtonian magazine’s list of “Top Docs,” and one of them—Nichole Pardo—was featured on the cover. Not too shabby.
The practice is notable for another reason as well: It doesn’t accept Medicaid patients.
This draws attention to an under-covered aspect of the debate over Medicaid expansion. While advocates speak of it as “making health care available” to the needy, what it really does is make coverage, rather than care, available to them. A newly enrolled Medicaid patient can get the money to pay a doctor. But can she get the doctor to take it?
On his website, Foust blasts insurance companies that “hiked insurance premiums and gouged consumers. … Insurance companies denied care to those with pre-existing conditions … and refused coverage to those who needed it most. … We cannot go back to the days when insurance companies could arbitrarily … deny coverage.” In a commentary on the Foxhall practice’s website, Dr. Jerome praises the Affordable Care Act—particularly because now “women cannot be denied insurance” and because the plan’s standards mandate coverage for a wide variety of treatments.
Doctors, however, can operate under a much different set of standards. They can deny care all they want. Statewide, roughly one in five physicians will not accept new Medicaid patients—usually because Medicaid pays only two-thirds as much as private insurance does, on average.
Obamacare Continues to Under Perform Edmund Haislmaier / August 02, 2014
Edmund F. Haislmaier is an expert in health care policy and markets at The Heritage Foundation — and is frequently asked to assist federal and state lawmakers in designing and drafting health reform proposals and legislation.
Obamacare’s initial open-enrollment period ended in mid April. The big question since then has been, “What were the results?”
Hard data have been lacking — until now. My colleague Drew Gonshorowski and I have just finished reviewing insurance-market data from the first quarter of 2014, and we can report that Obamacare’s results are not very impressive.
Certainly they’re not as impressive as the Obama administration would like you to believe. On May 1, outgoing health and human services secretary Kathleen Sebelius triumphantly reported that 8 million people had picked a plan through the exchanges during open enrollment. Yet, since then, HHS has assiduously refused to provide figures for how many of those 8 million actually completed the transaction. Nor has HHS provided any breakout of exchange sign-ups by those who were previously uninsured versus those who were already insured but obtained replacement coverage through the exchanges.
Several prominent organizations — specifically, the Rand Corporation, the Kaiser Family Foundation, the Urban Institute, McKinsey & Company, and Gallup — have attempted to fill the information gap with their own coverage surveys. Yet even well-constructed surveys have limitations and, at best, can offer only approximate answers. Analysts and commentators (on both the left and the right) have also weighed in with varying guesstimates and interpretations.
Now, newly available health-insurance enrollment data provide a clearer and more comprehensive picture of the changes in coverage during the initial implementation of Obamacare. Unlike estimates based on survey results, the newly available data consist of actual enrollment counts for the private market, Medicaid, and the Children’s Health Insurance Program (CHIP).
The data on private coverage come from quarterly reports that insurers file with state regulators. At this point, only the first installment (data from the first quarter of 2014) of what we need for a full assessment is available. Because of delays in processing enrollments and a surge in exchange applications in March, we must wait for second-quarter data to see the complete picture.
Nonetheless, this first tranche of data is highly revealing. Drew and I present the numbers and analyze them in more detail in our new report, but here are three key takeaways from the data for the six-month period of October 1, 2013, through March 31, 2014:
– Net enrollment in the individual-coverage market grew by 2,236,942 individuals, while net enrollment in employer group coverage declined by 1,716,540 individuals.
– The decline in employer-sponsored coverage offset 77 percent of the gain in individual-market coverage, for a net increase in private-market coverage of only 520,000 individuals during the period.
– Medicaid and CHIP enrollment reports from the Centers for Medicare and Medicaid Services (CMS) show that enrollment in those programs increased by about 5 million individuals during the same six-month period, with 87 percent of those gains occurring in the 26 states (plus the District of Columbia) that elected to adopt Obamacare’s expansion of Medicaid to able-bodied adults.
The biggest piece of the puzzle still missing is the coverage status of the 3,777,438 individuals whom HHS reported as picking an exchange plan between March 1 and the close of open enrollment in April. Few, if any, of them would have had their coverage activated before the end of March, so those who actually gained coverage will show up in the second-quarter data, along with anyone who selected an exchange plan earlier but had his enrollment delayed beyond March due to the exchanges’ software problems.
