Tag Archives: health insurance

GOP: Poor Excuses and Paucity of Empathy

By all accounts the Graham-Cassidy+Heller version of health care destruction would yield a net coverage reduction for 243,000 Nevadans. Overall it would mean a 31% cut in Medicaid for children — that’s right — children.  There’s another 15% cut for services for people with disabilities.  And what’s the rationale for this atrocity?

(1) Because we promised!  This is probably the silliest reason to do anything ever.  I may have promised to offer someone a ride to go shopping, but if there’s a blizzard on the way then it’s downright stupid to “keep the promise.”

(2) Because Obamacare is failing!  And why would that be? Because Republicans refused to make some simple fixes (risk corridors, risk sharing, and reinsurance) and the individual health insurance is unstable.  It’s a classic case of tossing the baby out with the bathwater.  Or, of finding some perfectly “fixable” problems with a law and using those to rationalize pitching the entire thing.  Head UP: They’ll try this same approach with the financial sector reforms in the Dodd Frank Act.

And then there’s the part the Republicans aren’t talking about.

(3) Because they’ve wanted to get rid of Medicaid, Medicare, and to privatize Social Security from time out of mind.

This comment sums up the situation:

“The two keys to the Republican attitude are money and ideology. If you view the modern G.O.P. as basically a mechanism to protect the wealthy, Medicaid is an obvious target for the Party. The program caters to low- and middle-income people, and its recent expansion was financed partly by an increase in taxes on the richest households in the country.”

The concept can’t be articulated more simply or directly.

Then there are the sputtered talking points, common among Republican politicians and supporters to hike around the obvious but unspoken issues they have with the Affordable Care Act.

If we don’t pass this we’ll have socialized medicine.  Please.  Even Single Payer (or Medicare for all) isn’t socialized medicine.  Medicare insurance is used to pay PRIVATE providers for medical treatment.  This obviously isn’t a nationalized medical service plan.  Only by artificially conflating medical insurance with medical services can anyone assert that this is “socialism.”

There are no guarantees in life.  So if a family in Minnesota who has a child with muscular dystrophy may be required to pay higher premiums that’s the way the markets work.  It doesn’t get more morally bankrupt than this — especially since the current system does guarantee coverage for families with chronically ill children.

This issue is long past being a public policy issue, it has devolved into pure politics in which ‘points’ are scored by a party desperately hoping to cut taxes for its most generous donors at the cost of Americans’ health care.

So, every few weeks we’ll have to call our Senators to beg them not to destroy the Affordable Care Act and Medicaid for ourselves, our families, our friends, our neighbors, and our fellow citizens.

Call Senator Heller at his Las Vegas Office 702-388-6605; his Reno Office 775-686-5770; or his DC Office 202-224-6244. 

You may also want to call Senator Cortez-Masto to thank her for her support of health care access for Nevadans. 202-224-3542; 702-388-5020; 775-686-5750.

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Filed under Health Care, health insurance, Heller, nevada health, Nevada politics, Politics

Hellerisms on Parade: Health Care Edition

And then there was this:

“The individual mandate I thought was atrocious, was wrong and shouldn’t have been in Obamacare at all,” he said. “I don’t think your government should tell you to buy something that you can’t afford. And if you can’t afford it you pay a fine. Yet 90,000 Nevadans pay the fine.” — Senator Dean Heller

Let’s start with the assumption that Senator Dean Heller is a capitalist, a firm believer in the free market system.  He’s certainly reinforced this impression given any occasion to do so.  So, why was there an “individual mandate” in the Affordable Care Act?  — The answer is capitalism.

The more precise answer is the “adverse selection” problem in free markets.  The most concise explication I’ve found for this comes from the Economist’s View:

“To explain how the adverse selection problem arises in these markets, note that people purchasing health insurance generally have better information about their health status than the people selling the insurance. If insurance is offered in this market at somewhere near the average cost of care for the group, people will use the superior information they have about their own health status to determine if this is a good deal for them. All of the people expecting to pay less for health care than the price the companies are asking for the insurance will drop out of the market (the young and healthy for the most part; all that is actually needed is that some people are willing to take a chance and go without insurance). With the relatively healthy people dropping out of the insurance pool, the price of insurance must go up, and when it does, more people drop out, the price goes up again, and the result is just like in the used car example above: The market breaks down and nobody (or hardly anybody) can purchase insurance.”

