Governor Nathan Deal said the state Department of Community Health has been told to reduce its amended current fiscal year budget by 3 percent and then find 5 percent more in new cuts next year to help the state absorb Medicaid costs that continue to escalate. The state faces a Medicaid deficit that will approach $800 million during the next 18 months of its fiscal cycle.
Deal devoted nearly his entire speech to health care when he addressed the Georgia Chamber of Commerce annual “Eggs and Issues” breakfast Wednesday at the World Congress Center in Atlanta. The Governor also suggested folks who cannot attend Thursday morning’s State of the State address should monitor his “Tweeter” account. Deal will announce his budget during the speech, scheduled for 11:00 a.m. at the State Capitol.
“Georgians who have already received a paycheck this January have no doubt noticed that their payroll taxes went up and their take-home salary went down,” Deal said. “This is the cost of entitlements. If you think your taxes went up a lot this month, just wait till we hve to pay for ‘free health care.’ Free never cost so much.”
The push is on to quickly approve a Medicaid funding fix bill proposed by the Governor with an initial Senate floor vote perhaps this week. Lt. Governor Casey Cagle and House Speaker David Ralston echoed their support for the governor’s bill that would give the Community Health board the authority to continue the hospital provider fee that would otherwise sunset in June.
The fee paid by all Georgia hospitals based on annual revenue is used to draw down federal dollars that are redistributed to hospitals that serve Medicaid patients. The General Assembly enacted the fee three years ago to address a rapidly developing shortage in Medicaid funds caused by increased demand for services. Deal said 12-to-14 hospitals would face closure if the provider fee is not continued. DCH imposes a similar nursing home industry fee.
“In fact, we are one of 47 states that have either a nursing home or hospital provider fee or both,” Deal said. The governor said “it makes sense to me” that DCH should have authority over both fees “for maximum efficiency and effectiveness.” The move also means that state lawmakers would be spared having to vote to continue an expiring fee or impose a new one.
Deal said DCH has identified $109 million in cost-savings. “But this hardly covers the additional nearly $500 million in needed funds caused by growth in Medicaid expenses during the same time frame,” Deal said. “This means we must make necessary cuts in other agencies and core functions of government since raising taxes is not an option I will accept!”
The governor is no fan or friend to the federal health care reform law known as Obamacare.
During the past several months the Deal administration said it will not expand Medicaid eligibility starting in 2014 because the state cannot afford more than $2.5 billion that it currently spends annually on Medicaid. The federal government pays about $5 billion annually. Georgia anticipates its share of Medicaid costs will increase at least $1.7 billion over the next ten years.
Deal said the federal health care reform law will add $106 million to the cost of state-provided health care benefits for active and retired employees starting in 2014. He also said Georgia will be assessed a new $35 million insurance tax starting in 2015. About 13 percent of all state budget dollars currently pay for Medicaid or the state children’s health insurance programs.
“The irony to me is that there are those in the medical community who are urging the expansion of the Medicaid program while at the same time, they are seeing more and more medical providers refusing to accept Medicaid patients,” Deal said. “If you are losing money now how do you reconcile the number of patients on whom you will lose even more money.”
Georgia also said it will not create a state health insurance exchange, as envisioned in the federal health care reform law. “I see no benefit to our citizens to have a program bearing the name of the State of Georgia over which our elected or appointed officials have little if any say so,” Deal said. “While many federal programs come with strings attached, these strings turn states into marionettes to be manipulated by federal bureaucrats.”
As for “Tweeter,” the Governor noted, “My staff tells me that I am really getting into the modern age. You can go to my Tweeter account!” for updates on the State of the State address. The address will be carried live on General Assembly and Georgia Public Broadcasting websites. GPTV will broadcast the State of the State address and the Democratic leadership response in their entirety at 7:00 p.m. on the legislative program “Lawmakers.”
(Mike Klein is Editor at the Georgia Public Policy Foundation)
Health care policy is a complex beast with seemingly intractable political positions, lots of data to support or refute almost anyone’s perspective, tons of financial impact analysis – just last week the Congressional Budget Office released yet another health reform cost impact study — and at the end of the day, lots of ragged emotions that cloud and obscure the conversation.
Here is an idea that should not be overlooked: People will get sick and have accidents regardless of who is making policy and whatever that policy-of-the-moment happens to include or exclude. And when that happens, they need someone nearby who is able to help them.
