Bryan Caplan  

How Many Employers Will Stop Providing Health Insurance?

My Opening Statement... What is Special About Greece?...
Why is employer-provided health insurance so prevalent?  Economists usually point to the tax code.  Cash is taxed; health benefits aren't.  One interesting side effect of Obamacare is that it's going to put the standard view to the test.

How so?  If preliminary summaries of Obamacare are true, it looks like individual health insurance will soon be a better deal than employer-provided health insurance.  In the individual market, you can now wait until you're really sick to buy insurance: "Heads I win, tails I break even."  Firms won't have that gimme - and it seems more valuable than premiums' tax deductibility.  Admittedly, Obamacare imposes a small penalty on individuals who don't buy insurance, and a moderate penalty on firms that don't provide it.  But it still seems like it will be in the financial self-interest of many firms and their workers to get rid of insurance, and split the (cash savings minus penalties).

I seriously doubt that prominent institutions like GMU or Microsoft will take advantage of this golden opportunity during the next few years.   The outcry would be too great, and they care about their image.  But if most lower-profile employers take the bait, the stigma might melt away.

The big question, then, is: Will lower-profile employers stop insuring their workers?  Financially it seems like it makes sense (though the legislation is complicated enough that I could be mistaken).  If you buy into Robin Hanson's "showing that you care" model of health altruism, however, you've got to think twice.  People still get married despite the tax disadvantages; apparently people will pay thousands of dollars every year to avoid hurting each others' feelings.  Will employers and employees make a comparable choice - to leave thousands of dollars on the table every year to show how much they mean to each other?

Comments and Sharing

COMMENTS (50 to date)
Gavin Andresen writes:

I think small, new companies will not provide health insurance, and as they grow they will stick to that status quo.

I think the "showing you care" syndrome along with the endowment effect will keep existing employers from taking away existing health insurance.

If I'm right, then newer companies will have an advantage over older companies. But I'm an entrepreneur, so maybe that's just wishful thinking on my part.

floccina writes:

Even before the bill passed I had been hearing that many employers are dropping health or raising the deductibles. Judging from people I know, when people buy their own insurance they opt for high deductibles, which I think is a good thing. IMHO we were headed into a painful but positive period in health care were more and more people would end up with sensible high deductible insurance.

And BTW I do not think employers would have taken on provision of health insurance for their employees if health care spending was 17% of the economy when they started. Spending 17% of the USA economy IMHO requires the attention of almost all consumers each with their unique situations and demands. Delegating it to employers when it was 4% of the economy made more sense.

So maybe we were on "The Dawn Of Correction" (reference to the song by: The Spokesmen).

Dan Hill writes:

The middle classes are obsessed with the idea of avoiding any out of pocket expenses for anything that can remotely be categorised as healthcare (yes that's orthoganal to the meaning of "insurance" as you and numerous other economists have pointed our countless times, but true nevertheless).

The overwhelming majority of these same people don't think of the health insurance premiums paid by their employers as coming out of their salaries - they don't want employer provided health insurance to get a tax break, they want it because they think it's free.

That's a powerful equilibrium that I don't see being changed by Obamacare (and the core reason that it was totally impossible to adopt any sort of meaningful "reform").

At the margin some employers may stop providing health insurance due to economic pressures, but employees won't be happy about it. They may then react as you predict though, at least until they can find another job with benefits.

Robert writes:


Something is being left out of the "heads I win, tails I break even" argument. Even within the new system, there is a strong incentive to buy insurance even if you are healthy. In fact, the primary reason I carry insurance now is that it allows me to take advantage of the insurance company rates for routine care. For example, a physical with lab work costs about $600 if you are uninsured....but only about half that if you are insured. What I do is carry a relatively cheap high deductible ($10,000) policy (effectively, I pay for my own care), but I pay dramatically reduced prices because I get the BCBS rate for care instead of the MSRP.

For example, I recently had an MRI. The MSRP was $1,200, but the BCBS negotiated rate was $400. Since I have not met my high deductible, I had to pay, but only the $400. Simply by virtue of being insured (if barely), I avoided an $800 incremental expense. Those of us in the private/individual insurance market are well aware of this incentive to carry insurance. Even under the new regime, I will have a very muted incentive to play the "heads I win....." game because of the access I have to negotiated prices by virtue of holding a cheap, high deductible policy.

