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Tilting at Windmills

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August 28, 2009

THE PEARLSTEIN PLAN.... The Washington Post's Steven Pearlstein has written some pretty powerful columns on health care reform lately -- some of which I enthusiastically endorse, some of which I found less persuasive -- but today's piece is, in effect, the Pearlstein Plan. As the Pulitzer Prize-winning columnist sees it, "there is a deal to be had here if only Democrats would be willing to take it." The Pearlstein Plan has nine elements, including:

* Universal coverage. Finally, a requirement that every American purchase a minimum, a basic health insurance plan.

* Insurance exchanges. Each state or region will set up government-supervised insurance exchanges through which private insurers can offer policies to the uninsured, the self-employed and small businesses. Coverage standards will be set nationally, and participating companies must agree to take all customers, regardless of pre-existing conditions, at rates that vary only slightly by age.

* Options. Among the options would be lower-cost, high-deductible plans long pushed by Republicans. Another: nonprofit insurance "cooperatives" set up by participating hospitals and physicians groups offering an alternative to traditional fee-for-service medicine.

* Low-income subsidies. Households with incomes up to 300 percent of the poverty line would be able to buy the average-priced basic plan through the exchanges for no more than 15 percent of pre-tax income, with the balance paid for by the government.

* Employer mandate. All businesses would be required to pay for at least half of the cost of a basic insurance policy for all workers and their immediate family, or pay the government a progressive tax on payrolls over $250,000, exempting the smallest businesses. While distasteful to Republicans, the mandate would level the competitive playing field among firms that now offer health insurance and those that don't, while generating revenue to pay for premium subsidies.

* Tax on extravagant health plans. A tax of 25 percent would be imposed on health plans with an actuarial value of $10,000 for individuals and $20,000 for families, indexed to inflation. While distasteful to unions, the measure is designed to raise revenue for subsidies, make patients more cost-conscious and help force down insurance premiums.

The Pearlstein Plan, which would scuttle the public option altogether, would also include some "malpractice reform," cost-containment measures, and control on rationing.

Some of this approach seems fairly sound. Indeed, some of the Pearlstein Plan overlaps with what Democrats are already proposing.

I had one over-arching problem with the pitch. If there's "a deal to be had here," who is the deal with?

Pearlstein concedes the deal is not intended to win over Republican leaders on the Hill, because "they're determined to derail any health reform plan." That's clearly true. But Pearlstein goes on to say that his proposal would eventually win over "a sizeable number of Republicans who will come to realize that it's better for their careers to be on the right side of history than on the good side of the Republican leadership."

Really? I'd like to believe this is true, but I don't. Can anyone identify this "sizeable number of Republicans" who've expressed even the slightest hint of willingness to support reform? Remember, when the White House signaled a willingness to scrap the public option, not one GOP lawmaker -- literally, not one -- responded by saying, "Well, if Obama is willing to drop the public option, we're ready to find some common ground." On the contrary, Republicans shot down the trial balloon by insisting no concessions would be enough -- the GOP will oppose reform no matter what.

Pearlstein added that his compromise approach is also "necessary to win broad support from an American public wary of federal deficits, anxious about losing the health care it already has and fearful of radical change." Again, this sounds nice, but the Democratic plan already improves the deficit picture, let's people keep what they have, and steers clear of radical change.

What's more, even if Dems picked up on the Pearlstein Plan, the landscape wouldn't change. The "American public" is responding to baseless, ridiculous, and insane ideas from the likes of Beck, Limbaugh, Palin, Armey, and LaRouche cultists. Would these right-wing lunatics suddenly become more responsible if the Pearlstein Plan were on the table? Of course not -- reality has nothing to do with their attacks anyway.

Obama, Pelosi, and Reid could hold a press conference today, offering a reform package with no public option, no tax increases on the middle class, no "death panels" or "death books," no funding for abortion, no coverage of undocumented immigrants, no rationing, and some "malpractice reform" thrown in, and Republicans would immediately respond with, "It's not good enough."

Why? Because they don't support health care reform.

Steve Benen 12:50 PM Permalink | Trackbacks | Comments (39)

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A "sizeable number" of Republicans? Well . . . I guess Pearlstein thinks that two is a sizeable number!