Now, if a person is reasonably conversant with capitalism and the patterns intrinsic to the operation of free markets, then the problem of  ‘adverse selection’ should be part of that person’s lexicon.  Granted it’s not an easy thing to explain, but the Economist’s View post quoted above offers the “used car” analogical example which makes the concept more accessible.   Therefore, if Senator Heller is indeed a capitalist, and if he has better that average economic knowledge base, then his explanation of his opposition to the individual mandate makes absolutely no sense whatsoever.

There’s also the political side of the issue, recall that Obama’s original plan didn’t contain an individual mandate while Secretary Clinton’s proposal did, and the result:

“Once elected, Obama quickly recognized the inescapable truth: An individual mandate was essential to make the plan work. Without that larger pool of premium-payers, there is no feasible way to require insurance companies to cover all applicants and charge the same amount, regardless of their heath status.” [WaPo]

There’s just no way to get around the problem of Adverse Selection, and still have an insurance system based on free market capitalism. 

Those still unsure about their understanding of Adverse Selection and how it operates in a free market system may want to consult some of the following sources:  Investopedia is a good source for short, concise, definitions of economic terms such as Adverse Selection. The Economic Times also has a dictionary style definition.  Risk Management specialists have a more technical definition.  Those wishing to dive a bit deeper into the weeds might want to see the World Bank’s explication.   There’s also an explanation from the National Association of Insurance Commissioners which goes into greater depth. (pdf)

Granted the individual mandate isn’t popular — that part is easy — but anyone who professes to be a free market capitalist (as does Senator Heller) can’t ignore the principle of Adverse Selection and how that concept impacts the insurance markets.

The alternatives to a purely market based insurance system in which the most people possible can obtain health insurance at relatively affordable rates are problematic for the free-marketeers.  A public option (federally sponsored insurance program operating in the general market) is one possibility.  Another alternative simply removes the free from free market — the single payer, or Medicare for All proposal, in which public insurance pays for medical services delivered in the private market.  At the furthest end of the spectrum would be nationalized medical health services such as the British or French systems. The arguments for and against each of these are ideological and political, and not necessarily relevant to the discussion of free market based health care delivery.  However, they do mitigate, from divergent directions, the issue of Adverse Selection.

The problem for Senator Heller is that he can maintain his free market positions OR he can oppose the individual mandate, but in light of the persistent and perpetual issue of Adverse Selection he can’t do both.

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Filed under Economy, Health Care, health insurance, Heller, nevada health, Nevada politics, Politics

Rest and Repair: Progressive Dreams and Conservative Nightmares

When last we spoke, the topic was moving from how to stabilize the individual health insurance plan market toward how best to deliver the services and do so without bankrupting American workers. Now we’re in the land of Progressive Dreams and Conservative Nightmares.

Republicans use the expression “patient centered medicine” as code for a system n which the individual (and individual policy holder) is responsible for how much, and what kind, of insurance coverage he or she may have.  This system works in theory, but has severe implications when it collides with reality.  As noted here, and in other analyses, the delivery of health care is not a “market” in the true sense of the term.  A market requires a voluntary transaction, and a diagnosis of a serious illness or the result of an accident aren’t voluntary in the sense of a face life or other form of elective medicine.  Not only is there not a market in the economic sense of the term, but health care is not necessarily an “individual” matter.

Philosophical Review and Reality Check

If I choose not to seek treatment for a communicable disease, perhaps because I don’t feel I can afford the treatment, I am placing my co-workers, neighbors, and heaven only knows who else, in peril.  If I choose not to seek rehabilitation after having an accident causing injury, then I place my own productivity in jeopardy, and reduce the value of my services to my employer and co-workers.  If, for financial reasons, I choose not to have something such basic as an annual physical exam, then I have chosen to ignore the ramifications of this decision on those around me.  My ‘freedom’ places the freedom of others to function in a safe and secure environment in jeopardy.

