Health care reform in the United States has a long history. This article covers two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 (), which amended the PPACA and became law on March 30.
History of national reform efforts
Here is a summary of reform achievements at the national level in the United States. For failed efforts, State based efforts, native tribes services and more details generally, see the main article History of health care reform in the United States.
1965 President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital and general medical insurance for senior citizens paid for by a Federal employment tax over the working life of the retiree, and Medicaid permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states.
- Robert M. Ball, the then Deputy Director of the Bureau of Old-Age and Survivors Insurance in the Social Security Administration had defined the major obstacle to financing health insurance for the elderly several years earlier: the high cost of care for the aged and the generally low incomes of retired people. Because retired older people use much more medical care than younger, employed people, an insurance premium related to the risk for older people needed to be high, but if the high premium had to be paid after retirement, when incomes are low, it was an almost impossible burden for the average person. The only feasible approach, he said, was to finance health insurance in the same way as cash benefits for retirement, by contributions paid while at work, when the payments are least burdensome, with the protection furnished in retirement without further payment.
1997 The State Children's Health Insurance Program, or SCHIP, was established by the federal government in 1997 to provide health insurance to children in families at or below 200 percent of the federal poverty line.
2010 The Patient Protection and Affordable Care Act is enacted by President Barack Obama, providing for the phased introduction over four years of a comprehensive system of mandated health insurance with reforms designed to eliminate "some of the worst practices of the insurance companies" — pre-condition screening and premium loadings, policy rescinds on technicalities when illness seems imminent, lifetime and annual coverage caps. It also sets a minimum ratio of direct health care spending to premium income, and creates price competition bolstered by the creation of three standard insurance coverage levels to enable like-for-like comparisons by consumers, and a web based health insurance exchange where consumers can compare prices and purchase plans. The system preserves private insurance and private health care providers and provides more subsidies to enable the poor to buy insurance.
The 2010 Federal Reform Legislation
In March 2010, President Obama gave a speech at a rally in Pennsylvania explaining the necessity of health insurance reform and calling on Congress to hold a final up or down vote on reform. , the legislation remains controversial, with some states challenging it in federal court and opposition from some voters. Uninsured Americans, with the numbers shown here from 1987 to 2008, are a major driver for reform efforts
Expanding Medicaid and subsidizing insurance
The law includes health-related provisions that take effect over several years, including expanding Medicaid eligibility for people making up to 133% of the federal poverty level (FPL), subsidizing insurance premiums for people making up to 400% of the FPL ($88,000 for family of 4 in 2010) so their maximum "out-of-pocket" payment for annual premiums will be on sliding scale from 2% to 9.5% of income, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing health insurance exchanges, prohibiting insurers from establishing annual coverage caps, and support for medical research.
Guaranteed issue, community rating, individual mandate
Starting in 2014, the law will prohibit insurers from denying coverage (see guaranteed issue) to sicker applicants, or imposing special conditions such as higher premiums or payments (see community rating). Health care expenditures are highly concentrated with the most expensive 5% of the population accounting for half of aggregate health care spending, whereas the bottom 50% of spenders account for only 3%, which means that insurers' gains to be had from avoiding the sick greatly outweigh any possible gains from managing their care. As a consequence, insurers devoted resources to such avoidance at a direct cost to effective care management which is against the interests of the insured. Instead of providing health security, the health insurance industry had, since the 1970s begun to compete by becoming risk differentiators, seeking to insure only those with good or normal health profiles and excluding those considered to be or likely to become unhealthy and therefore less profitable. According to a study from Cambridge Hospital, Harvard Law School and Ohio University, 62% of all 2007 personal bankruptcies in the United States "were driven by medical incidents, with [75% having had] health insurance."
Also starting in 2014, the law will generally require uninsured individuals to buy government-approved health insurance the individual mandate. Government-run exchanges may present information to facilitate comparison among competing plans, if available, but previous attempts at creating similar exchanges "produced only mixed results." This requirement is expected to reduce the number of the uninsured from 19% of all residents in 2010 to 8% by 2016. Some analysts believe that the 8% figure of uninsured are expected to be mostly illegal immigrants (5%), with the rest paying the fine unless exempted. Whether or not this is true remains unclear based on presently available data.
