Senate Takes First Step To Repeal Obamacare — So What’s Next? Thursday, Jan 12 2017 

At about 1:30 a.m. on Thursday, Republicans moved one step closer to repealing a law they have railed against since the moment it was passed nearly seven years ago.

By a final vote of 51-48, the Senate approved a budget resolution that sets the stage for broad swaths of the Affordable Care Act to be repealed through a process known as budget reconciliation. The resolution now goes to the House, where leaders are hoping to approve it by the end of the week.

The powerful tool sets up a fast track for repealing large parts of Barack Obama’s major domestic achievement; the best guess is that the Senate is still several weeks away from largely repealing Obamacare. But as the process continues, large questions still loom over how — and when – Republicans will replace the healthcare law.

An expedited repeal, starting with a vote-a-rama

The vote took place during a session known as a “vote-a-rama.” These all-night vote-fests happen surrounding budget resolutions, which allow senators to propose unlimited amendments, as the New York Times’ Thomas Kaplan explained this week.

The passage of the resolution kicks off the budget reconciliation process. That process is special because a reconciliation measure cannot be filibustered, meaning it allows the Senate to pass a bill with a simple majority (as opposed to needing 60 votes to overcome a filibuster). That’s good for Republicans, who hold 52 of the Senate’s 100 seats.

Once the House approves the measure, which could happen as soon as Friday, committees from both chambers will meet to create instructions telling the budget committee what repeal should look like. Once repeal legislation is drafted, both houses can pass it with a simple majority, and then it would go to President Trump for signature.

Should that repeal legislation pass both houses and be signed by a President Trump, it would cut out important provisions of Obamacare, but would still not repeal the entire law.

Budget reconciliation only allows Congress to repeal parts of the bill — more specifically, the parts that deal with how much the government spends or taxes people. That means this process can’t repeal, for example, the parts of the bill that allow young adults to stay on their parents’ insurance or the rules saying companies couldn’t deny coverage for people with pre-existing conditions.

But those are the parts of the law that end up costing a lot of money, while the parts that can be repealed through budget reconciliation — like the mandate that people have coverage (which is enforced through a tax), billions of dollars in Medicaid funds and subsidies for private coverage — bring money into the system to help balance out the cost equation.

Democrats try to send their own messages

Democrats went into Wednesday night with a messaging plan: Use vote-a-rama to get Republicans on the record about what may come next. That plan consisted of proposing amendment after amendment to force Republicans to vote on Medicaid expansion, funding for rural hospitals, women’s access to health care and other popular programs.

Democrats know this is a train they can’t stop. As the night drew to a close, all they could do was stage a protest.

Senators aren’t supposed to give speeches during a vote, but Sen. Tammy Duckworth, D-Ill., a disabled Iraq War veteran, ignored the rule.

As the presiding senator was gavelling for order, Duckworth said, “For all those with pre-existing conditions, I stand on prosthetic legs to vote no!”

The gavelling continued as Sen. Al Franken, D-Minn., said, “I vote no on behalf of the more than 2.3 million Minnesotans who can no longer be discriminated against because of the ACA!”

What’s next (and when)? That’s complicated…

Republicans are united on wanting to repeal Obamacare. But they’re more divided over the timeframe of that repeal, as well as what happens next.

At one point, it appeared likely that congressional Republicans would take a “repeal and delay” approach — that is, pass repeal legislation that would only be implemented far down the road, to allow time to craft a replacement for Obamacare.

But now divisions are growing. House Speaker Paul Ryan this week said he would like a repeal and a replacement for Obamacare to come “concurrently.” And in a Wednesday press conference, President-elect Donald Trump indicated that he would like the two to happen in quick succession, though he didn’t provide much more clarity on that timeframe.

“It will be repeal and replace. It will be, essentially simultaneously,” he said, later adding, “It will be various segments, you understand, but will most likely be on the same day or the same week — but probably the same day — could be a same hour.”

Other Republicans, however, believe the process won’t be so abbreviated.

“I don’t see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,” said Maine Republican Sen. Susan Collins.

