This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Remarks by the President in Town Hall on Health Care
The White House
Grand Junction, Colorado
August 15, 2009
Question: As a child I had polio, and I had a series of surgeries, 52 of them, to correct my poor structure of bones — between here, Denver, Montrose, and the Mayo Clinic in Phoenix, Arizona. I have been blessed with a good insurance, generally excellent doctors and care. However, my major concern in cost, even with good — even with a good insurance, the cost has been high, practically when I have been gone out of the network. Why should our doctor treatment choice be limited by a geographic area or the state? What kind of competition is this, Mr. President? (Applause.)
The President: This raises an important question, because it goes to the overall debate that’s taking place out there right now. When we talk about reform, you hear some opponents of reform saying that somehow we are trying to ration care, or restrict the doctors that you can see, or you name it. Well, that’s what’s going on right now. It’s just that the decisions are being made by the insurance companies.
Now, in fairness, we probably could not construct a system in which you could see any doctor anywhere in the world anytime, regardless of expense. That would be a hard system to set up. So if you live in Maine, you know, we’re going to fly you into California, put you up. I mean, you can see — and I’m not trying to make light of it — you can just see the difficulty.
So any system we design, there are going to have to be some choices that have to be made in terms of where you go to see your doctor, what’s going on, et cetera. That’s being done currently in the private marketplace.
(President Obama then uses this as a segue to discuss other aspects of reform.)
“So if you live in Maine, you know, we’re going to fly you into California, put you up.”
Obviously, giving someone who lives in Maine the choice of having the option for an expense-paid trip to California to receive health care is not one of the goals of health care reform. That’s not exactly what is meant by choice. This was an exaggeration on the part of the President to make the point that, of course, we can’t have choice.
And the reason we can’t have choice? Because the politicians have decided on a model of reform using private insurers that take away choice by mechanisms such as limiting the panels of contracted providers. He blames the insurance companies for this, but then accepts the intrusive role of the private insurers as inevitable because we “… could not construct a system in which you could see any doctor…”
This bungled response was not because President Obama doesn’t understand the policy issues. Clearly he does. He knows that a single-payer Medicare-for-all program would provide patients with free choice of their physicians. But he also realizes that he has made a policy decision that would not allow that. Thus the diversion into the all-expense-paid transcontinental trip. Oh wait… that’s only for the insurance executives.
Tell President Obama and Congress that we demand to have free choice of our own physicians. No more private insurers’ closed panels that take away our choices.
As the leading proposal out of the gate for health care reform in this session of Congress, the House bill (H.R. 3200, America’s Affordable Health Choices Act) during this August recess stage is considered the most robust of the various proposals so far coming out of congressional committees. This act has an overall goal to “reform the insurance marketplace to ensure that everyone can purchase quality, affordable health insurance coverage”. It would do so by creating a not-for-profit public option to compete with private insurers in an attempt to “keep them honest.” The public option would be offered to individuals and small businesses through a National Health Insurance Exchange whereby people can comparison-shop among available plans. Most operational details as to how these exchanges would actually work are still unclear.
As we saw in a prior post, the public option has generated intense opposition from the insurance industry, other stakeholders in the medical-industrial complex, Republicans, Blue Dog Democrats, and conservative astroturf groups. Even in the House, where the public option has stronger support, it has been whittled down to at best a small program available perhaps to only 10 million uninsured and small businesses, hardly a big threat to the insurance industry. In the powerful Senate Finance Committee, the public option has been pushed off the table in an attempt to gain bipartisan support through a compromise – creation of co-ops, a concept advanced by Senator Kent Conrad (D-N.D.). Even more nebulous operationally than exchanges, the idea is that people and small businesses would be able to buy co-op memberships through state insurance exchanges. These co-ops would be not-for-profit and would include members in their governance, thereby removing the perception among opponents of a “government-run” program. On the House side, a recent amendment to H.R. 3200 by the Energy and Commerce (E & C) Committee also called for establishment of member-run co-ops to provide coverage through the Exchange.
So do these sound like reasonable approaches to our health care problems? After all, co-ops sound as American as apple pie, and we have some good examples in such long-standing integrated health plans as Group Health Cooperative of Puget Sound.
Unfortunately, the main problem with these approaches is that they won’t work. They will add to the complexity and bureaucracy of our fragmented system, cost more instead of less, and fail to reform the insurance marketplace. In fact, private insurers will find health reform, even if enacted along the lines of H.R. 3200, to be another bonanza assuring new revenue streams for years to come.
If enacted, exchanges and co-ops offering a small public option will only raise hopes for reform that will never come, and are therefore a cop-out for those shaping this year’s reform attempt. Here are just some of the many reasons that health insurance exchanges are bound to fail:
- H. R. 3200 restricts access to coverage through the Exchange to individuals who are not enrolled in qualified or grandfathered employer or individual coverage, Medicare, or Medicaid (with some exceptions).
- The public option will not be implemented until 2013, or perhaps only until private plans have been shown not to save money ( the so-called “trigger”).
- Because of its relatively small market share, the public option will not have enough market clout to counteract the practices of private insurers, and will become the only option for sicker people with higher-cost care.
- There are almost no restraints on insurance premiums in any of the proposals; an amendment by the House E & C Committee limits premium increases to no more than 150 percent of the annual percentage increase in medical inflation, and provides exemptions if this would “limit a health plan’s financial viability.”
- In order to avoid competition, the insurance industry has successfully lobbied to prevent premiums for a public option to be much lower than those of private plans.
- There are no good examples yet of successful exchanges. California has 15 years’ experience with an exchange, and it has been a failure. A July 2009 Issue Brief by the California HealthCare Foundation details its problems and demise. It was initially intended to “provide an easy to navigate single point of entry where people could go to choose among several health plans, reduce the cost of coverage (using three primary mechanisms: reduce administrative costs by achieving economies of scale, command lower prices, and foster market competition), and enhance portability of coverage.” None of those objectives were achieved.
Instead, the California Exchange achieved few administrative efficiencies, lacked pricing power, and was burdened by adverse selection of sicker enrollees. Private insurers gamed the system and loaded up the Exchange with people with more expensive illnesses. Despite large start-up funding, the experiment was unsustainable, and was shut down in 2006.