Some analysts have argued that the insurance premium structure may shift more costs onto younger and healthier people. Approximately $43 billion was spent in 2008 providing unreimbursed emergency services for the uninsured and the Act's supporters argued that increased the average family's insurance premiums. Other studies claim the opposite: "The argument for reduced ER visits has been shown to be largely a canard...insuring the uninsured will lead to, very approximately, a doubling of health expenditures for the currently uninsured." The studies suggest that making insurance mandatory rather than voluntary will tend to bring younger, healthier people into the insurance pool, shifting the cost of the Act's increased spending onto them.
Efficacy of health insurance
The 2010 Acts require insurers to cover more costs, requiring that at least 80% of premiums must be spent on medical care or "quality improvement" (see loss ratio) and requiring full coverage for screenings and immunizations, and by prohibiting lifetime and annual caps. Some insurance schemes had been considered inadequate.
Some argue that expanding insurance coverage may lead to better health, while other studies claim the opposite. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States associated with lack of insurance. Other studies found less correlation,; see also  More broadly, a 1997 analysis estimated the number of people in the United States insured and uninsured who die per year because of lack of medical care was nearly 100,000. Recent reports have found that expanding coverage for psychiatric drugs has worsened the health of many children, who incur costly and lifelong side effects such as diabetes. However, many of these studies fail to disclose that such examples of "expanded coverage" focus on narrow, non-representative subpopulations and do not, for example, reflect the likely large net benefit for the much larger subpopulations that have diabetes, hypertension, and resulting chronic kidney disease, all of whom would likely benefit from expanded coverage.
Some opponents to the Act have claimed that "80,000 people a year are killed just by "nosocomial infections" infections that arise as a result of medical treatment." These claims however are tenuous at best since the incidence of nosocomical infections is not causally linked to expanded insurance coverage, especially when preventative measures are a key component of the new proposed regime, includiing numerous measures aimed to reduce the rate of hospitalization and re-hospitalization and improve primary prevention efforts in the outpatient setting. Opponents to the Act also point to a randomized study of almost 4,000 subjects done by Rand and concluded in 1982, which purportedly found that increasing the generosity of people's health insurance caused them to use more health care, but made almost no difference in their health status." The actual summary of the Rand study by Rand itself is quite different: "The poorest and sickest 6 percent of the sample at the start of the experiment had better outcomes under the free plan for 4 of the 30 conditions measured. Specifically, Free care improved the control of hypertension. The poorest patients in the free care group who entered the experiment with hypertension saw greater reductions in blood pressure than did their counterparts with cost sharing. The projected effect was about a 10 percent reduction in mortality for those with hypertension. Free care marginally improved vision for the poorest patients. Free care also increased the likelihood among the poorest patients of receiving needed dental care. Serious symptoms were less prevalent for poorer people on the free plan. Cost sharing also had some beneficial effects. Participants in cost sharing plans worried less about their health and had fewer restricted-activity days (including time spent in seeking medical care)."
Reduce the deficit
Reducing the deficit was another driver in health care reform. The reform legislation that passed was estimated by the Congressional Budget Office to reduce the deficit by $138 billion over 10 years. However, the CBO numbers are the subject of some debate.
Eliminate overpayment in Medicare Advantage
Medicare Advantage plans are offered by private insurers and provide benefits over and above coverage in Medicare Parts A and B and receive funding from the Medicare fund for taking on Part A and B coverage. However, under a revised contract made during the previous Bush presidency, Medicare was overpaying the private insurers. MedPAC estimated the overpayment as being approximately $12 billion a year. This meant that the average person in traditional Medicare was paying $90 a year as a subsidy to private insurers for which they received zero benefit and eliminating this overpayment would save $177 billion over ten years.