By the way, none of this is very satisfying. I like neither the current system nor the new legislation. But given either system, there is a still an incentive to carry insurance.

RE writes:

I wonder how much the current high unemployment rate will matter.

As the unemployed start taking advantage of the new scheme, I suspect they will be more willing to accept jobs without benefits. They would probably accept them now if offered.

If the rate drops because people get jobs (as opposed to giving up), then there are (potentially) a lot of people going into work who won't be as demanding for benefits. They and the firms that hire them are the ones to watch over the next year or so.

Alex J. writes:

Recently, my wife had a procedure denied by our insurance company. The claim was deemed medically necessary, but excluded from our coverage. The insurance company's would've paid $2,000 to the doctor to do it, but his cash fee was $7,000. We asked the doctor if we could just agree to pay the $2,000 price. He told my wife that he's bound by his agreement with the insurance company to charge at least that much when dealing with people who are paying cash. If he is caught charging less, he will get delisted by the insurance companies.

I don't know how this is not considered an uncompetitive business practice. It seems like the sort of thing that could only be stable when the number of entities paying for health care is very low.

My all too varied recent experiences with the health care industry have demonstrated a great deal of room for improvement on various dimensions, but our recent "reform" discussions have addressed none of it.

Biomed Tim writes:


Do you think maybe as more people decide to become uninsured, the "non-negotiated" price will change? Would it increase?'

Dan Weber writes:

Alex J, I've heard anecdotally of many doctors giving discounts for people without insurance. I don't know if those doctors were risking themselves for their patients.

Floccina writes:

Alex J. I wonder if your doctor can get around the agreement by offering a rebate or calling it a prepayment discount or calling the procedure by another name.

When questions arise about Medicare regulation on pricing outside of their beneficiaries, several important distinctions are apparent. Health providers are free to charge what they want, and offer discounts based on the fact that these are “Pre-paid Services” and not comparable to “Covered billable services” that are subject to most of the regulatory text.

For example, most hospitals offer a special discount for services referred to as “Prepaid Services.” Such services may include facility fees for prepaid cosmetic surgical services, and uninsured services. Under that arrangement, the hospital is able to discount services that are not equivalent to those billed to Medicare – which are referred to as “Billable services.” A recent clarification by Medicare services distinctly allowed hospitals to discount “billable services” for uninsured patients, without it affecting the calculation of their customary charges which would otherwise affect the hospitals’ reimbursement schedule from Medicare.

Jeff writes:

this will accelerate the destruction of the health insurance industry ...
If they are required to cover all who apply and the newly sick buy coverage the insurance companies need the young and healthy to also buy to offset the financial risk of the sick. But the tax/fee for not buying healthcare insurance is paid to the Government and not to the healthcare insurance companies. So they end up with more risks and the government gains the offset for those risks.

Chris Bolts Sr. writes:

The penalty for noncompliance is so small that the rational businessman or individual would find it in their best interest to forgo health insurance. Add in the blatantly toxic incentive of being able to get insurance when you're sick and anyone who doesn't take the deal would be acting foolishly. That should about answer your question whether Obamacare is better for employers and individuals, Bryan.

However, as I mentioned in another thread by Arnold Kling, socialized responsibility always end in failure. So maybe the rational and prudent choice for businesses and individuals to make is stay where they are until they realize they must handle their own affairs and not government.

dk writes:

It seems almost certain that large employers of low- to middle-income workers will have to drop coverage after 2014 because the subsidies for the exchanges are much greater than the implicit tax subsidies for employer insurance: an employer that offers insurance won't be able to compete for those workers with an employer that does not. We could see big changes in the labor market for low- and middle-income workers as a result.

The disruptions might even be significant enough to prompt widespriead calls for another "reform" by 2015, with its main plank being equal subsidies for employer-provided insurance. Then we'll really see just how massive a budget buster this thing is.

JP writes:

I think most of you miss the point. Everyone's premiums will being going up. With ObamaCare, you will be liable for up to $8000 in extra premium costs if you earn $65000 a year, and up to $12000 if you earn up to $88000 a year. The President has specified subsidies for those who earn up to $88000 a year, but the amount isn't written into stone.

