The Dangers Inherent in American Healthcare

That the US healthcare system—from its insurance structure, drug pricing realities, and the entirety of its delivery mechanisms—is expensive and convoluted is not news. The dangers inherent due to these factors should not be underestimated. Americans spend more per capita on healthcare than any other nation, but health outcomes for Americans are far from the best.

One stark sign of this is that, according to the most recent 2018 Centers for Disease Control and Prevention (CDC) data, for the third year in a row life expectancy in the United States declined. This kind of drop has not been seen since 1915 to 1918, a time span that included not only a world war but also the deadliest global flu pandemic on record. - washingtonpost.com

The reality is that US life expectancy is below that of every one of the 28 nations that make up the European Union (EU). And end-of-life issues are not the only concern. The US infant mortality of 5.6 per 1,000 is over 60 percent higher than the EU average of 3.6 per 1,000.

There are a myriad of ways that the approach unique to US healthcare creates danger for citizens. From the opioid crisis (which is tied to the market realities of the pharmaceutical industry), to deaths due to medical error (tied to labor shortages in hospitals), to lack of access to care - there are many factors throughout the sprawling system that are driving the poor health outcomes in the American healthcare system.

The “system” is disjointed, overly complex, uncoordinated, and oftentimes driven more by profit-seeking than patient care. This has led to a situation where, on the macro level, the healthcare “system” itself is disjointed while, on the micro level, the healthcare that individuals have access to does not support the body’s ability to heal itself.

Not A New Problem

This is hardly a new situation. The Byzantine nature of American healthcare is based on a number of factors, from the random governance structure of the nation, the power that advertising — as opposed to measured planning — played in shaping the American healthcare industry, and a pivotal interpretation by the Internal Revenue Service (IRS) regarding how to treat health insurance premiums.

Much of this background was covered in a special series by NPR’s Planet Money in 2009:

Before the birth of modern medicine, hospitals were poorhouses where the indigent went to die. Then came the advent of effective medicines, especially antibiotics, along with a revolution in medical schools.
Suddenly, says economic historian Melissa Thomasson, “hospitals are marketing themselves as places to have babies.” The professor at the Miami University in Ohio says that in the early part of the 20th century, hospitals were able to focus on happy outcomes.
Healthcare became much more effective, and much more expensive. Clean hospitals, educated doctors and real pharmacological research cost money. People proved willing to pay for care when they were really sick, but it wasn’t yet common to go for checkups or survivable illnesses.
By the late 1920s, hospitals noticed most of their beds were going empty every night. They wanted to get people who weren’t deathly ill to start coming in.
An official at Baylor University Hospital in Dallas noticed that Americans, on average, were spending more on cosmetics than on medical care. “We spend a dollar or so at a time for cosmetics and do not notice the high cost,” he said. “The ribbon-counter clerk can pay 50 cents, 75 cents or $1 a month, yet it would take about 20 years to set aside [money for] a large hospital bill.”
The Baylor hospital started looking for a way to get regular folks in Dallas to pay for healthcare the same way they paid for lipstick—a tiny bit each month. Hospital officials started small, offering a deal to a group of public school teachers in Dallas. They offered a plan for the teachers to pay 50 cents each month in exchange for Baylor picking up the tab on hospital visits.

And thus was born American-style health insurance and so began the convoluted system of today. From the onset, consumer-facing marketing and indirect financing schemes played an integral role in shaping healthcare in America.

Unlike many other Western nations, the experience of the Second World War did not change this trajectory. Throughout the rest of the developed world, national health systems were overhauled in the aftermath of the war when centralized economic planning was instituted to rebuild national economies.

For example, the loss Winston Churchill suffered in the British general election of 1945 was driven, in part, by the opposition of his Conservative Party to the Labour’s proposed National Health Service, which promised “cradle-to-grave” care (a goal that reverberated throughout Commonwealth countries like Canada, Australia, and India). It imposed a level of logic and order on Britain’s approach to providing stable healthcare to its entire population.