Political positions of the main parties
The Democratic Party supports the amended 2010 legislation. The Act aims to ensure health insurance is available to all citizens; to make more employers responsible for their workers' health insurance; to extend subsidies to middle income persons who have no employer insurance; and extend Medicaid to more people than had been the case previously. The Act directs federal spending to community health centers and to computerize health care records to encourage accurate sharing of data between health providers and reduce errors. The Act taxes expensive insurance plans and adjusts the split of Medicare funding between traditional Medicare and Medicare Advantage plans. The Act reforms payment systems and Medicare, which may reduce the perverse incentive system that pays hospitals with poor recovery records more than hospitals with better recovery records. The Act increases Medicare prescription drug coverage. President Obama said he had heard from Americans with pre-existing conditions whose lives depend on getting insurance coverage; stories of patients being denied coverage, and of families with insurance who are just one illness away from financial ruin. He said that the Act would protect people from the worst practices of the insurance industry. He said it would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. He claimed that if they did nothing, millions of Americans would lose their health care and the deficit would grow. He said that premiums would increase and patients would be denied the care they need, and that small business owners would continue to drop coverage altogether. He said he would not walk away from those Americans, and he urged others in Congress not to do so either. He highlighted that the American Medical Association considers the Act an improvement over the status quo. He challenged anyone, from either party, with a better plan that would bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, to let him know.
The GOP's official current position as represented by the House majority is that the Affordable Care Act should simply be repealed, leaving the law as it was previously. The House of Representatives voted for this in January 2011, though it is unlikely that the Senate would pass it and some expect that the President would veto any attempt at repeal. The Republicans' previous proposal for health care reform in 2009 would have placed people with pre-existing conditions who are unable to get affordable coverage into high risk insurance pools and would have continued the previous practice of allowing insurers to discriminate against them in terms of coverage and premiums. Republicans opposed the Affordable Care Act during passage. Not a single representative in the House or Senate voted in favor of the bill. This opposition was broadly based on objections to rises in taxation, especially of the so-called "Cadillac insurance plans" and the corollary increase in government spending on affordability subsidies. The GOP also objected to a new Health Insurance Rate Authority that would determine whether rate increases were "unreasonable" and to enforced rebates or premium reductions, and to any proposal that might have allowed government funds to subsidize abortion. The opposition declared the law to be a "government takeover of health care". One version of an original draft prepared in the House of Representatives did call for a "public option" (a public insurer as one extra choice for consumers, competing against private insurers). Some Republicans have contested the constitutionality of the individual health insurance mandate (a requirement to have medical insurance or else pay a fine). Both the government and the insurance industry have argued that this is a necessary prerequisite to achieve universality and equity for other insurance payers and to prevent people buying insurance only in time of need. The government argues that its constitutionality is covered under the Commerce Clause, whereas detractors argue that this is wrong. , this matter is still before the courts and so far three out of five federal court decisions have ruled in favor of it being constitutional and two against. Mitt Romney has said that the new law does not resemble the Massachusetts health care plan and did not support it. Some Republicans (for example Charles Grassley) as well as the conservative think tank Heritage Foundation previously supported an individual mandate, but no longer do. The same is true of the concept of the insurance exchanges which the bill sets up, which some Republicans and the Heritage Foundation once supported.
Betsy McCaughey, a health care analyst who came to political prominence after she helped defeat the Clinton health care plan of 1993, "got the ball rolling" in July and August 2009 when she called the bill "a vicious assault on elderly people" that will "cut your life short". McCaughey was joined in spreading the idea by other pundits and conservative media that had had helped defeat the Clinton era legislation, including The Washington Times and The American Spectator. According to The New York Times, McCaughey also falsely claimed that presidential advisor Dr. Ezekiel Emanuel thought that the disabled should not be entitled to medical care, which helped inspire Palin's warnings about "death panels". Both McCaughey and Palin's remarks about what Palin called an alleged 'death panel' were based on opinions about Ezekiel Emanuel and previous page 425 legislation.
Emanuel is an opponent of legalization of doctor-assisted suicide or euthanasia. FactCheck.org said, "We agree that Emanuel's meaning is being twisted. In one article, he was talking about a philosophical trend, and in another, he was writing about how to make the most ethical choices when forced to choose which patients get organ transplants or vaccines when supplies are limited." An article on Time.com said that Emanuel "was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources ... 'My quotes were just being taken out of context.'" Regarding page 425 of a health care bill, Congressman Earl Blumenauer (who sponsored the legislation) said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". Page 425 of this legislation is similar to end-of-life counseling that became law when George W. Bush was president.
