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Old 02-05-2011, 09:44 AM   #61
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I have no problem with a better bill. In fact I am very much in favor of changes. I just don't want to repeal the current bill before going there. If the current legislation is reversed I firmly believe it will be decades before we reform the system.
My thought exactly. Keep their feet to the fire.
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Old 02-05-2011, 09:55 AM   #62
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Will Medicare or Medicade be around much longer?

Peter Ferrara and Larry Hunter: How ObamaCare Guts Medicare - WSJ.com
Altogether, ObamaCare cuts $818 billion from Medicare Part A (hospital insurance) from 2014-2023, the first 10 years of its full implementation, and $3.2 trillion over the first 20 years, 2014-2033. Adding in ObamaCare cuts for Medicare Part B (physicians fees and other services) brings the total cut to $1.05 trillion over the first 10 years and $4.95 trillion over the first 20 years.
These draconian cuts in Medicare payments to doctors, hospitals and other health-care providers that serve America's seniors were the basis for the Congressional Budget Office's official "score"—repeatedly cited by the president—that the health-reform legislation would actually reduce the federal deficit. But Mr. Obama never disclosed how that deficit reduction would actually be achieved.

.
I've been trying to check the numbers in this quote, and I can't. The CBO reports that I've found don't do any numbers beyond 2019. Neither does Richard Foster (referenced by Ferrara).

The biggest cuts to hospitals that I can find is in subtitle E, section 3401 which is $157 million over the first 10 years in the CBO report. This is remarkably close (probably too close) to the $155 billion that the AHA agreed to early in the process "Under the plan, negotiated primarily by Senate Finance Committee Chairman Max Baucus (D-Mont.), hospitals would accept $155 billion in cuts if the administration and its congressional allies succeeded in extending health insurance to tens of millions of people who are now without coverage." Healthcare reform gets boost from hospital groups - Los Angeles Times Basically, if the gov't reduces the number of uninsured people showing up at the door, the hospitals lose less money on bad debts, and the hospitals are willing to send some of the savings back to the gov't.

So Ferrara's $3.2 trillion and $4.95 billion are a mystery.

http://www.cbo.gov/ftpdocs/113xx/doc11355/hr4872.pdf
https://www.cms.gov/ActuarialStudies...2010-04-22.pdf
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Old 02-05-2011, 10:09 AM   #63
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IIRC, while the Wyden/Bennett plan required everyone to pay into it, it was through the tax system, so there were no individual mandates like the type that are currently being challenged in the courts. Everyone with earned income pays into Medicare, and to the best of my knowledge, it has never seriously been challenged in the courts.
I liked the general concepts of the Wyden/Bennett plan. I believe it would have led to the demise of the employer based health insurance system - a desirable outcome in my opinion. I would be comfortable with changes along these lines. Just don't take away my Medicare Obamacare in the meantime
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Old 02-05-2011, 10:10 AM   #64
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I have no problem with a better bill. In fact I am very much in favor of changes. I just don't want to repeal the current bill before going there. If the current legislation is reversed I firmly believe it will be decades before we reform the system. In the meantime (probably most of my life) we will be back facing the potential to lose coverage at the whim of carriers in many (most?) states.

A significant part of my concern is my personal situation. My daughter has a pre-existing condition. That is as much my problem as hers if she ends up uninsured. Should she encounter devastating HC costs because of a catastrophic illness I would end up cutting my ER lifestyle to the bone to help her before I would toss her under the bus. With mandatory coverage the scenario is much more rosy. As long as she is covered by insurance catastrophic HC costs won't bankrupt me. Even if she becomes disabled I could easily afford to support her in my home or elsewhere. But I couldn't afford endless medical costs. I wouldn't face those costs in most other developed countries and I don't want to face them here.

While the concerns I expressed are personal I see similar concerns regularly expressed on this board. Lots of potential retirees are afraid to leave work because they fear they could lose coverage due to pre-existing conditions. In my opinion, the current unsatisfactory situation is far preferable to the previous worse situation - it is as simple as that. Change, sure. A return to the previous status, horrible.
My feelings also. I really do not like the new laws mandate but I like some features of the law better than what we had in some areas. If they were serious about improving it there would be just a replace bill not a repeal first. I think if it is repealed there will not be a replacement.
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Old 02-05-2011, 10:11 AM   #65
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In last week's issue, Newsweek Magazine had an article about one tiny aspect of health care costs.