In Georgia, we need help. “You’ve hit on a significant issue for the state,” said state Department of Community Health deputy commissioner Blake Fulenwider. “There is no doubt about that.”
Fulenwider, two other state officials, an Obama administration official and a national children’s advocate sat together last week for a Georgia Children’s Advocacy Network discussion about what the recent U.S. Supreme Court federal health care law decision might mean for Georgia children. Might is a precarious word because of the November presidential election.
As the 90-minute session began to end, Fulenwider noted, “Today is an example that none of the things that we talk about have easy answers.” Debate will continue here for months about whether to expand Medicaid eligibility and how to create a health insurance exchange, if at all.
Here is a reality check: Today Georgia has a significant physician shortage and the state also anticipates a shortage of 38,000 nurses over the next decade. That is what a Georgia Health Sciences University report concluded last August when it was submitted to the University System Board of Regents. Urban medical facilities are overloaded and there are vast health care brownfields in rural areas.
An Association of American Medical Colleges report published in August 2011 said, “Without immediate statewide cooperation in expanding medical education and residency programs, the state may never again have an adequate supply of physicians. For too long Georgia has relied on out of state and international physicians to make up for the lack of Georgia trained doctors. Without changes in the state’s medical education system, Georgia will rank last in the United States in physicians per capita by 2020.”
No Silver Bullet for Medical Access
The University system report said the state is 1,450 graduate medical education positions below the national average and 315 below the average of southeast states. That forces students to leave Georgia for medical education which, in turn, decreases the possibility they will return to practice medicine back in Georgia. The state has 20.8 physicians per 100,000 persons; the national average is 35.7 physicians.
Governor Nathan Deal recognized the urgency of this shortage by creating 400 new physician residency slots in this year’s budget. Unfortunately, training hundreds of new physicians when you are short by many hundreds more means you are still short.
To further stress the already stressed system, about one-third of physicians and almost 40% of registered nurses statewide are eligible to retire now or within ten years. Many higher education programs are trying to address shortages but Georgia is clearly catching up, not getting ahead.
“Providing coverage does not mean providing access,” Fulenwider admitted. “We continue to be challenged with our budget environment and landscape that we’re in, in maintaining and being an attractive payer for our Medicaid providers. We’ve got to be sure that we’ve got boots on the ground to deliver service. I wish there was a silver bullet answer to that. There is not.”
Supreme Court Decision Impact
The U.S. Supreme Court decision threw a wrench into health care policy decisions. Whereas media was intently focused on what might happen with the individual mandate provision, the justices by a 5-4 vote blindsided nearly everyone by ruling states cannot be forced to expand Medicaid, and states cannot be penalized if they refuse to expand. The individual mandate was upheld as a legal tax. Health insurance exchanges were also upheld, although they will likely exist in many forms.
Here is part of the Georgia landscape. State decisions on Medicaid eligibility expansion and what to do about a health insurance exchange will not be announced until after voters decide whether Mitt Romney will replace Barack Obama. A state Medicaid redesign train that left the station early last year has been sent to a side rail but some elements will be implemented.
Georgia faces a November 16 deadline to tell the federal government how it plans to establish a health insurance exchange required by federal law unless a new Romney administration that would assume office in January issues exemptions and begins to dismantle the law.
“There will be an exchange in Georgia one way or another,” suggested JoAnn Corte Grossi, who works for the Obama administration as Mid-Atlantic States Director at the U.S. Department of Health and Human Services. That was her message to the Georgia CAN! panel last week.
Will the Obama administration be flexible with states that would prefer to receive Medicaid block grants? “We’ve obviously gotten lots of letters from lots of governors asking questions like that,” Grossi said. “Sorry to punt on this one but the honest answer is decisions are still being made.”
Some State-Based Decisions Already Made
Some state-based changes will happen regardless of November elections: Georgia foster care children – currently 26,409, according to the Department of Community Health — will move to care management organizations. Medical records will follow children regardless of where they live or how often their placement changes. This is similar to how the state manages health care for low-income Medicaid and PeachCare children. The change is anticipated in mid-2014 when the state executes new managed care contracts.
Georgia also decided Medicaid eligibility will continue to be done in conjunction with eligibility for food stamps, temporary assistance for needy families and child care subsidies. The state will launch a new consumer-focused web portal but that might take three years to develop.