A lot of the political debate centered on the prevention of the Federal funding of abortion with some groups claiming that abortion would become easier or would be financed by the government. In the legislation that was finally passed the existing law preserved the principle of no federal funding for abortion (except in cases of rape, incest, or to preserve the life of the mother). The law requires people to pay for that element of coverage with a separate check to create a specific fund which is not subsidized and which is used to fund these services. State insurance commissioners are charged with policing this "segregation of funds". Whether insurers in the exchanges can offer abortion coverage at all was left as a matter for individual States to decide. The default is that insurers will be allowed to offer abortion coverage as they do now unless a State passes legislation to the contrary.
According to Obama, America's health insurance industry has spent hundreds of millions of dollars to block the introduction of public medical insurance and stall other proposed legislation. There are six registered health care lobbyists for every member of Congress. The campaign against health care reform has been waged in part through substantial donations to key politicians. The single largest recipient of health industry political donations and chairman of the Senate Committee on Finance that drafted Senate health care legislation is Senator Max Baucus (D-MT). A single health insurance company, Aetna, has contributed more than $110,000 to one legislator, Senator Joe Lieberman (ID-CT), in 2009.
America's Health Insurance Plans, a lobby group funded by American private health insurance companies published its plans for health care reform in December 2008. The key elements called for co-ordinated national strategy for health care with insurance regulation set in a national framework but enforced by the states. It also called for a personal health care mandate requiring every American to have health insurance or face penalties. This, it said, was a necessary pre-requisite for guaranteed issue policies to prevent insurers from having to pre-screen applicants and set limits on coverage for pre-existing conditions, otherwise healthy people would put off buying insurance until they get sick. It also called for the establishment of body to reform the payment system (including a shift from fee-for-service to fee-for-quality-outcomes), and a body to undertake Comparative effectiveness research because it admitted that the current system was not effective at providing value for money or even best practice and computerization and standardization of health care records and claims processing. Most of the issues which AHIP called for in its plans have been implemented by the Obama administration and Congress in the reform process with the exception of a completely national framework for health care insurance regulation. Though the bill does place certain national rules for insurance to qualify as being "coverage" acceptable within the meaning of the individual mandate, states have retained the power under the reforms to regulate the industry and this was not put in a national framework.
Possible future reforms
The Patient Protection and Affordable Health Care Act 2010 contained provisions which allows the Centers for Medicare and Medicaid Services (CMS) to undertake pilot projects which, if they are successful could be implemented in future.
Universal health care
An analysis of the United States National Health Care Act by Physicians for a National Health Program who estimated the savings at $350 billion per year.
The universal health care proposal pending in Congress is called the United States National Health Care Act (H.R. 676, formerly the "Medicare for All Act.") The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings, probably because of the 40% cost savings associated with universal preventative care and elimination of insurance company overhead costs.
Balancing doctor supply and demand
The Medicare Graduate Medical Education program regulates the supply of medical doctors in the U.S. By adjusting the reimbursement rates to establish more income equality among the medical professions, the effective cost of medical care can be lowered.
A key project is one that could radically change the way the medical profession is paid for services under Medicare and Medicaid. The current system, which is also the prime system used by medical insurers is known as fee-for-service because the medical practitioner is paid only for the performance of medical procedures which, it is argued means that doctors have a financial incentive to do more tests (which generates more income) which may not be in the patients' best long term interest. The current system encourages medical interventions such as surgeries and prescribed medicines (all of which carry some risk for the patient but increase revenues for the medical care industry) and does not reward other activities such as encouraging behavioral changes such as modifying dietary habits and quitting smoking, or follow-ups regarding prescribed regimes which could have better outcomes for the patient at a lower cost. The current fee-for-service system also rewards bad hospitals for bad service. Some have noted that the best hospitals have fewer re-admission rates than others, which benefits patients, but some of the worst hospitals have high re-admission rates which is bad for patients but is perversely rewarded under the fee-for-service system.
