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Every non-profit or academic institution focused on aging in America (e.g. AARP, Older Women’s League, American Society on Aging, etc.) supports the American Care Act. It’s great news that the Supreme Court ruled the law was constitutional. With this ruling, insurance companies will no longer be able to deny coverage, or charge more because of a pre-existing condition, or force women to pay higher premiums than men. Preventive care will continue to be covered at no cost, and seniors will continue to save money on prescription drugs (5.3 million Medicare Part D beneficiaries have already saved $3.7 billion on prescriptions since the law was enacted).

The ACA is a major step toward ensuring affordable and quality health coverage for millions of working families, elders, and children. Therefore, it is surprising to me that many Americans don’t believe the ACA will help them. A Kaiser Family Foundation report found that people believe young adults and children are likely to benefit from the new law, but not themselves or their families. Thirty-seven percent of respondents felt the law will make no difference in their lives, thirty-one percent felt they will be worse off.

Where are these answers coming from? Is it that a case being brought to the Supreme Court is enough to reduced people’s opinions of the law? Who are the individuals against the ACA…do they understand the implications for American’s health system and the American people’s well-being?

The ACA is in no way perfect, but many of the laws are designed specifically to help older people acquire and pay for comprehensive health care. An AARP article lists the number of ways the law supports older adults:

  • Insurance companies cannot drop you if you become sick or disabled
  • They cannot have lifetime dollar limits on your coverage
  • Medicare recipients receive annual wellness visits, preventive services, and immunizations at no additional cost
  • As mentioned, people with Medicare Part D now receive discounts on prescription drugs while in the doughnut hole. The Part D discounts will gradually increase until 2020, when the doughnut hole will close
  • In 2014, insurers can no longer deny coverage if you have a preexisting condition
  • In 2014, insurance “exchanges” will provide better access and options to self-employed people, small businesses and others who are unable to find affordable coverage

The Supreme Court’s decision is a significant move in the right direction. It will help the United States build a health care plan for our future that is on par with what other developed nations provide already: Affordable health care coverage as a right, not a privilege.

Today the University of Massachusetts Boston has made the fourth edition of “The Guide for Elders: Planning that Protects You and Your Assets” available for free online. The Guide which started in 1993 and has continued to be revised over time (most recently in 2010) hopes to be a resource for older adults so they know what steps to take to get and keep their affairs in order. There are “increasing numbers of reports of elderly people being abused, exploited, or victimized in ways that rob them of their life savings and their dignity. Those cases involving financial exploitation saw elders victimized by friends, neighbors, and even family members.”

Financial and health care matters are often confusing and the Guide provides their readers with clear descriptions and scenarios to illustrate problem areas. After reading the Guide you should be able to answer a number of questions: Why do I need a power of attorney, health care proxy, or will? When should I consider entering a nursing home? What can I do if I get “ripped off,” or if I am the victim of a crime or abuse?

Although not intended as a substitute for individual counsel and assistance, the Guide will allow you to prepare and determine if your situation needs additional professional advice. As clearly stated in the introduction, “Elders need to know what steps they can take to avoid being victimized and what they should do when and if it happens to them. This Guide’s…emphasis is on prevention and avoidance of problems, with the recognition of the old adage that an ounce of prevention is worth a pound of cure.”

In the field of gerontology, long-term care planning is a very hot topic. I can’t pick up an aging newspaper or journal without some mention of this issue. That is not to say I am surprised by the attention it gets. One of the most startling facts I learned in class was that unpaid caregivers provide services valued at $450 billion per year!

Long-term care (LTC) is an essential expense and while many dream of a healthy retirement filled with vacations and relaxation, this is far from the reality. Most people will grow old and frail and need LTC during their retirement years. Unfortunately, most are not planning for it and the government is cutting back on affordable options that could help. Though Americans are not planning for LTC, they are worried. A California poll on this issue found that two-thirds of people don’t know how they will be able to afford LTC. They are just as concerned about this expense as the cost of their future healthcare. So if people are aware of the problem, why the inaction? Perhaps it’s because they don’t know where to begin. What affordable options do they have so they can age with dignity and independence, living how they want in the place they choose?

Information to Consider:

What is Long-Term Care = when you are not able to complete personal care or other daily activities on your own. This is most often the result of a chronic illness or disability. In some cases, the illness or disability may include cognitive impairment.