Wisconsin Republican Sen. Ron Johnson also seemed to say on Tuesday that the process could take a while, involving multiple intermediate steps. As he told WBUR’s Here and Now:

“If you had a bridge that’s about ready to collapse, you know, the first thing you would do is you’d start working to repair that bridge,” he said. “You aren’t going to blow it up; I mean, at least people have a bridge to use. Repair that so people can use it while you start building other bridges.”

Collins is one of five Republican senators who this week proposed that the resolution provide more time for committees to craft their instructions.

One big concern for Republicans here is repealing a law they detest without disrupting the lives of the roughly 20 million people insured because of that law, including 6.4 million Americans insured through ACA exchanges.

Americans definitely want some sort of change — in an NPR-Ipsos poll released Thursday, 38 percent said the ACA should be “strengthened or expanded,” and close behind, 31 percent said it should be repealed and replaced. Meanwhile, only 6 percent said it should be “left as-is” (the poll had a margin of error of plus or minus 3.5 percentage points).

With reporting from Susan Davis.

Copyright 2017 NPR. To see more, visit

Aetna-Humana Merger Could Lower Cost Of Doctor Visit, Study Says Wednesday, Jan 11 2017 

Whether health insurers Aetna and Humana can merge will likely soon be decided, and the outcome might just have an impact on the price you pay at the doctor’s office.

A new study from researchers at Harvard shows what could happen to the amount policyholders have to pay for a doctor’s visit.

The findings, published in Health Affairs, show that the lower prices consumers pay shopping wholesale — for example, at Costco — also apply to health care. Insurance companies with more buying power – through having more policyholders – pay lower prices for health care services. For instance, insurers with more than 15 percent of a market population paid the least amount for an office visit: $70. That increased to $88 for an insurer with less than 5 percent of marketshare.

“Our results indicate that insurers with substantial bargaining power pay rates that are 21 percent lower, on average, than the rates paid to the same providers by insurers with little bargaining power,” the study authors write.

Medical providers set payment rates but insurance companies pay a portion of that rate. It’s common practice that if a health provider is ‘in-network,’ a patient will only pay a co-pay. But when patients go ‘out-of-network,’ they usually pay the total cost that the insurance company doesn’t cover.

The study also says that there might need to be more policies to limit the influence of having so much market share as a result of consolidation.

Study authors looked at over 15 million health care claims from a national database of 60 insurance companies in every state. Large insurers were able to negotiate lower prices with large provider practices.

A decision will likely come before February 15, the deadline Aetna and Humana have set for finalizing the $37 million deal.

Report: ACA Repeal Would Cost Kentucky 45,000 Jobs, $700M In Taxes Friday, Jan 6 2017 

If the Affordable Care Act is repealed without a plan to replace it, Kentucky stands to lose 45,000 jobs. That’s according to a new report from the Commonwealth Fund, a nonpartisan health research group.

The state would also lose $700 million in state and local taxes, according to the report.

The estimated number of jobs lost is based on the current repeal plan in Congress that would immediately do away with the employer and individual mandate. In 2019, Medicaid expansion and tax subsidies to buy coverage on the individual market would also go away.

Because Republicans are still deciding on a replacement plan, the impact of what that might be wasn’t calculated for the report.

As reported by NPR, a poll released Friday by the Kaiser Family Foundation shows that 75 percent of Americans say they either want lawmakers to leave the ACA alone, or repeal it only when they can replace it with a new health care law.

The bulk of the jobs would be lost in areas where there are heavy concentrations of hospitals and other health care companies, like Louisville. That’s according to Leighton Ku, director of the Center for Health Policy Research at The George Washington University and lead author on the report.

“Congress has said they want pro-growth policies, and one of the first items on the agenda isn’t pro-growth at all and it’s at risk of having serious adverse affects for state economies and state budgets,” Ku said.

More than $23 billion is coming into the state via funds from the federal government to pay for Medicaid expansion enrollees’ care and for tax subsidies so people can get insurance on the exchange market.

Ku and his team used a model to trace where that federal money goes first and found hospitals, pharmacies, doctor’s offices and insurance companies are the first place it ends up. But then purchases are made for medical equipment, new construction, renovations and most of all, to pay employees.

“That flows to the employee, and they buy food, pay for housing, and the same thing happens when money goes to another business: the money trickles through the economy,” Ku said. “Because this is much a broad, sweeping law and it affects so much money, the repercussions are much broader.”