If we would only pay attention to history, we would know that co-ops will fare no better than exchanges. Many co-ops were started during the 1930s in the years of the Great Depression, only to fail in most instances despite initial government subsidies. Most of these co-ops never reached sufficient size to either become financially viable or to counteract market problems. Only a few have succeeded over the years. An excellent example is Group Health Cooperative in Washington State, which today has some 600,000 members in an effective integrated health care system. But despite its reliance on salaried physicians in a large well-managed group practice, it still has to compete against its competitors and has almost as much trouble containing costs. Group Health today has only a 9 percent market share in Washington State. It has increased its premiums by an average of 12.3 percent a year since 2000 (four times the rate of inflation), and is raising its premiums in 2009 by 13 percent (compared with 17 percent by Regence BlueShield).
Proponents of co-ops today grossly underestimate the difficulty in setting up co-ops, both in terms of start-up costs and lead times in the best of cases. It took Group Health 62 years to reach an enrollment of 500,000, which many health analysts figure is the minimal viable size. As a champion of co-ops, Senator Conrad acknowledges that start-up funding would be high for co-ops, requiring some $4 billion, while others estimate $10 billion. (Ibid, Sack above)
So where does all this leave us in this summer of discontent over health care? Despite the vigorous efforts of the Administration and many members of Congress, exchanges and co-ops won’t work. They won’t make health insurance more affordable. They are a political compromise position in an effort to gain bipartisan support for a bad health care bill. Beyond not fixing the insurance problem, they won’t contain runaway costs of health care. But that is the subject of the next post.
Adapted from Do Not Resuscitate: Why The Health Insurance Industry Is Dying, and How We Must Replace It, and The Cancer Generation: Baby Boomers Facing a Perfect Storm, with permission from the publisher, Common Courage Press.
John Geyman, M.D. is the author of The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008 by John Geyman. With permission of the publisher, Common Courage Press
Buy John Geyman’s Books at: http://www.commoncouragepress.com
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
We are proud of the NHS
By David Cameron
The Blue Blog
August 13, 2009
People still care about the issues they care about, and thanks to the internet they can voice their concerns whenever they want. Just look at all the support which the NHS (National Health Service) has received on Twitter over the last couple of days. It is a reminder – if one were needed – of how proud we in Britain are of the NHS.
Millions of people are grateful for the care they have received from the NHS – including my own family. One of the wonderful things about living in this country is that the moment you’re injured or fall ill – no matter who you are, where you are from, or how much money you’ve got – you know that the NHS will look after you.
That’s why we as a Party are so committed not just to the principles behind the NHS, but to doing all we can to improve the way it works in practice. So yes, we will spend more on the NHS, but we will also improve it so that it is more efficient and responsive to patients. People working on the frontline will actually be able get on with the job they signed up for, without getting tied up in a web of targets. And we will put more power in the hands of patients by giving them better information about the care they can expect to receive.
Underlying these reforms, and our whole approach to the NHS, will be one big ambition – that future generations will be even prouder of the NHS than we are today.
The Right Honourable David Cameron MP is the leader of the Conservative Party in the United Kingdom. Many believe that he will replace Gordon Brown as Prime Minister.
For those of us in the United States who want to know more about the horrors of their government-run, socialist system of health care, Conservative David Cameron would be the first to expose how government ownership and management are a threat to the health of the people. But that is not his message.
As he says, “One of the wonderful things about living in this country is that the moment you’re injured or fall ill – no matter who you are, where you are from, or how much money you’ve got – you know that the NHS will look after you.” He has joined the people of his nation in supporting the NHS, in reaction to the outrageous distortions and lies being propagated in the United States.
Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP) recently stated, “As the American people have learned the facts, support for a government-run plan has plummeted.”(AHIP release, Aug 4)
What facts? Lies about the United Kingdom’s NHS? Lies about Canada’s medicare? Or lies about the consequences of providing all of us the benefits of our Medicare program which is working so well for our senior citizens and individuals with long-term disabilities?
The British and Canadians have identified the lies and are waging a campaign to set the record straight. We need to greatly intensify our efforts to do the same here.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
End-of-Life Care: Where Ethics Meet Economics
By Uwe Reinhardt
The New York Times
August 14, 2009
… the debate — really, shouting match — over health-care reform has focused on end-of-life care in recent weeks…
An earlier report in The Wall Street Journal had quoted physicians at Memorial Sloan-Kettering Canter Center in New York stating that “the standard treatment regimen for advanced colon cancer, which can include Erbitux [and Eloxatin and Avastin] in the mix, is close to $250,000 for 19-20 months of treatment. … And for that money, patients may get only a few months [of added life].”
And therein lies a dilemma increasingly faced by modern societies.
Readers are well advised to read Senator Isakson’s thoughtful comments on end-of-life planning, along with an equally thoughtful research brief “Advance Care Planning: Preferences for Care at the End of Life,” published in March 2003 by the Agency for Health Care Research and Quality.
The thrust of that research brief, as of the Senate bill and of Section 1233 of the House bill, was to enhance the probability that the end-of-life care actually received by a person should conform to his or her own preferences, rather than either the physician’s or the government’s preferences.
Health spending in the United States has doubled every 10 years during the past four decades. It may well do so again in the coming decade. As health spending grows year after year roughly twice as fast as the payroll that supports private health spending in this country, Americans sooner or later will have to confront the hard questions about access to expensive treatments, perhaps after a rational national conversation, if such can still be had in America.
Posted reader comment:
Ethics meets economics not only at the end of life, but throughout a lifetime of health care. Economics provides us with various alternatives on financing health care, and ethics provides us with the decency to do it the right way.
But the pervasive noise seems to be drowning reason out. For example, when a protester complained to Sen. Specter that he wasn’t listening to what they wanted, Sen. Specter asked him to tell him just that. The protester was flummoxed, and only after being prompted by several others in the audience, he said, “tort reform.”
It would be tragic if those crafting reform allow themselves to be influenced by those who understand neither the economics nor the ethics. Perhaps it would be even worse if they allow themselves to be influenced by the moneyed interests who understand very well the economics, but could care less about the ethics.