Even so, this first installment of enrollment data marks a shift from speculation to reality in the ongoing public debate over Obamacare. It also offers guidance on what to expect next.
Assuming no further erosion in employer group coverage, and further assuming that all the individuals who picked an exchange plan during the last two months of open enrollment actually obtained coverage, it now appears that the upper bound for any net increase in private coverage during the first year of Obamacare will be in the neighborhood of 5 million individuals. Of course, those two assumptions are big ifs, so the final figure might well be lower.
We also know that Medicaid enrollment continues year-round. CMS reported that a further 1.1 million individuals were added to the Medicaid rolls in April. Thus, it’s pretty safe to project that when the final figures for Obamacare’s first year are in, the Medicaid expansion will be responsible for over half of any net increase in health-insurance coverage. In that regard, it should be noted that the Medicaid expansion population consists of able-bodied working-age adults, 82 percent of whom don’t have dependent children and 52 percent of whom are ages 19 to 34.
So far, this is not a particularly impressive performance — unless, of course, you believe that giving several million able-bodied, working-age adults substandard government health coverage as a consolation prize for remaining unemployed or underemployed — and doing so at considerable disruption and expense for everyone else — constitutes a significant achievement or an acceptable substitute for pro-growth economic policies.
Obamacare Architect Jonathan Gruber Admited in 2012 That Subsidies Were Limited to State-Run Exchanges
Earlier this week, a three-judge panel in the D.C. Circuit Court ruled that, contrary to the Obama administration’s implementation and an Internal Revenue Service rule, Obamacare’s subsidies for private health insurance were limited to state-run health exchanges.
The reasoning for this ruling was simple: That’s what the law says. The section dealing with the creation of state exchanges and the provision of subsidies states, quite clearly, that subsidies are only available in exchanges “established by a State,” which the law expressly defines as the 50 states plus the District of Columbia.
Obamacare’s defenders have responded by saying that this is obviously ridiculous. It doesn’t make any sense in the larger context of the law, and what’s more, no one who supported the law or voted for it ever talked about this. It’s a theory concocted entirely by the law’s opponents, the health law’s backers argue, and never once mentioned by people who crafted or backed the law.
It’s not. One of the law’s architects—at the same time that he was a paid consultant to states deciding whether or not to build their own exchanges—was espousing exactly this interpretation as far back in early 2012, and long before the Halbig suit—the one that was decided this week against the administration—was filed. (A related suit, Pruitt v. Sebelius, had been filed earlier, but did not challenge tax credits within the federal exchanges until an amended version which was filed in late 2012.) It was also several months before the first publication of the paper by Case Western Law Professor Jonathan Adler and Cato Institute Health Policy Director Michael Cannon which detailed the case against the IRS rule.
Jonathan Gruber, a Massachusetts Institute of Technology economist who helped design the Massachusetts health law that was the model for Obamacare, was a key influence on the creation of the federal health law. He was widely quoted in the media. During the crafting of the law, the Obama administration brought him on for consultation because of his expertise. He was paid almost $400,000 to consult with the administration on the law. And he has claimed to have written part of the legislation, the section dealing with small business tax credits.
Obama’s Law Professor Laurence Tribe: ‘I Wouldn’t Bet’ on Obamacare Surviving Next Legal Challenge By Joel Gehrke July 11, 2014 3:54 PM
President Obama’s old Harvard Law professor, Laurence Tribe, said that he “wouldn’t bet the family farm” on Obamacare’s surviving the legal challenges to an IRS rule about who is eligible for subsidies that are currently working their way through the federal courts.
“I don’t have a crystal ball,” Tribe told the Fiscal Times. “But I wouldn’t bet the family farm on this coming out in a way that preserves Obamacare.”
The law’s latest legal problem is that, as written, people who enroll in Obamacare through the federal exchange aren’t eligible for subsidies. The text of the law only provides subsidies for people enrolled through “an Exchange established by the State,” according to the text of the Affordable Care Act. Only 16 states decided to establish the exchanges.