Jonathan Duttweiler is Manager for Medicaid Eligibility at the Department of Human Services. He said 2,100 staff caseworkers currently average 571 Medicaid recipient clients. The average caseload would increase by 400 additional clients to almost 1,000 per caseworker if Medicaid expands starting in 2014. Duttweiler said the state has fewer caseworkers today than it had 15 years ago.
The state also requested and received a federal waiver from the health care law provision that insurers must spend 80 percent of each dollar earned on health care. The state position was that “smaller insurers wouldn’t be able to meet that 80 percent threshold,” said Jay Florence, legal counsel for the state office of insurance. The waiver required 70 percent spending levels last year, 75 percent this year and 80 percent starting next year.
The Georgia CAN! health care policy panel discussion was peppered with data. Indeed, at times it seemed almost no sentence was complete without a number included. One of those seated in the audience was Dr. Harry Heiman, director of health policy for the Satcher Health Leadership Institute at the Morehouse School of Medicine.
“I understand your lens,” Heiman told the panel. “My lens as a family physician is I am seeing children every day, adults every day that suffer health consequences for lack of access to quality care. Clearly, we need a balanced approach that understands your challenges and the challenges of the children and adults in our state.”
Medicaid is a beast. About one-in-five Georgians receives Medicaid health care. That is 1.7 million people. Fifty-nine percent of statewide births are Medicaid babies. Another couple hundred thousand children are enrolled in PeachCare, the state children’s health insurance program. Medicaid could grow by hundreds of thousands more if the U.S. Supreme Court upholds the federal health care reform law in its decision expected next month.
Not at all surprisingly, Medicaid redesign questions were abundant when three of Governor Nathan Deal’s advisors met with Georgia Children’s Advocacy Network members at the Freight Depot in Atlanta. The advisors made no presentations and took questions for 90 minutes.
Health policy advisor Katie Rogers named telehealth reimbursement policies, portable electronic records, better outcomes for vulnerable children, physician shortages in some specialties, how to manage health care in counties that are medically underserved and treatment options for chronic childhood illnesses as part of the wide-ranging Medicaid redesign conversation.
Next month the U.S. Supreme Court will rule on constitutionality of the 2010 federal health care reform law. If upheld the Patient Protection and Affordable Care Act provisions often known as ObamaCare could add 620,000 new Medicaid patients to the state program. Rogers predicted, “People who haven’t had access to services are going to seek services probably very quickly.”
Georgia Medicaid cost $7.78 billion in fiscal year 2010, according to Kaiser State Health Facts. Federal funds pay 66% and the state is responsible for the rest, about $2.7 billion. Georgia Medicaid program redesign is being managed by the Department of Community Health with private partner assistance from Navigant. The project is described in a comprehensive design strategy report available on the DCH Medicaid website.
This project is so important to Georgia’s health care community that it is being closely monitored by many organizations outside government. Cindy Zeldin is executive director at Georgians for a Healthy Future which advocates for improved statewide access to quality health care.
“The three buckets when we look at improving Medicaid would be one, just coverage, getting kids who are eligible but who are not enrolled today into the program so they at least have that front door access,” Zeldin told the Public Policy Foundation this week.
“Second, improving access to care, just making sure there is a mechanism to make sure that being in Medicaid means you can see a provider if you need to,” Zeldin said. For instance, the state has no OB-GYN practitioners in 39 counties, which is an impediment to women’s health.
“Third would be improving outcomes and accountability, what you are asking managed care companies to report on and making sure you are measuring outcomes that ensure quality care.”
The Supreme Court opinion expected next month will also decide whether Georgia must create a health insurance exchange. Last December a state report to Governor Deal said a private or quasi-governmental exchange would be preferable to one imposed by the federal government, but Georgia would prefer that it is not required to create any exchange. Georgia opposes the federal health care reform law and it joined the suit that challenges the constitutionality.
“If the law is upheld as it stands now we will work very quickly to implement a state exchange,” Rogers said. “If the law is not upheld the discussion will begin again on whether or not to move forward with a state exchange. Part of the concern is without the individual mandate would people want to buy insurance through the exchange?”
Education and Public Safety Issues
Education and several public safety issues were also discussed during the open forum.