How Much Care Do You Need = about two-thirds of today’s elders will need LTC support. Women need care longer (on average 3.7 years) than men (on average 2.2 years), mostly because women typically live longer.

Who Will Provide Support = help comes from 3 sources: (1) family and friends (2) agencies with certified staff or (3) hiring help on your own. For many, a blended approach to LTC is needed.

How Do You Plan and Pay = the National Care Planning Council has a detailed guide to planning for your LTC needs. This 7 step plan involves understanding the care settings and available government programs, who you should call on for help, how you can pay for services, and how you can protect your assets. More information about the public and private sources for funding LTC can be found on the Department of Health and Human Services website.

Getting Started:

It may be daunting to see all the steps and options to consider. I’m asking you to start thinking about this decades before it’s needed! Perhaps having the following conversations is a better starting point for some of us. Begin thinking about LTC and your own life. Then when you do your research, you’ll be aware of your personal needs and desires.

(1) Talk with your spouse, adult children, friends, or siblings about whether they might care for you if I became ill or disabled. Tell them how you feel about relying on their help.
(2) Ask your family doctor whether you might be at higher risk for needing long-term care someday based on your medical and family history or lifestyle risk factors.
(3) Talk with a financial planner, insurance agent, attorney, or other financial advisor about how you would pay for long-term care services if you need them.

The 2011 OWL Mother’s Day report  starts with a very strong statement: “Health care for all is a women’s issue…” Why would this be? Men also need and use our health system. Yet, the case is made for how women’s lives are affected by health care coverage or a lack there of. Women play a large role in managing care for sick family members, most often providing this care themselves. Widows can often be left impoverished if their husbands’ chronic illnesses dwindled savings accounts and assets. In late life, women find themselves 60% more likely to need help with basic daily activities (i.e. eating, dressing, bathing) compared to men. This paints a picture in our minds: Grandma spent her 60’s and 70’s caring for grandpa. He had heart problems and diabetes but she made sure he took his medications, got to his appointments, and was cared for till the end. Now in her 80’s, grandma finds herself sick, poor and alone in a big, empty house. Since women’s life expectancy continues to exceed that of men’s, this story is all too familiar.

“After a lifetime of caring for others, older women often need affordable care but find that the costs are high and their options are severely limited.” I’ve described to you a common late-life situation for women. Let’s keep this image in our minds as we discuss how the Affordable Care Act (ACA) aims to support Americans as they age. People, like grandma, find themselves skipping preventative services because Medicare requires them to pay a 20% co-payment. This cost is found to be a disincentive for approximately half of Medicare beneficiaries who do not use preventative services available to them.  Grandma lives on a fixed income of $1,000/month from Social Security (the average benefit is $1,177) and this means that paying a $30 co-pay to see her doctor gives her $30 less for grocery shopping that month. She isn’t feeling sick, so she prefers to spend the money on food. This begs the question: Should she have to make that choice?

 
The good news is changes to our health care system are happening over the next few years and should support people in old age. Below I’ve highlighted some of the changes but please read the full report or see this great summary of the Health Reform Law from the Kaiser Family Foundation for more details.

Health Insurance Reforms

  • Medicaid will be expanded to cover 16 million Americans (all legal residents up to 133% of the federal poverty level will be eligible)
  • Retroactive cancelling of insurance because of accidents or sickness, denying coverage because of pre-existing conditions, and basing premiums on health status, gender and genetics will all be prohibited
  • Insurance companies must devote at least 80 – 85% of premium dollars received to medical benefits and quality improvement and they must provide justifications for any excessive rate increases, making this information available to consumers

Medicare

  • People who reach the “donut hole” on prescription drug coverage will get a large discount on drugs and biologics and this discount will grow each subsequent year.  The hole will be closed in 2020
  • Beneficiaries will receive a free annual exam, free flu and pneumonia shots, and any covered service that is given a grade A or B by the U.S. Preventive Services Task Force must be provided at no cost
  • Medicare payments will be reduced for hospitals that have high HAC rates (hospital-acquired conditions) and incentives will be provided to hospitals that improve their transitional care and partner with community services to reduce readmission rates