The IRS issued a regulation expanding the pool of enrollees who qualify for the subsidies. Opponents of the law, such as the Cato Institute’s Michael Cannon and Jonathan Adler, argue that the IRS does not have the authority to make that change. (Halbig v. Burwell, one of the lawsuits making this argument, is currently pending before the D.C. Circuit Court; the loser will likely appeal the decision to the Supreme Court.)
“There are specific rules about when and how the IRS can deviate from the plain language of a statute,” Cannon explained to National Review Online, arguing that the subsidies regulation fails to comply with those rules.
The IRS can deviate from “absurd” laws, in theory, but the subsidies language is not absurd. “It might be stupid, but that’s not the test for absurdity,” Cannon says. Similarly, the IRS can deviate in the case of scrivener’s errors — typos, basically — but this is not a typo, Cannon says, because the language was written into repeated drafts of the law.
“They not only keep that language in there, but they even inserted it, this same phrase again, right before passage while the bill was in [Senate Majority Leader] Harry Reid’s office,” Cannon says. “So, it’s not a scrivener’s error, either.”
Finally, the IRS could fill in ambiguous gaps in a law. The problem for the IRS, though, is that the subsidies language is not ambiguous. Even Tribe acknowledged that the language is clear, according to the Fiscal Times.
“Yet in drafting the law, Tribe said the administration ‘assumed that state exchanges would be the norm and federal exchanges would be a marginal, fallback position’ — though it didn’t work out that way for a plethora of legal, administrative and political reasons,” the Fiscal Times writes.
Tribe suggested that the case will, like the individual mandate challenge before it, hinge on Chief Justice John Roberts’s decision. “He would be asking himself the hard question: ‘Is it so clear under existing law that it has to be construed in this literal and somewhat bizarre way . . . that subsidies or tax credits cannot be provided on the federal exchanges, or is it sufficiently ambiguous that it gives me the necessary legal wiggle room’ [to side with the administration once again?]” Tribe said.
Forbes contributor Jeffrey Dorman notes that a recent ruling in a case involving the Environmental Protection Agency could make it harder for Roberts to conclude that he has that wiggle room.
Court Rules That Subsidies in Obamacare’s Federal Exchange are Illegal, Dealing Huge Legal Blow to Health Law Peter Suderman|Jul. 22, 2014 10:33 am
Whitehouse.govThe U.S. Court of Appeals for the D.C. Circuit delivered a huge blow to Obamacare this morning, ruling that the insurance subsidies granted through the federally run health exchange, which covered 36 states for the first open enrollment period, are not allowed by the law.
The highly anticipated opinion in the case of Jacqueline Halbig v. Sylvia Mathews Burwellreversed a lower court ruling finding that the federally run exchange did have the authority to disburse subsidies.
Today’s ruling vacates the Internal Revenue Service (IRS) regulation allowing the federal exchange to give subsidies. The large majority of individuals, about 86 percent, in the federal exchange received subsidies, and in those cases the subsidies covered about 76 percent of the premium on average. The essence of the court’s ruling is that, according to the law, those subsidies are illegal. (According to an administration official, however, the subsidies will continue through the appeals process.)
The court’s ruling agreed with challengers who argued that the plain language of the law, which in multiple instances limits subsidies and credits to any “Exchange established by the State,” does not allow subsidies to be disbursed in exchanges where a state declined to establish its own exchange and is instead run by the federal government. Basically, the federal government cannot step in and create and run an exchange that is somehow still an exchange established by a state.
“We conclude that appellants have the better of the argument: a federal Exchange is not an ‘Exchange established by the State,’ and [the relevant section of the law] does not authorize the IRS to provide tax credits for insurance purchased on federal Exchanges,” the decision says.
‘I,’ ‘Me,’ ‘My’—Obama Uses First Person Singular 199 Times in Speech Vowing Unilateral Action July 11, 2014 – 8:56 PM
Not counting instances when he quoted a letter from a citizen or cited dialogue from a movie, President Barack Obama used the first person singular–including the pronouns “I” and “me” and the adjective “my”–199 times in a speech he delivered Thursday vowing to use unilateral executive action to achieve his policy goals that Congress would not enact through the normal, constitutional legislative process.
“It is lonely, me just doing stuff,” Obama said at the speech in Austin, Texas, according to the official transcript and video posted on the White House website.