– Don McCanne, MD
By Kip Sullivan, JD
When the Senate Health, Education, Labor and Pensions (HELP) Committee passed a bill on July 15 creating an anemic “public option” program, Health Care for America Now (HCAN) and other “public option” proponents were ecstatic. They welcomed the “public option” in the HELP committee bill, proclaiming it “strong” or “robust.” But the actual provisions in the HELP Committee bill call for numerous “community health insurance options,” not the single “Medicare-like” plan promised by “public option” advocates. That means the individual “options” will probably be as small and weak as the co-ops now under discussion in the Senate Finance Committee. More importantly, these “community options” will almost certainly be run by insurance companies.
Finding the HELP Committee bill
To determine what the HELP Committee “public option” proposal is, one must first find a final version of the legislation that came out of the committee. Ordinarily, that is not a difficult process. But for some reason, the HELP Committee bill still has no bill number and, three weeks after it was voted out of the HELP committee, still is not available for the public to read. That might sound like a sloppy way to run a Senate committee, but I have confirmed with two sources that there is no final bill available. An aide in the Washington office of Senator Al Franken (D-MN), with whom I spoke on August 7, referred me to the draft bill posted at the HELP Committee’s Website. At this Website, the draft bill appears in two pieces, one labeled “the Affordable Health Choices Act” and the other labeled “the additional Chairman’s mark on coverage.” It is in the “Chairman’s mark” segment of the bill, beginning at page 77, that we find “Section 3106: Community health insurance option.”
Summary of Section 3106 in semi-plain English
Section 3106 is difficult to read. It fails to offer clear definitions of critical terms, it uses different terms to describe the same thing, and it contains unnecessarily abstract language. Because it is poorly written, it requires at least two readings to understand it. I will tell you first what I derive from it in the plainest language possible, and then discuss some of its provisions so you can judge for yourself whether I got it right.
Section 3106 requires the Secretary of the Department of Health and Human Services (DHHS, the federal agency within which Medicare and Medicaid are housed) to create multiple health insurance companies that, together, will make “public” health insurance available for sale to the non-elderly in every state in the country. The Secretary will not be using federal employees to make this happen. The Secretary is required, rather, to contract with nonprofit insurance companies to create health insurance policies that will qualify as “community health insurance options.” (Some of the bill’s language seems to be confusing by design. What meaning is conveyed by adding “community” and “options” to “health insurance”?)
The corporations that contract with the Secretary to create these “community” health insurance companies will be required to meet the same standards insurance companies currently must meet in order to serve as “Medicare Administrative Contractors” (MACs) to administer Medicare’s traditional program. These corporations must, in other words, be insurance companies.
To get some idea of which insurance companies meet current MAC standards, and are therefore the ones likely to get contracts with the Secretary under the HELP Committee bill, consider this list of the companies that now have MAC contracts with the Centers for Medicare and Medicaid Services (CMS, the agency that runs Medicare):
• Cahaba Government Benefit Administrators, a subsidiary of Blue Cross and Blue Shield of Alabama;
• First Coast Service Options, a subsidiary of Blue Cross and Blue Shield of Florida;
• Highmark Medical Services, a division of Highmark Blue Cross Blue Shield of Pennsylvania;
• National Government Services, a subsidiary of WellPoint, the nation’s largest health insurance company measured by enrollment (as opposed to revenues);
• National Heritage Insurance Corporation, which is a subsidiary of Electronic Data Systems (the firm Ross Perot founded) which is now a subsidiary of Hewlett Packard;
• Noridian Administrative Services;
• Palmetto GBA, a subsidiary of Blue Cross Blue Shield of South Carolina;
• Pinnacle Business Solutions, a subsidiary of Blue Cross Blue Shield of Arkansas;
• Trailblazer Health Enterprises, a subsidiary of Blue Cross Blue Shield of South Carolina;
• Wisconsin Physicians Services Health Insurance Corporation.
Most of the large health insurance companies, such as United HealthCare and Cigna, have also held similar contracts in the past.
Now that I’ve tried to explain Section 3106 in the Mother Tongue, it is time to immerse ourselves in the actual bill language. In the next section I review the language that indicates Section 3106 is proposing multiple “options,” not a single Medicare-like program. In the section after that I review the language that indicates the multiple “options” will be created by nonprofit insurance companies like Blue Cross Blue Shield.
Decoding Section 3106: Is it one “option” or multiple “options”?
Section 3106 proposes multiple “options,” not a single Medicare-like program, but this is not apparent at first. The first three sentences contradict each other. The very first sentence says there will be multiple “options” serving “communities” (not the whole country):
“Nothing in this section shall be construed to require a health care provider to participate in a community health insurance option….”
The second sentence says the same thing about individual patients and repeats the phrase – “a community health insurance option.” These first two sentences indicate the HELP Committee is referring to an entity at the “community” level, not the national level, and the Committee anticipates there will be many of these entities, not just one of them.
But the third sentence confuses the reader by referring to the local entities as a single program:
“The Secretary [of the Department of Health and Human Services] shall establish a community health insurance option to offer … health care coverage… throughout the United States.”
But as we read on, we encounter provision after provision that indicates the HELP Committee definitely envisions a balkanized “option.” Some provisions reveal that intention by referring to “options” plural. Others reveal it by giving the states the authority to determine essential features of “options” sold within their boundaries, such as the required reserve levels and maximum benefits. A single national program can’t have 50 different reserve requirements and 50 different benefit levels.
Here are two examples of the use of “options” plural in Section 3106: (1) Under a section entitled “Applicable rules,” we learn a previously enacted law “shall apply to community health insurance options”; and (2) a section entitled “Ombudsman” begins, “In establishing community health insurance options, the Secretary shall….”
Here are two examples of provisions giving the states authority to define key features of “options”: (1) The only sentence in a section entitled “States may offer additional benefits” reads, “A state may require that a community health insurance option offered in such State offer benefits in addition to the essential health benefits required under [another subsection]”; and (2) under a section headed “Solvency,” we find, “A community health insurance option shall … be subject to the solvency standard of each State in which such community health insurance option is offered.”