The Debate Over Digital Mammograms - Newsweek

The conclusion was that newer technology is preceived to be automatically better....even when it does not improve the outcomes of an illness. And that there is pressure to "buy new" and spend money without any improvement in health care.

I don't mean to be representing Newsweek as the current healthcare tattle-tell, but there was an interesting article in the prior week's magazine as well.

Why Almost Everything You Hear About Medicine Is Wrong - Newsweek


This discussed how shabby so much of "medical drug research" really is. And that this research is often reflected in medical practices when it does little to improve care. The one sentence that stuck me in this article is that when research about a drug results in a "negative" conclusion (meaning the conclusion is that the drug does NOT do what they meant it to do), the publication of that research may be delayed, sometimes for years, so that physicians continue to prescribe it and the drug company can continue to make money.

My conclusion is that the health care system is for sale to anyone to wants to make money from it, and that's why costs are so high. And providing good patient care is not important except to well-meaning providers who are doing the best they can to meet patient care needs.
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Old 02-05-2011, 10:17 AM   #66
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I have no problem with a better bill. In fact I am very much in favor of changes. I just don't want to repeal the current bill before going there. If the current legislation is reversed I firmly believe it will be decades before we reform the system.
At the (big) risk of mis-stating your position, I think the internal reasoning might go:

"I think the present bill has important faults. But, I don't think we have the national consensus or the political will/courage to do anything better right now. We just had a bruising, damaging political brawl over this, and we are bitterly divided and 'fought out.' The new law has flaws that will become evident and we can fix these individual problems as they present themselves--they will be smaller, more evident, and more manageable to resolve than trying to re-think everything. We can incrementally improve until what we end up with reflects what the people, through their representatives, want. If we repeal everything, we are back to the big untacklable questions and everything is in chaos for a few years or decades."

I can understand that this line of reasoning. I can even see a case where the present law eventually turns into something I'd much rather see: Costs get so high that employers make the rational decision to pay the fines and dump everyone into the exchanges--good. With everyone in the exchanges, we have the makings of a private market--good. Maybe that will make it easier to get costs under control, but only if the costs are not transferred to a different third party--the taxpayers. Medicare, Social Security, government spending in general: We don't have good record of controlling costs when we lump them together and "somebody else" ("the rich", the next generation, etc) will pay the bill. OTOH, we have an excellent record of controlling costs when individuals pay for what they use. We just have to get a balance--Granny can't pay for her liver transplant if she needs one.

If the GOP is smart, they'll build a marketable "replacement" bill to complement their "repeal" campaign. The present bill is not popular, but elements of it are. Basically, people like the idea of more benefits, but don't like to pay for them. Big surprise. If a GOP replacement bill can be constructed that gets us to a better place more quickly than the current path (including all the incremental fixes we already see are coming--make them from the start), then maybe they can sell this. Unfortunately, it's a complex problem and the voters don't do well with complex problems.

Time is not on the GOP's side. Once the subsidy flows begin, the "tyranny of the majority" aspect of democracy will effectively take over and we'll have a new, unsustainable entitlement forever. That, I think, is the main driver for rapid legislative repeal or a judicial overturn of this law. I agree with that objective both for the "political" reason and because I think we'll be in a better place faster if we build a better foundation from the start. But I could certainly be wrong.
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Old 02-05-2011, 10:18 AM   #67
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I have no problem with a better bill. In fact I am very much in favor of changes. I just don't want to repeal the current bill before going there. If the current legislation is reversed I firmly believe it will be decades before we reform the system.
OK, but IMO no faction of Congress is going to be able to repeal this w/o also offering up a replacement for much of it.

There is a segment of the population that is helped out by portions of the bill (as in your family's case, and probably mine to a lesser extent). There will be a lot of dramatic (and often justified) screaming from those corners if things are simply repealed w/o some replacement.

We can agree to disagree on this, it is just speculation anyhow, but I think we have a better chance of getting something positive accomplished by using this bill as a "prototype-dry-run-exercise", throwing it out, and now putting together something that really works and addresses cost and the ties to employment and all the other bugaboos.