“I’m just telling the truth now,” Obama told the crowd. “I don’t have to run for office again, so I can just let her rip. And I want to assure you, I’m really not that partisan of a guy.”
In what could be the latest move toward a 2016 presidential bid, New Jersey Gov. Chris Christie (R) offered a wide-ranging critique of President Obama’s domestic and foreign policies.
Speaking to reporters at the National Governors Association on Saturday, Christie labeled Obamacare, the administration’s signature legislation, a “failure on a whole number of levels” and said it should be repealed.
“But has to be repeal and replace with what. It can’t just be about repeal,” Christie told the audience. “What I’ve said before is, what Republicans need to be doing is putting forth alternatives for what should be a better healthcare system.”
He also urged his GOP colleagues to keep bringing up their opposition to same-sex marriage, even though a series of court decisions have overturned many statewide gay marriage bans.
“I don’t think there’s some referee who stands up and says, ‘OK, now it’s time for you to change your opinion,’” according to Christie.
Christie also said the latest outbreak of violence between Israelis and Palestinians was partly the White House’s fault because the administration “does stand up for our friends.”
The Sad Story of Obamacare: Reason’s In-Depth Treatment of the Health Care Fiasco That Won’t Go Away
J.D. Tuccille|Jul. 1, 2014 12:03 pm
It fills the headlines, it chills the public, it elevates your premiums, and it dogs hopes for decent health care coverage. That’s right, we’re talking about Obamacare—the government scheme that refuses to die, despite every sign that it’s doing itself in (and maybe taking us with it). Reason writers look at the history of this policy monstrosity, the laughable efforts by its promoters to make it palatable, and the deep flaws in the way it has been crafted and implemented.
Even better, we look at alternative approaches and innovations that promise better health care for the future. And we look at ways of presenting those alternatives to a public that wants care, but has certainly grown jaded about pie-in-the-sky promises.
Obama racking up judicial losses as Supreme Court rules on Obamacare, union dues
President Obama suffered two final defeats in the Supreme Court on Monday, capping a 2013-2014 term in which the justices delivered several judicial hits to the White House while taking a firm stand against the unchecked power of the state.
The administration’s losses on Obamacare rules and compulsory union dues served as a rebuke on the Supreme Court’s final day after months of judicial decisions to rein in big government on issues such as snooping without a warrant, campaign finance restrictions and Mr. Obama’s recess appointment powers.
Just as damning was the way the court ruled in some of those cases. Chief Justice John G. Roberts Jr. corralled unanimous votes on privacy and recess appointments — cases that dealt stinging defeats to Mr. Obama, himself a lawyer and former lecturer on constitutional law.
In the more than five years that Mr. Obama has been in office, the court has rejected the government’s argument with a 9-0 decision 20 times.
During the eight years each in the administrations of George W. Bush and Bill Clinton, the government lost on unanimous votes 15 times and 23 times, respectively. That puts the Obama administration on pace to greatly exceed recent predecessors in terms of judicial losses.
Confusion over doctor lists is costly for Obamacare enrollees in state
Fustration and legal challenges over the network of doctors and hospitals for Obamacare patients have marred an otherwise successful rollout of the federal healthcare law in California.
Limiting the number of medical providers was part of an effort by insurers to hold down premiums. But confusion over the new plans has led to unforeseen medical bills for some patients and prompted a state investigation.
More complaints are surfacing as patients start to use their new coverage bought through Covered California, the state’s health insurance exchange.
“I thought I had done everything right, and it’s been awful,” said Jean Buchanan, 56. The Fullerton resident found herself stuck with an $8,000 bill for cancer treatment after receiving conflicting information on whether it was covered.
Kaitlyn Krasselt and Jayne O’Donnell, USA TODAY4:02 p.m. EDT June 29, 2014
Federally funded programs will add at least 2,300 new primary care practitioners by the end of 2015, but the funding for at least one of those programs is set to expire at the same time, contributing to a massive shortage of doctors available to treat patients — including those newly insured through the Affordable Care Act and Medicare.
The U.S. is expected to need 52,000 more primary care physicians by 2025, according to a study by the Robert Graham Center, which does family medicine policy research. But funding for teaching hospitals that could train thousands more of these doctors expires in late 2015.