Posted by: The Caped Composer on August 28, 2009 at 1:04 PM | PERMALINK

If the GOP were interested in that there didn't have to be a deal. The GOP could have passed it anytime between 2001 and 2007. Dems rarely used the filibuster and there is no way they would have dared filibuster health care. That plan didn't materialize because the GOP won't take the political hit for mandating that people buy coverage. Moreover once universal coverage exists then a subsequent Democratic congress could impose regulations (no recission, no disqualification for pre-existing conditions) that the insurance industry wants to avoid.

Posted by: rk on August 28, 2009 at 1:06 PM | PERMALINK

> "a deal to be had here," who is the deal with?

Duh. The money spent in the last six months of life is the big green elephant everyone's pretending not to see.

The deal is to leave the last-six-months tap deep into that money -- not just tapping family money, but the Medicare money available once the family's sucked dry.

Why? Because the bean counters must have done the numbers and projected the losses if more doctors gave better counseling about extreme measures when death is going to happen soon, about hospice, and about the option to die peacefully instead of in the hospital.

That's the big lump of money.

That deal appears to have been made already -- don't tell any more people any better about the option, early, while they're competent to make their own decisions. Leave the money tap in and the suction on.


Posted by: Hank Roberts on August 28, 2009 at 1:08 PM | PERMALINK

"Without a public option, I feel like I've got a gun to my head telling me that I am forced by law to pay some CEOs obscene salary with no guarantee that I'm not going to get the shaft if I get sick." --Digby

Posted by: morganstern on August 28, 2009 at 1:10 PM | PERMALINK

It would probably nail down the Blue Dogs in the House and the likes of Landrieu, Campbell, et al in the Senate (all of whom might as well be Republicans). That would probably be sufficient because it would probably also get the one or two real GOP votes (Snowe and Collins) to break the filibuster. I agree that Republicans otherwise seem determined to be on the wrong side of history, again.

Posted by: nonplussed on August 28, 2009 at 1:10 PM | PERMALINK

Oh, and more Digby from the same post, warning Democrats against screw their own base at their own party's mortal risk:

"After 2000, what is it going to take for the Democrats to realize that constantly using their base as a doormat is not a good idea? It only takes a few defections or enough people staying home to make a difference. And there are people on the left who have proven they're willing to do it. The Democrats are playing with fire if they think they don't have to deliver anything at all to their liberal base --- and abandoning the public option, particularly in light of what we already know about the bailouts and the side deals, may be what breaks the bond.

It's really not too much to ask that they deliver at least one thing the left demands, it really isn't. And it's not going to take much more of this before their young base starts looking around for someone to deliver the hope and change they were promised."

Posted by: morganstern on August 28, 2009 at 1:13 PM | PERMALINK

The only "deal to be had here" is for progressives to completely compromise away their demands and for the public to just hand a blank check to private ins..

Republicans are no longer in the picture as they are no longer credible as a party but the democratic divide between conservadems and progressives is where this deal is intended to be effective and not for the side of the people.

Posted by: bjobotts on August 28, 2009 at 1:17 PM | PERMALINK

Malpractice reform? I am unable to take anything seriously from a person who thinks we need "malpractice reform" unless that person means caps on the rates insurers charge for malpractice coverage.

Posted by: Jay on August 28, 2009 at 1:19 PM | PERMALINK

I like the edge in Steve's post today. There's no speculating. Republicans aren't interested in reform in any form (tort reform isn't reform). That's just the way it is.

Funny how Steve gets it, most of his readers get it, but those with power and influence are still struggling.

Posted by: Chris on August 28, 2009 at 1:19 PM | PERMALINK

The reason Obama is down in the polls is because he doesn't appear to be keeping his promise to bring change (not merely change from the Bush administration). I know Washington is a difficult place, and the view from the Oval Office must seem very different, and how many times can you here, "Mr. President that is not the way things work," but, it doesn't matter, this guy was sent to Washington to change things and to get certain things done, not incrementally, but radically, from the inside out, and if he doesn't deliver on that pledge, or at least go down fighting for that change, then he has lost my support. I might still like him personally, and think he has a great family, but I will conclude that the rhetoric was bullshit and there was no hope of change. If I wanted an incrementalist I would have voted for Hillary.