A patchwork of 50 different reserve requirements and 50 different benefit levels seems a far cry from “public option” proponents’ vision of a single, Medicare-like plan covering the whole country.
Decoding continued: “Option” means Blue Cross Blue Shield
The second major cause of confusion in Section 3106 is its use of four terms, all of them vague, to describe the insurance companies that will sell the “options.” The bill uses these four terms interchangeably: “community health insurance option,” “qualified carrier,” “qualified entity,” and “contracting administrator.”
A brief example: In subsection 1 of a section entitled “Start-up Fund,” the bill establishes a “Health Benefit Plan Start-up Fund … to provide loans for the initial operations of a community health insurance option.” But subsection 2 says loan money from this fund is supposed to go to “carriers,” and subsection 3 says it shall go to “contracting administrators.” (“Carriers” is a term Medicare just phased out after four decades of use. The term referred to insurance companies which processed claims from doctors. Medicare now uses the term “Medicare administrative contractors.” The HELP Committee’s bill writers no doubt meant to refer to “contracting administrators,” not “carriers.” As I indicated above, “contracting administrators” will look almost exactly like the MACs that now serve Medicare.) Finally, subsection 5 says the loans must be repaid by “the community health insurance option” (not carriers or contracting administrators).
The only reasonable interpretation of this goulash is that insurance companies known as “contracting administrators” will be put in charge of creating health insurance companies all over the country that will contain “community health insurance” in their titles.
This interpretation is confirmed by subsequent provisions in Section 3106. In a section entitled “Authority to contract,” the bill says the Secretary may “enter into a contract with a qualified entity” to perform the same duties MACs perform for Medicare, and once this contract has been signed the entity becomes “a contracting administrator.” (These contracts must last at least five years and may not last more than ten years.) In addition to meeting the MAC standards, contracting administrators have to be:
• able “to offer a community health insurance option”;
• “eligible to offer health insurance” (I assume this strange phrasing means the insurance company is licensed in the state where it hopes to sell “options”);
• able to achieve “delivery of benefits”; and
• able to “promot[e] high quality clinical care.”
The requirement that the contracting insurers be able to “promote high quality clinical care” is a tip-off that the HELP Committee wants the insurance companies that will run the “community options” to use managed care cost-control tactics. A second tip-off is that Section 3106 does not guarantee patients the right to choose their own clinic and hospital. Instead the bill only requires that a ”community” insurer will be one that “offers a wide choice of providers.” In short, an entity that meets the MAC standards plus the additional criteria in Section 3106 amounts to your basic, non-profit managed care insurance company. The big ones these days include many Blue Cross Blue Shield companies and the nonprofit HMOs such as Kaiser Permanente, Group Heath of Puget Sound, and HealthPartners.
The only conceivable development that could keep existing non-profit insurance companies from winning the contracts to develop and run the “community options” would be the birth of dozens of non-profit companies with the expertise of insurance companies between the time Section 3106 becomes law and the time the law takes effect. In theory, that could happen. But it is extremely unlikely. It is unlikely because of the short time period between the date Section 3106 is enacted and the time it takes effect, and because of the difficulty of creating corporations with the expertise to create health insurance companies.
Section 3106 does contain language that should please HCAN and other “public option” advocates who were expecting the HELP Committee to endorse a Medicare-like “option.” In two places, Section 3106 says the Secretary “shall negotiate” provider rates. But without a guarantee that the “options” in each state will enroll tens or hundreds of thousands of people, and without a requirement that providers participate, this is a meaningless provision.
This leads me to my last observation about Section 3106. How are contracting administrators supposed to create a customer base and a network of providers? Can they do it with whatever loans will be made available to them from the Start-up Fund? Section 3106 offers no answers to these questions.
If my interpretation of Section 3106 is correct – if the Senate HELP Committee’s “option” program is going to be balkanized and run by the nonprofit wing of the insurance industry – then reasonable people have to conclude that the deck is really stacked against the Committee’s “option” program. Even if Section 3106 authorized public employees, not Blue Cross Blue Shield employees, to create the dozens or hundreds of “community health insurance options” called for by Section 3106, the program would fail to pose any challenge to the insurance industry and might even die in the cradle. The health insurance industry has been very difficult to break into since at least the 1980s, and has become more so in the wake of the merger madness that swept through the industry in the early 1990s. But if public employees are not going to be directly responsible for creating the “community options” – if the nonprofit wing of the insurance industry is going to be doing that – then the entire “community option” project of the Senate HELP Committee amounts to a cruel joke on the public. Should the public trust corporations like Blue Cross and Kaiser Permanente to make a good faith effort to build competing insurance companies?
Section 3106 is a mess, but its meaning becomes clear after several readings. Section 3106 does not create the “Medicare-like” program promised by Jacob Hacker, HCAN, Howard Dean, and other “option” advocates. Instead it proposes a program that authorizes DHHS to create numerous health insurance companies tied to geographic areas, and to contract with members of the existing insurance industry to create and possibly run those companies.
Leaders of the “public option” movement have an obligation to advertise the HELP Committee bill truthfully. It is not accurate to say the HELP Committee bill creates a “robust” or “strong” public option. It is not even accurate to say the HELP Committee bill creates one “option.” The truth is the “option” is balkanized and very weak. In fact, HCAN, Andy Stern, Howard Dean and other “option” advocates who have praised the HELP Committee bill should do more than cease to praise it. They should tell Congress they oppose it.
Kip Sullivan is a member of the steering committee of the Minnesota Chapter of Physicians for a National Health Program.
Panelists from Staten Island Community Groups and PNHP encountered angry jeers from “anti-government” mob in Staten Island Church Healthcare Forum Wed Aug. 12th. Differences between single payer and current house bill were felt to be irrelevant by the vocal audience members.
This meeting was organized by Staten Island Family Health Care Coalition. Katie Robbins (Healthcare Now) and I were asked to present the House Bill 3200 and our critique. Katie missed our talk part due to a subway mishap but videotaped the event and will edit it. Event organizers told us that OFA was invited but did not send anyone to the meeting. There were police present as a menacing call was received by organizers prior to the event saying “there better not be any illegal immigrants there.”