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Old 02-05-2011, 10:23 AM   #68
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I liked the general concepts of the Wyden/Bennett plan. I believe it would have led to the demise of the employer based health insurance system - a desirable outcome in my opinion. I would be comfortable with changes along these lines. Just don't take away my Medicare Obamacare in the meantime
donheff,

I know you followed the health care debate closely. Why do you suppose the Senate Democrats never got behind Wyden/Bennett? I believe it had 30 co-sponsors, about half of whom were Republicans. Also, it was closer to (and IMO, better than) the original House bill than Obamacare.
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Old 02-05-2011, 10:58 AM   #69
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Interesting article written by Ron Wyden and Robert F. Bennett that appeared in the Washington Post on August 5, 2009:

How We Can Achieve Bipartisan Health Reform


We refuse to let partisanship kill health reform -- and we are proof that it doesn't have to.

As 12 U.S. senators from both sides of the aisle who have widely varying philosophies, we offer a concrete demonstration that it is possible to find common ground and pass real health reform this year. The process has been rocky, and slower than many had hoped. But the reports of the death of bipartisan health reform have been greatly exaggerated. Now is the time to resuscitate it, before the best opportunity in years is wasted.

Democratic activists have long campaigned for universal coverage and quality benefits. Republican activists zero in on empowering individuals and bringing market forces to the health-care system. Our approach does both. In our discussions on the Healthy Americans Act, each side gave a bit on some of its visions of perfect health reform to achieve bipartisanship.

The Democrats among us accepted an end to the tax-free treatment of employer-sponsored health insurance; instead, everyone -- not just those who currently get insurance through their employer -- would get a generous standard deduction that they would use to buy insurance -- and keep the excess if they buy a less expensive policy.

The Republicans agreed to require all individuals to have coverage and to provide subsidies where necessary to ensure that everyone can afford it. Most have agreed to require employers to contribute to the system and to pay workers wages equal to the amount the employer now contributes for health care. The Congressional Budget Office has reported that this framework is the only one thus far that bends the health-care cost curve down and makes it possible for the new system to pay for itself. It does this by creating a competitive market for health insurance in which individuals are empowered to choose the best values for their money and by cutting administrative costs and spreading risk across large groups of Americans.

First, we allow all Americans to have the same kind of choices available to us as members of Congress. Today, more than half of American workers who are lucky enough to have employer-provided insurance have no choice of coverage. Members of Congress who enroll their families in the Federal Employees Health Benefits Program often have more than 10 options. This means that if members of Congress aren't happy with their family's insurance plan in 2009 or insurers raise their rates, they can pick a better plan in 2010. Our plan would give the consumer the same leverage in the health-care marketplace by creating state-run insurance exchanges through which they can select plans, including their existing employer-sponsored plan.

Beyond giving Americans choices, our approach also ensures that all Americans will be able to keep that choice. We believe that at a time when millions of Americans are losing their jobs, members of Congress must be able to promise their constituents that "when you leave your job or your job leaves you, you can take your health care with you." Our approach ensures seamless portability.

Our point is not that our framework is the only way to reform the system or to reach consensus. But our effort has shown that it is possible to put politics aside and reach agreement on reforms that would improve the lives of all Americans. Insisting on any particular fix is the enemy of good legislating. A package that will entirely please neither side, but on which both can agree, stands not only the strongest chance of passage but also the best chance of gaining acceptance from the American people.

We didn't undertake this effort because we thought it would be easy; in fact, we started working together because we knew it would be hard. Passing health reform is going to require that we take a stand against the status quo and be willing to challenge every interest group that is jealously guarding the advantages it has under the current system, because health reform isn't about protecting the current system or preserving the advantages of a few. We can't forget that we are working on life-and-death issues facing our constituents, our families, our friends and our neighbors.

It's time to stop trying to figure out what pollsters say the country wants to hear from us and focus on what the country needs from us. The American people can't afford for Congress to fail again.

Ron Wyden is a Democratic senator from Oregon. Robert F. Bennett is a Republican senator from Utah. The other authors of this op-ed, and co-sponsors of the Healthy Americans Act, are Sens. Debbie Stabenow (D-Mich.), Ted Kaufman (D-Del.), Daniel K. Inouye (D-Hawaii), Mary Landrieu (D-La.), Joseph I. Lieberman (I-Conn.), Bill Nelson (D-Fla.), Judd Gregg (R-N.H.), Michael D. Crapo (R-Idaho), Lindsey O. Graham (R-S.C.) and Lamar Alexander (R-Tenn.).
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Old 02-05-2011, 11:00 AM   #70
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donheff,