In other words, only a fool will pay so much extra in premiums when all he has to do is pay the fine and wait until he/she is sick. At that point some HHS bureaucrat will enroll you in Medicare. Until then, you pocket the savings.

A young person can go a decade or more without ever needing a doctor. And it really doesn't matter since that person in reality is already covered. The big losers will be insurance companies (there are forbidden to price risk), and the taxpayer.

ic writes:

JP: The big losers will be ...the taxpayer.

What is new?

jt writes:

I'm guessing that a lot of small employers will find ways to turn lower-paid employees into contract workers, with some increase in pay to compensate for loss of health insurance. Many younger, healthier self-employed workers will figure out that it's much more profitable to pay a small annual penalty for NOT having insurance, since they can always get guaranteed-issue coverage for anything expensive.

Strangely enough, this is more or less what many of us have been recommending: Eliminating standard employer-paid insurance and encouraging individuals to pay for the small stuff out of their own pockets.

Rob Mandel writes:

all of them.

which is both good and bad. good because it puts the consumer (you know, Mises consumer sovereignty thing!!) in control. But it won't matter, because, well, it'll be all government health care. There'll be no more private insurers.

Joe Teicher writes:

I don't really get why no one is mentioning this, but what about accidents? How are you going to buy insurance between the time when you hit the tree and 3 weeks later when you wake up in the ICU with a 500K+ hospital bill? It would be nice if you could buy cheap accident insurance that would cover only bad accidents, and nothing else, and then just buy real insurance if you get sick, but does that even exist? AFLAC pays for accidents, but not nearly enough to pay the medical bills. Without a way to deal with accidents, I think most risk averse people will continue to want health insurance, even if premiums rise significantly.

rtc writes:

Obamacare breaks the long established social contract between the worker and employer, and provides a financial incentive for employers to drop their Group Health Insurance plans. Employers have provided Group Health Ins for their workers because the Group Policy was provided to all employees without any restriction for pre-existing conditions. A feature that the employee could not get when purchasing an individual policy. Now that ALL Health Insurance MUST be sold without a pre-existing condition restriction, there will be NO social necessity for employers to provide the coverage for their employees.
Furthermore, the penalty to be paid by the employer for NOT providing insurance for workers is substantially less than the Group Insurance costs the employer. Employers will drop their plans as soon as they can do so. The law then requires the individual to provide their own health insurance. Good luck to all those those union democrat voters who think this will not happen to them. I perdict this will happen to every worker in the USA within 6 years.

Joseph Somsel writes:

The coverage and cost effects start this September. Insurers will be required to accept "children" to age 26 and the "children's pre-existing conditions" must be covered. (If Bloomberg via Drudge is to be believed.)

My employer has fixed rates for me this year. I assume that their contracting insurers have a fixed rate with my employer.

With legally mandated costs increasing, who eats 'em? Will the higher costs get passed alone this year to me or my employer, or is the insurance company stuck?

My HR lady at my employer hasn't a clue yet.

Vicki Davisson writes:

How do we know that the new Health Czar Sebelius is going to approve high-deductible health care plans? Remember insurance companies can only offer plans approved by her, and the price has to be "reasonable" or "affordable" (which can be whatever she says it means).

Also the marriage penalty is paid for more reasons than fear of hurting a mate's feelings. Some of us still believe in the Bible and in not living in sin (how old-fashioned that is!).

Alex I hope you can work out a deal with the doctor. Can you pay him $2500?

Heather writes:

How do we know that the new Health Czar Sebelius is going to approve high-deductible health care plans?

She's not. And the bill spells out exactly what coverage "approved" plans must cover. Everyone gets super-comprehensive coverage or pays the fine.

john b writes:

The one sure bet is that many employers will avoid the care/don't care trap by not adding employees unless absolutely necessary. As gov't mandated cost per employee goes up you can bet that salaries and benefits go down. Sometimes they go down to zero. That's change you can believe in.

Bob writes:

If what I read is correct, companies that employ more than 50 people (such as mine) will pay a $2,000 per worker fine if they do not offer health insurance. My employer's share of my annual health insurance premium (me, wife & 2 children) this year is $8,381.62. I suspect we'll all be dumped and have to get insurance on our own.