In contrast, the United States did not suffer the direct physical cataclysm that most of its foes and allies did. And the US experience in World War II created very different circumstances with regards to how the healthcare system developed:

The modern system of getting benefits through a job required another catalyst: World War II. Thomasson says that if the Great Depression inadvertently inspired the spread of employer-based health insurance, World War II accidentally spread the idea everywhere. 
“The war economy is an entirely different ballgame,” Thomasson says. The government rationed goods even as factories ramped-up production and needed to attract workers. Factory owners needed a way to lure employees. She explains that the owners turned to fringe benefits, offering more and more generous health plans. 
The next big step in the evolution of healthcare was also an accident. In 1943, the Internal Revenue Service ruled that employer-based healthcare should be tax free. A second law, in 1954, made the tax advantages even more attractive.
Thomasson cites the huge impact of those measures on plan participation. “You start from 9 percent of the population in 1940 to 63 percent in 1953,” she says. “Everybody starts getting in on it. It just grows by gangbusters. By the 1960s, 70 percent [of the population] is covered by some kind of private, voluntary health insurance plan.”
Thus employer-based insurance, which started with Blue Cross selling coverage to Texas teachers and spread because of government price controls and tax breaks, became our system. By the mid-1960s, Thomasson says, Americans started to see that system—in which people with good jobs get healthcare through work and almost everyone else looks to government—as if it were the natural order of things. NPR.org

It is because of this unplanned — and wholly unique — series of events that the United States now has the most complex, least efficient healthcare system in the world. And why it is also “the only developed country with an employer-based health insurance — really, the only one. - vox.com 

While the United States spends $3 trillion on healthcare annually — representing $8,500 per person and nearly 18 percent of the total US economy (while no other country spends over 12 percent) — its health outcomes are poorer. This fact has left individual Americans facing a myriad of “options” — including for millions the option of having no access to care — with no meaningful counterbalance to the power of insurance companies, Big Pharma and, increasingly, the large corporate healthcare conglomerates that provide direct care.

Welcome to the Cutting Costs/Rising Costs Vice

The US system continues to be not only bureaucratically cumbersome but also an inherent risk factor for the health of many, if not most, citizens. Since costs are out of control, there’s always extreme pressure to limit care.

This manifests itself in many ways, perhaps none more obvious than the inherent pressure on doctors, especially general practitioners, to cut to a minimum their actual human interaction with patients. Last century American doctors were expected to have a semblance of a relationship with their patients — to not simply read their chart, but to know them on some level — which is an approach that is rarer and rarer due to economic forces far beyond individual doctors’ control:

It would be absurd to try to increase the productivity of musicians by having them play faster. Yet healthcare executives force an increase in the number of patients seen by physicians each day by establishing productivity targets that limit office visits to fixed time periods, such as 15 minutes or a half-hour. This apparent increase in productivity, however, is not sensitive to the impact of these seemingly arbitrary standards on patient outcomes.
In fact, if you measure (as you should) a physician’s productivity not by inputs (number of patients seen) but by the quality of outcomes achieved, you’ll find that physicians can often achieve greater overall productivity by spending more time with fewer patients. For example, many patients with chronic kidney disease eventually need dialysis. Extensive research shows that patients have better outcomes (longer lives and fewer complications) when dialysis is started with a fistula (requiring a surgical procedure to connect an artery to a vein) or a graft rather than a catheter. Patients with optimal starts also cost tens of thousands of dollars less per year. Yet more than half of U.S. dialysis patients today start dialysis suboptimally, with a catheter.
Clinicians in several of our other ongoing research projects, especially those treating patients with chronic conditions, such as diabetes and congestive heart failure, tell us similar stories. If they could spend more time and money educating and monitoring their patients, the total spending on the patients’ conditions would decline dramatically. High-level administrators, however, focused solely on line-item expense categories on their P&Ls, often overlook these opportunities to reduce the total costs of treating their patients while improving outcomes. Such opportunities should be highly relevant for the new accountable care organizations, which have incentives to reduce the total costs of treating covered patients, including costs incurred at other facilities. - hbr.org

This is the trap that most healthcare professionals — and their patients — find themselves in because of a healthcare system that is illogical, unorganized, and driven by the pursuit of profit over the stable long-term delivery of services.

Challenges In Seeking Preventive Care

There are many ways this national commitment to what is clearly an irrational system reverberates through people’s lives. It inhibits their ability to not only get healthcare when needed, but to access the medically integrated preventive care that will make it less likely they’ll need more expensive acute care later.