I know you followed the health care debate closely. Why do you suppose the Senate Democrats never got behind Wyden/Bennett? I believe it had 30 co-sponsors, about half of whom were Republicans. Also, it was closer to (and IMO, better than) the original House bill than Obamacare.
Mystery to me and I tried to figure out how Wyden ended up getting steamrolled at the time. His plan was a much better plan.
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Old 02-05-2011, 11:22 AM   #71
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donheff,

I know you followed the health care debate closely. Why do you suppose the Senate Democrats never got behind Wyden/Bennett? I believe it had 30 co-sponsors, about half of whom were Republicans. Also, it was closer to (and IMO, better than) the original House bill than Obamacare.
I don't know. I liked the proposal. I suspect the powers that be were too beholden to the unions to head this way. While I tend to rant against the GOP and support many Democratic initiatives the Dems can be complete D**k heads on a lot of things.
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Old 02-05-2011, 11:22 AM   #72
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I just read through the articles that Silver provided links to.

I am no expert in why medical care costs so much, but I have observed this tendency in people surrounding me, including my immediate family. We always want to have the very very newest technology, the newest drugs. For self-preservation, we want to live forever, costs be damned. No matter how little a chance that the cure may work, we want it. Of course it is easier to demand something when we do not have to sell our house and liquidate all of our accounts to pay for it.

But these new things may not work at all. Still, no matter. We do not want to believe that some of the new-fangled stuff may just be placebos, and expensive ones at that. There are many contributing factors to the problem we have. Yet, "mea culpa" is not often observed in this society.
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Old 02-05-2011, 12:01 PM   #73
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I suspect the powers that be were too beholden to the unions to head this way.
Me too.

Even though my extended family has benefitted extensively over the years from public sector unionization, I've cringed at a number of fed gov't actions involving the bailouts, Obamacare and other things that were blatantly paybacks for political support. Many just seemed so "Chicago" and products of "Da Machine."
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Old 02-05-2011, 12:02 PM   #74
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If we look at the bigger picture, we now spend approx 6% of our GDP on all these defense/foreign aid things. We spend 16% of GDP on health care today. Does anybody think that the new legislation, mandating more medical care for more people, is going to reduce that cost? If not, then we can see that, once the government health care assimilation is complete, all our defense and foreign aid for the entire year will pay for about 4 months of PPACA-care.
I'm pretty sure there is still a little bit of private spending in that 16% of GDP that goes to health care. "Only" half of health care spending goes through government controlled and operated (VA) health care, or a national single payer (Medicare/Medicaid/Tricare/SCHIPS) plan. The other half (~8% of GDP) goes through care paid by private insurance or out-of-pocket.

We could shut down all government health care, and effectively throw everyone into out-of-pocket or private insurance. I suspect we'd wind up somewhere around 10-12% of GDP, as some of the folks on government plans would manage to scrape up private insurance premiums or at least pay out of pocket for as much care as they could afford.

This is the model used in most countries, primarily the so-called 'Third World' nations. Unlike those countries, however, we would still have a guild-style system backed by government regulation working to constrain the supply of trained medical providers. On the other hand, folks in the US don't have access to the Diba or Mori-men. (DD just published on care in rural Sierra Leone. Eeep!)
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Old 02-05-2011, 03:07 PM   #75
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Removing all the "we're wonderfully bipartisan" paragraphs in the Wyden/Bennett article, I get this:

Quote:

The Democrats among us accepted an end to the tax-free treatment of employer-sponsored health insurance; instead, everyone ... would get a generous standard deduction that they would use to buy insurance -- and keep the excess if they buy a less expensive policy.

The Republicans agreed to require all individuals to have coverage and to provide subsidies where necessary to ensure that everyone can afford it. Most have agreed to require employers to contribute to the system and to pay workers wages equal to the amount the employer now contributes for health care.
This is essentially a voucher where you get to keep part of the voucher if you buy a cheaper plan. No description here about what taxes we'll raise to fund the vouchers for people who don't currently have group insurance.

I think one positive of this idea is that it provides universal coverage.
Then they say

Quote:
... this framework is the only one thus far that bends the health-care cost curve down and makes it possible for the new system to pay for itself. It does this by creating a competitive market for health insurance in which individuals are empowered to choose the best values for their money and by cutting administrative costs and spreading risk across large groups of Americans.
I'm very skeptical about that. Health care is far more complex and emotional that most things we buy. When the time comes to decide whether another few physical therapy sessions, or back surgery, or a digital mammogram is really worth the extra money, people will still be spending "somebody else's money". I could imagine keeping the vouchers low enough that people would have to accept high deductibles, but they describe the vouchers as "generous".