Long-Term Care 

  • The Community Living Assistance Services and Support (CLASS) Act will provide a voluntary long-term care insurance program available to all working Americans. When an individual becomes eligible and needs long-term care services an average cash benefit of $50/day will be given to help them pay. Beneficiaries have control over their own care, so this includes paying family or friends who provide help at home.
  • Home and Community Based Services (HCBS) aim to provide a network of services within state and local areas to meet the needs of elders aging in place. A new protection called under HCBS will attempt to prevent “spousal improverishment” by only counting the ill spouse’s income when determining eligibility.
  • Nursing home care will be improved as the ACA aims to make the system, procedures, staffing and care more transparent and regulated. The Elder Justice Act is a part of this, in an attempt to identify and prevent elder abuse.

In the United States everyday people are providing 85% of needed long-term care for their family members and friends. These roles are generally unpaid and at the expense of their own careers, health, and well-being.  Rather than creating a health system that works, we have created a system that to a large extent depends on informal caregivers yet still costs us 17% of GDP.  The ACA is not a perfect system and will not be fully up and running for a few years. Still, it is a step in the right direction and will expand coverage to 95% of the population and support those who care for the people they love.

If you find yourself bombarded with mixed messages or feeling confused about the new health care changes, I encourage you to at minimum read the OWL Mother’s Day report’s appendix. Here the authors address a number of major myths about the Affordable Care Act and answer some common questions about the policies and coverage.

While on a recent phone conversation with my best friend we got to talking about her parents and their (in her opinion) impulsive purchase. They were in North Carolina on vacation and bought a plot of land. They plan to build a house on it over the next couple of years and by the time they retire it will be ready for them to move in. Being a gerontology student and always thinking about long-term care needs, I babbled on for a few minutes about universal design. If they intend to build this home and stay in it for as long as possible, I told my friend, then they should consider their future needs.

Recent statistics show that about 80% of baby boomers want to remain in their homes for as long as possible (and Obama’s new Affordable Care Act may help them do just that with the Community Living Assistance Services and Supports (CLASS) program and the expansion of Home and Community-Based Services. A story for another time). If you start planning for it now, you don’t have to have oodles of money to build a house from scratch like my friend’s parents. Let me share with you what I feel are the key components of universal design and home modifications:

  • Think About Daily Activities – when modifying your home to support you in old age focus on making it easy to perform basic activities like bathing, cooking, or getting into and out of your home. Examples:
  1. Install grab bars in the bathroom
  2. Replace doorknobs or faucet handles with lever handles
  3. Install handrails on both sides of any staircases inside or outside your home (or consider ramps)
  4. Create some easy access storage in the kitchen such as a pull-out pantry or adjustable shelves
  • Consider the Age of Your Home – Most older adults live in homes that are over 20 years old and these can have some issues as you age. Some updates to your home can help you age in place. Examples:
  1. Install proper insulation, storm windows, and air conditioning so you have good heating and ventilation
  2. Create 36-inch wide doorways throughout the house for easy access with a wheelchair or walker
  3. Move outlets 18-inches off the floor so you’ll be able to reach them without much bending
  4. Put your laundry on the main floor (definitely get it out of the basement!)
  • Make Safety a Priority – Think about your aging parents. What parts of their home make you nervous? The clutter, the dim lighting, the slippery bathroom? These may also become a safety concern for you one day. Examples:
  1. Get rid of throw rugs (they are very hazardous!)
  2. Place non-slip strips in the bath tub, the kitchen and on any outdoor or indoor stairways
  3. Install bright lighting inside and outside the home, and make sure switches are easy to use and access
  4. Rearrange your furniture so there is plenty of space to move around a room

There are many companies out there that will sell you some pretty sleek looking products. You definitely do not need to spend that kind of money, but I think some people fear their home will look like a hospital if they integrate basic universal design.  Just remember this is entirely up to you, your tastes and your budget. If you start planning for it now and modify your home over time the benefits could greatly outweigh the costs. Below are some resources if you are interested in learning more:

National Resource Center on Supportive Housing and Home Modification

  • Comprehensive list of online resources
  • Directory for finding services in your area

US Department of Health and Human Services

There is a lot of talk in my classes and coursework about lonely, isolated elders. We discuss how older, disabled individuals living in nursing homes, assisted living, or alone in the community have a hard time interacting with others. Not because they don’t want to but because they have little opportunity for interaction. Maybe they won’t see anyone for days at a time. Maybe they do, but their service provider won’t chat with them beyond pleasantries. Maybe family comes by occasionally or they see them on holidays.