Lack of General Practitioners

One of the clearest problems is the shortage of general practitioners, aka family doctors, due to any number of factors — one of which is the significantly higher wages that specialists can demand in the US healthcare system. This has led to a situation —especially dire in rural areas and lower-income urban areas —of people not having access to basic, frontline medical care and, instead, clogging emergency rooms with routine medical matters. - usnews.com

Many Insurance Policies Create Challenges

But for many, even if there are medical practitioners available, a lack of health insurance — or network restrictions, copays, and deductibles — restrict the ability of individuals to access medical resources. Though the Affordable Care Act of 2010 included requirements that health insurance plans cover a limited number of preventive and screening services (such as immunizations), most treatments beyond these widely accepted, basic frontline procedures are not guaranteed.

This is especially lacking in several areas, most notably dental coverage. Poor dental health is linked to other health issues, including an increased risk of cancer and a higher likelihood of suffering from cardiovascular diseases. - nytimes.com

Likewise, a range of other effective preventive treatments, such as chiropractic care, massage, and physical therapy are also subject to an outright lack of coverage or problematic insurance policy restrictions. This results in a less holistic treatment pattern for many, if not most, Americans. Limited access is granted to a limited number of preventive care procedures—at least for people with insurance—while a whole host of multidisciplinary approaches are out of reach of those who might benefit from them (especially people with lower-end plans or no insurance at all).

Drug Pricing

Another area where the privatized and fragmented realities come into extreme clarity is the lack of any mechanism to control the costs of drugs—even treatments invented long ago that play an important role in controlling symptoms, bettering health, and lowering long-term medical expenses.

This is nowhere more apparent than in the current crisis of insulin pricing. It’s a natural hormone, one that diabetics do not create on a sufficient-enough level to control their blood sugar. The patent for its production was sold in 1923 for $1 in order to make it widely available. Yet, today, there are Americans paying around $300 for a single vial of the drug, which represents a price increase of over 1,000 percent since it was patented—and that’s with inflation accounted for. - bbc.com

Another tragic effect stemming from the lack of oversight of pharmaceutical companies — and of the profit motive being the prime driver of their decision-making — that is currently sweeping the United States is the opioid crisis. It is, in and of itself, one of the prime causes of the current decline in US life expectancy and has turned over the “big pharma” rock and brought to light the ugliness of its operations.

Over the past decade this crisis has killed over 200,000 people, in large part because the ingrained approach of treating symptoms with “there’s a pill for that” was leveraged by the dishonest operations of several large drug manufacturers:

The opioid crisis is a culmination, not an aberration, of the prescription drug industry’s business model. Essentially, the opioid epidemic is a cautionary tale that points to what we can expect if lawmakers don’t take meaningful action to rein in drug corporations’ power to set prices, gouge patients and boost profits at the expense of people’s lives.
The courts won’t stop drug corporations’ aggressive marketing of medicines, a key factor in jump-starting the frenzy of prescriptions than led to the opioid epidemic. Drug companies routinely spend far more on marketing and advertising than on research and development, despite the industry’s claims to the contrary.
The opioid crisis is on the starkest - and deadliest - example of a medical system that is not only unwilling to examine the whole patient, as opposed to their symptoms, but one that can also become actively hostile to the health of those patients.

Treatment of Symptoms, Not Core Health

All of this results in a healthcare “strategy” that is dangerous because holistic approaches to overall health and treatment are made more difficult. Even though the advantages of medical integration have become apparent — a healing-oriented approach over one that is disease-focused, a more personalized strategy to medicine, and an appreciation of not just physical symptoms but also of the mind and spirit — the jagged American system of numerous health insurers, rival networks, and weak oversight by governmental agencies makes adapting integrated approaches more challenging.

Issues With Acute Care

These are the dangers of the American health system before someone gets seriously ill, or when it is obvious that treatment is necessary. Once a critical or acute illness or accident occurs, things do not get any better.

Crisis in Ambulance Services

Another crisis currently hitting rural areas especially hard is the collapse of the emergency response system. Like so much of the US healthcare system, there is no centralized — even at the state level, much less federal — system for ensuring that emergency services are provided:

And those ambulance services are closing in record numbers, putting around 60 million Americans at risk of being stranded in a medical emergency. Because so many emergency medical services (EMS) agencies have been struggling financially, some states are stepping in with funding. But emergency medical experts say it’s not enough to cure the dire situation. - nbcnews.com

This problem is driven both by a shortage of volunteers to operate EMS services and funding cuts to the departments themselves, as well as the inability to collect a large portion of insurance reimbursements when some patients receive payment for out-of-network services directly from their insurance companies and then don’t forward payment to the EMS organizations (in large part because these individuals are oftentimes swimming in debt after suffering a major medical emergency).