He needs to articulate even more suscinctly what he is willing to accept and not accept in the bill and demand that such a bill get done by whatever means necessary. Maybe this is going on in private, but he needs to show a bit more muscle in public. He went to sleep last year during August and then came out swinging. Here's hoping to a repeat performance.

Posted by: Scott F. on August 28, 2009 at 1:27 PM | PERMALINK

The "Pearlstein plan" is stupid:

**it focuses entirely on "insurance," not at all on "care."

**it contains NO provisions for cost containment.

In other words, it's a big give-away to the insurance companies.

Posted by: Mauimom on August 28, 2009 at 1:29 PM | PERMALINK

When are Dems going to start playing hard ball with Republican Senators from rural states? Seems like it might be time to update the formulas for ag subsidies, don't you think?

Posted by: Jon on August 28, 2009 at 1:30 PM | PERMALINK

What you describe is not health care reform. It's mandatory payments to the insurance mafia while covering the crime by claiming there's some sort of 'universal coverage' benefit.

In fact, at the low end of income, it's a 15% theft of pretax income, with deductibles so large that those who are not well off can not afford to pay for care. All the poor can afford to do is pay their new insurance tax.

I'd bet the conservatives would love such a deal. But if progressives fall for this crap they may as well castrate themselves, go home, and shut up.

Obama has failed to support viable reform by dismissing single payer, then not supporting a public option, then cutting a deal with big Pharma, then leaving the Blue Dogs to do his dirty work.

He's no Ted Kennedy.

Posted by: Samosa on August 28, 2009 at 1:32 PM | PERMALINK

The cost of forcing the uninsured to buy insurance would be outrageous for them ad a political death knell for whoever pushes this.

As I calculate it, Perlstein would force the uninsured pay upwards of $12,000/year per household to buy HC Ins. His Low-income subsidies would require those making less than 300% of poverty line (roughly %60,000 for family of 4) to pay 15% of their pre-tax income for HC Ins. -- e.g., 15% of 60,000 = $12,000/yr [about the cost of avg. HC plan in high-cost state of Mass, by the way].

Is he kidding?! That would totally unaffordable for an uninsured family or force them into significant financial hardship. Any party that mandates that on families and households will provoke a backlash and suffer mightily in elections.

And the rationale for it provided by the analogy for mandatory car insurance is specious. We make people buy insurance if they want to own and drive a car (which is a choice, though a necessity in most parts of country). But now we're going to force people to buy insurance because they umm what, are present in the US, living and breathing here -- something over which most have little choice?

HC is a basic human right and the govt. has an obligation to provide it, or see that others do so in a reasonable, universally accessible, affordable way. All other industrialized nations in world do it along those lines, with some variations. And we're going to force the uninsured to pay for the own HC insurance? If they could afford that they wouldnt be so many uninsured!

If Dems back something like Perlstein is proposing, they deserve to lose elections for along time. But on the up side for them, they should all get positions on Ins. company boards... Idiots!

Posted by: Tim Dunn on August 28, 2009 at 1:33 PM | PERMALINK

I really don't understand why the Democrats just don't force the Republicans to vote no on bills that most of their constituents clearly would want.

In polls, insurance companies are widely hated and vast majorities support universal coverage.

For example, why not make the Republicans vote these four bills in this order:

(1) Insurance reform: Eliminate pre-existing conditions, the ability for insurers to drop your policy (especially when you are sick), and caps on lifetime spending.

(2) Medicare for children: Extend Medicare to everyone under 18.

(3) Buy into Medicare: Allow anyone who wants to, regardless of age, to buy into Medicare.

(4) Medicare Lite for all: A short list of cheap procedures, focused on preventive care, are billed to Medicare regardless of other insurance coverage or lack of coverage.

All four of these are simple, easily understood, and should be very difficult for Republicans to vote against.

What am I missing? Why don't the Democrats do this?

Posted by: Greg on August 28, 2009 at 1:35 PM | PERMALINK

What we all seem to be missing is the need to sell the American public. It is hard as hell to find any Democrat any place who is doing much to outline the any of the plans and justify it to the general public. Mostly we are wasting our time trying to deal with Republican politicians. To Pearlstein's great credit, his proposed deal, which has lots of elements of one or more of the current proposed plans, is clearly articulated and easy to understand. Stop wrestling with the Republican pigs and start explaining the details of the Democratic plans. You might be surprised how many people are hungry for the facts.