One-third of the jobs lost would be positions in health care. Here’s a breakdown of where the other job losses would come from, according to the report.

  • 6,000 retail jobs
  • 4,600 construction and real estate jobs
  • 13,500 other private employer jobs
  • 2,000 finance/insurance jobs
  • 1,400 state/local government jobs

Rand Paul Might Stop An Obamacare Repeal. Here’s How Thursday, Jan 5 2017 

Kentucky Sen. Rand Paul said Wednesday that he would not vote to repeal the Affordable Care Act, known to many as Obamacare, without voting for a replacement plan on the same day. He made the comments on MSNBC’s “Morning Joe.”

“Here’s the great irony, this week we’re going to vote on a budget,” he said. “Everybody is hot and heavy to vote on this budget because they want to repeal Obamacare. But the budget they’re going to introduce will add $8.8 trillion to the debt over the next 10 years. So I told them look, I’m not going to vote for a budget that never balances.”

Paul formed the Senate’s first Tea Party Caucus and has said balancing the budget should be a more important priority than doing away with the Affordable Care Act. On Thursday, he met with members from the House Freedom Caucus to drum up opposition to the repeal if there’s no immediate replacement plan.

Congress is currently examining a process to repeal parts of the law, including the individual and employer mandates that say individuals must have health insurance, and that large employers must offer it to employees. If the bill is approved, these provisions would go away immediately.

The Medicaid expansion program and subsidies for people to buy insurance on the individual market would go away in 2019 or possibly after under the GOP plan. The part of ACA that keeps insurers from barring people with pre-existing conditions from coverage, and other consumer protections, wouldn’t be touched.

The reason why it would cost so much money, as Paul said, is Republicans don’t have a replacement plan.

Budget Buster

Imagine all the money that went into paying for Medicaid expansion, the subsidies and all the other little parts you have never even heard of – as a pie.

Most of the money pie are taken up by paying for the new people on Medicaid expansion and for people with subsidies for marketplace coverage. But those programs were paid for with new taxes on the health care sector.

So you get the money from the pie back, but then that has to go toward making up for the loss of those taxes.

The $8.8 trillion figure comes from a report by the Committee for a Responsible Federal Budget, a non-partisan public policy think tank.

“Repealing the entire ACA would leave no funds available for ‘replacement’ legislation, and in fact would require” lawmakers to come up with other ways to save money to not contribute to the national debt, the group says.

Under repeal, 30 million more people would become uninsured by 2019, which is higher than the uninsured population pre-health law, according to the Urban Institute’s analysis of the budget resolution that would do away with the law.

Health policy expert Edwin Park said what is likely to happen if this repeal goes through without a replacement is the collapse of the insurance market.

“You’d have consumer protections like the prohibition against denying coverage with people with pre-existing conditions remaining in place, but at the same time no subsidies to buy coverage in that market, no individual mandate,” said Park, who is vice president for health policy at the Center on Budget and Policy Priorities, a liberal research and analysis group. “As a result, the only individuals who are likely to enroll are likely those who are sickest.”

Paul echoed that sentiment on “Morning Joe.”

“There are many health care analysts who are predicting bankruptcy for insurance companies and a massive insurance company bailout within first 6 months of repeal,” he said. “Adverse selection gets worse if you get rid of the individual mandate.”

On Wednesday, Senate Democratic Leader Charles Schumer said in a news conference that Democrats have no plans to help Republicans come up with a replacement for the ACA.

“It’s not the Democrats that would be pushing 20 million people off insurance,” he said. “It’s the GOP’s obligation to come up with a proposal.”

Obama Makes A Last-Ditch Effort For His Signature Health Care Law Wednesday, Jan 4 2017 

President Obama meets with Democrats on Capitol Hill today, looking for ways to preserve his signature health care law in the face of stiff Republican opposition.

Senate Republicans have already taken the first step toward repealing Obamacare. On Tuesday, they introduced a budget resolution that would ultimately allow Republicans to unravel large parts of the Affordable Care Act with a simple majority vote.

Democrats still hope to defend the law, which has extended health insurance to some 20 million Americans. Repealing the law would very likely strip protection from many of those people. So far, Republicans have not reached agreement on how to replace Obamacare. And the outgoing administration mocks the idea of repeal now and replace later.