Education policy advisor Kristin Bernhard said several early childhood education programs lead the priority list heading into next year’s General Assembly. Do not expect support for private school vouchers or increasing the age for compulsory school attendance from 16 to 18.
“The voucher conversation isn’t on the table for us,” Bernhard said. “We’re more interested in increasing the quality of public education for all students everywhere.” On compulsory school attendance she said, “The evidence is not necessarily compelling that raising the age of mandatory school attendance automatically results in an increased graduation rate.”
Education headlines over the next year will include incorporating the state’s version of new national core curriculum coursework, dual enrollment for middle school students taking high school courses or high school students taking college courses, tenth grade college readiness testing, and preparation to expand career pathways education now scheduled for fall 2013.
Also, Georgia admits that it has too many high school graduates who require remedial courses when they enter college. “We know that students are graduating from high school not ready for college,” Bernhard told 100 Georgia Child Advocacy Network members. Part of this discussion is how these students can be assisted by resources inside the state technical college system.
This week the Illinois Senate President proposed his state enact internet gaming legislation to get in front of a potential federal law that would grandfather existing state programs but prevent other states from creating new ones. Do not expect anything like that in Georgia.
It is well documented that the lottery-funded HOPE scholarship, grant and pre-K programs can no longer afford to fully fund their commitments. Governor Deal opposes a proposed casino-style project and Bernhard says, “What we’re looking at is what we can do to boost the existing revenue streams.”
Several folks applauded when public safety advisor Thomas Worthy said, “I have no doubt that we will probably see and definitely sign a juvenile code rewrite next year.” HB 641 was a substantial effort to rewrite piecemeal juvenile laws that are decades old. It passed the House but then was stopped before Senate consideration so more work could be done on cost.
“Everybody is in agreement on the policy side of things,” Worthy said. “We are there. The stakeholders are there. Agencies are now there. Now what we are tasked with doing is figuring out a way to not only pay for implementation but actually ascertain savings that will come under the bill.” Worthy said consultation has begun with the Pew Center on the States; Pew assisted with criminal justice reform legislation that Governor Deal signed this month.
Worthy also acknowledged, “Not only do we have a horrible child trafficking problem within our state, (Interstate) 75 is used to move folks going to other states.” This year HR 1151 in the General Assembly created a commission to study child trafficking and make recommendations.
(Mike Klein is Editor at the Georgia Public Policy Foundation)
Governor Nathan Deal and Attorney General Sam Olens issued strong statements on Monday in support of overturning federal health care reform, just a few hours after the U.S. Supreme Court said it will review legislation that became law 20 months ago.
Olens said the Supreme Court hearing scheduled for early next year is “a crucial step in our long fight to reign in the federal government’s unconstitutional over-reach into the healthcare marketplace.” Deal’s statement recognized “the fight against the crippling mandates of Obamacare,” which has become a popular term for federal health care reform.
Georgia is among 26 states that sued President Barack Obama’s administration to overturn the Patient Protection and Affordable Care Act, which became law in March 2010. The central and dominant point of contention is whether a federal government individual mandate could require that each American purchase health insurance or face financial penalties starting in 2014.
Governor Deal said, “Obamacare would vastly expand our state’s Medicaid enrollment, creating a huge new tax burden on Georgia taxpayers. Frankly, our state can’t afford these new unfunded mandates, and what we’re seeing is that the majority of states feel the same way. The outcome of this case is hugely important to the future of Georgia, and we have high hopes for a favorable decision from the Supreme Court next year.”
During his State of the State address in January Deal said the federal health care law would add 650,000 Georgians to state Medicaid rolls, costing $2.5 billion in new state expense over ten years. “It’s appropriate and expected that the court would rule on an issue so central to Americans’ individual liberties. As governor, I’m especially happy to see the court look into whether the federal government can force state governments to take on huge new spending programs.”
Olens outlined the scope of the Supreme Court review: “The Court has agreed to review whether the individual mandate exceeds the limited powers of Congress; whether the individual mandate, if unconstitutional, can be struck down on its own or whether the whole law must fall; whether the federally mandated expansion of Medicaid exceeds Congress’s powers under the Spending Clause of the Constitution; and whether the Anti-Injunction Act affects the Court’s jurisdiction to hear the challenge to the individual mandate.”