On the administrative expense side, they're claiming that individual private health insurance has lower administrative expenses than our current group private health insurance or than Medicare. I'm skeptical. They claim there is a CBO report supporting this, I guess my next step is to go looking for that report.

Edit: found a source, haven't read it yet http://cboblog.cbo.gov/?p=91
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Old 02-05-2011, 03:17 PM   #76
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I have no problem with a better bill. In fact I am very much in favor of changes. I just don't want to repeal the current bill before going there. If the current legislation is reversed I firmly believe it will be decades before we reform the system. In the meantime (probably most of my life) we will be back facing the potential to lose coverage at the whim of carriers in many (most?) states.(snip)
OK, but IMO no faction of Congress is going to be able to repeal this w/o also offering up a replacement for much of it.(snip)
We can agree to disagree on this, it is just speculation anyhow, but I think we have a better chance of getting something positive accomplished by using this bill as a "prototype-dry-run-exercise", throwing it out, and now putting together something that really works and addresses cost and the ties to employment and all the other bugaboos.

-ERD50
But what if the lawsuits succeed all the way up to the Supreme Court? Wouldn't that result in repeal of the existing law, with no replacement?
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Old 02-05-2011, 03:22 PM   #77
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When the time comes to decide whether another few physical therapy sessions, or back surgery, or a digital mammogram is really worth the extra money, people will still be spending "somebody else's money". I could imagine keeping the vouchers low enough that people would have to accept high deductibles, but they describe the vouchers as "generous".
Observation: The whole dynamic of the "how much care do I want to buy" decision hinges on whether this decision is made in advance (whether to choose a "no frills" or "with everything" insurance plan) or at the time of service ("the copay for the next therapy session is 25%, which is $100 out of my pocket. Does my back hurt that much?").

The "no-frills" plans would be cheap and lean--and mean. They'd offer care based strictly on what some care optimization board decided was worthwhile. Probably palliative care only for 80+ YOs with cancer. Expect to share a room when in the hospital. Expect to see a lot of PAs rather than MDs. Lots of older "good enough" drugs rather than the optimum choice. The higher cost plans would offer more extensive care.
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Old 02-05-2011, 03:30 PM   #78
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(snip) When the time comes to decide whether another few physical therapy sessions, or back surgery, or a digital mammogram is really worth the extra money, people will still be spending "somebody else's money". I could imagine keeping the vouchers low enough that people would have to accept high deductibles, but they describe the vouchers as "generous".(snip)
How do other countries that already have universal health coverage solve this problem? In the UK, as I understand it, all health care is paid for with "someone else's money" (i.e. tax funded single payer). I think it was the doctor from the UK who stated frankly during his interview that some of his patients weren't really sick, they made appointments basically because they were lonely. Yet even so, the UK's system costs them less than ours costs us.

Maybe such superfluous appointments and treatments are not really that significant a cause of our high costs here in the US.
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Old 02-05-2011, 04:05 PM   #79
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But what if the lawsuits succeed all the way up to the Supreme Court? Wouldn't that result in repeal of the existing law, with no replacement?
Yes, but that is different from Congress (who need votes) doing it.

If the SC repeals it, I would expect action by Congress to get a new, Constitutional bill in place. I'll cross my fingers they do a better job the 2nd time around. From what I've seen of the discussion here on this Wyden/Bennett proposal, it sounds on the right track (haven't been through the details though).

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Old 02-05-2011, 04:17 PM   #80
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Yes, but that is different from Congress (who need votes) doing it.

If the SC repeals it, I would expect action by Congress to get a new, Constitutional bill in place. I'll cross my fingers they do a better job the 2nd time around. From what I've seen of the discussion here on this Wyden/Bennett proposal, it sounds on the right track (haven't been through the details though).

-ERD50
I hope you're right about Congress taking action to get a new bill in place if the SC repeals the current bill. Is it too much to hope for our elected representatives to put their differences aside and do their best to write and pass the best health care bill possible? If they fail, I vote for sending our crack team of moderators up to Capitol Hill to get the political ranting out of the process and set 'em straight.
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