Arguing that “freedom” requires I accept responsibility for my own health — and health care — in turn requires that everyone else accept the same responsibility even though we have no control over the actions and decisions of others which may impact our own health.  This would be caveat emptor carried to irrational extremes.

If we’ll accept the notion that we are herd animals in our present form, and our socialization requires we not place others in jeopardy willfully or involuntarily, then what options are available within the current system to make sure we are healthy enough to be productive and not ‘infect’ the neighbors?

Dreams and Nightmares

At the risk of inserting more artificiality into this discussion, let’s assume that we maintain our system of paying for medical services with a combination of out of pocket and insurance resources.  What systemic changes can we make to expand the resources to more people in the individual (and employer) markets without changing the fundamental nature of our system?  The options range from tweaks to overhauls.

At the tweak end of the spectrum Senator Claire McCaskill (D-MO) offers a plan to allow residents in areas abandoned by health insurance corporations to purchase insurance offered by companies on the District of Columbia Insurance Exchange.  As discussed yesterday, a more middle of the spectrum suggestion is to revise or renew insurance company options for risk adjustment, risk corridors, and reinsurance to encourage the corporations to remain in rural markets.

The public option model moves us along the spectrum, and is available in legislative form in the text of HR 1307 in the 115th Congress.

“For years beginning with 2018, the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide for the offering through Exchanges established under this title of a health benefits plan (in this Act referred to as the ‘public health insurance option’) that ensures choice, competition, and stability of affordable, high-quality coverage throughout the United States in accordance with this section. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.”

The public option provides insurance plans which could be restricted to abandoned areas or extended nationwide depending on the final structure of the legislation.

Republicans see a slippery slope in the public option proposal — today the public option tomorrow the single payer plan.  As noted previously, there’s nothing “socialized” about proposals establishing Medicare for all, because the Medicare insurance plan pays for privately delivered services.  However, again, Republicans see any extension of access, with public support, as a step towards nationalized health care.  This makes for intriguing intellectual disputation, but it doesn’t really further the process of making more Americans healthier, or easing the burden of health care insurance from American businesses.  The burden is illuminated by the often quoted:

“For large multinational corporations, footing healthcare costs presents an enormous expense. General Motors, for instance, covers more than 1.1 million employees and former employees, and the company says it spends roughly $5 billion on healthcare expenses annually. GM says healthcare costs add between $1,500 and $2,000 to the sticker price of every automobile it makes.” [CFR]

A pre-ACA Rand study supported the general conclusion that employer sponsored health care insurance combined with rising health care costs was a drag on economic growth:

“The analysts found no significant relationship between the percentage of workers with ESI in the U.S. industries in 1986 and the percentage change in employment in the corresponding Canadian industries over the 19-year study period. The lack of a relationship suggests that excess growth in health care costs does have adverse economic effects and that these effects are more pronounced in industries that have a higher percentage of workers with ESI.”

While the Republicans may envision nightmares of nationalization, some of the industries which provide employer sponsored insurance who support their agenda are simultaneously encumbered with expenses not shouldered by their foreign competitors whose employees are provided with public sponsored health insurance.

Perhaps we could advance our public discourse on health insurance if (1) we would stop discussing the topic as if it were an ethereal scholastic issue in which generalizations and speculations replace hard data and human experience; (2) we would look at a variety of proposals ranging from small technical changes to the Affordable Care Act to technical changes to stabilize the insurance market to full public support for privately delivered health care services.

*H/T to Mark Stufflebeam and @Karoli for suggestions and resources!

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Filed under Health Care, health insurance, Politics

Beware The Artful Codger

One congressional Representative for our northern neighbor, Idaho, has a problem in his Lewiston office: Too many artful codgers showing up there around lunch time with complaints about his political philosophy.

“A spokesman for U.S. Rep. Raul Labrador’s office in Lewiston has filed a complaint alleging a threat from a group of local citizens who routinely visit congressional offices.

Scott Carlton reported the issue to the U.S. Capitol Police early last month. Carlton, who works out of the congressman’s downtown Lewiston office, declined to comment when contacted by the Tribune and referred all questions to Doug Taylor, Labrador’s spokesman in Meridian, Idaho.