Projects at CMS are examining the possibility of rewarding health care providers through a process known as "bundled payments" by which local doctors and hospitals in an area would be paid not on a fee for service basis but on a capitation system linked to outcomes. The areas with the best outcomes would get more. This system, it is argued, makes medical practitioners much more concerned to focus on activities that deliver real health benefits at a lower cost to the system by removing the perversities inherent in the fee-for-service system.
Though aimed as a model for health care funded by CMS, if the project is successful it is thought that the model could be followed by the commercial health insurance industry also.
2010 Patient Protection and Affordable Care Act details
Key provisions of the health-care legislation passed in March 2010 are:
Within one year of enactment (2010 2011)
- Insurance companies barred from dropping people from coverage when they get sick, ending the practice of rescission. Lifetime coverage limits eliminated and annual limits restricted.
- Young adults able to stay on their parents' health plans until age 26. Many health plans previously dropped dependents from coverage when they turned 19 or finished college.
- Uninsured adults with pre-existing conditions will be able to obtain health coverage through a new program for high risk pools that will expire once new insurance exchanges begin operating in 2014.
- Insurance companies cannot deny group or new (non-grandfathered) individual coverage to children under age 19 due to a pre-existing condition.
- A temporary reinsurance program is created to help companies maintain health coverage for early retirees between the ages of 55 and 64. This also expires in 2014.
Medicare drug plan beneficiaries who fall into the Medicare Part D coverage gap (the so-called "doughnut hole") will get a $250 rebate. The new law eventually closes that gap completely. (The old law required the sick person to pay 100% of their own annual medicine costs after $2,700 was spent in the coverage year and did not start again until after $6,154 was spent).
- A tax credit becomes available for some small businesses to help provide coverage for workers.
- A 10% tax on indoor tanning services that use ultraviolet lamps goes into effect on July 1.
Effective during 2011
- Medicare provides 10% bonus payments to primary care physicians and general surgeons.
- Medicare will cover the full cost of annual wellness visits and personalized prevention plan services for beneficiaries. New health plans will be required to cover preventive services with little or no direct cost to patients.
- A new program under the Medicaid plan for the poor goes into effect in October that allows states to offer home and community based care for the disabled that might otherwise require institutional care.
- Payments to insurers offering Medicare Advantage services are frozen at 2010 levels. These payments are to be gradually reduced to bring them more in line with traditional Medicare.
- Employers are required to disclose the value of health benefits on employees' W-2 tax forms.
- An annual fee is imposed on pharmaceutical companies according to market share. The fee does not apply to companies with sales of $5 million or less.
Effective as of 2012
- Physician payment reforms are implemented in Medicare to enhance primary care services and encourage doctors to form "accountable care organizations" to improve quality and efficiency of care.
- An incentive program is established in Medicare for acute care hospitals to improve quality outcomes.
- The Centers for Medicare and Medicaid Services, which oversees the government programs, begins tracking hospital readmission rates and puts in place financial incentives to reduce preventable readmissions.
- New tax reporting changes were to come in effect to prevent tax evasion by corporations and individuals. However, in April 2011 President Barack Obama signed a bill repealing this provision, because it was burdensome to small businesses. Under the existing law, businesses have to notify the IRS on 1099 form of certain payments to individuals for certain services or property over a reporting threshold of $600. The requirement was going to be changed so that payments to corporations and individuals must also be reported. Originally it was expected to raise $17 billion over 10 years. The amendments made by Section 9006 of the Act were originally intended to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.
Effective as of 2013
- A national pilot program is established for Medicare on payment bundling to encourage doctors, hospitals and other care providers to better coordinate patient care.
- The threshold for claiming medical expenses on itemized tax returns is raised to 10% from 7.5% of income. The threshold remains at 7.5% for the elderly through 2016.
- The Federal Insurance Contributions Act tax (FICA) is raised to 2.35% from 1.45% for individuals earning more than $200,000 and married couples with incomes over $250,000. The tax is imposed on some investment income for that income group.
