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Kaiser Health News

The Policy, and Politics, of Medicare Advantage

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Thu, 23 Mar 2023 18:00:00 +0000

The Host

Julie Rovner
KHN


@jrovner


Read Julie's stories.

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Julie Rovner is chief Washington correspondent and host of KHN's weekly health policy , “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Medicare Advantage, the private-sector alternative to original Medicare, now enrolls nearly half of all Medicare beneficiaries. But it remains controversial because — while most of its subscribers like the extra many plans provide — the program frequently costs the federal more than if those seniors remained in the fully public program. That controversy is becoming political, as the Biden administration tries to rein in some of those payments without being accused of “cutting” Medicare.

Meanwhile, President Joe Biden has signed a bill to declassify U.S. intelligence about the possible origin of covid-19 in China. And new evidence has emerged potentially linking the virus to raccoon dogs at an animal market in Wuhan, where the virus reportedly first took hold.

This week's panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

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Panelists

Jessie Hellmann
CQ Roll Call


@jessiehellmann


Read Jessie's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

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@JoanneKenen


Read Joanne's stories

Margot Sanger-Katz
The New York Times


@sangerkatz

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Read Margot's stories

Among the takeaways from this week's episode:

  • The Biden administration recently changed the formula used to calculate how much the federal government pays private Medicare Advantage plans to care for patients with serious conditions, amid allegations that many of the health plans overcharge or even defraud the government. Major insurers are making no secret about how lucrative the program can be: Humana recently said it would leave the commercial insurance market and focus on government-funded programs, like its booming Medicare Advantage plans.
  • The formula change is intended to rein in excess spending on Medicare — a huge, costly program at risk of insolvency — yet it has triggered a lobbying blitz, a vigorous letter-writing campaign in support of the popular Medicare Advantage program. On Capitol Hill, though, party leaders have not stepped up to defend private insurers as aggressively as they have in the past. But the 2024 campaign season could hear the parties trading accusations over whether Biden cut Medicare or, conversely, protected it.
  • The latest maternal mortality rates released by the Centers for Disease Control and Prevention show the problem continued to worsen during the pandemic. Many states have extended coverage for a full year after women give birth, in an effort to improve care during that higher-risk period. But other problems limit access to postpartum care. During the pandemic, some women did not get prenatal care. And after the fall of , some states are trouble securing providers — including one rural Idaho hospital, which announced it will stop delivering babies.
  • The federal government will soon declassify intelligence related to the origins of the covid pandemic. In the United States, the fight over what started the pandemic has largely morphed into an issue of political identity, with Republicans favoring the notion that a Chinese lab leak started the global health crisis that killed millions, while Democrats are more likely to believe it was animal transmission tied to a wet market.
  • And in drug price news, Sanofi has become the third major insulin maker (of three) to announce it will reduce the price on some of its insulin products ahead of a U.S. government policy change next year that could have cost the company.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Vice News' “Inside the Private Group Where Parents Give Ivermectin to Kids With Autism,” by David Gilbert

Jessie Hellmann: The Washington Post's “Senior Care Is Crushingly Expensive. Boomers Aren't Ready,” by Christopher Rowland

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Joanne Kenen: The New Yorker's “Will the Ozempic Era Change How We Think About Being Fat and Being Thin?” by Jia Tolentino

Margot Sanger-Katz: Slate's “You Know What? I'm Not Doing This Anymore,” by Sophie Novack

Also mentioned on this week's podcast:

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

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To hear all our click here.

And subscribe to KHN's What the Health? on SpotifyApple PodcastsStitcherPocket Casts, or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Title: The Policy, and Politics, of Medicare Advantage
Sourced From: khn.org/news/podcast/podcast-khn-what-the-health-290-medicare-advantage-policy-politics-march-23-2023/
Published Date: Thu, 23 Mar 2023 18:00:00 +0000

Kaiser Health News

KFF Health News’ ‘What the Health?’: The Supreme Court and the Abortion Pill

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Thu, 28 Mar 2024 19:45:14 +0000

The Host

Julie Rovner
KFF News


@jrovner


Read Julie's stories.