The citizen group, LC Valley Indivisible, is comprised of mostly older residents of the Lewiston-Clarkston Valley, according to its members. The organization is loosely affiliated with the national Indivisible groups that call for town hall meetings with members of Congress to raise issues regarding President Donald Trump’s administration.” [SR]

The group members recall a civil engagement with Scott Carlton, Labrador’s spokesperson. Carlton told people at a Chamber of Commerce gathering that the group was “aggressive,” and reported that he (Carlton) had contacted Capitol Police who have jurisdiction over congressional offices. [Spokesman pdf]

Not that those in Nevada’s 2nd congressional district can complain about this issue too strenuously, Mark Amodei (R-NV2) hasn’t scheduled a public performance since venturing out to Carson City recently. It is noteworthy that Amodei told the Reno Gazette Journal: “… he would not vote for any plan that resulted in reduced coverage for anyone. “No, I don’t think you can say forget it, we’re going to let them be uninsured because as a practical solution, that’s not an answer and somebody ends up paying in the end anyhow,” Amodei said.”

Now, Representative Amodei has a GOP plan before him that does precisely that — reduces health insurance coverage for people in his district, and the amendments to the bill recently announced make the situation even worse, dismantling Medicaid protection for seniors in record time.  However, Representative Amodei doesn’t appear to want to pencil in a town hall meeting in a major metropolitan area in his district — like Reno/Sparks?  Perhaps some of those artful codgers, similar to the Lewiston lunch bunch, might show up?

However, there are other ways to get the attention of elected representatives. I am particularly fond of the Empty Suit Town Hall. Let’s hear it for Lexington, Kentucky:

“…voters in Lexington, Ky., have been clamoring for the state’s congressional representatives — Senate Majority Leader Mitch McConnell, Sen. Rand Paul and Rep. Garland “Andy” Barr — to tackle constituents’ questions in person. They even booked a venue for Saturday and hand-delivered town hall invites to the politicians’ offices.  The legislators were a no-show, but that didn’t stop things. Instead of McConnell, Paul and Barr, organizers propped up three mannequins wearing suits.” [WaPo]

Perhaps not the best optics for a congressional delegation? At least it’s better to be an empty suit than to sic the Capitol Police on office visitors?

There are other ways to contact GOP representatives like Mark Amodei — and this should be done before the vote on the Repeal/Replace bill on Thursday.

For those living in District 2 there’s Amodei’s contact form for quick e-mail messages. Simply scroll down the page to the “e-mail link.”  The page also has the phone numbers for Amodei’s offices in Reno Phone: (775) 686-5760, Elko Phone: (775) 777-7705 , and Washington, D.C Phone: (202) 225-6155.

This is as good a time as any to remind Representative Amodei what he said to the Gazette Journal: “… he would not vote for any plan that resulted in reduced coverage for anyone. “No, I don’t think you can say forget it, we’re going to let them be uninsured because as a practical solution, that’s not an answer and somebody ends up paying in the end anyhow,” Amodei said.”

Now, if only those artful souls in Idaho can get the attention of their Representative…

 

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Filed under Amodei, Health Care, health insurance, Medicaid, Nevada politics, Politics, Republicans

Myths and Legends: The Medicaid Issue in Nevada

There was a Republican politician on my television screen this morning telling me, or trying to tell me, that Medicaid was “meant for mothers, children, and those who couldn’t work…” This is outdated. Then, he tried to convince me that Medicaid was being “abused” by those who work and ‘game the system,’ while spouting platitudes about the Free Market and the Joys of Competition.  Let’s start at the very beginning.

This is the explanation of Medicaid as reported by Nevada’s Division of Health Care Financing and Policy (pdf)

“Medicaid is the nation’s main public health insurance program for people with low incomes and the single largest source of health coverage in the U.S.”

The program is meant to help people with low incomes.