Kristyn writes:

One of the largest problems with the reform is that the federal government will be regulating what insurance policies are required to cover. So those high deductible plans that actually work to discourage overuse of medical plans will no longer be legal and you will have to pay a fee to the IRS if you have one. As everyone who currently has high deductible plans switches to new low deductible, covers every sniffle plans it will encourage overuse of medical resources and drive costs up which will be passed through to consumers through higher premiums.

R.J. Lehmann writes:

I think the $3,000 per employee penalty that is imposed on firms with more 50 employees is a bit more than a "moderate" penalty. Add that to the existing tax benefit, the tax credits a business can become eligible for if it supplies coverage and the 2.5% of income surcharge the employee would pay for not maintaining coverage, and it's hard to imagine many large firms that wouldn't continue to do so.

But for sub-50 employee firms that don't face any penalties, then certainly, if they were providing it before, they won't be now. The elimination of annual and lifetime benefit caps is going to drive premiums through the roof.

Koblog writes:

We'll see what happens come January 2011, when group policy premiums triple.

Conveniently timed by the Democrats for after the November elections.

Will companies be able to afford such expensive group policies or will they simply pay the $750/employee penalty, which will be much smaller than the cost of health care.

A larger question: why should an employer have to supply my health care in the first place? They don't supply my other needs like food, housing, clothing or transportation.

The plan, of course, is to drive the private insurers out of business, leaving only our benevolent Federal Government led by King Obama as our Savior.

Except, of course, the Federal Government is broke.

And that may be the true goal behind it all: the destruction of the United States of America.

Larry Ice writes:

OK. Everyone's arguing from the company's point of view. Lower costs, social contract, etc.

What about companies who need high wage, high skilled employees? Most of these companies already 'self-insure'. That is, they pay into financial pools that finance their employees health care needs, and typically hire an Aetna or United Healthcare to administer their insurance plans.

There will be an impact on their costs as Obamacare pushes up prices for everyone (Driving up demand and simultaneously shrinking supply).

But the backlash against dropping their plans, even if they do become more expensive, would be too great a risk. High wage, high skilled employees already vote with their feet. If your employer drops his health care and your buddies at XYZ corp. still have theirs, guess where the high wage employee is going to seek a job?

Kristyn writes:

Larry Ice - Unemployment is about 10%. So many people are out of work the employers have the upper hand in negotiations. The pool of unemployed skilled labor is large and the available number of jobs is small. It doesn't matter what the employee wants, the company can do as it chooses (the cheapest option) in this situation. To get back to 4-5% unemployment, the economy would have to add 250k jobs a month for the next 5 years. Given that this is unlikely to occur and the new mandates begin to go into effect over the next 4 years, it is in the company's interest to drop coverage.

Thomas writes:

I think it's really going to depend on what the workforce looks like. At a Microsoft or Yahoo or other similar company with an, on average, very highly compensated workforce, I think that we'll see the employer continue to provide coverage. For those employers with a workforce at the other end of the spectrum, I think we'll see employers discontinuing coverage. The tax subsidies still have real value to highly compensated employees, and they will not receive a subsidy in a state exchange. In addition, individuals with significant assets will continue to carry insurance, because even though they could get insurance later in the event of extended or chronic illness, there would be an uninsured risk of expense due to accident or severe illness prior to an insurance election, and because they have assets, they'll want to insure against that.

What the law does not seem to contemplate is that employers can restructure their workforces. Consider a law firm with 100 lawyers and 75 support staff, for example. Presently some number of those lawyers are highly compensated employees who receive a tax subsidy for insurance purchased through their employer, some number are partners who purchase with after tax dollars (no tax subsidy), and the rest are the various support personnel needed to operate such a firm (mail room, secretaries, clerks, etc.), who receive a much smaller tax subsidy for their insurance purchase. If the firm were to outsource its mailroom functions to a new entity with fewer than 50 employees, the new entity could provide roughly the same cash compensation to those employees as they receive now while providing them access to state exchanges and subsidies that could be worth up to $12000. The firm would have its compensation cost reduced (because it now pays both salary and a portion of health care cost), and the employees would end up better off (in some cases significantly better off). Why wouldn't we expect the firm to re-organize to take advantage of this free money?

John writes:

Consider the nose of the camel. Right now the penalties for non-compliance is small. But...

