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HIV/AIDS Housing and the Affordable Care Act

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1 HIV/AIDS Housing and the Affordable Care Act
Presented by the National AIDS Housing Coalition 2012 United States Conference on AIDS Caesar’s Palace Hotel Las Vegas, Nevada September 29, 2012 2:30-5:30 PM

2 Seminar Faculty Chair Shawn Lang, CT AIDS Resource Coalition, Hartford, CT Seminar Faculty Cassandra Ackerman, Columbus, OH Jeff Allen, Ormond Beach, FL Art Bendixen, AIDS Foundation Chicago, Chicago, IL Nancy Bernstine, National AIDS Housing Coalition, Washington, DC Christine Campbell, Housing Works, Inc., Washington, DC Michael Kaplan, Cascade AIDS Project, Portland, OR Kathie Hiers, AIDS Alabama, Birmingham, Alabama Gina Quattrochi, Bailey House, New York, New York Ginny Shubert, Shubert Botein Policy Associates, New York, New York

3 Housing is HIV Prevention and Health Care: An Overview
Shawn Lang Connecticut AIDS Resource Coalition

4 Homelessness—a major risk factor for HIV infection
Rates of HIV infection are 3 times to 16 times higher among persons who are homeless or unstably housed, compared to similar persons with stable housing. 3% to 14% of all homeless persons are HIV positive (10 times the rate in the general population). Over time studies show that among persons at high risk for HIV infection due to injection drug use or risky sex, those without a stable home are more likely than others to become infected.

5 HIV—a major risk factor for homelessness
Up to 70% of all PLWHA report a lifetime experience of homelessness or housing instability. 10% to 16% of all PLWHA in some communities are literally homeless at any time —sleeping in shelters, on the street, in a car or other place not meant for human habitation. Many more PLWHA are unstably housed, faced with housing problems or the threat of housing loss. Rates of housing need remain high - as some persons get their housing needs met others develop housing problems.

6 Housing instability = poor health outcomes for PLWHA
Homeless/unstably housed PLWHA are less likely to receive appropriate health care & experience higher rates of opportunistic infections, HCV and other co-morbidities. The all-cause death rate among homeless PLWHA is five times the death rate for housed PLWHA. The death rate due to HIV/AIDS is among homeless PLWHA is seven to nine times the death rate due to HIV/AIDS among the general population. Poverty is the most significant factor contributing to HIV health inequities.

7 Housing status predicts HIV risk behaviors
Research shows a direct relationship between housing status and risk behaviors among extremely low income HIV+ persons with multiple behavioral issues. Homeless or unstably housed persons were 2 to 6 times more likely to use hard drugs, share needles or exchange sex than stably housed persons with the same personal and service use characteristics. Homeless women were 2 to 4 times as likely to have multiple sex partners as housed indigent women - in part due to the effects of physical violence. Harm reduction and other behavioral prevention interventions are much less effective for participants who lack stable housing.

8 Housing is HIV Medical Care
Receipt of housing assistance is among the strongest predictors of accessing HIV care. Homeless/unstably housed PLWHA whose housing status improves over time are: More likely to report HIV primary care visits, continuous care & care that meets clinical practice standards More likely to return to care after drop out More likely to be receiving HAART Increased housing stability is positively associated with: Effective HAART (viral suppression) Better HIV related health status ( as indicated by viral load, CD4 count, lack of co-infection with HCV or TB) Significantly decreased mortality (a SF study shows that access to supportive housing reduced mortality among homeless PLWA 80% over a 5-year period)

9 Housing is HIV Prevention
Over time, studies show a strong association between change in housing status and risk behavior change. Over time, persons who improved housing status reduced risk behaviors by half; while persons whose housing status worsened over time were 4 times as likely to exchange sex. Access to housing also increases access to appropriate care and antiretroviral medications which lower viral load, reducing the risk of transmission.

10 Housing Saves Costs People coping with homelessness are frequent users of expensive crisis services including shelters, jails, and available emergency and hospital care. The CHHP cost analysis documented that improved housing stability reduces these costs my amounts that more than offset the costs of housing intervention. Generating an average annual savings of $6,000. Each new HIV infection prevented through housing stability saves over $300,000 in lifetime medical costs. An ongoing study of PWHIV enrolled in a SF housing program showed that median healthcare costs for high users (>$50,000/year) dropped from $100,000/year prior to housing to $1,819 after placement.