“The PPACA extended coverage to many of the non-elderly uninsured people nationwide. The June 2012 Supreme Court Ruling made Medicaid expansion optional for states, and Nevada elected to join the expansion and maximize federal dollars. Effective January 1, 2014, this move broadened Medicaid eligibility to nearly all adults under age 65 with income at or below 138% of the Federal Poverty Level (FPL). At the end of SFY 2014 that meant that there were an additional 125,989 new enrollees in Nevada Medicaid, and increased expenditures of $154,816,777.00. These new expenditures are 100% federally funded.” [NV med pdf]

Medicaid expansion added those working Americans who were earning 138% of the poverty line and below, (pdf) and more specifically: (1) Those between the ages of 19 and 64 who are earning less than 138% of the FPL. (2) Pregnant women in homes earning less than 165% of the FPL. (3) Children from birth to 19 years of age in homes wherein the earnings are at or below 205% of the FPL, with a small premium required in some cases. Translated into real people with real levels of low income earned, this means a family of four would be eligible for Medicaid in Nevada if the family earnings are less than $2795 per month; for pregnant women if the earnings are at or less than $3341 per month; and families are eligible for the kids’ Check Up program if family earnings are less than $4151 per month.

If we calculate annual earnings, then monthly earnings of $2795 mean an annual income  of $33,540. At $3341 annual earnings of $40,092, and at $4151 annual income of $41,630. Nevada’s median income is $52,431 (2015). To put these numbers in perspective, the average weekly wages of a person working in a private restaurant in this state are $382, or $1528 per month ($18,336 yearly). [DETR] The average rent for a 2 bedroom apartment in Las Vegas, the obvious site for most private restaurants, is $932 per month. [RJ] In short, not only are wages not all that generous in Nevada, the benefits available for Nevada families aren’t all that generous either.

Republicans, however, strenuously oppose benefits for adults capable of working. This would make infinitely more sense IF and ONLY IF they were willing to support a living wage for all employees. One really doesn’t get to have it both ways.  Either you want a reduction in benefits that most working people can afford to purchase on their own because they have the financial resources to do so, or you want lower wages which mean that individuals and families cannot afford those things, like health insurance, and the public benefits are required to make up the difference.  However, at this point we slam into another GOP myth.

Free market competition will make health insurance affordable for everyone, even those who are working in low wage jobs.  Good luck with that. Personally, I have yet to hear anyone explain with any specificity why health insurance corporations will be flocking to Clark, Washoe, or even Esmeralda counties because there is more “free market” applied to the situation. If the insurance companies weren’t wildly excited about selling individual and family health insurance before the enaction of the ACA, why would they do so now? Unless, of course…

They could sell policies that didn’t cover all that much? That cost more for those between the ages of 50 and 64?  That didn’t cover maternity expenses? That didn’t cover preventative care? That didn’t cover drug rehabilitation and mental health services in parity with physical treatments? That only covered the items required in those states with the least consumer protections? And, even then all we have to look to is the situation in Nevada when insurance corporations were free to offer what they were pleased to call comprehensive policies.  Again, if they weren’t interested in selling a plethora of individual and family policies then why believe they would be now?

And that Free Marketeering? It doesn’t work in the health care industry:

“In a free market, goods and services are allocated through transactions based on mutual consent. No one is forced to buy from a particular supplier. No one is forced to engage in any transaction at all. In a free market, no transactions occur if a price cannot be agreed.

The medical industry exists almost entirely to serve people who have been rendered incapable of representing their own interests in an adversarial transaction. When I need health services I often need them in a way that is quite different from my desire for a good quality television or a fine automobile. As I lie unconscious under a bus, I am in no position to shop for the best provider of ambulance services at the most reasonable price. All personal volition is lost. Whatever happens next, it will not be a market transaction.” [Forbes]

The only thing I can say with any certainty is that the Republicans have little idea exactly what constitutes a Free Market, and instead are waving it like a banner crovering their underlying desire to be free from the moral requirements compelling us to be our brother’s keepers.  The range of misanthropic explications are appalling, from “we need not do anything because the poor will always be with us anyway,” to “when Jesus told us to provide for one another he only meant fellow Christians.”

The Repeal and Replace campaign is as void of humanity as it is of understanding of the reality of most family economics, and of the comprehension of what the term ‘free market’ actually means.