In the years to come I envision an environment where these homes are filled with laptops, web cameras, and cell phones. There is no way the Baby Boomers are going to leave technology behind as they make their way through old age.  They will stay connected because they want to, they know how, and (as many of us have experienced) there is little going back once you’re technologically savvy. Nursing homes will most likely be a very different thing in the future and not nearly as isolating.

So, that leaves us with today’s elders. One of the biggest problems is not getting the technology to them. Companies like Best Buy take our old, broken computers off our hands. A part of me believes they wouldn’t mind donating them to nursing homes and low-income schools so those in need can stay connected. Pretty good PR right? No, the larger issue is probably instruction. How do you teach mass numbers of older people all that they can do with a computer?

I am not talking about teaching them what a mouse is and how to type a letter in Word. I want them to know how they can stay connected to family through email, instant messaging, and Skype. How they can research anything and everything on Wikipedia, learn a language for free on Livemocha, and laugh at the younger generations on YouTube. How they can participate in forums related to their interests or start a blog to share their thoughts with the world. How they can stay connected to the outside and don’t have to feel alone during the last years of their life.

It is not something that can be changed over night but I do think we should start talking about how what the rest of us think of as a normal part of our daily lives may be the answer for older, disabled, isolated adults. We should be trying to empower them to stay connected to the world, we have the technology! Imagine if they did not have to rely on visits from busy family and friends to relieve their loneliness.  They take control of their situation and socialize as much or as little as they want to, so that when family final does come by you may hear them say, “Oh, can you wait a minute? I just need to finish up my conversations,” as you watch them close 4 IM windows saying goodbye to their international friends.

On Tuesday, January 12th, a massive 7.0 magnitude earthquake struck the poorest country in the Western Hemisphere, Haiti. As of January 25th, the U.S. Geological Survey has located 53 aftershocks of magnitude 4.5 or greater. The U.S. government has mobilized resources and people to aid in the relief effort, coordinating with the United Nations and the international community. In the mist of all this funding and support, what is being done for the older Haitians?

Haiti’s first census in 24 years, conducted in 2003, revealed a number of pressing problems. When we reflect on this information after the natural disaster it provides evidence that the needs of the Haitian elderly are great. Approximately 800,000 people in Haiti are over the age of 60. The maternal mortality ratio and the HIV/AIDS prevalence rate are the highest in the Western Hemisphere, with 523 deaths per 100,000 live births, and a rate of between 4 and 5 percent respectively. This indicates a large number of grandparents are raising their grandchildren, leaving them with the added responsibility of caring for their needs as well as their own in this time of crisis. As the sole caretakers, the relief becomes even more important, as the lives of children are also at stake.

The census also showed that over 50% of the population is below the poverty headcount ratio at $1 a day, and 78% of the population is below the $2 a day ratio. This ranked Haiti the twelfth poorest nation in the world prior to the earthquake. The quake struck in the most populated area of the country and the International Red Cross announced that as many as 3 million people had been affected.

We often do not think about what it means to be old when a crisis like this hits. Imagine when life is normally hard on an average day and you are an elderly person, what the addition of devastation such as this would do. In a tragedy this massive, the needs of older people too often go unmet. On January 17th the Associate Press reported that there is no food, water or medicine for the 85 surviving residents of the Port-au-Prince Municipal Nursing Home, barely a mile from the airport where a massive international aid effort is taking shape. The residents initially believed their relatives would come to feed them, because many live in the slums nearby. “But I don’t even know if my children are alive,” Jacqueline Thermiti, 71, told reporters. The group has expressed anger at the seeming lack of outside interest in the residents of the nursing home, which is close to the areas around the collapsed presidential palace and Roman Catholic cathedral, which teem with journalists and international rescue teams. Unfortunately for these and countless other elderly victims, reaching emergency-aid stations or standing in line for hours for medical care is impossible.