11 How Supportive Housing Links with the Affordable Care Act
Christine Campbell Housing Works

12 Overview of the Affordable Care Act
Signed into law March 2010 Goal is to decrease the number of uninsured Americans, improve overall health outcomes and reduce the overall cost of healthcare Despite several state challenges, the Supreme Court upheld the individual mandate provision and found the Medicaid Expansion provision coercive thereby allowing states to opt out without risking federal funding.

13 Caveats There is no panacea. Covering the costs of support services in housing programs continues to be a challenge. The Affordable Care Act will be implemented differently from state to state – what your state implements will be dependent on strong advocacy and involvement on all our parts.

14 Overview of the Affordable Care Act
Requires insurers to issue policies regardless of medical condition and the same policies and coverage to people of the same age and geographical locations regardless of gender or pre-existing condition Health Insurance Exchanges: Individuals and families above 100% and 400% poverty can purchase insurance with federal subsidies on a sliding scale Medicaid Expansion to all individuals at or below 133% of poverty Most homeless HIV+ adults will be Medicaid eligible in 2014

15 Possibilities: Affordable Care Act and Supportive Housing
Care Management - Health Homes (ACA Section 2703) and Managed Care Organizations Home and Community Based Waivers [1915(i) of Social Security Act – amended by ACA] Rehabilitation Option Targeted Case Management

16 Health Home Eligibility
To the extent elected by the State in its approved State plan, those eligible for Medicaid with: two or more chronic conditions;  One chronic condition and are at risk for a second; or   a serious and persistent mental health condition.  

17 Chronic conditions identified in statute include mental health, substance use disorder, asthma, diabetes, heart disease, and being overweight (as evidenced by a BMI of >25). States may request that CMS identify other chronic conditions for purposes of eligibility. States may request to base eligibility on additional or different chronic conditions in a SPA. While CMS approval is discretionary, this flexibility provides States the option to request to expand the chronic conditions list to include more beneficiaries or use more specific chronic conditions to target the population.

18 Health Home Services Comprehensive care management Care coordination
Health promotion Comprehensive transitional care/follow-up Patient and family support Referral to community and social support services

19 Policy and Advocacy Priorities and Considerations
States will need to participate in Medicaid Expansion to maximize funding opportunities States and housing providers need to ensure supportive housing is targeting high need/high cost HIV+ homeless individuals as those whose health care utilization will be positively impacted through this approach while achieving future cost savings. States will need to determine Medicaid payment option that will best serve their clients to reimburse supportive housing services and then advocate for them to be inclusive of the needs of PLWHA’ – such as getting HIV/AIDS included as a chronic condition.

20 Policy and Advocacy Priorities and Considerations
New organizational configurations with appropriate policies, regulations and technical assistance, are needed to transition current supportive housing capacity to Medicaid eligible environments Systems with appropriate funds and training are needed for tracking and managing costs for HIV+ homeless individuals and families.

21 State Health Home Models

22 New York State’s Health Home Model
Gina Quattrochi Bailey House

23 New York State’s Health Home Model
Medicaid funded Targeted Case Management transitioned to Health Home Care Management Goal is to provide comprehensive medical care management to frequent users of high end Medicaid funded services Components of Care Management (formerly TCM) include “locate and engage” and shared medical records Reimbursement based on acuity rates – homelessness as “acuity factor” being negotiated in NYS Health Information Technology HIT is strongly encouraged in the SMD letter, but is not required. If HIT is neither feasible nor appropriate the State will need to respond accordingly in the State Plan Amendment (SPA) submission. In the absence of HIT, the State will need to demonstrate how they achieve the care coordination activities between multiple settings of a health home through other methods.

24 New York State’s Health Home Model
Care Management (formerly TCM) is not limited to HIV+ Medicaid users Not currently designed to fund services in supportive housing; it’s not a funding stream , it’s a system for medical case management using Medicaid Organizations that become Care Management providers (formerly TCM providers) must have or develop EMR (electronic medical record) capacity TCM is not limited to HIV+ Medicaid users Not designed to fund services in supportive housing Organizations that become TCMs must have or develop EMR capacity

25 Oregon’s Health Home Model
Michael Kaplan Cascade AIDS Project

26 Triple Aim: Vision for Oregon
Better health. Better care. Lower costs.

27 Accountable Care Organizations
Providers and suppliers work together to coordinate care for patients under Medicare; Goal: Deliver seamless, high quality care; Improving health outcomes with lower cost. Patient-centered organizations with providers, suppliers and beneficiaries on governing board; Must take responsibilities for 5,000 beneficiaries