The timetable established by the Court – arguments in February or March and a decision likely in June – means the justices will deliver their opinion before Republican and Democratic presidential nominating conventions, and months before November 2012 national elections that could become a referendum on the expansion of federal government ala the health care model.
Four federal appellate courts have heard Patient Protection and Affordable Care Act cases. The Supreme Court accepted the case that came through Atlanta’s 11th Circuit Court of Appeals where justices ruled the individual mandate is unconstitutional.
Opponents include the National Federation of Independent Business, a small business group, and states that argue the law’s expansion of Medicaid eligibility will become a budget buster. Medicaid expenses are the single fastest growing segment of the Georgia state budget.
Supporters counter argue that reform — sometimes known as Obamacare — will make health care more accessible to millions of Americans. Some supporters consider the measure to be as historic as the creation of Social Security, Medicare and the Civil Rights Act.
Federal appellate courts in Cincinnati and Washington upheld the law. One in Richmond, Virginia declined to rule because the individual mandate provision is not in force until 2014.
(Mike Klein is Editor at the Georgia Public Policy Foundation)
Georgia’s governor and attorney general said Friday’s decision by the federal appeals court in Atlanta that strikes down the federal health care reform individual mandate is “a huge step toward victory” but ultimately, ObamaCare will be decided by the U.S. Supreme Court.
Governor Nathan Deal and Attorney General Sam Olens issued a statement about two hours after the 11th Circuit Court of Appeals in Atlanta released its 2-to-1 opinion:
“We applaud today’s ruling from the United States Court of Appeals for the 11th Circuit striking down the individual mandate as ‘a wholly novel and potentially unbounded assertion of congressional authority.’ Today’s ruling recognizes the core principles of our federalist system and reminds an over-reaching federal government that the Constitution applies to it, too.
“We do not, however, agree with all findings in the decision. Unlike the 11th Circuit, we believe that the Obama administration should be taken at its word that the individual mandate is crucial to the whole bill, and that the whole bill should be struck down.
“But this much is certain: Federal health care reform is on life support, and this case will be decided by the Supreme Court of the United States. Today is a huge step toward victory, but it is also a day that emphasizes the importance of the work ahead.”
Friday’s decision came in a case filed by Florida and joined by 25 states including Georgia. In January, federal judge Roger Vinson ruled all of federal health reform was unconstitutional. The federal government appealed. Friday’s decision rejected only the individual mandate.
Chief Judge Joel Dubina and Circuit Judge Frank Hull found “the individual mandate contained in the Act exceeds Congress’s enumerated commerce power.”
Their majority opinion said, “What Congress cannot do under the Commerce Clause is mandate that individuals enter into contracts with private insurance companies for the purchase of an expensive product from the time they are born until the time they die,” the opinion said.
Judge Stanley Marcus disagreed in dissent. He wrote that the majority opinion ignored the “undeniable fact that Congress’ commerce power has grown exponentially over the past two centuries, and is now generally accepted as having afforded Congress the authority to create rules regulating large areas of our national economy.”
Obama administration options include asking the complete 11th Circuit Court to review the opinion, or it could appeal directly to the U.S. Supreme Court.
Three federal appeals court cases are working their way toward a Supreme Court resolution. The court in Cincinnati upheld ObamaCare and court in Richmond has yet to issue its opinion. A decision by the U.S. Supreme Court would come during the 2012 presidential election year.
(Mike Klein is Editor at the Georgia Public Policy Foundation)
Georgia congressman Tom Price warned Thursday that the outcome of the debt ceiling limit battle in Washington could send President Barack Obama down the road toward a successful re-election bid unless Republican Party members decide to hang together and vote together.
“It is imperative to stop the madness in Washington,” Price said during a conference call with health care policy analysts from around the nation. “The bill that will be on the (U.S. House of Representatives) floor this afternoon is not at all what I would have wanted it to be, nor likely what you would have wanted it to be, but it is I believe the only kind of construct that can get through the Senate and force the President to be signed into law.”
The Galen Institute and the Institute for Policy Innovation originally scheduled the four-term Georgia congressman for a health care policy discussion. That was forced to share the clock with the debt ceiling controversy that seems to change almost hourly. Price said Republican Party members should support the bill advanced by House Speaker John Boehner of Ohio.
