by Eric Reinhart - JAMA Network - June 27, 2023
Since the beginning of Ronald Reagan’s presidency, the proportion of workers in the United States who belong to a union has declined by approximately 50%, while income inequality has increased by approximately 20%.1 Today, just 10% of all US workers are employed in unionized positions.1 But following the recession that started in 2007 and 2008 and then the temporary resurgence of a social democracy during a pandemic that exposed neoliberal policy as a public health disaster, labor organizing against exploitation and public abandonment has been increasing. Amid growing concern about workforce attrition associated with the demoralization of nurses and physicians in a flailing medical industry shaped by profit rather than ethics,2,3 health care workers have become increasingly involved in this revival of labor politics.
A wave of nurses’ strikes and house staff unionization has put this ideological shift front and center in contemporary health care politics. There are now approximately 70 000 physician union members in the US, representing 7% of physicians—a nearly 30% increase relative to a decade ago. Much of this interest in labor movements is likely due to house staff exploitation via high medical-education costs, undercompensation, excessive work hours, and an infantilizing hierarchical culture characterized by intensive personality policing under the veneer of racist, misogynistic, and classist professionalism norms and their self-defensive moralisms.
It is into this context that the analysis of housing affordability and housing-related benefits for house staff by Brewster et al interjects.4 Using data from the 2022 to 2023 academic year, Brewster et al4 found that compensation levels at 60% of 855 institutions administering residency programs imposed rent-burdened status on their resident physicians (ie, they required residents to devote >30% of monthly income to rent). Brewster et al4 also found that while inflation-adjusted rental prices increased by 18% between 2000 and 2022, inflation-adjusted first-year resident salaries decreased by 0.2% during that same period. Concluding with a call for more equitable compensation, Brewster et al4 note that resident labor unions have been associated with improved access to housing stipends.
This adds to what should be already clear rationale for physicians, nurses, and other health care workers to unionize to protect their own interests and to protect patient safety by improving working conditions.5 But there is another intertwined and more fundamental issue at stake: the political education of the most influential workers in what may be the most powerful industry in the US.
Worst-among-peer-nations life expectancy, alongside globally unparalleled health care spending and rapidly declining trust in medicine, public health, and government, make undeniable that the US is in need of a basic reorganization of its health systems. After allowing health care over the last half century to be dominated by private entities motivated by profit and enabled by depoliticized concepts of charity as substitutes for rights guaranteed by public systems, to achieve meaningful change will require a repoliticization of care. This must be linked with mass movements to demand public investment in universal health care and, even more importantly for public health, infrastructures for everyday nonmedical care that are essential for preventing disease and shrinking the currently elephantine footprint of reactive US medicine.6,7
As underlined by the tradition of social medicine left to us by physicians like Rudolf Virchow, Frantz Fanon, and Paul Farmer, the practice of medicine—let alone public health—is intrinsically political.8 To deny this is itself a political act in service of the status quo of US health capitalism that is inflicting at least tens of thousands of preventable deaths each year. And yet the most significant resistance to the explicit politicization of medical care so that we might organize for redress of policy-manufactured health inequalities comes from inside our own house.
Many US physicians, who—once out of training—are rewarded for their loyalty to the existing industry with mean salaries more than twice those paid to physicians in the next-highest-compensating nation, have been professionalized into a convenient political nihilism. As historians of the profession, like Paul Starr, Charles Rosenberg, and Rosemary Stevens, have shown, we have for more than a century been indoctrinated into what Max Weber described as the protestant ethic and the spirit of capitalism.9
At the center of US medical ideology are twinned ahistorical notions of meritocracy and individualism by which public responsibility for protecting health is replaced by personal responsibility, irrespective of the history and policies determining one’s circumstances. These ideas operate both on interpersonal and structural planes, shaping physicians’ perceptions, standards of care, and institutional practices. This, in turn, prepares us to absorb the self-affirming narrative that we supremely value patient autonomy while also believing that we have no ethical duty to counter the heteronomy imposed by viciously “free” markets that serve the rich by perpetually extracting maximum wealth and labor from the poor.