I explained the basics of 3200 and where 3200 fits into the legislative process. I said I was for single payer, Medicare 2.0 for all and that it is a terrible misconception that healthcare is a zero sum game whereby the some must sacrifice to cover the uninsured. With “everybody in, nobody out” public insurance for all there would be plenty to go around and we could all do better by getting better value for our healthcare dollar with this fiscally conservative program. Jeers and interruptions came from the audience.
Other panelists included the MC, an internist with the Richmond MSSNY (AMA affiliate), a representative from the Richmond Chamber of Commerce, who outlined her members concerns with high costs of compliance with 3200, a representative from an HHC “safety net” facility who told stories of how help was needed for many, a representative from Jewish Community Services who tries to connect people with insurance about current problems of loopholes in eligibility as well as eligibles who don’t know they can get Medicaid, the director of a SI FHQC who described hardships at his centers and expressed concern that primary care physician supply would be inadequate to meet needs if everyone were insured. Many in the audience were impatient with all presentations, wanting to speak and clearly angry that Cong. Mc Mahon was not there. This was expressed through heckling, groaning, eye-rolling and interruptions.
A representative from McMahon’s office was present and attempted to field questions from the jeering crowd about McMahon’s non-presence. He committed to a future event with McMahon to explain the legislation as it evolves.
The MC then had audience members line up at a microphone to speak and tried to limit those who were yelling out. The first audience member mocked the bodyweight of the woman who convened the conference. This drew disapproval even from some among the “angry yeller” ranks, but also laughter. Major themes expressed by the group in an apparently orchestrated fashion: need to minimize government and taxes, accusations that proposed health reform is, variously “Trojan horse” for single payer or “Soviet” “Socialized medicine”. Someone yelled out from the sidelines questioning Obama’s citizenship. Right after that, one man, one of few blacks in the audience got up and left.
Other recurrent themes were the need for personal responsibility to buy insurance (“they got ipods, they should buy health insurance”), that illegal immigrants and others who “contribute nothing” are getting free services at the expense of “hard working Americans”. In response to a panelist’s story about a foot amputation in a diabetic who could not afford healthcare someone called out “Come on, she really couldn’t afford the $200 podiatry visit?”. When one panelist told the story of an insured person who nearly lost her house to pay for chemo an audience member called out to say “My insurance covered my chemo”.
Along with demands that the government get out of healthcare was rage at proposed cuts to Medicare and purported ineligibility for Medicaid for homeowners (sometimes in the same sentence) while illegals get a “free ride”. One of the panelists who worked getting people insurance had earlier said that the “homeowner exclusion” was a misconception. One person demanded “an end to class warfare”.
Other ideas expressed: Tort reform will control costs, tax cuts would lead to more jobs and then everyone could afford “to take care of themselves without the government”. I and others occasionally interjected to indicate points of fact on what was and was not in the bill (ie many of the suggested changes to public programs made by “the angry” are in the bill, the bill does not provide insurance to undocumented immigrants etc.).
We ended late when we had to leave the venue (a Moravian Church). Someone from the audience came up to me afterwards and made a comment I think is correct. He said noone cares what’s in the bill, it’s not really about the bill or healthcare but a bigger worldview.
In this worldview all of the panelists are part of an elite monolith who “don’t get it”. Some or all of the “the angry” were from the Staten Island Tea Party Organization. I’d estimate they made up half the crowd of about 150. They were coordinated and had notes. A rallying cry to throw representatives who vote for reform out of office and “keep listening to talk radio” led to fist pumping and cheers.
A soft spoken young man working with the forum organizers volunteered to give Katie and I a lift to the train. In the car he said he was really for socialized medicine rather than single payer.
Press coverage in Staten Island Advance (no mention of single payer) http://www.silive.com/news/advance/index.ssf?/base/news/1250163911258370.xml&coll=1
Based on comments at a July 1st Federalist Society debate on health reform
Single payer: freedom, choice and quality
Healthcare is a human right. It is fundamental and instrumental to life, liberty and the pursuit of happiness.
We are paying for a first rate system but getting a mediocre one, getting phenomenally low value on the dollar. We spend twice as much as other developed nations but are not healthier as a result. In many indices of major health outcomes we trail other developed nations. We have scarcity in the midst of excess. This is a scandal and a shame and we can do better.
I reject the notion that many propose, that healthcare is a zero-sum game in which universal access threatens quality. Universal access combined with public accountability will enhance quality. The whole system is stronger and better if we all go in together to one big risk pool. By publically insuring everybody, we could, with the money we are spending now, provide what we need/when we need it healthcare for everyone. This is single payer, Medicare 2.0. It is public insurance with private delivery.
Single payer is controversial in some circles. However, it’s beneficial effects regarding cost containment are generally conceded on all sides. I will not dwell on these. I will focus instead on how single payer can enhance freedom, choice, and quality in American medicine.
The “Other in our midst”
Before going on I want to first address a pernicious idea promoted by many who oppose health reform head on. It is rarely spoken of directly. There are many who would like you to believe that there is some “other” in our midst whose ills and lifestyles account for the poor health status and high costs of Americans. These are, variously, overweight, substance abusing, drunken driving, gun-fighting, illegal immigrant, unwed mothers, smokers and others.
“Others” aren’t the cause of high costs
The idea that the bad aspects of our system are limited to various “others” is a folly, and a dangerous one. The “expensive” people in healthcare are the sick and, alas, we will all be there someday, somehow. The single biggest risk factor predicting high utilization of healthcare services is not obesity, smoking, drinking or other putatively “voluntary” lifestyle factors. It is age. The bulk of healthcare spending in any given year is on a very sick minority. The majority has an interest in protecting this minority because, literally, we could join them anytime.
“Others” aren’t the cause of bad US healthcare outcomes.
There are more unwed mothers and many, many more smokers in Europe. Conventional wisdom about alcohol use aside, there is no evidence that Europeans suffer fewer medical complications of alcohol overuse than we do. They are also rapidly gaining on us in girth and also have large populations of documented and undocumented immigrants.
Quality and Quantity of US Care
As I have said we have scarcity in the midst of excess with healthcare distribution according to ability to pay/get reimbursed. Up to a third of overall medical expenses are judged to be due to unnecessary interventions. At the same a third of Americans say they are cutting back on medications and routine medical care due to cost.