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Julie Rovner is chief Washington correspondent and host of KFF Health News' weekly health policy news , “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “ Politics and Policy A to Z,” now in its third edition.

In its first case since the overturning of Roe v. Wade in 2022, the Supreme Court this week looked unlikely to uphold an appeals court ruling that would dramatically restrict the availability of the abortion pill mifepristone. But the court already has another abortion-related case teed up for April, and abortion opponents have several more challenges in mind to limit the procedure in states where it remains legal.

Meanwhile, , including former , continue to take aim at popular health programs like Medicare, Medicaid, and the Affordable Care Act on the campaign trail — much to the delight of Democrats, who feel they have an advantage on the issue.

This week's panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

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Sarah Karlin-Smith
Pink Sheet


@SarahKarlin


Read Sarah's stories.

Alice Miranda Ollstein
Politico

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@AliceOllstein


Read Alice's stories.

Lauren Weber
The Washington Post


@LaurenWeberHP

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Read Lauren's stories.

Among the takeaways from this week's episode:

  • At least two conservative Supreme Court justices joined the three more progressive members of the bench during Tuesday's oral arguments in expressing skepticism about the to the abortion drug mifepristone. Their questions focused primarily on whether the challenging the drug had proven they were harmed by its availability — as well as whether the best remedy was to broadly restrict access to the drug for everyone else.
  • A ruling in favor of the doctors challenging mifepristone would have the potential to reduce the drug's safety and efficacy: In particular, one FDA decision subject to reversal adjusted dosing, and switching to using only the second drug in the current two-drug abortion pill regimen would also slightly increase the risk of complications.
  • Two conservative justices also raised the applicability of the Comstock Act, a long-dormant, 19th-century law that restricts mail distribution of abortion-related items. Their questions are notable as advisers to Trump explore reviving the unenforced law should he win this November.
  • Meanwhile, a Democrat in Alabama flipped a state House seat campaigning on abortion-related issues, as Trump again discusses implementing a national abortion ban. The issue is continuing to prove thorny for Republicans.
  • Even as Republicans try to avoid running on health care issues, the Heritage Foundation and a group of House Republicans have proposed plans that include changes to the health care system. Will the plans do more to rev up their base — or Democrats?
  • This Week in Medical Misinformation: TikTok's algorithm is boosting misleading information about hormonal birth control — and in some cases resulting in more unintended pregnancies.

Also this week, Rovner interviews KFF Health News' Tony Leys, who wrote a KFF Health News-NPR “Bill of the Month” feature about Medicare and a very expensive -ambulance ride. If you have a baffling or outrageous medical bill you'd like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Julie Rovner: KFF Health News' “Overdosing on Chemo: A Common Gene Test Could Save Hundreds of Lives Each Year,” by Arthur Allen.

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Alice Miranda Ollstein: Stat's “Fetal Tissue Research Gains in Importance as Roadblocks Multiply,” by Olivia Goldhill.

Sarah Karlin-Smith: The Washington Post's “The Confusing, Stressful Ordeal of Flying With a Breast Pump,” by Hannah Sampson and Ben Brasch.

Lauren Weber: Stateline's “Deadly Fires From Phone, Scooter Batteries Leave Lawmakers Playing Catch-Up on Safety,” by Robbie Sequeira.

Also mentioned on this week's podcast:

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Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our click here.

And subscribe to KFF Health News' “What the Health?” on SpotifyApple PodcastsPocket Casts, or wherever you listen to podcasts.

——————————
Title: KFF Health News' ‘What the Health?': The Supreme Court and the Abortion Pill
Sourced From: kffhealthnews.org/news/podcast/what-the-health-340-supreme-court-mifepristone-march-28-2024/
Published Date: Thu, 28 Mar 2024 19:45:14 +0000

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Kaiser Health News

California Is Expanding Insurance Access for Teenagers Seeking Therapy on Their Own

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April Dembosky, KQED
Thu, 28 Mar 2024 09:00:00 +0000

When she was in ninth grade, Fiona Lu fell into a depression. She had trouble adjusting to her new high school in Orange County, California, and felt so isolated and exhausted that she cried every morning.