Standard US medical education is designed to defend and reproduce these professional norms, including through the so-called informal curriculum, through which many of the most formative political lessons and class affiliations are imbibed. The fact is that physicians have been receiving a political education for generations—it has just been largely off the books. And it has been overwhelmingly conservative, profoundly uncritical, and reflexively protective of an ethically bankrupt field that has spent a century building up a capitalist health care industry.
The exploitative conditions faced by medical trainees have been a key component of our political apprenticeship. These conditions also function to recruit those who are more likely to be receptive to it. By making training so financially burdensome that it is often inaccessible to all but people from wealthy families, who bring with them their class backgrounds, medical schools enforce a selection pressure that aids in perpetuating existing professional norms by suppressing their potential disruption by individuals who belong to communities most harmed by them.
Poor working conditions for residents and fellows, which are endured with the certainty of future financial security and high status, also function to normalize exploitation. This likely spills over into how physicians view the labor conditions of our patients and associated public policy. Because physicians typically have limited personal stakes in labor politics beyond our training years, many are more likely to accommodate exploitation than to protest it. Instead of fueling solidarity and attention to labor rights as a key political determinant of health, our own encounters with workplace abuse often inure physicians to it rather than provoke us to join with coworkers and patients to demand policy changes to protect workers across all industries.
The recent push for structural competency curricula has been attempting to nudge physicians into alignment with actual care.10 But we must move beyond hesitant subtleties. Medical trainees deserve an explicitly political education—one that breaks down and transcends simplistic partisanship—adequate to allow us to understand the history and economic ideologies shaping our everyday work.
We should prepare physicians to embrace care as a practice that extends well beyond the clinic and that necessarily hinges on power and policy—and thus on political organizing and struggle. Resident unionization is a key training ground for this work that, to rebuild US health, must continue beyond residency. If medical institutions are to have any ground on which to stand as they preach health equity, they should support residents’ organizing efforts and begin giving substance to their rhetoric by guaranteeing their workers proper protections rather than continuing to exploit them.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2806421
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States Try Easing the Burden of Long-Term Care’s High Cost
Seeing their own financial benefits, too, Washington and California are among the states creating programs to help older residents.
by Mark Miller - NYT - June 16, 2023
It’s a retirement concern few of us want to face: At some point, four out of five older Americans will need help with daily needs like bathing, dressing, using the toilet or preparing meals.
Paying for such long-term care presents retirees with difficult choices. Medicare coverage is very limited. Private long-term care insurance policies are complicated and expensive. Medicaid, which insures low-income people, pays for long-term care only when a patient’s assets have been almost completely spent. And many will rely on family members for help.
In Washington, D.C., policymakers and lawmakers have long agreed on the need for a government-sponsored solution — but not how to pay for it, said Howard Gleckman, senior fellow at the Urban Institute and author of “Caring for Our Parents: Inspiring Stories of Families Seeking New Solutions to America’s Most Urgent Health Crisis.”
“It’s an obvious, pressing problem, and there’s a great deal of interest among politicians in something like a public program, until you start talking to them about paying to make it work,” Mr. Gleckman said. “You’re going to have to raise the payroll tax. You can call it a contribution or whatever you want, but politicians look at it and they see a tax increase — and they say forget about it.”
Now, a handful of states are acting on their own. In July, Washington State will start the WA Cares Fund, a public long-term care insurance program. California is considering a similar plan. Minnesota and several other states are studying options.
State-sponsored long-term care insurance programs raise some thorny questions, including rules for mandatory participation, how to make benefits portable when people move and how to coordinate the public plans with supplemental commercial policies.
But states that are moving forward see their programs as essential to addressing the needs of aging populations and a way to rein in swelling Medicaid spending on long-term care.
“More and more, it’s something that is just overwhelming state budgets,” Mr. Gleckman said.
Many Americans will need help
Most people will require some assistance with daily living needs, but the intensity and duration are impossible to predict.
Four out of five 65-year-olds will need some amount of long-term care during their remaining years, according to a study by the Center for Retirement Research at Boston College.
The researchers found that one-fifth of retirees will need no support, but about one-quarter will have severe, and expensive, care needs.