Make no mistake, unnecessary procedures are not just expensive, they cause net harm including permanent injury and deaths. High costs are not just lamentable for bean counters, they mean large numbers of Americans don’t seek timely care and don’t take meds.
High Tech Care, Research and Innovation
Our supposed reward for accepting the harsh reality of un- and under-insurance is high tech medicine and a system on the cutting edge of research and innovation. This is a false choice. Systems without for profit insurance are clearly able to support high quality and high tech medical care as well as cutting edge research.
There are more frequent hip replacements in Sweden and more bone marrow transplants in France and Italy. Japan and several European countries have many more CT and MRI machines per capita than we do.
Biomedical researchers benchmark advances in knowledge by numbers of journal articles and how often other researchers cite those articles. The US trails several European nations in this regard. Half the top ten pharmaceutical companies are European and pharmaceutical industry R&D per capita is greater in Sweden, Denmark and the UK than in the US.
We do a lot of clinical trials, but, frankly, these are rarely designed to answer questions clinicians want answered (like is this medicine any better than what we’ve got already) instead they are focused on marketing needs.
The case of “proton pump inhibitors”
I want to discuss one particular type of drug because I think the case illustrates how profit incentives can distort quality and value in healthcare and why it’s so important to Big Pharma to negotiate with many different payers rather than a single powerful one. Multiple payers keep Americans paying the highest drug prices in the world and make it profitable to recycle old inventions rather than come up with new ones.
Take, for example proton pump inhibitors (PPIs ). This category of medication was discovered in the late 80s and was a significant advance. It’s used for stomach problems. The bedrock science research used to discover the drug was supported by US taxpayers via the National Institute of Health. Nexium, the purple pill you may have heard of or actually take, is manufactured by an Anglo Swedish company which is the market leader in the PPI field. It is used mostly to treat heartburn, re-christened by industry marketers more ominously as GERD or gastroesophageal reflux disease.
New developments in this area since the late 80s looks like this: 6 new branded PPIs in 15 different forms made by 5 different pharmaceutical companies only 2 of which are American. There is no scientific basis for believing any of the new formulations are better than the original one.
The original idea and basic research was done by an Austrian born and Scottish educated American. He was working for a Swedish company at the time and is now at the US Dept of Veteran’s Affairs.
The basis for the most recent new PPI patent, issued over 20 years after the innovative compound was discovered, was for compounding the drug with baking soda so it would be “immediate release”. Ultimately $44M was spent on product research and $48M was spent on marketing including a full time sales force of 400. This is poor health value for dollars spent.
The PPI market is now driven largely by inappropriate prescriptions which are now estimated to accounting for up to 70% of all usage. The problem is bigger than the money wasted. Stomach acid fights infection as well as causing stomach irritation. Use of these drugs causes increased rates of pneumonia and has contributed to the emergence of a treatment resistant superbug known in shorthand as “c diff”.
Now I’d like to address choice.
We need to get real on choice. If there’s a single payer, everyone takes it. I looked up my choice with my current plan (Aetna FEHB) versus traditional non-privatized Medicare. I looked up my choices in two places: Wilkes-Barre PA and zip 10025 on UWS Manhattan where I live and work. In both places I had more choices of doctors in a range of specialties with Medicare. Sometimes Medicare recipients had over four times as many doctors to choose from as I did. No, I didn’t get “just the best”, most everyone on Aetna also took Medicare.
I also know about choice available with private versus public Medicare from the range of referral options I discovered I had for my patients at Bellevue. Want cancer care at Sloan Kettering or deep brain stimulation neurosurgery for Parkinson’s at Columbia? You better have “real” public Medicare, not one of the privatized “Advantage” plans, because they don’t take them.
Private insurance offers the false “choice” of picking which for-profit shareholder accountable entity will get to limit your choices. Let me say it again. Private insurance means limited choices. Single payer means you choose to see anyone you want.
Let’s talk Wait Times
When I was pregnant many years ago I had private insurance but had to pull strings to get an appointment with an OB/GYN anytime in the first trimester of my pregnancy.
Last week I called up my gynecologist’s office to check on appointment availability and found there is a two 2 month wait.
Wait times for various services are related to the profitability of delivering those services rather than to medical urgency.
These are the wait times I found for Columbia Presbyterian Eastside Practice on East 60th Street in Manhattan:
To see dermatologist to evaluate a “suspicious mole”: 3 months
To see a dermatologist for a cosmetic evaluation: 2 weeks
For medical evaluation for insomnia which may include a lucrative “sleep study”: 3 weeks.
To get a mammogram: 3 months
I could get my hip replaced electively in Toronto sooner than I can get a mammogram or see my GYN in Manhattan. I know that because wait times and procedure availability for all sites is web published in Ontario to help patients choose where to go for care. No equivalent information is available to me in NY.
Let me address the feared army of bureaucrats:
I have seen this army. It is not coming, it has already arrived! US physicians report MORE external reviews of their clinical decisions to control costs than doctors in other countries. Here’s a recent example from my practice to show you why we feel that way:
This was at a model private rural care delivery system in Pennsylvania with sophisticated electronic health records. I ordered an ultrasound of the carotid arteries in a patient who had just had a stroke. This is deeply within standard non-controversial medical practice since carotid artery disease can cause strokes. A screen popped up informing me that the patients insurance would not cover the test. I don’t know how much the test costs, our medical culture involves ordering from a menu with no prices. It seemed safe to assume it was at least several hundred dollars an amount my clinical judgment told me might be challenging for this particular person.
In the great tradition of modern medicine, using all the bureaucratic skills as I have learned in dealing with multiple payers and random requirements over many years, I jiggered his ICD-9 diagnosis codes until the procedure was flagged as approved. This was a waste of my time. My time, by the way, was paid for by the greater “system”.
That same week I was also called on to consult on a patient who found herself in the “donut hole” of the entirely private Medicare part D drug plan, unable to afford critical medicines for multiple sclerosis. I confess, I had nothing to add. She needed the drug, it’s massively expensive (>1K/mo), there is no cheap alternative, and she could not afford it. Industry patient assistance programs had multiple barriers to access and, when Part D was initiated, categorically declined to assist most of these patients. I suggested a social worker get involved although I knew a social worker had already been involved. End of depressing consult. She was in the hospital for timely performed elective knee replacement, paid for by her insurance.