“That ultimately is nothing more than just bait and switch,” said White House spokesman Josh Earnest.

The American Medical Association issued a similar note of caution in an open letter to lawmakers. The association, which supported the Affordable Care Act when it passed seven years ago, acknowledged that the law is imperfect, but said any effort to cut costs or increase choice should at least preserve the existing level of coverage.

“Before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies,” wrote the association’s CEO, James L. Madara. “Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.”

Reconciliation is a procedural tactic that would allow Senate Republicans to unwind large parts of the Affordable Care Act without the threat of a Democratic filibuster.

Some Republican senators are wary of stripping health insurance from people without a plan to take its place. And conservative health care scholars Joseph Antos and James Capretta of the American Enterprise Institute warn that repeal without simultaneous replacement “carries too much risk of unnecessary disruption to the existing insurance arrangements upon which many people are now relying to finance their health services.”

Republican House Speaker Paul Ryan is undeterred, calling the budget resolution “the first step towards relief for Americans struggling under Obamacare.” In a statement, Ryan said his goal is “to ensure that patients will be in control of their health care and have greater access to quality, affordable coverage.”

President-elect Donald Trump weighed in via Twitter, writing, “People must remember that ObamaCare just doesn’t work, and it is not affordable.”

He pointed to a 116 percent increase in premiums for people buying insurance on the government-run exchange in Arizona this year. Premium increases for exchange customers nationwide averaged 25 percent. Most customers shopping on the exchanges receive a government subsidy that helps to defray some or all of the increase.

Even with the higher prices and uncertainty surrounding Obamacare, the administration says customers have been signing up for coverage on the exchanges at a record pace.

Copyright 2017 NPR. To see more, visit

Attn Parents: If You’re Obese, Your Child Could Be At Risk For Developmental Delays Tuesday, Jan 3 2017 

Do obese parents negatively affect the health of their children? A new study out Tuesday from the National Institutes of Health says that’s likely the case.

The study, published in the journal Pediatrics, took data from more than 5,000 mothers and babies, and tracked the weight of the mothers’ partners. In addition to weight, researchers measured children’s motor skills, including whether they could hold up their head and whether they could grasp a parent’s finger.

Children were tested at 4 months of age and retested 6 more times through age 3. When they enrolled, mothers also provided information on their health and weight — before and after pregnancy — and the weight of their partners.

Key findings:

  • Compared to children of so-called “normal” weight mothers, children of obese mothers were almost twice as likely to fail a motor skill test by the age of three.
  • Children of obese fathers were also almost twice as likely to fail a social skills test.
  • Kids with two obese parents were almost three times more likely to fail a problem solving test by age 3.

Edwina Yeung, a researcher with the NIH, said more research needs to be done before the findings would have an impact in the real world. That could include targeted programs to help kids of obese parents develop those skills.

Yeung started out researching diabetes and obesity in adults, but eventually found that the roots of health problems later in life start young.

“We all know it’s difficult to lose weight and maintain weight loss for many people,” she said. “I came to realize the trajectory toward that begins much earlier. I wanted to understand the earlier risk factors.”

Yeung said epigenetics could be a cause for the reduced social skills. All DNA is alike, but it’s epigenetics that determines what portions are highlighted. She said there could be a link between the fathers genes and how DNA is turned on in the brain that would affect social skills and problem solving.

Yeung said that while the study doesn’t prove anything just yet, she will continue to work with study participants and hopes that others will use the results to do other research.

Monday Business Briefing: Enjoy those double-digit stock returns while you can (2017 may not be so kind) Monday, Jan 2 2017 

Welcome to the Jan. 2 Monday Business Briefing, your private business intelligence digest from Insider Louisville. In this first edition of 2017, we recap the 2016 stock market, with a look ahead to this year. Investors — unlike savers — enjoyed some pretty nice returns in 2016, but a local stock researcher worries the underlying […]

Medicaid Is Seeing Huge Gains In Substance Abuse Treatment In Kentucky Wednesday, Dec 28 2016 

Since Kentucky’s Medicaid expansion in 2014, far more people are receiving treatment for opioid and heroin addiction than before. That’s according to a report released Wednesday by the Foundation for a Healthy Kentucky.