Population growth will drive most of the need for family care doctors, accounting for 33,000 additional physicians, the study says. The aging population will require about 10,000 more. The Affordable Care Act is expected to increase the number of family doctors needed by more than 8,000, the study says.
Farzan Bharucha, a health care strategist with consulting firm Kurt Salmon, says the ACA should have focused more on the primary care shortage “because we already knew there was a problem — and we knew implementation of ACA would potentially make it worse.”
Health and Human Services spokeswoman Erin Shields Britt says continuing to build the primary care workforce will take time, but she notes President Obama’s budget working its way through Congress has several new ways to expand the primary care workforce, which includes nurse practitioners and pediatricians. The ACA, she says, significantly increases the number of primary care providers in underserved areas and increases Medicare and Medicaid payment for services delivered by primary care practitioners.
Health care costs have risen to $23,215 a year for the typical family of four that gets insurance through work, according to a new report from Milliman Inc., Seattle-based consultants and actuaries.
Although employers pay the largest portion of that health tab at 58 percent (or $13,520) per year, an increasing share of costs has shifted to workers and their families, the Milliman report notes. Workers pay health costs through payroll deductions ($5,908 annually) and out-of-pocket expenses ($3,787).
Health policy analyst Edmund Haislmaier says employees actually end up paying all of the costs because their health plans cut into cash wages.
“If that money wasn’t spent on the employee’s health plan, it would be available for higher wages or more retirement savings,” Haislmaier, asenior research fellow with The Heritage Foundation, told The Foundry.
Health care costs for Americans continue to rise, but the overall annual rate of increase for a family of four is at its lowest since Milliman began calculating costs in 2002. In almost every year for the past 10, the growth rate for family health spending has slowed, the report says.
“That’s because of what’s going on in the way employers and families buy health care and how health care is delivered,” Haislmaier said. “It’s not just fluctuations in the economy or new laws and regulations.”
So far, Milliman finds, “emerging reforms” required by the Affordable Care Act, or Obamacare, have had little direct impact on the cost of care for the typical family of four “because this family tends to be insured through large group plans.”
The report points to a combination of factors, some of which increase health spending, such as specialty drugs, while others decrease health spending, such as cost control measures taken by providers.
However, Obamacare’s upcoming tax on “Cadillac” plans (valued at $27,500 or more for a family of four) will prompt employers to scale back those large group plans to avoid penalties, the report notes.
Here’s what the Obama administration wants you to know about health insurance premiums under Obamacare: On average, people who selected subsidized insurance plans through the federally-run insurance exchange paid $82 a month, out of their own pockets, for health insurance. People who selected “silver” health plans—the most popular tier of coverage offered in the exchange—paid less: $69 per month, on average. Almost 70 percent of the people who signed up for subsidized plans through the federal exchanges are paying less than $100.
Those are the average premium prices that the Obama administration highlights in a press release touting a new government report on Obamacare and health premiums.
But there are several things to remember about those figures.
One is that they’re incomplete. The data released by the administration doesn’t account for premiums in the 14 states that ran their own exchanges this year.
Another is that those averages conceal an awful lot of variation. Even with the federally run exchange covering the majority of states, Obamacare varies quite a bit from state to state. Out of pocket insurance costs in Mississippi averaged about $23 a month, but came in at $148 in New Jersey. About a third of people buying subsidized coverage through the federal marketplace were paying more than $100. And the report focuses on the majority of participating individuals who bought subsidized coverage: 14 percent of people whoselected plans in the federal exchange through the end of open enrollment got no tax credits at all.
That’s another thing to remember: The administration’s premium averages are based on out-of-pocket costs after the law’s tax credits and subsidies are factored in. Those subsidies end up offsetting quite a bit of the cost of insurance under Obamacare. But if you strip away the subsidies, individual market health insurance has, on average, become significantly more expensive in the wake of Obamacare, according to a newly published analysis by the Manhattan Institute.
Relying on a 3,137 county comparison of the five cheapest individual plans available prior to Obamacare with the five cheapest plans through the exchanges, the study by health policy fellow Yevgeniy Feyman found that, on average, premiums were up 49 percent under Obamacare. Again, that’s an average, and it masks some variation—in New York, which had unusually restrictive, badly designed health insurance market rules prior to Obamacare, premiums are actually down quite a bit—but it indicates that the overall trend for unsubsidized premiums is up.