“The data does clarify how large the risk is,” said Anqi Chen, research economist and assistant director of savings research at the center. “Some people may be ignoring the fact that they may need care later in life, and that it will require resources either from family or tapping savings.”
Many Americans appear to be in a state of denial about long-term care. A survey by The Associated Press-NORC Center for Public Affairs Research found that 49 percent of Americans ages 40 and older expect Medicare to pay for their long-term care. In reality, the program covers only 100 days in a skilled nursing facility after a hospital stay. The survey also found that 69 percent of respondents had done little or no planning for long-term care needs — and just 16 percent were confident that they would have the money to pay for that help.
A major long-term care need can be financially catastrophic. In 2021, the median annual national cost of a private room in a nursing home was $108,405, according to the most recent figures from Genworth, a large long-term care insurance underwriter that publishes an annual survey on the cost of care.
Not all long-term care is provided in nursing facilities. A great deal of it is provided at home, which can bring expenses down significantly. Costs also vary greatly by location. And much of the labor is provided by unpaid family members and friends. AARP estimates that there were 38 million family caregivers in the United States in 2021, providing an estimated $600 billion in uncompensated care.
“For families that don’t have insurance, the question is whether they have the financial resources to purchase care, or are there family caregivers available,” Ms. Chen said. “And, is that a reasonable expectation to place on family members?”
Insurance might seem like a sensible way to protect against these unknown risks. But the private long-term care insurance business has floundered over the past decade.
The idea of a public-private solution is not new. A decade ago, Mr. Gleckman co-founded the Long-Term Care Financing Collaborative, which brought together policy experts with a wide array of political leanings. The group agreed on a framework that would combine a national universal government program with initiatives aimed at revitalizing the market for private policies.
Washington State’s approach
With no action at the federal level, Washington State is moving forward with its own program. Over time, nearly all residents will contribute premiums via a mandatory payroll tax, and the benefit is universal.
In July, most workers in the state will start paying a 0.58 percent payroll tax on their wages to fund the program. Starting in 2026, participating residents will be able to claim a benefit if they have a demonstrated need for assistance with three or more activities of daily living. The maximum lifetime benefit of $36,500 will be adjusted annually for inflation; it is geared to cover about one year of care at home. (Ten years of contributions are required to qualify to receive the benefit, but near-retirees will be able to receive a partial benefit starting in 2026 geared to the number of years that they have contributed.)
A key aim of the program is to provide relief for middle-class families that are forced to spend down their life savings to receive long-term care through Medicaid, according to Ben Veghte, director of the WA Cares Fund at the Washington State Department of Social and Health Services.
“It gives families some breathing room to address their loved one’s care needs,” Mr. Veghte said.
The program is expected to reduce the state’s Medicaid spending, which Washington expects to account for 8.9 percent of its total budget in the 2023-25 period. Absent WA Cares, that figure would jump to 10.9 percent by the end of this decade and 17.6 percent by 2045.
Washington has considered some complicated questions, including who can be exempt from participating. The legislation that state lawmakers approved in 2019 created an exemption for residents who had private coverage. The state later added a deadline on applying for that exemption — prompting more than 480,000 people to rush to buy the coverage, hoping to avoid the tax. They overwhelmed the insurance companies still selling long-term care policies in the state.
Those applications had to be submitted by the end of 2022. But there is no requirement that buyers maintain their coverage or prove that they still have it.
“We’ve been concerned that people would just buy coverage and then drop it, which really would be counterproductive,” said John Mangan, vice president for state relations at the American Council of Life Insurers. “If people drop their private coverage and are not subject to the public plan, they’re not covered at all — and that means they could wind up on Medicaid, which is not the goal.”
Currently, out-of-state workers who commute to work in Washington can apply for exemptions from the program; so can spouses of military personnel. (All federal employees, including military personnel, are also exempt.) People who have temporary nonimmigrant work visas, such as seasonal farmworkers, can apply for exemptions. Some disabled veterans who can get care through the Department of Veterans Affairs are exempt.
Portability of benefits poses another challenge. The program’s financial model assumes participation only by state residents; a commission has recommended several options for allowing people who have become vested in the program to receive a benefit if they move.
Questions also remain about some issues, including how supplemental private policies will coordinate with the public program.