 

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To Our GOP Friends Who Don’t Seem To Have A Clue How Insurance Works

We might go for the Ryan budget bill in regard health insurance directly, but others have already noted that either (a) he doesn’t have a clue how insurance works, or (b) he’s trying to pull a fast one on the American public.  At any  rate, the phase I of the ACA repeal is essentially a gigantic giveaway to health insurance and pharmaceutical corporations, a tax boon to those in the upper 0.1% income bracket, and a dismantling of the Medicaid program. The contents of Phase II have been tipped.  It’s on the Speaker’s website, but requires a bit of unpacking:

“Administration actions, notably by HHS Secretary Price, to stabilize the health insurance market, increase choices, and lower costs…”

Translation: The content of health insurance policies, currently listed as “essential provisions” for all policies, is under a head on assault.

If a corporation is going to offer a comprehensive health insurance policy for sale to customers, it must include “ambulatory care for patients in a hospital or not,” “emergency services,” “hospitalization,” “pregnancy, maternity, and newborn care,” “mental health and substance abuse treatment,” “prescription drugs,” “rehabilitation,” “laboratory services,” “preventive and wellness care,” “pediatric care including vision and oral care,” and “birth control and breastfeeding coverage.”

Now, just guess what parts of this coverage the GOP finds objectionable?  If you guessed anything having to do with WOMEN give yourself the prize of the day.

Why, the guys grouse, do I have to have a policy covering maternity and neo-natal care, birth control prescriptions, and pediatric care?  It’s because of how insurance works.

Aside from the obvious part wherein it requires both men and women to create a ‘maternity situation,’ the whole idea of insurance is encapsulated in the word POOL.

“When you buy insurance, you join many others who pay money to an insurance company.  The insurance company uses the money collected to pay claims that are submitted by those who have purchased insurance.  The money is “pooled” and losses and expenses are shared.  An important aspect is the members of a pool share similar risk characteristics.” [HIW]

In the case of health insurance, the “shared characteristic” of note is that everyone who buys a policy is a human being, who at some point will need health care.  The more people (policies) in the pool the wider the risk can be shared. And, that’s the point of insurance — spreading the risk among as many policy holders as possible.

Creating ‘cafeteria’ policies might be profitable for the insurance corporations, but it doesn’t make health care affordable for most people.  If we carve out special coverage for maternity care and remove this from the larger pool (which includes men) all this serves to do is to increase costs for those remaining in a smaller pool.  Similarly, if prostate cancer screening and treatment is carved out from comprehensive coverage, this serves to increase costs as the overall pool is diminished.

Got it? If not, think of your auto insurance.  10 people buy GenZ Insurance, 9 of them never file a claim, 1 does. The costs related to the one claim are shared among those who bought into the pool and paid premiums to maintain their insurance.  We require all automobile owners in this state to have at least minimal insurance. In Nevada, this means you have to have a policy covering $15,000 for bodily injury or death in an accident for one person, $30,000 for bodily injury or death of two persons in an accident, and $10,000 to cover property damage. Thus, all Nevada drivers must have at least minimal participation in the auto insurance pool. Again, the larger the pool the greater sharing of risk, the entire point of having insurance.

Back to health insurance, if we thought Phase I is a disaster, Phase II should be even worse. Phase III is the ‘portability canard.”  Has it occurred to anyone in the GOP hierarchy that nothing that really prevents insurance corporations from selling their policies across state lines — IF they agree to accept the standards set by state insurance commissions for the protection of their consumers.  More on this later — if necessary.

 

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Filed under Economy, Health Care, health insurance, Insurance, Politics

My List

Monday morning the need for accountability becomes paramount.  There are some issues which require continuous investigation and reporting, my list:

  • The efforts of the Russian government to interfere in the 2016 election. Investigations have been launched, some ongoing since last summer.  Efforts to curtail or stall these investigations could easily be characterized as evidence substantiating the charges.
  • The efforts of Tom Price as a cabinet member to implement the elements of his Empowering Patients First Act, which would send the health insurance system back to the days of junk insurance and perhaps worse should the corporations be allowed to bypass state consumer protection systems.
  • The unholy alliance of Pruitt, Perry, et.al. to deconstruct environmental protection in favor of protecting the interests of exploiters and polluters.
  • The efforts to suppress voting and civil rights.
  • The privatization of public education, and coordinated efforts to use public funds to support religious efforts.
  • The tendency to demonize members of minority/ethnic communities.

That should keep journalists busy for a while?

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