In response to the vast needs of the older victims AARP, HelpAge USA, and HelpAge International have worked closely together rushing emergency relief to the Haitian elderly population. HelpAge is the only international relief agency that focuses on the unique needs of older people in an emergency. One hundred percent of donations to the AARP Foundation Haiti Relief Fund will go directly to those most in need and AARP will match donations up to $500,000. To learn more visit http://www.helpageusa.org or http://www.aarp.org/foundation

Long-term care is paid for by a combination of public and private payers, though these are by no means equal. The central idea to integrate these two payers and develop a three-tier system of long-term care funding is the focus of the research paper, “Funding Long Term Care: Applications of the Trade-Off Principle in Both Public and Private Sectors.” This three-tier system consists of social insurance which provides the floor for protection. Private insurance and personal savings supplement the social insurance and when these sources fail to provide coverage, public welfare in the form of Medicaid will act as a safety net. This short essay will examine the pros and cons of a three-tier system for long-term care.

The paper used to assess pros and cons is from the Journal of Health Care Finance titled, “Financing long-term care for elderly persons: What are the options?” This paper discusses the private funding, public funding, and public-private options. It is a helpful article to use in examining the previously mentioned one. The article points out that with public funding those families now providing care would be free to use paid caregivers. Since we know a large proportion of long-term caregiving is provided by unpaid family members, the system would become swamped with these additional elders needing care. Also, the article points out the inflexibility of the government to adjust to changes or to administer services efficiently. We know that technology and health care are rapidly changing and therefore the needs for recipients will also change. Increased usage would also result in increased costs to the government and since the entitlement programs are already in trouble financially, providing more services to more people may not be the best route.

This is relevant to the previously mentioned paper because the three-tier system incorporates a floor protection which would be available to all individuals and therefore would increase the number of people receiving care. Like previously mentioned, all those individuals obtaining care from unpaid caregivers are now going to utilize the system and require paid care. This financial change may be larger than expected, even though the private insurance and personal savings are supplementing this coverage.
With regard to the private aspect of the plan, the article warns that this private-public partnership would benefit the upper-income people most. Increasing coverage to include them will also increase the spending, since they most likely did not use much social insurance in the past. Also, since these individuals are more likely to be able to have a large amount in their private insurance and personal savings and they are essentially fine without the floor protection, is it fair to tax payers and the lower income persons that this public-private partnership serves to protect the assets of the wealthy. Also, will this supplemental coverage be affordable to the middle-income groups. If decent private insurance is costly and individuals are saving for a variety of things, not only long-term care coverage, will these supplements be adequate? A good question to ask in this time of economic crisis and reform would be, how much savings will this change in long-term care provide to Medicare and Medicaid? If saving is impossible, then will the change dramatically hurt the programs financial situation?

I think the most interesting and important aspect of the previously mentioned article is not the adjustment of currently used systems into a three-tier system, but instead the “trade-off” aspect. Most if not all of the above mentioned criticisms can perhaps be modified and corrected using some type of trade-off. For example, if the long-term care funding sources allow users to pay family members for their care, this could correct the large inflow of recipients should the three-tier system be implemented. Another example could apply to the private issues, where people buying private insurance would have some that is tied in with their annuity or life insurance policies. Therefore, individuals do not feel like they lose money if the never need long-term care because something is given to beneficiaries upon their death. If, however, long-term care is needed, this money can be used and their families do not have to assist with payments. Any future long-term care reform needs to consider this trade-off approach more seriously to encourage the usage of supplementary features and provide the aspect of choice for those utilizing these features.

While I was reading an article for class on international comparisons of long-term care I noticed little was mentioned on women specifically. We are aware that women live longer and utilize more long-term care services then men, in addition to being more likely to be the provider of care regardless of whether it is formal or informal. I found a few short articles looking at this topic. One is an issue brief by the Kaiser Family Foundation looking at Medicaid’s Role for Women and examining long term care as well. The second is an AARP Fact Sheet specifically focusing on Women and Long-Term Care.