B. Watson writes:

Some have pointed out that it makes sense to pay the $700/year fine and reap the benefits by joining when you get sick. This makes even more sense if you don't really have to pay the $700/year fine...

Section 5000A(g)(1):
IN GENERAL.—The penalty provided by this section shall be paid upon notice and demand by the Secretary, and except as provided in paragraph (2), shall be assessed and collected in the same manner as an assessable penalty under subchapter B of 23 chapter 68.

Cool, as long as there's nothing unusual in paragraph (2)...

SPECIAL RULES.—Notwithstanding any other provision of law—
‘‘(A) WAIVER OF CRIMINAL PENALTIES.— In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure.
‘‘(B) LIMITATIONS ON LIENS AND LEVIES.—The Secretary shall not—
‘‘(i) file notice of lien with respect to any property of a taxpayer by reason of any failure to pay the penalty imposed by this section, or
‘‘(ii) levy on any such property with respect to such failure.

...completely toothless. I call rise in uninsured.

Gary Rogers writes:

The real decision is whether a company will drop health insurance before they lay off workers. I suspect that the new provisions will soften the effects of dropping healthcare enough that it will becoome common for companies to drop healthcare first then workers.

DOuglas2 writes:

Will business or other associations use their group negotiating power to purchase something that does not "count" as "health insurance" but functions as insurance against unexpected healthcare expenses?
They would still have to pay the fine, but would probably satisfy their employees/association members far more than sending them to the more expensive "individual health insurance" market.

Doc Merlin writes:

"I don't know how this is not considered an uncompetitive business practice. It seems like the sort of thing that could only be stable when the number of entities paying for health care is very low."

It is, but they are exempt from such laws.

Chris Bolts Sr. writes:

B Watson, that's just what I wanted to read: a law which does not intend to enforce the law. But that is to be expected: after all, even with 17,000 extra employees it'd be kind of hard to get 150+ million Americans (let's just say there are 150 million kids who members of the 150+ million Americans) to comply with the law.

Doc Merlin writes:

"I don't know how this is not considered an uncompetitive business practice. It seems like the sort of thing that could only be stable when the number of entities paying for health care is very low."

It is, but they are exempt from such laws.

R.J. Lehmann writes:

$750 per employee was the penalty number in the Senate bill that Obama signed Tuesday. Under the Reconciliation Act, the penalty is $2,000 per employee or $3,000 for each one that actually gets coverage through one of the exchanges.

Larry writes:

The problem with ObamaCare is that no one really knows how companies or their workers will respond, so we really have no idea what the cost to the taxpayer will be (although we know that it will be larger than projected). It is very interesting to see the discusiion above as people try to determine how they could maximize their benefit under different scenerios.

I know that the authors of ObamaCare do not have a clue as to how this will turn out, and yet the arrogance of this group of Ivy Leagers knows no bounds. Afterall, they know what is best for us. They are the "vanguard of the proletariet."

Rick writes:

Part Time Employees? How do they fit in? I've seen nothing. Do they count toward the 50 employee size? Require health care by employer? There are large parts of America there.

So, expect new juggling over how many hours/week employees get. That ought to really help, not.

John writes:

Another wild card is whether people will be able to afford insurance or even afford to pay the penalties. There are a lot of people who are barely able to make ends meet -- people who overcommitted on debt in the last decade, and are now scraping to try and save their houses from foreclosure, pay their utility bills and keep ahead of their debt. This includes "high earners" with high incomes that are being consumed by heavy mortgages. Just because you make X dollars per year doesn't mean that you have Y dollars in disposable income.

If the economy keeps deteriorating, it is very likely that we will see a tsunami of bankruptcies and foreclosures as hundreds of billions of dollars of struggling families' paychecks are hoovered out of the economy to fund a brand new, bloated health care system that no one can afford, while at the same time retail sales plummet as people's discretionary income dries up and disappears into the new health care bill or penalty.

topgun writes:

There is another reason employers may not stop giving health benefits. Provision of health benefits can also be looked at as an incentive provided to hire and retain people. This may not be as relevant in these days of high unemployment but in general, it holds true. Firms that drop health coverage may lose employees to their competitors.