All of the drugs which can change the course of multiple scleroris are “biologics”. There is no current pathway for these to become generic and deal making in the production of current democratic legislation includes protections to further protect these agents from generic competition.
I want to adress freedom.
Single Payer separates insurance from employment, thus liberating business from a major drag on international competitiveness. Single payer also ends the “job lock” phenomenon where people stay in dead jobs because of insurance availability. The end of job lock supports a flexible labor market and the healthy entrepreneurship, which is the backbone of American innovation.
Private Health Insurance: not enough security
There is no freedom without security. Private insurance does not provide even the relatively healthy population they cover with health security. Most US bankruptcy involves medical debt. Medical bankruptcy is unknown in other developed nations.
This past june the LA Times reported that congressional investigators found that three private health insurers canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.
It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.
A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.
The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.
One employee, for instance, received a perfect 5 for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.
Now I do not always feel that Uncle Sam is my best friend. Nonetheless, I do feel better about Uncle Sam than I do about these private insurance companies. It’s not very complicated, the government is publically accountable, privately held companies are accountable to their shareholders.
Most Americans including most physicians support single payer health insurance. Special interest health industry lobbies are spending $1.4M DAILY to help spread a message of fear about health reform and continue on with a “business as usual”. But American values and American health are best supported by a single payer system.
I am not afraid of the postal system. I am not afraid of the highways. I am not afraid of Medicare and I am proud to serve in our Department of Veteran’s Affairs. I have seen the rough edges and devastating human consequences of our failed system over and over again. Government provision of health insurance is the best way to guarantee healthcare quality and assert individual freedom and choice in obtaining this basic human right.
Health care for all
By Helen Thomas
San Francisco Chronicle
August 12, 2009
It’s all so sad. Well-organized conservatives have launched a full-scale attack on health care reform. And they appear to be winning — for now.
I covered the battle to create the Medicare system back in the 1960s. The cries of “socialized medicine” worked for years until President Johnson rammed Medicare through Congress in 1965.
What kind of a nation are we if we do not provide everyone with the excellent medical care that only some of us now receive?
I continue to think the so-called single-payer system is the only answer to the nation’s obligation to make sure that no one lacks health care. Yes, single payer means a government-run health insurance program for all — the prevailing system in Canada and in many nations in Europe.
President Obama is making a big mistake by ignoring the single-payer proposal.
In 2003 before he became a U.S. senator from Illinois, Obama actually called himself a single-payer “proponent.” But now that he is president, Obama has buckled to Republicans and conservative Blue Dog Democrats in pursuit of consensus. My question is if Congress passes a watered-down version of health care that doesn’t truly cover everyone, is the result worth it?
President Obama should lay down markers for real health care reform — meaning we all kick in to a national program instead of fattening the pocketbooks of the insurance financiers.
Instead, the president has given up on Medicare for all, calling single payer “impractical.”
He still has time to do the right thing and nothing to lose.
For the full article:
Helen Thomas doesn’t ever give up, thank goodness. As she writes, President Obama “still has time to do the right thing.”
The Value of Provider Networks and the Role of Out-of-Network Provider Charges in Rising Health Care Costs
AHIP (America’s Health Insurance Plans)
One tool that health insurance plans use to improve quality and make health care more affordable for consumers is the establishment of provider networks.
Some out-of-network providers are charging exorbitant prices — several hundred or even over a thousand percent of the Medicare reimbursement for the same service in the same area. Recent examples: $4,500 for an office visit when Medicare would have paid $134; $14,400 for removal of a gallbladder when Medicare would have paid $656; and $40,000 for a total hip replacement when Medicare would have paid $1,558.
Consumers who are charged exorbitant fees by out-of-network providers incur additional costs because the protection against balance billing generally does not extend to services provided out-of-network. This detracts from the ability of health plans to offer affordable access to out-of-network providers for those consumers who want the advantages of a network, but also maintain the option to go out-of-network if they choose.
New Report Examines Out-of-Network Charges by Some Physicians
August 12, 2009
While the issue of how much is appropriate for out-of-network physicians to charge has not been part of health reform discussion to date, this report demonstrates that it needs to be. No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.
“As policymakers pursue health care reform, we encourage them to look at how much is being charged for services, particularly since higher charges don’t mean high quality of care,” said AHIP President and CEO Karen Ignagni. “With the nation facing the crushing burden of rising medical costs, all stakeholders should be focusing on constructive ways to bring costs under control.”
As we look at comprehensive health care reform, we really have to ask ourselves just what is it that the private insurance plans are providing us in exchange for their exorbitantly high administrative costs and the costly administrative burden they place on the health care delivery system?
Risk pooling? Public systems pool risk much more effectively than private plans. In fact, the private insurance industry wastes resources in their efforts to avoid risk. They’re not selling us the equitable risk pooling function that we want, and yet they’re charging us more for their lousy services. We don’t need that.
Managed care? Patients and their health care professionals do not want intrusive administrative managers intervening in their care. The private insurers have received that message and have backed off on the more explicit prohibitions of care. What they have not backed off on is selling us ever more of their wasteful, expensive managed care administrative services that are no longer particularly effective in moderating health care costs increases. They are perpetuating their unwanted intrusions, and they are charging us more for that. We don’t need that either.
So what service are they providing us? They have instituted private sector price controls by establishing contracts with hospitals, laboratories, health care professionals and other sectors of the health care delivery system. Their report released this week confirms that this is an important function. Prices set by the health care industry are much higher than prices dictated by the health insurance industry. If you think health insurance premiums are high now, just think of what they would have been without the private sector price controls applied to the contracted networks of providers.
Of course, there are trade offs. It is very expensive to provide the administrative services of both the insurers and the providers that are necessary to establish and manage these contracts. More dollars are diverted from actual health care to pay for these administrative excesses. A more perverse trade off is that patients are denied their free choice of health care professionals, hospitals, and laboratories since they must choose from the limited in-network panels provided by the insurers. They are limiting our choices, and they are charging us more for these unwanted services. Who wants that?