Lu wanted to get help, but her Medi-Cal plan wouldn't therapy unless she had permission from a parent or guardian.

Her mother — a single parent and an immigrant from China — worked long hours to provide for Fiona, her brother, and her grandmother. Finding time to explain to her mom what therapy was, and why she needed it, felt like too much of an obstacle.

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“I wouldn't want her to have to sign all these forms and go to therapy with me,” said Lu, now 18 and a freshman at UCLA. “There's a lot of rhetoric in immigrant cultures that mental concerns and getting treatment for that is a Western phenomenon.”

By her senior year of high school, Lu turned that experience into activism. She campaigned to change state policy to allow 12 and older living in low-income households to get mental health counseling without their parents' consent.

In October of last year, Gov. Gavin Newsom signed a new law expanding access to young patients covered by , which is called Medi-Cal in California.

Teenagers with commercial insurance have had this privilege in the state for more than a decade. Yet parents of children who already had the ability to access care on their own were among the most vocal in opposing the expansion of that coverage by Medi-Cal.

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Many parents seized on the bill to air grievances about how much control they believe the state has over their children, especially around gender identity and care.

One mother appeared on Fox News last spring calling school therapists “indoctrinators” and saying the bill allowed them to fill children's heads with ideas about “transgenderism” without their parents knowing.

Those arguments were then repeated on social and at protests held across California and in other parts of the country in late October.

At the California Capitol, several Republican lawmakers voted against the bill, AB 665. One of them was Assembly member James Gallagher of Sutter County.

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“If my child is dealing with a mental health crisis, I want to know about it,” Gallagher said while discussing the bill on the Assembly floor last spring. “This misguided, and I think wrongful, trend in our policy now that is continuing to exclude parents from that equation and say they don't need to be informed is wrong.”

State lawmaker salaries are too high for them or their families to qualify for Medi-Cal. Instead, they are offered a choice of 15 commercial health insurance plans, meaning children like Gallagher's already have the privileges that he objected to in his speech.

To Lu, this was frustrating and hypocritical. She said she felt that the opponents lining up against AB 665 at legislative hearings were mostly middle-class parents to hijack the narrative.

“It's inauthentic that they were advocating against a policy that won't directly affect them,” Lu said. “They don't realize that this is a policy that will affect hundreds of thousands of other families.”

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Sponsors of AB 665 presented the bill as a commonsense update to an existing . In 2010, California lawmakers had made it easier for young people to access outpatient mental health treatment and emergency shelters without their parents' consent by removing a requirement that they be in immediate crisis.

But at the last minute, lawmakers in 2010 removed the expansion of coverage for teenagers by Medi-Cal for cost reasons. More than a decade later, AB 665 is meant to close the disparity between public and private insurance and level the playing field.

“This is about equity,” said Assembly member Wendy Carrillo, a Los Angeles Democrat and the bill's author.

The original law, which regulated private insurance plans, passed with bipartisan and had little meaningful opposition in the legislature, she said. The law was signed by a Republican governor, Arnold Schwarzenegger.

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“Since then, the extremes on both sides have gotten so extreme that we have a hard time actually talking about the need for mental health,” she said.

After Carrillo introduced the bill last year, her office faced threats. She said the goal of the law is not to divide families but to encourage communication between parents and children through counseling.

More than 20 other states allow young people to consent to outpatient mental health treatment without their parents' permission, including Colorado, Ohio, Tennessee, and Alabama, according to a 2015 paper by researchers at Rowan University.

To opponents of the new law, like Erin Friday, a San Francisco Bay Area attorney, AB 665 is part of a broader campaign to take parents' rights away in California, something she opposes regardless of what kind of health insurance children have.

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Friday is a self-described lifelong Democrat. But then she discovered her teenager had come out as transgender at school and for months had been referred to by a different name and different pronouns by teachers, without Friday's knowledge. She devoted herself to fighting bills that she saw as promoting “transgender ideology.” She said she plans to sue to try to overturn the new California law before it takes effect this summer.

“We're giving children autonomy they should never have,” Friday said.

Under the new law, young people will be able to talk to a therapist about gender identity without their parents' consent. But they cannot get residential treatment, medication, or gender-affirming surgery without their parents' OK, as some opponents have suggested.