“If something like this doesn’t happen, then I believe Barack Obama’s hand is strengthened to a huge degree,” Price said, “and not just in the area of the debt ceiling and spending, but in every other single aspect that the Congress will deal with over the next 15 to 16 months and make him much more likely to get re-elected.”
The House debt limit ceiling bill has broken the Republican Party into factions. Three Georgia congressmen – Phil Gingrey, Tom Graves and Paul Broun – oppose the Boehner legislation because they believe it does not cut enough from federal government spending. Tea Party Republicans oppose the bill. Others argue the Boehner bill is the best option at this moment. Read more »
Stephen Moore remembers asking his son, who’s the best basketball player in the world? They agreed, it’s LeBron James, who earns about $40 million per year in salaries and endorsements. Moore posed a question to his son: how long would it take LeBron James to earn $1 trillion? The answer is a staggering 25,000 seasons. Not even Michael Jordan played that long!
Moore delivered the economic keynote address at this past weekend’s conference hosted by the Georgia Public Policy Foundation and the Conservative Leadership Policy Institute. Moore is the Wall Street Journal’s senior economics writer, a member of its editorial board, the author of six books and a former senior economist on the Congressional Joint Economic Committee.
Here’s the point Moore made with his LeBron James example: We hardly know what $1 trillion means even as we watch the federal government routinely run debt into the several trillions.
“We have spent too much money, we have borrowed too much money, we have printed too much money and we have taken too much power from the states,” Moore said. “Milton Friedman taught us this 30 or 40 years ago. There’s no free lunch. If Washington or the state of Georgia spends a dollar, that dollar has to come from somewhere.”
Last week the National Commission on Fiscal Responsibility and Reform floated a draft report with ideas to reduce the national debt by $4 trillion over 10 years. Dozens of proposals would significantly change Social Security, other federal entitlements and discretionary spending.
Moore’s remarks in Atlanta on Saturday are timely because of that report, and also because Congress went back to work Monday, ready to argue about what to do with your money.
Tuesday’s agenda will include the Senate debate on funding earmarks. Thursday’s action will move to the White House where President Barack Obama, Democratic and Republican leaders seem ready to dig in their heels about extension of Bush-era federal income tax cuts. Congress also needs to fix the alternative minimum tax for 2010 taxpayers before the holiday break.
“We had better make sure we extend all the Bush tax rates come next January,” Moore told 250 conference attendees. “If you want to balance the budget in Washington, if you want to balance the budget here in Atlanta, you want more rich people.”
Here’s why: Rich people invest; investment triggers growth; growth triggers more employment; employed people purchases products and services and employed people pay taxes, exactly the opposite of unemployed people who require government services paid for by employed people.
Moore believes the nation has arrived at a critical historical point: “The number one issue is this, what country is going to be the global number one super power? For our lives, the United States has been a force for good. We’ve led the world.
“But now for the first time in our lives we have an honest to god rival. And who is that; China, now becoming one of the most prosperous countries in the world. China predicts in 18-to-20 years that it will catch the United States,” Moore said.
“China is focused right now like a laser beam on competitors. They have their eye on the ball. That’s what we need to do as a nation and that’s what we need to do in Georgia. Everything you do, make sure you keep in mind, is this going to make Georgia more competitive?
“Step one and I’m deadly serious about this: Abolish the state income tax. This is not a radical idea. There are nine states in this country that have no state income tax,” Moore said. “Texas, Florida, Tennessee; these states are able to pay their bills without having an income tax. It’s so obvious; the states without an income tax are the ones that have driven growth.”
Georgia’s Special Council on Tax Reform is expected to propose some revisions to the state’s 6% individual income tax when it reports to the General Assembly in January. Sources say it might propose reduced individual income tax rates in a new model that would move taxation away from earned income and toward taxation of services and products purchased.
Moore predicted the Republican majority U.S. House will pass a bill to repeal Obamacare, the Senate will not and health care will become “death by a thousand cuts.” He predicted the individual mandate will be eliminated. “What we need to do with health care is, we need to allow states to begin to experiment. Let people buy insurance from anywhere they want to.”
Moore started his address with this idea: “The election we just saw was not a victory for the Republican Party. It was a victory for the conservative movement and free market principles.” He finished with this idea: “Both parties are still fighting with each other. It’s like none of them learned the lesson.”
Mike Klein is Editor at the Georgia Public Policy Foundation.
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