“The journey has been bumpy at times, but businesses do want to ensure that people can stay in the work force or get back into the work force, particularly women, who are often the caregivers,” said Rachel Smith, president and chief executive of the Seattle Metropolitan Chamber of Commerce.
California and Minnesota take steps
Lawmakers in several other states have introduced bills to either study or enact public long-term care insurance programs. Minnesota is weighing several options, including two that aim to make private insurance more affordable.
But, Washington aside, the most significant plan being developed is California’s. The state is studying the financial feasibility of several options for a public insurance program, with possible legislative action expected in 2024.
“If California moves ahead, it will be exciting because it’s a huge state,” Mr. Veghte said. “That could really break the dam for the rest of the country.”
Like Washington, California would fund its program through a payroll tax, but the state is considering a “progressive” tax system that would feature a contribution cap and a waiver for low-income residents. Another difference is that the tax might be split between employees and employers.
California is weighing a range of benefit designs, some of which would be considerably larger than Washington’s. For example, one option would provide a maximum benefit of $110,400 per year, for up to two years, covering home-based services and residential facilities.
“The reality for us is that by the start of the next decade, 25 percent of our population is going to be 65 or older, and that’s about 8.4 million people in California,” said Michael Soller, deputy insurance commissioner for communications and press relations at the California Department of Insurance. “Leaving California seniors to fend for themselves is just not an option for us.”
https://www.nytimes.com/2023/06/16/business/retirement-long-term-care-insurance.html
Doctors, patients, corporatization, and moral crisis
by Joshua Freeman - June 26, 2023
In the last few years a fair amount has been published, especially in the medical media, about physician burnout. This term includes everything from frustration, to saying they would not encourage their children to become doctors, to leaving the profession or retiring early, to, in extreme but sadly not rare cases, suicide. The emphasis has usually been on the amount of work that the doctors have to do, the stress of new technologies such as the “electronic medical record” that, rather than simplifying things or making them more efficient, mainly create much more time-consuming work, and the ever-present threat of malpractice suits and other litigation against them. Recently, the NY Times Magazine, in “The Moral Crisis of American Doctors” by Eyal Press (June 15, 2023), presents more balanced and accurate coverage.
The article discusses the work of Wendy Dean, a psychiatrist and administrator at the US Army research center. Dr. Dean was shocked to learn that the rate of suicide in physicians was higher than that of the active-duty military.
The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.
Dr. Dean thought about this issue in terms of “moral injury”, generally thought to affect those who participated in or observed horrible violations of their moral compass in war, such as the murder of civilians.
Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and [her co-worker] Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”
The article goes on at length, comparing the doctors to
assembly-line workers who fear for their jobs if they speak out, to non-compete
and non-disclosure agreements they are forced to sign, to the way that this
manifests in particular specialties, such as Emergency Medicine.
This piece gets to the heart of the matter more than almost anything that has been published in the mainstream media. I would summarize the lesson as: The pursuit of profit is dangerous to your health. The transformation of medical care from control by doctors to control by accountants and venture capitalists means that something other than what is best for the health of people, as individuals and as a population, is the primary consideration driving the structure and implementation of health care. It is not a pretty picture. Yes, doctors make and have always made mistakes. Yes, doctor have often been avaricious themselves. Yes, sometimes people have been hurt or died from unnecessary procedures. But at least in theory most doctors believed that what they were doing was for the best interests of their patients.
We have moved beyond (or backward from) that. We have entered an era in which an assembly-line mentality has been implemented in American healthcare, when doctors and other healthcare workers are seen as replaceable cogs, when the provision of healthcare is, like selling cars or liquor or financial instruments is not mainly about the “product” but is just a vehicle for generating money for its owners and managers. Tough luck, all you “burned out” doctors, probably suffering from moral crisis. Tough luck, sick people.
This has been a long time coming. The deprofessionalization of medicine should have been predictable decades ago, and it was. In a recent blog post (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023) I cite two books. “American Health Empire” (1971) by Barbara and John Ehrenreich and other members of the HealthPAC collective, showed how even then hospitals and health systems were being corporatized. Paul Starr’s 1982 book “The Social Transformation of American Medicine” focused on the impact of this on the professional role of physicians.