Nor can minors run away from home or emancipate themselves under the law, as opponents have also suggested.

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“This law is not about inpatient psychiatric facilities. This law is not about changing child custody laws,” said Rachel Velcoff Hults, an attorney and the director of health of the National Center for Youth Law, which supported AB 665.

“This law is about ensuring when a young person needs counseling or needs a temporary roof over their head to ensure their own safety and well-being, that we want to make sure they have a way to access it,” she said.

Removing the parental consent requirement could also expand the number of mental health clinicians in California willing to treat young people on Medi-Cal. Without parental consent, under the old rules, clinicians could not be paid by Medi-Cal for the counseling they provided, either in a private practice or a school counselor's office.

Esther Lau struggled with mental health as a high school student in Fremont. Unlike Lu, she had her parents' support, but she couldn't find a therapist who accepted Medi-Cal. As the only native English speaker in her family, she had to navigate the health care bureaucracy on her own.

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For her, AB 665 will give clinicians incentive to accept more young people from low-income households into their practices.

“For the opposition, it's just about political tactics and furthering their agenda,” Lau said. “The bill was designed to expand access to Medi-Cal youth, period.”

This article is from a partnership that includes KQED, NPR, and KFF Health News.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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——————————
By: April Dembosky, KQED
Title: California Is Expanding Insurance Access for Teenagers Seeking Therapy on Their Own
Sourced From: kffhealthnews.org/news/article/california-teen-access-mental-health-care-without-parental-consent/
Published Date: Thu, 28 Mar 2024 09:00:00 +0000

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As AI Eye Exams Prove Their Worth, Lessons for Future Tech Emerge

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Hannah Norman, KFF
Wed, 27 Mar 2024 09:00:00 +0000

Christian Espinoza, director of a Southern California drug-treatment provider, recently began employing a powerful new assistant: an artificial intelligence algorithm that can perform eye exams with pictures taken by a retinal camera. It makes quick diagnoses, without a doctor present.

His clinics, Tarzana Treatment Centers, are among the early adopters of an AI-based system that promises to dramatically expand screening for diabetic retinopathy, the leading cause of blindness among working-age adults and a threat to many of the estimated 38 million Americans with diabetes.

“It's been a godsend for us,” said Espinoza, the organization's director of clinic operations, citing the benefits of a quick and easy screening that can be administered with little training and delivers immediate results.

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His patients like it, too. Joseph Smith, who has Type 2 diabetes, recalled the cumbersome task of taking the bus to an eye specialist, getting his eyes dilated, and then waiting a week for results. “It was horrible,” he said. “Now, it takes minutes.”

Amid all the buzz around artificial intelligence in health care, the eye-exam technology is emerging as one of the first proven use cases of AI-based diagnostics in a clinical setting. While the FDA has approved hundreds of AI medical devices, adoption has been slow as vendors navigate the regulatory process, insurance coverage, technical obstacles, equity concerns, and challenges of integrating them into provider .

The eye exams show that the AI's ability to immediate results, as well as the cost savings and convenience of not needing to make an extra appointment, can have big benefits for both patients and providers. Of about 700 eye exams conducted during the past year at Espinoza's clinics, nearly one-quarter detected retinopathy, and patients were referred to a specialist for further care.

Diabetic retinopathy results when high blood sugar harms blood vessels in the retina. While managing a patient's diabetes can often prevent the disease — and there are treatments for more advanced stages — doctors say regular screenings are crucial for catching symptoms early. An estimated 9.6 million people in the U.S. have the disease.

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The three companies with FDA-approved AI eye exams for diabetic retinopathy — Digital Diagnostics, based in Coralville, Iowa; Eyenuk of Woodland Hills, California; and Israeli software company AEYE Health — have sold systems to hundreds of practices nationwide. A few dozen companies have conducted research in the narrow field, and some have regulatory clearance in other countries, including tech giants like Google.

Digital Diagnostics, formerly Idx, received FDA approval for its system in 2018, following decades of research and a clinical trial involving 900 patients diagnosed with diabetes. It was the first fully autonomous AI system in any field of medicine, making its approval “a landmark moment in medical history,” said Aaron Lee, a retina specialist and an associate professor at the University of Washington.