The difference, then, is being made up by federal subsidies. According to the administration’s report, those subsidies are carrying 76 percent of the total cost of subsidized insurance plans selected in the federal exchange. The out-of-pocket average is $82. But the actual average premium price, without subsidies, is $346.
To the extent that insurance is relatively cheap, it’s because taxpayers are footing a big chunk of the bill. Obamacare didn’t reduce the price of insurance; if anything it raised it—and then used tax revenues to cover the difference.
That’s frequently how subsidies work—they lower the out-of-pocket price tag, but, by separating consumers from meaningful price signals, they also distort markets in ways that drive up the overall cost, leaving the public to pick up the ever-growing tab.
LIFE IS NOT ONE HUGE HOSPITAL June 18, 2014 Rituparna Basu https://ari.aynrand.org/blog/2014/06/18/life-is-not-one-huge-hospital-2
Advocates of universal coverage seek to create a society in which, if you can’t afford health insurance, the government forces others to provide it for you. What is the moral defense for treating some people as slaves to the needs of others? At the American Medical Association’s JAMA Forum, Austin Frakt presents one argument (citing other scholars):
[T]here is a “social obligation to protect opportunity.”
From this, a lot follows. One’s opportunity is threatened by poor health. In sickness, one cannot learn or earn as efficiently, let alone enjoy the same length or quality of life. Therefore, protecting opportunity implies protection of access to health care services that promote and preserve health. And, it’s hard to argue with the notion that such access should be protected equally.
I have two comments:
First, “protecting opportunity” is a euphemism for destroying people’s opportunities. If the government forces Joe to spend a portion of his income footing Sandra’s medical coverage, Joe’s ability to pursue his own opportunities, such as the longest, highest-quality life for himself, is impeded. In practice, the “social obligation to protect opportunity” means the government sacrifices people who have earned opportunities to pursue better lives for themselves, for the sake of those who have not earned them.
Second, it’s true that life can be harder for Sandra when she’s sick compared to when she is healthy. But why does this impose an obligation on others to support her? In fact, it doesn’t. Other people’s medical needs, no matter what challenges they present these individuals, do notimpose an obligation on you.
I’m reminded of a passage from Ayn Rand’s “Apollo 11,” in which Rand memorably summarizes her response to the notion that need is a first mortgage on the time, efforts and lives of others:
Poverty is not a mortgage on the labor of others — misfortune is not a mortgage on achievement — failure is not a mortgage on success — suffering is not a claim check, and its relief is not the goal of existence — man is not a sacrificial animal on anyone’s altar nor for anyone’s cause — life is not one huge hospital.
Nothing justifies treating people as if they are the servants of others. Universal coverage is immoral.
Thousands to Be Questioned on Eligibility for Health Insurance Subsidies
By ROBERT PEARJUNE 15, 2014
WASHINGTON — The Obama administration is contacting hundreds of thousands of people with subsidized health insurance to resolve questions about their eligibility, as consumer advocates express concern that many will be required to repay some or all of the subsidies.
Of the eight million people who signed up for private health plans through insurance exchanges under the new health care law, two million reported personal information that differed from data in government records, according to federal officials and Serco, the company hired to resolve such inconsistencies.
The government is asking consumers for additional documents to verify their income, citizenship, immigration status and Social Security numbers, as well as any health coverage that they may have from employers. People who do not provide the information risk losing their subsidized coverage and may have to repay subsidies next April.
Federal subsidies for the purchase of private insurance are a cornerstone of the Affordable Care Act. More than eight out of 10 people who selected health plans through the exchanges from October through mid-April were eligible for subsidies, including income tax credits. So far this year the federal government has paid out $4.7 billion in subsidies, and the amount is expected to total $900 billion over 10 years.
Since June 1, the government has notified hundreds of thousands of people that “the information in your application doesn’t match what we found in other records.” Accordingly, the notice says, “you need to follow up as soon as possible and provide more documents to make sure the marketplace has the correct information.”
“If you don’t send the needed documents,” it says, “you risk losing your marketplace coverage or help you may be receiving to pay for such coverage.”
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