Posted by: Ron Byers on August 28, 2009 at 1:38 PM | PERMALINK

I agree with Tim Dunn and Samosa. Individual mandates without a public option turns me into an absolute opponent -- and will cost the Dems power for a generation. Do the math. I'm a single women who makes $50k annually, well below the average median income for my area. Without employer-provided insurance, I would be forced to spend $625 a month for mandated insurance?! That's almost as much as my house payment! Put me in jail; there is no way I could afford that.

Posted by: ColleenC on August 28, 2009 at 1:45 PM | PERMALINK

Greg: I like your ideas. It's hard to imagine how taking the path you suggest would or could end up any worse than what has already happened.

Back to the Perstein plan: He says insurers **could** participate in these exchanges. But why would they? And what if they don't?

Posted by: Bulworth on August 28, 2009 at 2:03 PM | PERMALINK

Hey Colleen, I'm in a similar boat to you except I don't make half of $50,000 a year. When I read I have to pay fifteen percent of my income, I just threw up my hands.

I spend 60% of my income just keeping a roof over my head, energy is another 25%, leaving the last 15% of my income to buy food, clothes, house maintenance and "entertainment."

What the hell? How am I supposed to carve out 15% of my income for this shit? Are they kidding me?

But other than that, Pearlstein's plan doesn't sound that bad. Well, except for the additional humiliation that I will have to endure traipsing my poorly dressed ass to wherever every six months or a year to verify my income, monstrously difficult when you are self-employed.

Yeah, the whole thing sounds f*cking delightful.

Hey, I'm one of those holdouts who think we should have true universal healthcare which means everyone gets a card, have at it. Pay for it through an income tax that starts at the top, taxing highest income largest amount and percentage coming down to lowest income. Anyone gets a card who signs up for one, regardless of income, employment or immigration status.

As in other universal plans elsewhere, if you have the means to step outside the system, you should just go right ahead.

The statement that offended me no end in Pearlstein's plan is "make patients more cost-conscious." If this means, don't go to your doctor once a week just because, that's one thing, but if what is meant is that I should think twice before going to see a doctor, or even shop around for your care, it's insanity.

Posted by: karen marie on August 28, 2009 at 2:19 PM | PERMALINK

Shorter Pearlstein Plan:

Let's enact legislation that guarantees HUGE amounts of cash will continue to be shoveled to the insurance companies by every man, woman, and child in the country. And, uh, let's not impose any curbs or regulations on the insurance companies, lest they have to cut back on CEO salaries or other vital functions.

Posted by: Domage on August 28, 2009 at 2:26 PM | PERMALINK

"* Options. Among the options would be lower-cost, high-deductible plans long pushed by Republicans. "

This already is an option in the form of health savings accounts. I got me one of these Republican doozies. I was forced to look for something with lower premiums than my previous high premium/high deductible plan. But the problem is that now, my lower premiums are rising each year AND my deductibles (now well over $10,000 a year) are also rising with a yearly inflation add on . If this largely self insurance plan is not a form of rationing, I don't know what is. Kind of good news/bad news -- it does provide more incentive to stay away from the freaking doctors and hospitals. I can be my own "death panel" if I want to save a buck by taking more risk. Choice, Republican style ... with a big up front dollar cost.

Posted by: lou on August 28, 2009 at 2:31 PM | PERMALINK

Sounds like a good start, and there's nothing incompatible there with adding a public option too.

And unless you're a paid whore for the health insurance industry, there's no logical reason to reject the addition.

Posted by: melior on August 28, 2009 at 2:33 PM | PERMALINK

Domage, what do you think is coming out of the various house committees? The fix is in. That is why the Republicans are lying and demanding we talk about their lies and why the Democrats are either actively engaged stamping out Republican lies or are standing silent. I hope we aren't as disappointed with the final "Obamacare" plan as we were with Bush's Medicare D. Given how the issue is being approached by the media we won't know what is actually proposed until it is too late.

Posted by: Ron Byers on August 28, 2009 at 2:35 PM | PERMALINK

I had one over-arching problem with the pitch. If there's "a deal to be had here," who is the deal with?