Eric Rasmusen writes:

This bill is so screwed up it might actually turn out to be good policy. Here's what might happen:

1. Employers all stop covering health insurance, because it costs too much and the employer penalty is cheaper.

2. Individuals won't buy insurance till they get cancer. At that point, they will.

3. Since (a) only sick people will buy insurance, and (b) extra mandates also make health insurance more expensive, the price of health insurance will at least triple.

Thus, in the end we'll be left with nobody having health insurance, and all the moral hazard that's driving up health costs will disappear. Well-- not quite. We'll still have Medicaid, so anybody who spends all his assets and loses his job will get free medical care after that.

But maybe government subsidies would kick in at some point in time. In that case, maybe insurance would only go up to $20,000/year for an individual, and we would in effect have a ban on our existing style of insurance combined with compulsory catastrophic insurance, financed by taxes.

kay writes:

in the end: when 85% of those currently covered by insurance see their premiums go up and service levels go down - they will be very very unhappy with this healthcare insurance bill - its funny, doesnt the congress and white house realise that 85% of americans read thier healthcare bills every month? people will see the "change" and be very upset!

Don Nourse writes:

As for accidents, why couldn't car insurance policies add this coverage. I think this is a big hole in the plan and it's an incentive for both the employer and the employee not to take coverage and just pay the fines.

Hildebrand, The Insurance Warden writes:

That's a silver lining, in my view (not because I work in the industry, though). I've long been disgruntled over employer-sponsored insurance. I would rather have my income given to me as cash than benefits so that I can make my own choice as to who my insurer will be.

For the nonce, I'm fortunate that this year, our company health insurance plan changed, and we have more choice than before. But when Obamacare really goes into full swing, I suppose that I'll decide to become one of those who pays the fine for not having insurance, rather than keeping insurance all the time.

Jeremy, Alabama writes:

I suspect the damage of Obamacare will fall most heavily and most rapidly on the working poor.

If "employing" someone introduces a large, fixed cost that is independent of rate of pay, then the lowest paying, lowest skilled jobs will be administratively changed by the employer from "employment" to "temporary contract".

It does not take long to train a shelf-stocker, pallet-nailer or burger-flipper. These jobs are unfortunately destined to be temporary contract labor, condemned to a life of moving between jobs every few weeks, and with no hope of stability or a reliable paycheck. They will still not have insurance.

Gmama writes:

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CK in WA writes:

To answer Joe's question about buying insurance for accidents. YES, you can buy liability insurance. However, it is NOT cheap.

As a small business owner we discovered some interesting things:

A) We cannot buy L&I insurance (that has recently changed I guess), but is very expensive and who wants to fight with L&I to get medical bills paid if you get hurt on the job.

B) Our medical ins. will NOT cover my husband if he is hurt while working for our own business.

C) The commercial auto policy will NOT cover him if he is hurt while outside of the vehicle. He drives a dump truck. So, if he accidentally falls off the truck while wiping down the sideboards and breaks his neck--the auto ins. doesn't cover it.

We were told the only other option was to purchase liability insurance. I checked into it and it was ridiculously high.

One other thing most people don't realize. The homeowners ins. YOU PAY FOR will NOT cover you if you get hurt. For example; you and your neighbor are working on your roof. Both fall off and break one leg each. Your homeowners will pay for your neighbor's med. bills but NOT yours! Sucks, eh! Reason: You can't sue your own insurance company.

ALL insurance is a complete racket in my opinion. I tallied up what we pay in just insurance each year and it came to $16,073.00 per year. Auto, medical, life, comm. auto/gen. liability. RIDICULOUS INDEED!

Govt. needs to regulate insurance companies!

CK in WA writes:

Here's a question:

How will this affect Prevailing Wage Medical Benefits???

If a company no longer has a co. health plan, will the medical prevailing wage benefits be paid out in paycheck to employees instead?

CK in WA writes:

What is going to stop BIG companies from starting several different companies and keeping them all below the minimum amount of workers? Nothing.

So, if you had one company with 100 workers you could split it, form two separate companies with 50 workers each and get exempt from having to provide med. insurance and the big fines.

By the is my understanding the individual person will be fined 695.00 (reduced in final fix), BUT businesses will pay a percentage of their total payroll. The % depends on the size of the company/number of employees.

Does anyone else think companies may form several smaller companies? They could still work on the same projects anyhow, so what would it matter.

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