The report shows a 740 percent increase in substance abuse services for Medicaid expansion beneficiaries. The number of Kentuckians with traditional Medicaid who received treatment for substance was four times higher between 2014 and 2016, according to the report.

The increase coincides with a regional epidemic in the use of heroin and other opioids.

“The highest incidence of substance abuse is in young adults, and we also know that the highest incidents of a lack of insurance is in young adults, said Ben Chandler, president and CEO of the foundation. “And the ACA has expanded coverage to that population. And they’ve obviously used it in many instances to seek treatment.”

Courtesy Foundation for a Healthy Kentucky

There’s also been a 15 percent increase in inpatient substance abuse treatment admissions since 2012.

The Affordable Care Act, also known as Obamacare, required Medicaid plans, small employers and exchange plans to offer mental health and substance abuse treatment.

Traditional Medicaid only provided very limited substance abuse coverage to pregnant women and children. The newly expanded population included childless adults earning up to about $15,000 a year, and families.

By 2014, the death rate in Kentucky due to drug overdoses was more than 24 per 100,000 people, compared with 15 per 100,000 people nationwide. The majority of these overdoses were due to opioid use, according to the Kentucky Justice and Public Safety Cabinet.

By 2014, prescription opioid overdoses declined slightly to 47 percent, and heroin deaths had increased to 22 percent.

Expanded Medicaid in Kentucky and nationwide is now in question as President-elect Donald Trump — along with the Republican-led Congress — has vowed to repeal and replace the ACA. Trump has proposed giving states pools of money to use as they wish with limited requirements.


Hosparus to raise $1.3 million to expand Inpatient Care Center Tuesday, Dec 27 2016 

Hosparus, one of the largest nonprofit hospice organizations in the country, is seeking to raise $1.3 million to add a third wing to its center downtown. The 25-bed Hosparus Inpatient Care Center, on the sixth floor of the Norton Healthcare Pavilion on Broadway, opened in 1995, with 12 beds, and expanded to 25 beds during a […]

The Future Of Medicaid May Be Found In Indiana, Where The Poor Pay Tuesday, Dec 27 2016 

To get a glimpse of where Medicaid may be headed after Donald Trump moves into the White House, it may be wise to look to Indiana.

That’s where Seema Verma, Trump’s pick to run the Centers for Medicare and Medicaid Services, comes from. And that’s where she put her stamp on the state’s health care program for the poor.

Verma is a private consultant who was hired by Indiana Governor and Vice President-elect Mike Pence to design a Republican-friendly expansion of Medicaid under the Affordable Care Act. The state paid her almost $5 million over four years through 2017, according to the contracts.

She sees the federal Medicaid program as a bureaucratic nightmare that hamstrings states and encourages poor people to remain dependent.

“The Medicaid program has not kept pace with the modern health-care market,” she testified at a Congressional hearing in 2013. “Its rigid complex rules designed to protect enrollees have also created an intractable program that does not foster efficiency quality or personal responsibility.”

The plan she came up with for Indiana requires poor Medicaid recipients to make monthly payments for their insurance, or lose benefits.

“Seema was very committed to extending coverage to low-income families in Indiana,” says Cindy Mann, who was the CMS official who negotiated the deal with Verma on that state’s Medicaid expansion.

She says throughout the negotiations, Verma was “very committed to a particular ideology. That ideology is very much focused on personal responsibility.”

Verma did not respond to multiple requests to be interviewed for this story.

Pence was one of the few Republican governors who took the Obama Administration up on its offer to pay the lion’s share of the costs for states that expanded their Medicaid programs to people whose incomes reach 138 percent of the poverty level, or $16,243.

But rather than simply offer coverage to more people, the state sought a waiver to revamp their program. That’s the deal that Verma worked out with Mann.

Indiana’s program, which extended Medicaid to about 246,000 people who weren’t eligible before, is infused with Verma’s ideas of how to make poor people take responsibility for their health care.

It had a complex system of carrots and sticks.

Beneficiaries make monthly payments from $1 to about $27 into individual health savings accounts, and the state also contributes. That money can be used for doctor visits and prescriptions.

If beneficiaries get vaccines and other preventive care, they get a discount on their premiums the following year.

But they can also be penalized. People whose incomes are above the poverty line can be cut off for three months if they miss a payment. Those below the poverty line are knocked down to a plan with fewer benefits.