Another huge warning signal was, or should have been, the explosion of the space shuttle Challenger on January 28, 1986. As reported at the time and in multiple more recent articles (e.g., Engineer Who Opposed Challenger Launch Offers Personal Look at Tragedy, Remembering Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch, both from 2012), engineers for the Morton Thiokol corporation knew that there was a problem with key pieces of the shuttle (the infamous “O-rings”), and had been ignored by their bosses when they called attention to it. And never went public with it for fear of losing their livelihoods. Until after the disaster. At the time, it was noted often how this conflicted with the codes of ethics of the engineering profession. But engineers were no longer self-employed independent professionals; they were employees of huge profit-seeking corporations. Many of us who were doctors pointed to this, saying this trend was not limited to engineering, but was happening to other professions, including medicine. It had not yet progressed that far, but was moving down that track.
Independent physician practice, solo or group, single or
multi-specialty, has begun to disappear, as practices were acquired by larger
companies. Sometimes these were physician-owned, and seemed to continue to
carry the same “old” values. But then they were bought out by hospitals, health
systems and private investors. So were the hospitals. We got a lot of glitz -- fountains
and art work in our entry halls and fancy new machines, and investment in our
practices, particularly those “product lines” that had the greatest “return on
investment” measured, of course, in dollars and not human health. How could we,
as ethical medical professionals, buy into the casual use of such terms as “product
lines” and “return on investment” when talking about the health of our patients.
Some of the explanation is greed, and some of it is psychological, as doctor began to think that using corporate-speak meant that they were cool, and allowed them to hobnob with the real power players in control of the industry. Many doctors obtained MBAs. And now some of them are very rich. Some are even CEOs. It’s not surprising that doctors can be smart enough to achieve this, or that they can be as susceptible to the lure of power and money as anyone else. It also does not mean that all doctors who get MBAs use it to limit care in order for their company to make more money. But that does not make it good for the people of the nation. And it can, and often does, create another moral conflict, perhaps even moral crisis.
Another recent piece, by the Reverend William Barber and
Gregg Gonsalves in The Guardian, “The
fourth leading cause of death in the US? Cumulative poverty”, is scarcely
unrelated, although rather than focusing on physicians it focuses on patients
(the medical term for “people”). It clearly and thoroughly documents the impact
that poverty has upon health. And while the poor are the tip of the iceberg,
the most vulnerable, the cutbacks on care that come from megalomaniacal pursuit
of money affects much larger parts of the population.
Because we have a healthcare system that is designed to make money for the corporate entities that control it, that system does not deliver quality care to many (or most) people. As a result it creates unfulfilling, stressful, and sometimes intolerable working conditions for its employees, including physicians. Moreover, in the classic “divide and conquer” technique long used by those in control, it leads to people being angry at their doctors for the frustrations and denials that they experience, which they mistakenly believe the doctors control. The denials of care are made by the insurance companies that they have (and often choose, such as Medicare Advantage). The long delays for getting appointments and the inadequate time physicians spend listening is the result of the management of the health systems that employ them, not only treating doctors as assembly-line workers but patients as widgets to be produced. If it seems impersonal and uncaring, it is.
So what is to be done? Doctors can start by demanding that
their professional organizations, beginning with the AMA, condemn and resist
this corporate transformation. They also must recognize that they are no longer
independent practitioners, but employees, just as the Morton Thiokol engineers
were, and that the greatest protection that they – and their patients – have is
unionization. You, doctors, may be well-paid workers, but you are workers! Unions
can educate people, their members and the public, about how the power is
actually distributed and who is calling the shots. Other people can respond by
contacting their political representatives and demanding that the power and
authority of private corporations over their health care be drastically curbed;
this includes insurance companies and health-care companies. A great first step
would be to repeatedly demand that every representative and senator, every
state legislator, sign on to support a universal health insurance system, such
as Medicare for All.