Orrin Hatch? Lindsay Graham? John McCain? The Mainiacs?

The "universal healthcare via mandates and subsidies approach" could get a few Senate Republicans on board, I'd guess, though I'd also guess there would be near universal opposition among House Republicans.

But what I want to know is: I notice conspicuously missing from the Pearlstein plan is regulation of the health insurance industry (community rating, guaranteed issue, etc.). Pretty weak stuff.

Posted by: Jasper on August 28, 2009 at 3:19 PM | PERMALINK

As Steve correctly concludes (and which Ezra failed to notice), this is a 'compromise' made up in Perlstein's head.

It's the Village speaking. Nothing more.

Posted by: leo on August 28, 2009 at 3:40 PM | PERMALINK

"What we all seem to be missing is the need to sell the American public."

Ron nailed it -- Democrats have done an absolutely, positively, SHITTY job of selling the concept of universal health care the American people.

Not some weak-ass plan that's nothing but an industry handout like Pearlstein's (I can respect the effort, but others have noted the gigantic flaws in the plan), nor some bullshit compromise like co-ops or even a public "option."

But a real, true, honest-to-god universal system that would work well and save us billions of dollars and thousands of lives.

Dems had the chance from 1993 until now to do this and failed.

They took the GOP's bait in the 90s and got dragged into the culture wars ... were bullied into submission under Bush, letting him crap on the Constitution and caving in to every GOP demand ... and are now, even after winning two historic elections and controlling Congress and the White House, failing to do what a vast majority of Americans actually want them to.

This total lack of foresight is why we're probably not going to get anything close to an adequate plan, and why the GOP has been able to distort and lie on the issue so easily.

Yes, we can't go back and change history. But it'd be nice if Dems would at least start acting as if they give a damn, even at this late date.

Posted by: Mark D on August 28, 2009 at 3:51 PM | PERMALINK

Yeah, what is with this new 15% insurance tax...on the GROSS?

Even leaving aside the fact that most of those 300% plus-poverty line families are working and lower middle class people who can barely make their bills as it is, the income verification and allowance notifications bureaucracy for that idea would be a frickin nightmare. Talk about adding unnecessary costs.

Jeeze. Obviously these people have no idea whatsoever what 15% of income means to the Democrats' BASE CONSTITUENCY. And for a high-deductible insurance plan that would be just about as useless as having nothing at all, would not encourage preventive care and would be administered by the same corporate bean-counters who are already committing death by spreadsheet daily?

Ridiculous. Utterly, irredeemably ridiculous. A prescription for Democratic suicide.

Posted by: Julia Grey on August 28, 2009 at 3:56 PM | PERMALINK

The sooner we get health insurance companies totally out of lives the healthier we will be.

Posted by: Bonnie on August 28, 2009 at 4:07 PM | PERMALINK

This is the kind of plan that sounds sensible to people who already have great health insurance and/or make a whole lot of money.

A 15% regressive surtax on everyone in exchange for "insurance" with deductibles so high that it will be like having no insurance at all for most people is just a FABULOUS idea. No really. Not at all the kind of thing that will turn both chambers of Congress over to the Raving Loony Party.

Posted by: tatere on August 28, 2009 at 4:13 PM | PERMALINK

The "Pearlstein Plan" blows chunks.

Posted by: Joe Friday on August 28, 2009 at 5:10 PM | PERMALINK

$20K isn't an extravagant plan.

It doesn't even cover crutches or orthopedic devices when you break your toe, or using the old MRI at the local clinic to diagnose tendon damage on the knee that's turned backwards but shows no bone damage...

Posted by: Crissa on August 28, 2009 at 5:45 PM | PERMALINK

Liberals - I am one of them - have too long been blinded by the so-called "public option." Originally, we wanted a "single payer system," which would be terrific. But Obama made the calculation that "single payer" will never fly, so he settled for the "public option."

After much thought, I have come to the conclusion that the "public option" is a mirage. After all the restraints legislators are placing on it, we may as well get rid of it.

The important thing we need is not new options but the assurance that we would have competition that would bring costs down. The exchange in Pearlstein's plan should be our main focus for achieving competition.

Removing the "public option" will remove the main argument that the hard right and the crazies have been using to kill health reform. Putting stiff regulations to be overseen by the exchanges would give us what we need.