Overdependence on Emergency Room Care

Even when individuals suffering from a dire medical situation do make it to the emergency room, the facility may already be overwhelmed. This is because emergency rooms are the dumping grounds of American healthcare, where every other problem and flaw in the system ends up.

People who lack dental care and develop a tooth abscess end up there. Those struggling with opioid addiction end up there. A patient whose regular physician is overbooked and unable to fit them in on short notice will end up there. The sick without health insurance end up there. And, of course, legitimate medical emergencies end up there.

In fact, according to a 2017 study from the University of Maryland School of Medicine (UMSOM), nearly half of all medical care takes place in emergency rooms:

The use of emergency care resources for non-emergency cases has been controversial, since initial emergency care patients often end up being seen for non-emergency medical issues. Some experts argue that emergency departments are covering for deficiencies in inpatient and outpatient resources, and for a lack of effective prevention strategies. This could contribute to the high rate of emergency department use. They argue that emergency room use should be reduced. - sciencedaily.com

Adding to the chaos of emergency rooms being overburdened from the fallout of the healthcare system not efficiently allocating resources, there is also a burgeoning crisis of violence and other social issues accumulating there as well. Drug abuse, homelessness, and antisocial behavior due to untreated mental health issues are an increasing risk factor for doctors, nurses, and occasionally other patients in emergency rooms. - city-journal.org

Nursing Shortage

The disjointed nature of the American healthcare system, along with long-term demographic realities, also creates a stressful work environment for nurses — the workforce that is in many ways the backbone of care. The combination of an aging population — creating both more patients and the reality of nurses retiring in greater numbers — has created a vicious circle where nurses are pulling longer and longer shifts in deteriorating working conditions. Additionally, nursing schools are struggling to meet the demand for training nurses at a rate sufficient to keep up — in part due to an inability to recruit qualified teachers — that is adding to the problem, often with a profound effect on patient safety:

America’s 3 million nurses make up the largest segment of the health-care workforce in the U.S., and nursing is currently one of the fastest-growing occupations in the country. Despite that growth, demand is outpacing supply. According to the Bureau of Labor Statistics, 1.2 million vacancies will emerge for registered nurses between 2014 and 2022. By 2025, the shortfall is expected to be “more than twice as large as any nurse shortage experienced since the introduction of Medicare and Medicaid in the mid-1960s,” a team of Vanderbilt University nursing researchers wrote in a 2009 paper on the issue. - theatlantic.com

Needless to say, when the largest percentage of frontline workers in a sector are chronically shorthanded, mistakes are far more likely to occur. Studies have shown that hundreds of thousands of patients die in US hospitals due to medical errors. - vox.com

Stresses of the Residency System

The way doctors are trained is, in some ways, a prime example of the segmented, unhealthy reality of the American health system. Increasingly, there are calls to reform a system that seems designed to create stress, poor lifestyle and eating habits, and an inability to broaden the focus beyond the immediate symptoms towards a medically integrated, holistic analysis.

That recent reforms by the Accreditation Council for Graduate Medical Education (ACGME) limiting resident physicians to 80-hour workweeks (with at least 10 hours off between shifts) is seen as a profound improvement in work conditions speaks volumes to how brutal the culture of physician training had become. It can’t be surprising that it’s difficult for many doctors to appreciate the work-life balance and a multidisciplinary approach to patient health when their formative training is exactly the opposite:

Wellness, a state of physical and emotional well-being, often feels unattainable during residency. The daily frustrations of navigating a complex system, the personal insecurities, exposure to traumatic experiences, and immense time commitments are overwhelming. These and other barriers can make the pursuit of personal well-being seem futile. A large and growing body of evidence suggests that not only is it difficult to maintain personal wellness during residency but it may be even harder to avoid burnout and the associated risks of medical errors, depersonalization, depression, and even suicide. - worldwidescience.org

This not only leads directly to poor decision-making due to sleep deprivation and the accumulated effects of long-term stress — residents play a crucial role in diagnosing and treating patients in hospitals — but the experience imprints a certain approach to medicine that assumes that “crisis management” is the norm. It’s hard to see a patient as a “whole entity” when one’s current life and inherent training makes that hard to fathom.