- A 2.9% excise tax is imposed on the sale of medical devices. Anything generally purchased at the retail level by the public is excluded from the tax.
Effective as of 2014
- State health insurance exchanges for small businesses and individuals open.
- Individuals with income up to 133% of the federal poverty level qualify for Medicaid coverage.
- Healthcare tax credits become available to help people with incomes up to 400 percent of poverty purchase coverage on the exchange.
- Premium cap for maximum "out-of-pocket" pay will be established for people with incomes up to 400 percent of FPL. Section 1401 of PPACA explains that the subsidy will be provided as an advancable, refundable tax credit and gives a formula for its calculation. Refundable tax credit is a way to provide government benefit to people even with no tax liability (example: Child Tax Credit). According to White House and Congressional Budget Office figures, the maximum share of income that enrollees would have to pay for the "silver" healthcare plan would vary depending on their income relative to the federal poverty level, as follows: for families with income 133 150% of FPL will be 3-4% of income, for families with income of 150 200% of FPL will be 4-6.3% of income, for families with income 200 250% of FPL will be 6.3-8.05% of income, for families with income 250-300% of FPL will be 8.05-9.5% of income, for families with income from 300 to 400% of FPL will be 9.5% of income. In 2016,the federal poverty level is projected to equal about $11,800 for a single person and about $24,000 for family of four. See Subsidy Calculator for specific dollar amount.
- Most people required to obtain health insurance coverage or pay a tax if they don't.
- Health plans no longer can exclude people from coverage due to pre-existing conditions.
- Employers with 50 or more workers who do not offer coverage face a fine of $2,000 for each employee if any worker receives subsidized insurance on the exchange. The first 30 employees aren't counted for the fine.
- Health insurance companies begin paying a fee based on their market share.
- Medicare creates a physician payment program aimed at rewarding quality of care rather than volume of services.
- An excise tax on high cost employer-provided plans is imposed. The first $27,500 of a family plan and $10,200 for individual coverage is exempt from the tax. Higher levels are set for plans covering retirees and people in high risk professions.
Health reform and the 2008 presidential election
- Christensen, Clayton Hwang MD, Jason, Grossman MD, Jerome, ''The Innovator's Prescription'', McGraw Hill, 2009. ISBN 978-0-07-159208-6
- Terry L. Leap, Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to do about It (Cornell University Press, 2011).
- Mahar, Maggie, ''Money-Driven Medicine: The Real Reason Health Care Costs So Much'', Harper/Collins, 2006. ISBN 978-0-06-076533-0
Starr, Paul, The Social Transformation of American Medicine, Basic Books, 1982. ISBN 0-465-07934-2
- Malhotra, Umang, ''Solving the American Healthcare Crisis'', iUniverse, 2010. ISBN 978-1-4401-8018-7
Articles and links
Comparing Health Care Plans: A Guide to Reform Proposals, Committee for a Responsible Federal Budget
Doctors support universal health care: survey, Reuters, March 31, 2008 (first reported in Annals of Internal Medicine).
Health Care Reform Chronology 2010 2018, from Aon Corporation
Health Care Cost Survey Reveals High-Performing Companies Gain Health Dividend (2009) from Towers Perrin
Hidden costs, value lost: uninsurance in America. Institute of Medicine Committee on the Consequences of Uninsurance. Washington, DC: National Academies Press, 2003.
Paying More, Getting Less from Dollars & Sense
Reducing Costs While Improving the U.S. Health Care System: The Health Care Reform Pyramid by Deloitte, January 2009 (Broken link)
Sick Around the World: Can the U.S. learn anything from the rest of the world about how to run a health care system? from Frontline, PBS.
- Barack Obama - Town Hall Transcript - August 11, 2009
- Charlie Rose Show - Interview with Mayo Clinic President & CEO Denis Cortese
- The New Yorker-Atul Gawande-The Cost Conundrum-June 2009
- GAO-U.S. Financial Condition and Fiscal Future Briefing-2008
- President Obama Remarks by the President to a Joint Session of Congress on Health Care September 9, 2009
- News media
- Financial information
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