The Kaiser Issue Brief sets the stage for our discussion. It discusses how most people with disabilities receive Supplemental Security Income (SSI) and therefore qualify for Medicaid since they are already deemed to have a severe disability. The other way to qualify is to “spend down” assets to meet the state’s income threshold and obtain Medicaid coverage. This is essentially making people spend away all income and assets, pushing themselves into poverty before the government will give assistance. Lastly, in some states if medical expenses are very high they may meet the state’s “medically needy” income standard and be eligible for Medicaid. The issue brief tells us that over 4 million low-income elderly women have Medicaid paying for their long-term care services. This is no surprise as women comprise the majority of seniors on Medicaid (70%), they live longer than men, and are disproportionately poorer. Women live longer then have a higher rate of chronic illnesses and disability than men, obviously translating to some required long-term care. The article tells us that nearly 75% of nursing home residents and 66% of people receiving home health care are women. This costly expense may be devastating for these older women on fixed incomes. It is common for the husband to go through a costly illness and pass first, leaving the widow behind with what is left of their assets. She cared for him during his illness and saw to his long-term care needs, utilizing their funds as necessary. However, she is now left with little funding and no one lives with her to provide care if she starts to lose daily functioning. It is a blessing for those few women who have family or friends who can act as caregivers.

The AARP fact sheet goes into more detail about the major challenges women face as they get older, but this article also addresses the fact that women are also the primary providers of long-term care in both the formal and informal settings. Almost 66% of formal and informal caregivers are women. AARP addresses the issue of payment and that a major factor affecting income is marital status. We know, partly because men do not live as long, that almost 70% of women over age 75 are divorced, widowed, or never married. Only about 30% of men over 75 are in this category. This difference in marital status greatly affects the number of women who live alone. Statistics also show that these women living alone are on average more likely to have a lower income than men living alone or couples.

An interesting thing to mull over is the treatment of these women care providers. Currently there is no payment, pensions, or tax break for these women. Therefore it is perpetuating the long-term care system. More than 60% of women caregivers who were employed made sacrifices at work that ranged from cutting hours, refusing promotions, losing benefits, taking a leave of absence, working late or unusual hours, or choosing an early retirement. All of these resulted in one major change in the woman’s life; lower income. Not only are they unable to accumulate as much income as they could have had they no caregiving responsibilities, but they are also loosing Social Security income, and benefits like health insurance coverage if they choose early retirement or cut hours below a 40 work week (where many jobs do not provide benefits for part-timers). All of these sacrifices also lead to less possible savings for the future. They will most likely not have the income for a CCRC or home care, so when they are in need of long term care they too will need the help of a family member. Most likely another woman who is taking time off work to help. Moreover, we cannot forget the formal caregivers which are made up of almost 90% women, who are getting low pay, uneven hours, and often few benefits. Many employers even hire these caregivers on on-call schedules making it difficult for the provider to plan for her future.

I honestly don’t know what to do about this gender-based issue, but it is clear from my readings in class that no one is really talking about the long-term care crisis’ impact on this sex and the vicious cycle this system has them in. At least can we have some discussion on the subject?

I don’t see the problem with issuing gay couples the same Social Security rights as married couples so long as documentation proves they have been together 10 years or more, as is the requirement for married couples expecting a spousal benefit. If both members in the heterosexual couple work, the system would treat them like a two-earner couple, unless they can get more by taking the spouse benefit based on their partners PIA. Again, I do not see the problem with this right being given to homosexual couples. They are paying taxing just like heterosexual couples but their deductions and their benefits are not the same.

While this seems logical, and both conservative and liberal politicians have spoken in favor of it, no steps have been taken to give these couples the same Social Security rights as heterosexual couples. The Equal Access to Social Security Act was introduced to Congress in 2004, but was never addressed in the two year period so was cleared from the books. Then it was introduced again in 2006, but again cleared from the books. It has not been brought back for Congress to discuss.

An article I found from USA Today reports on the risks same-sex couples enter once they are in their retirement years. Not only do they face a much greater risk of spending the end of their lives in poverty because they’re ineligible for a host of federal protections, ranging from Social Security survivor benefits to estate tax exemptions, but couples who have lived together for decades may be barred from sharing a room in a nursing home or an assisted living facility. They are also unable, in many hospitals, to have next-of-kin privileges during hospitalization which is terrible for anyone dealing with illness. While some states recognize gay marriage and give them the same rights as straight married couples, the federal government still does not recognize gay marriage. Being treated differently on provisions run by the federal government, like Social Security and estate taxes, could greatly affect them especially if they are already vulnerable to falling into poverty. The aging baby boomer population will be over 70 million seniors, and more people means higher numbers of all cultures, races, and sexual orientations. We have not had a large population of homosexual couples in retirement before and how our government treats them may have serious repercussions for our aging population.

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