Medical Culture

Another aspect of medical culture that heightens the dangers of the American healthcare system is an unwillingness to openly discuss errors by the medical establishment, especially doctors. This is driven in part due to fears regarding malpractice litigation and the common trope of “this is how it’s done.”

One surprising fact about healthcare in the United States is that there is no central body that tracks and analyzes deaths and injuries due to medical errors. Some have proposed creating an agency similar to the National Transportation Safety Board — which has a team of dedicated professionals who immediately spring into action to investigate each and every plane crash that occurs — and has thereby built a vast store of knowledge that is used to steadily make flying safer. - science.gov

Once again, there is a tradition of not taking a bird’s eye view of how medicine is practiced and how that affects patients. Instead, the functions of the healthcare system are segmented and isolated.

Recovery and the Cost of Stressing About Paying the Bills

Once someone has made it through the gauntlet of acute care, the recovery phase presents its own challenges — including, for so many, the stress of dealing with the financial fallout of getting sick in America. Though the curtailment of hospital stays that people are afforded after illness, surgery, or even giving birth have not been exclusively negative — exiting environments that are de facto full of germs has had some positive results on outcomes — other aspects of the American-style recovery do come with costs.

Challenges of Rehabilitation Services

One of the clearest areas that endanger recovery and the maintenance of better overall health is the difficulty in arranging for — and paying for — rehabilitation services. It’s clear that services such as physical therapy, chiropractic care, massage treatment, and nutritional services are a positive for not only individuals but also are effective as a way to limit long-term medical expenses. But the complexity and cross-purposes of the healthcare system, especially the insurance sector, make rehabilitation care challenging:

Physical therapy and rehabilitation services are an important component of the healthcare continuum for addressing the pain and functional limitations that typically accompany MSK [Musculoskeletal] conditions. MSK conditions can lead to reduced socialization and quality of life and create participation restrictions that can be disabling… However, barriers to accessing physical therapy and rehabilitation outpatient care may be further contributing to the MSK-related disability in the United States. Over the past 4 decades, there have been substantial changes in the insurance coverage for therapy and rehabilitation services…
When exploring out-of-pocket costs for patients with private insurances, the variability of plans and benefits within payers can often be confusing for patients. In an ever-changing healthcare atmosphere, patients are often unaware of changes in their benefits from year-to-year, particularly for unexpected new onset conditions. Increased premiums lead to assumptions that benefits may stay the same or improve; however, this is often not the case, and patients may be unaware of the right questions to ask when exploring their benefits for services. For example, some plans will vary greatly for patients’ out-of-pocket costs based on where their services are rendered. A patient may be instructed over the phone that they would only be responsible for a $35 co-pay for physical therapy or occupational therapy, but when they receive their bill from a hospital-based clinic for a much larger amount, they do not realize that the information they had been given pertained to services received in a community-based private practice. Although the billing codes may be the same between the two facilities, the charges by the provider are different, leading to further confusion. - medbridgeeducation.com

This creates scenarios where patients whose health would undoubtedly be improved by having access to integrated medical services are failed by an insurance system that continually throws roadblocks in the way of attaining such beneficial healthcare.

Chronic Stress and Medical Debt

There is a long-established understanding that chronic stress is dangerous to one's physical health. It has a negative effect on everything from brain function to the immune system to cardiovascular health. It may be one of the most persistent negative forces on health outcome in America today.

The ugly irony is that the healthcare system in the United States is an engine for manufacturing stress. The overcrowded emergency rooms, lack of rural healthcare services, overworked professionals, endless paperwork, and more than any other factor, the financial burden imbues the entire healthcare system with a powerful force that works against everyone. The case of cancer survivors is one particularly acute example:

Medical financial hardship includes problems paying bills and other challenges with money; psychological stress like intense worry over unpaid bills; and behavioral issues like delaying needed care because of cost …
“Although cancer patients have benefited from newer and more advanced treatments, financial hardship may lead to emotional distress, cause changes in health behaviors, and jeopardize treatment adherence and health outcomes,” said lead study author Zhiyuan “Jason” Zheng of the American Cancer Society in Atlanta.
Young adults may struggle the most because cancer might interrupt their education and limit their access to employer-provided health insurance, Zheng said by email. This can have devastating health effects and lead patients to also face challenges like food and housing insecurity, he added.
“We already knew that extreme financial insolvency, i.e. bankruptcy, increases the risk of early mortality among cancer survivors,” Zheng said. “Although we don’t know the exact pathways, it has been hypothesized that financial hardship can cause high stress among cancer survivors, force some patients to be non-adherent to treatments to save money, and lower their overall quality of life. - reuters.com

The assumption that getting sick means at a minimum financial hardship and oftentimes extreme debt—something citizens of no other developed country have to deal with—has been so normalized in the United States that only after decades of reform efforts is the absurdity of this situation being made plain.

The Path Forward

Efforts to reform the illogical and counterproductive realities of the American health system have been prominent over the past few decades. From being a major plank in Bill Clinton’s campaign in 1992 (followed by its disastrous rollout during his first term) to the underlying logic of Obamacare to current efforts to expand Medicare — efforts have all pushed for a system that that is better organized, integrated, and holistic.

One major aspect of this is moving away from the current fee-for-service model, which drives compartmentalized medical care.

The American healthcare system by and large runs on what experts describe as a “fee-for-service” system. For every service a doctor provides—whether that’s a primary care physician conducting an annual physical or an orthopedic surgeon replacing a knee—they typically get a lump sum of money.
That’s how most businesses work. Apple gets more money when it sells more iPads, and Ford gets more money when it sells more cars. But healthcare isn’t like iPads or cars. Or at least, it’s not supposed to be.
When patients buy knee replacements, for example, what they’re buying isn’t really knee surgery itself. What they’re trying to buy is an improvement in their health.
But here’s the thing: Most American doctors aren’t paid on whether they deliver that improved health. Their income largely depends on whether or not they performed the surgery, regardless of patient outcomes. Their patient’s knee could be good as new or busted as always at the end — but in most cases, that doesn’t factor into their surgeon’s ultimate pay…
There is a growing movement in healthcare to change this and tether payments to patients’ outcomes. The nonprofit Catalyst for Payment Reform estimates that 10.6 percent of all health-care dollars paid are paid in some type of value-based arrangement, where the patient’s outcome factors into how much the health-care provider earns. Obamacare is running dozens of little experiments in the Medicare program that also try to pay doctors more when they provide higher-quality care. There are now penalties, for example, if a patient returns to the hospital after something was screwed up the first time. Those seem like they might be working; the number of preventable readmissions has steadily dropped since late 2010. - vox.com

This is a pivotal aspect of any meaningful reform and the foundation for moving forward — creating a healthcare system that rewards better health outcomes, as opposed to more profitable heath care procedures.

Changing this funding reality is part and parcel with building a better framework for medical integration. This term encapsulates the effort to move away from medical care being sliced and diced into pieces that can then be billed for (often at levels that at best seem arbitrary and at worst exorbitant). It builds a team-orientated methodology — as opposed to the “referral to a specialist after running many tests” approach that is so much a part of the current system.

The need to better manage healthcare costs in the United States — especially given our aging population — while providing much better health outcomes is clear. Creating a more team-orientated model, one that incorporates not only medical doctors and nurses but also a range of other providers — such as chiropractors, massage and physical therapists, and nutritionists — is vital:

The need for all medical and health professions trainees to understand how to work across disciplinary boundaries is noteworthy, given that the stakes are high and that working together effectively requires more than simply ensuring that team members are smart people. Team members, especially those in leadership positions or with higher status, should actively invite input to ensure that team members voice all of their information. They should also be role models in expressing appreciation for diverse knowledge from all sources to ensure that team members’ input—regardless of who the team member is—will be considered and used in the team’s work. Such teams will be well suited to capitalize on their expertise, avoid errors, and provide effective patient care. - journalofethics.ama-assn.org

Creating a medically integrated and holistic healthcare system is not only a worthy goal, but a necessary one. The current dynamic of rising healthcare costs and services that lag behind the rest of the developed world is not sustainable.

The future of healthcare is clearly towards a more multidisciplinary approach, one that treats people and not symptoms. Such a system will not only be better for patients, but also more cost-effective and sustainable.

Getting there is the challenge.

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