There will still be plenty to do after that, but it would provide a structure for making things better.
https://medicinesocialjustice.blogspot.com/2023/06/doctors-patients-corporatization-and.html
Our primary healthcare system is a mess. I have a plan to fix it | Bernie Sanders
The bad news is that the US healthcare system is broken and dysfunctional. We spend twice as much per capita as almost any other country, nearly $13,000 per year, while 85 million Americans remain uninsured or underinsured. In addition, our health outcomes are often worse. In terms of life expectancy, for example, we live far shorter lives than the people of many other industrialized nations.
The system is failing ordinary Americans. On the other hand, the insurance and drug companies that dominate it have sky-high profits and their CEOs receive exorbitant compensation packages. The thousands of lobbyists those companies have on Capitol Hill are also doing very well.
It’s time for a change.
As disastrous as our overall healthcare system is, our primary care system is even worse. Tens of millions of Americans live in communities where they cannot find a doctor or dentist, even when they have insurance, while others have to wait months to get seen. Despite spending a huge amount of money on healthcare, the United States doesn’t have enough doctors, dentists, nurses, mental health practitioners, pharmacists or home healthcare workers. And that workforce shortage is getting worse.
Most countries spend between 10% and 15% of their healthcare budgets on primary care. Canada spends 13%, Germany spends 15%, Spain spends 17% and Australia spends 18%. We spend less than 7%.
In other words, instead of investing in disease prevention and enabling people to gain easy and timely access to the medical care they need, we spend heavily on expensive hospital and tertiary care. Our “system” is there big time when people end up in the hospital. We just don’t do much to keep them from going there.
Every major medical organization agrees that our investment in primary healthcare is woefully inadequate. They understand that focusing on disease prevention and providing Americans with a medical home will not only saves lives and ease human suffering, but save money. Providing primary care to all is not only good public policy, it is cost-effective.
The major backbone of our current primary care system, especially for low- and moderate-income Americans, is the Federally Qualified Community Health Center program. Today, 30 million men, women and children receive high-quality primary healthcare at community health centers in 14,000 neighborhoods located in every state in America. Many of these centers also provide dental care, mental health counseling and low-cost prescription drugs.
According to a recent study by an expert at the Kaiser Permanente School of Medicine, community health centers saved Medicare and Medicaid $25bn in 2021 alone.
In fact, research has shown that it is about $2,300 less expensive for a Medicaid patient to receive care from a community health center than at a private clinic and it is roughly $1,200 less expensive for a Medicare patient to receive care at a community health center than at an outpatient clinic.
At a time when millions of Americans have no option but to go to an emergency room for their basic healthcare needs, it turns out that an emergency room visit is about 10 times more expensive than going to a community health center.
One thing is certain. We cannot address the primary healthcare crisis unless we also address the major shortages that we have in our healthcare workforce. According to the most recent estimates, over the next decade our country faces a shortage of over 120,000 doctors – including a major shortage of primary care doctors.
The nursing shortage may even be worse. Over the next two years alone it is estimated that we will need between 200,000 and 450,000 more nurses.
We also have a shortage of some 100,000 dentists in America.
And, despite the very serious mental health crisis we are facing, there is a massive shortage of mental health service providers – psychiatrists, psychologists, social workers, counselors, addiction specialists and many more.
For many years members of Congress have talked about these crises. Now is the time to act. As chairman of the US Senate health, education, labor and pensions (Help) committee I am working hard to pass bipartisan legislation which will transform our primary healthcare system so that every American, no matter where they live or what their income might be, can get the care they need when they need it.
If we increased funding for primary care by $130bn over five years, through a combination of increased federal funding and the elimination of some of the enormous waste and bureaucracy in the current healthcare system, we could double the number of people using community health centers and come close to providing primary healthcare to every person in America.
Further, an investment of $40bn over five years could substantially increase the number of doctors, nurses, dentists and mental health care providers we desperately need.
Is this $170bn, five-year investment in our primary care system and healthcare workforce a lot of money?
Yes. It is. But let’s be clear. This $34bn annual investment to improve our healthcare system would amount to less than half of the increase that Congress provided to the Pentagon last year alone.
In my view, healthcare is a human right. The legislation that I am proposing would go a long way towards accomplishing that goal.
https://www.theguardian.com/commentisfree/2023/jun/28/us-healthcare-system-bernie-sanders
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