And if a patient unnecessarily goes to the emergency room, extra money comes out of the health savings account.

“There are many ways to try and effectuate personal responsibility,” Mann says. “Some states have moved forward with healthy behavior initiatives, for example. Some states have done some premiums and copays.” Indian’s plan requires everyone to contribute to a health savings account. “And so the responsibility was really translated into payment requirements, and with pretty strong consequences if somebody was unable to pay.”

She says Verma and Indiana wanted the penalties to be even harsher — a full year with no coverage for people who miss payments. But CMS rejected that idea.

So how does it work in practice? For Amber Thayer, a mom of three who lives in a Volunteers of America family shelter in Indianapolis, it’s been a bit of a nightmare.

Thayer’s a recovering addict who has been clean for six months with the help of the medication Suboxone. And she’s training to be a nursing assistant.

“It’s been quite quite the struggle, but we’ve gotten there and we’re doing great and we’re getting ready to get into our own home,” she says.

She pays $1 a month for her Medicaid insurance.

In October she got a bill for that one dollar from a different company than the one she had been dealing with. She assumed the state had switched her.

“It is only a dollar,” she says. “I could pay a dollar a month or I could pay $12 and that will cover me for the year. Unfortunately at that time I only had I believe it was like $2.38 on my card.”

So she called the company and used her bank card to pay the dollar.

But the company, or perhaps the state, lost track of her dollar, and her insurance was cut off. She had her bank statement and a receipt from the insurer that proved she paid. But she still spent six weeks, with multiple phone calls and visits to state health offices, trying to get her coverage restored.

All the while she scraped together enough money to buy Suboxone one dose at a time.

“I’m fearing, you know, the withdraws,” Thayer recalls.

But she was also afraid the loss of insurance would interfere with her ability to take her nursing assistant exam, which in turn would threaten the stipend she gets because she is in job training. “If I don’t get my stipend, we’re not going to have our money to help us move into our home.”

It’s these types of complications that have some advocates worried.

Adam Mueller, a lawyer for Indiana Legal Services, says he’s happy more of his clients have health insurance. But he says the state’s notion that people will feel more invested in their care if they pay $1 a month just doesn’t play out in the real world.

“They don’t feel like they have skin in the game,” Mueller says. “One guy told me that it feels like Indiana is trying to take his last $12.”

Joe Thompson, CEO of the Arkansas Center for Health Improvement, says it’s just hard to be poor.

“”The social stresses of low-income individuals probably make most aspects of managing through the day more difficult than if you have more affluence and have more resources available to deploy,” he says.

Thompson, who’s a former Arkansas surgeon general, helped develop a Medicaid program in his state that had many of the same features as Indiana, including premium payments and health savings accounts.

In the end, Arkansas decided it just wasn’t worth it.

“We had about a year and a half of experience there, and candidly the administrative cost and the operating aspects exceeded what the legislature subsequently perceived the benefit of that program was,” Thompson says. So the state scrapped the health savings accounts.

He says the ideas about personal responsibility are politically popular, but implementing them is too complex.

“We lose too many folks along the way, and we may be causing more challenges than we’re solving,” he says.

Arkansas still charges nominal premiums for some Medicaid recipients, but they pay them directly to insurers. The carrots and sticks and individual accounts are gone.

In Indiana, insurers also collect the premiums and administer the individual health savings accounts. James Gavin, a spokesman for the Family and Social Services Administration, says those costs are included in what the state pays the insurance companies, and so it’s not clear exactly how much Indiana is spending to administer the health savings accounts.

Verma has advised several states, including Iowa, Kentucky and Ohio, that are looking for Medicaid waivers from the federal government. Many of those waiver applications include cost features such as premiums or health savings accounts or incentives for healthy behavior.

“The cost sharing policy is not to burden the individual,” she told lawmakers at the 2013 hearing. “I think it’s to incentivize them and empower them to be part of the equation.”

When Verma testified in 2013, she urged lawmakers to make the process of getting Medicaid waivers easier.

If she’s confirmed as administrator of the Center for Medicare and Medicaid Services, it will be her and her staff who review waiver applications and determine if they should go forward.

Copyright 2016 NPR. To see more, visit

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