There should be a big overall nationwide exchange to assure consistent regulation and consistent and helpful consumer information.

The Republican leaders are against any healthcare reform. But we can get a few more of them to vote for it by dropping the "public option." Let's do it and let's improve insurance-company regulation.

Posted by: Paul Siegel on August 28, 2009 at 5:45 PM | PERMALINK

I'd love to agree with you -- your sensible, logical, and obviously focused on getting reform passed.

A few issues, however:

1. The exchanges would NOT, in fact, do anything to bring costs as he has them. There are no caps on premiums, just an idea that rates should be similar regardless of age, which does nothing about premium increases. There's also no regulatory framework even suggested, nor any limit on co-insurance. So those just won't be effective.

2. The hard right will NEVER be lacking for an argument, because they will argue against ... well, anything. No matter what concessions Dems give, the GOP will find something to whine about. They've been doing it for months now -- what makes you think they'll suddenly change?

3. Isn't a nationwide exchange where everyone can buy insurance that is cost-controlled and heavily regulated by the government a ... public option? I mean, if you think this is all just semantics, fine, let's have the discussion. I don't think you are, however.

It's simple: Without a firm, fixed, and feasible national option backed by the U.S. government, all we're going to get are half measures that will enrich insurance companies even more, force people into buying insurance they can't even afford, and just generally make the problem worse.

Since the GOP has no desire for reform, why the hell not just push the legislation the American public overwhelmingly wants?

Or does that just make too much sense for D.C.?

Posted by: Mark D on August 28, 2009 at 6:05 PM | PERMALINK

The players are different, but the play's the same: "In August (1994), George Mitchell, the Democratic Party's Senate majority leader, announced a plan [without the features that Republicans had opposed] that was almost pure symbolism--no employer mandates, very little content except a long-...term goal of universal coverage. Led by Bob Dole and Newt Gingrich, Republicans by September were opposing any plan."


Posted by: morganstern on August 28, 2009 at 7:43 PM | PERMALINK


"After much thought, I have come to the conclusion that the 'public option' is a mirage. After all the restraints legislators are placing on it, we may as well get rid of it. The important thing we need is not new options but the assurance that we would have competition that would bring costs down."

Without a Public Option, we are doomed to be forced by mandate to purchase healthcare insurance from the corporate healthcare insurance monopoly.

If you want to keep buying health insurance from the private-sector corporations, and pay for their mirrored corporate headquarters, and corporate jets, and corporate yachts, and corporate golf courses, and corporate resort condos, and corporate vacations, and bloated corporate bonuses, and bloated corporate stock options, and bloated corporate salaries, and bloated corporate sales commissions, and corporate stock dividends, and corporate profits, and on and on, all while they are not paying their fair share of federal income taxes, then by all means feel free to buy from them, where less then half of every premium dollar you pay goes to provide medical care.

But please don't call it competition.

"Removing the 'public option' will remove the main argument that the hard right and the crazies have been using to kill health reform."

They will just move on to the next RightWing propaganda.

Posted by: Joe Friday on August 28, 2009 at 8:05 PM | PERMALINK

They will just move on to the next RightWing propaganda.


There's reason to believe the nuttier "Tenther" elements of the right would begin going after other social programs.

Their SOP now is: under Republican presidents and congresses the Federal Government is king. Under Democratic president and Congresses we are a Republic and the "states" are king.

Posted by: trex on August 28, 2009 at 8:20 PM | PERMALINK

Tim, your math is bad. 12k is 20% of 60k, not 15%.

But a mandate without a public option would be a disaster.

As it happens, I am one of those people who, due to age and medical history, finds these numbers not as daunting as many. My wife and I are 58 and she is a cancer survivor. We pay through the nose for a 5k deductible. Those advocating such coverage need to wake up. Very high deductibles put you in the cash category where you get jacked around by providers.

Tell me another business on this planet where cash on the barrel head pays the highest price? I really, really want 1) all providers post their true, actual fees, not their bs billables and 2) that every service costs the same no matter the customer.

And btw, if you ever get really ill, be aware that not all providers will accept your insurance. And you may not find out until after the service is provided. My wife had two providers not accept our insurance from the largest insurer in the state for treatment of her cancer. How about a rule that says the provider has to accept your insurance?

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