The system, used by Tarzana Treatment Centers, can be operated by someone with a high school degree and a few hours of training, and it takes just a few minutes to produce a diagnosis, without any eye dilation most of the time, said John Bertrand, CEO of Digital Diagnostics.

The setup can be placed in any dimly lit room, and patients place their face on the chin and forehead rests and stare into the camera while a technician takes images of each eye.

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The American Diabetes Association recommends that people with Type 2 diabetes get screened every one to two years, yet only about 60% of people living with diabetes get yearly eye exams, said Robert Gabbay, the ADA's chief scientific and medical officer. The rates can be as low as 35% for people with diabetes age 21 or younger.

In swaths of the U.S., a shortage of optometrists and ophthalmologists can make appointments hard to schedule, sometimes booking for months out. Plus, the barriers of traveling to an additional appointment to get their eyes dilated — which means time off work or school and securing transportation — can be particularly tricky for low-income patients, who also have a higher risk of Type 2 diabetes.

“Ninety percent of our patients are blue-collar,” said Espinoza of his Southern California clinics, which largely serve minority populations. “They don't eat if they don't work.”

One potential downside of not a doctor do the screening is that the algorithm solely looks for diabetic retinopathy, so it could miss other concerning diseases, like choroidal melanoma, Lee said. The algorithms also generally “err on the side of caution” and over-refer patients.

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But the technology has shown another big benefit: Follow-up after a positive result is three times as likely with the AI system, according to a recent study by Stanford University.

That's because of the “proximity of the message,” said David Myung, an associate professor of ophthalmology at the Byers Eye Institute at Stanford. When it's delivered immediately, rather than weeks or even months later, it's much more likely to be heard by the patient and acted upon.

Myung launched Stanford's automated teleophthalmology program in 2020, originally focusing on telemedicine and then shifting to AI in its Bay Area clinics. That same year, the National Committee for Quality Assurance expanded its screening standard for diabetic retinopathy to include the AI systems.

Myung said it took about a year to sift through the Stanford health system's cybersecurity and IT systems to integrate the new technology. There was also a learning curve, especially for taking quality photos that the AI can decipher, Myung said.

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“Even with our stride, there's always something to improve,” he added.

The AI test has been bolstered by a reimbursement code from the Centers for Medicare & Services, which can be difficult and time-consuming to obtain for breakthrough devices. But health care providers need that approval to get reimbursement.

In 2021, CMS set the national payment rate for AI diabetic retinopathy screenings at $45.36 — quite a bit below the median privately negotiated rate of $127.81, according to a recent New England Journal of Medicine AI study. Each company has a slightly different business model, but they generally charge providers subscription or licensing fees for their software.

The companies declined to share what they charge for their software. The cameras can cost up to $20,000 and are either purchased separately or wrapped into the software subscription as a rental.

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The greater compliance with screening recommendations that the machines make possible, along with a corresponding increase in referrals to specialists, makes it worthwhile, said Lindsie Buchholz, clinical informatics lead at Nebraska Medicine, which in mid-December began using Eyenuk's system.

“It kind of helps the camera pay for itself,” she said.

Today, Digital Diagnostics' system is in roughly 600 sites nationwide, according to the company. AEYE Health said its eye exam is used by “low hundreds” of U.S. providers. Eyenuk declined to share specifics about its reach.

The technology continues to advance, with clinical studies for additional cameras — including a handheld imager that can screen patients in the field — and looking at other eye diseases, like glaucoma. The innovations put ophthalmology alongside radiology, cardiology, and dermatology as specialties in which AI innovation is fast.

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“They are going to come out in the near future — cameras that you can use in street medicine — and it's going to a lot of people,” said Espinoza.

——————————
By: Hannah Norman, KFF Health News
Title: As AI Eye Exams Prove Their Worth, Lessons for Future Tech Emerge
Sourced From: kffhealthnews.org/news/article/artificial-intelligence-ai-eye-exams-diabetic-retinopathy-innovation/
Published Date: Wed, 27 Mar 2024 09:00:00 +0000

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