There is one more trade off that has left a gigantic, gaping hole in the private insurance model of health care financing. There are many legitimate reasons why an individual may receive care from out-of-network providers. When the private insurers do not have contracts with these out-of-network physicians and hospitals, they have no ability to dictate private sector prices. If the private insurers pay the full out-of-network fees, in-network providers will cancel their contracts and then demand the same prices, thus driving up our insurance premiums. If the insurers do not pay these high out-of-network fees, the patient is stuck with them. This is one of the reasons that individuals with “good” insurance end up in bankruptcy due to medical debt.
The timing of this AHIP report is no accident. Congress and the administration have now agreed that individuals will be required to purchase private health plans, perhaps with the additional option of a private model plan that is public in name only. Since the insurers have agreed to provide coverage for everyone not covered by other public and private plans, and since they will continue to use contracted provider networks (PPO, POS, and HMO), they understand that a solution to the high prices of out-of-network providers will have to be provided.
What is their solution? Although it appears only between the lines, their proposal is really not that subtle. “Out-of-network providers are charging exorbitant prices.” AHIP places the entire blame on those who refuse to sign their contracts. “No mechanism exists to protect patients who seek care out-of-network from receiving bills that are unreasonable and unaffordable.” AHIP obviously is calling for a mechanism to control the prices of providers with whom the insurers have no contract.
Lacking the ability to enforce private market contracts that were never agreed to, there is only one other entity that can provide a price-control mechanism. Jumping out from the space between the lines of their report, that entity is obviously the government – yes, the GOVERNMENT! AHIP is implicitly supporting government price controls for health care. But then that isn’t such a foreign concept for them. For decades, they’ve been using price controls through their own private bureaucracies.
So the only service they are providing is a profoundly expensive, administratively wasteful set of fragmented, restricted networks of providers that fall short of controlling prices throughout the system, and for that we have to give up our choice of health care professionals and facilities, not to mention giving up more of our money.
What if we got rid of the private insurers and had the government do it instead? Our experience with Medicare should give us an idea of how that might work. The administrative waste in the Medicare program is much less than that of the private plans. The additional administrative burden placed on the health care delivery system would be reduced dramatically since the providers would have to deal with only one payer and one set of rules. Not only would all risks be pooled together into a single pool, that pool would be funded much more equitably based on ability to pay. Since virtually all physicians and hospitals would participate in the program, patient choice would be almost unlimited, including the right to choose an integrated health system, if so desired.
Just like the private plans, Medicare has established prices for those contracting with the program. But what about those providers who do not have contracts? These are like the providers over whom the private insurers have no control. Well, Medicare is a government program. As such they dictate the prices, with slight adjustments, for non-contracted providers. The only way a physician can charge a Medicare patient the full list price is to refuse to bill Medicare for any patient at all for a minimum of two years, and to have this patient sign an agreement that he or she likewise will not try to collect from Medicare.
So we already have the heavy hand of government administering price controls. But isn’t that what AHIP is not so subtly advocating? GOVERNMENT PRICE CONTROLS for those providers who refuse to sign their private insurance contracts! If the government is going to control prices anyway, then why would we need or even want the private insurance contracts?
BusinessWeek’s statement this past week that the health insurers have already won should not be accepted as a given, but should be considered a challenge to us to demand, in loud and clear terms, the reform that we need. Let’s make it a very hot August for our representatives in Congress, but let’s make our message effective by being polite while we generate heat.
From: Douglas W. Elmendorf, Director
To: Honorable Nathan Deal, Ranking Member, Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives
Congressional Budget Office
August 7, 2009
This letter responds to the question you asked at a July 16, 2009, committee markup concerning the Congressional Budget Office’s (CBO’s) analysis of the budgetary effects of proposals to expand governmental support for preventive medical care and wellness services.
Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall.
Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness.
Wellness services include efforts to encourage healthy eating habits and exercise and to discourage bad habits such as smoking.
… obesity is the end result of several interacting factors that are not all intrinsically unhealthy. One of those factors is obviously diet, which can be hard to regulate because many foods are safe to eat in moderation. Another key factor is lack of exercise, a bad habit that — like a poor diet — can be difficult for individuals to change and is particularly difficult for policymakers to influence. Approaches for losing weight reflect those difficulties: A variety of interventions appear to succeed in the short run, but relatively few participants are able to maintain their weight loss for a long period of time.
The Impact of Prevention on Reducing the Burden of Cardiovascular Disease
By Richard Kahn, PhD; Rose Marie Robertson, MD, FAHA; Robert Smith, PhD; David Eddy, MD, PhD
Aggressive application of nationally recommended prevention activities could prevent a high proportion of the (coronary artery disease) events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs.
Does Preventive Care Save Money?
By Joshua T. Cohen, Ph.D., Peter J. Neumann, Sc.D., and Milton C. Weinstein, Ph.D.
The New England Journal of Medicine
February 14, 2008
Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.
Prevention and wellness programs frequently can be very beneficial for our physical health and our sense of well being, and when they are, they may well be worth the investment of our time and money.
What is troublesome is that Congress and the administration have chosen the most expensive model of health care reform, and they are pretending that the savings from prevention and wellness will be a major source of financing that reform. They contend that much of the benefit allegedly would be beyond the ten years budgeted, because it would take that long to realize the savings. But almost all studies indicate that the hoped for savings will never materialize. We’ll be spending more instead.
Yes, improved prevention and wellness programs should be a goal of our health care reform efforts, but the two most urgent goals are to include everyone and to make health care affordable.
Including everyone is easy. Simply make enrollment automatic for everyone.
Affordability is much more difficult, but you do not begin by choosing the most expensive model of reform, then adding programs that cost yet more money, and then pretending that they will magically reduce costs well off into the future when there is no evidence to support that wish-it-were-true policy.
The first and most important step toward attaining affordability would be to reject the most expensive model of financing health care, and instead enact the least expensive model which also happens to be the most effective: a single payer, Medicare-for-all national health program. The task of improving prevention and wellness programs would be much simpler and less expensive under such a model.
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