28 Difference Between Medicare and Medicaid
A federal program attached to social security Available to all U.S. citizens 65 and older as well as people with certain disabilities. Available regardless of income Medicaid A joint federal and state program Helps low-income individuals and families Often targeted – families, pregnant women, children and disable. Eligibility rules vary by state

29 Coordinated Care Organizations (CCO)
A local network of all types of health care providers working together to deliver care for Oregon Health Plan clients Care is coordinated at every point-from where services are delivered to how the bills are paid CCOs shall serve Medicaid population and “dual eligible (Medicaid and Medicare)” enrollees

30 Elements of Coordinated Care Organizations (CCO)
Benefits and services are integrated and coordinated, One global budget that grows at a fixed rate, Local flexibility Local accountability for health and budget Metrics: standards for safe and effective care

31 Benefits & Services Integrated
Physical health, behavioral health, dental health Focus on chronic disease prevention and management Focus on primary care Get better outcomes: Health equity Prevention Community health workers/non-traditional health workers Electronic health records

32 Oregon’s 1115 Medicaid Waiver
Allows CCO’s as delivery system for Medicaid No reduction in benefits Allows use of Medicaid dollars for flexible services (e.g. - non-traditional health care workers). Provides $1.9 Billion over 5 years from feds tied to state showing reduction in per capita medical trend. Quality metrics to ensure savings not through service reduction, but improved health outcomes

33 CCO Timeline August 1, 2012 – First CCO’s come on line with waves to follow. Currently – 13 approved as of Sept. 1, 2012 Not before 2013, but eventually – HIV/AIDS targeted case management to be included in CCO Global Budgets By 2017 – CCO’s replace Oregon’s Medicaid Managed Care system CCOs include Medicare, State Public Employees & Private Business Sector – no target date set.

34 Understanding Oregon’s Epidemic
70% of state epidemic in three counties 15% estimated to be homeless or unstably housed 4256 PLWHA in Portland TGA In 2007 – ~20% of HIV-positive population in Oregon enrolled on Medicaid

35 CAP’s & Housing Program
CAP – Incorporated in 1985; $5.2 Million budget Mission – To prevent HIV infections, support and empower people affected and infected by HIV/AIDS and eliminate HIV/AIDS related stigma. Housing approx. $2 million of budget – provides emergency, short-term and long-term housing support (in $871k in direct assistance, 574 individuals supported in housing services)

36 CAP Housing Clients - Insurers
OMIP/FMIP – 36% Medicaid – 31% Medicare – 16% Private – 13% VA – 3%

37 CCO’s Serving Portland TGA
Two CCO’s Serving the Tri-County Area (36% of total Medicaid population – ~ $1.44 Billion) Family Care and Oregon Health Share(David & Goliath) Oregon Health Share (includes OHSU, 3 counties, 5 Health Systems, one insurer (Care Oregon) and one Housing/Health Agency (CCC) The systems engaged in OHS account for all HIV-positive patients in care in the tri-county area (Multnomah County FQHC, Kaiser IDC (50% of all positives)

38 How to link to Goliath - Challenges
While CCO’s will include medical, dental and behavioral health, no discussion or plan of how housing funds link Housing funds have greatest opportunity to impact frequent fliers HOPWA at CAP comes through city & state, while Ryan White & most of prevention through counties and CCO includes counties, but not city or state

39 Current Effort / Strategies
Be at the table, inclusion in discussions as CCOs form. Linking our work to CCO’s Every Housing Case Manager linked to a Medical Case Manager HRSA/SPNS – allow staff to input into EPIQ Starting to look at ability to bill under sub-contract to Medicaid Create/expand our own non-traditional health care workers (mental health peer specialists)

40 AIDS Foundation of Chicago
The Marriage (or engagement or hook-up) of AIDS Housing with the ACA’s Health Homes, ACOs, or Other Health Plans “A Chicago Model” Arturo V. Bendixen AIDS Foundation of Chicago

41 Increase access to care Increase quality / outcomes Decrease costs
HHS Mantra for the ACA Increase access to care Increase quality / outcomes Decrease costs

42 32,000,000 uninsured will become insured….
Up to 16,000,000 of them through Medicaid

43 Changed Landscape - $$$
No more “fee for service” Required coordinated care – NO MORE SILOS Increase health outcome DECREASE COSTS


45 Hospital Days Intervention Group: 2.7 fewer days than the Usual Care Group

46 Emergency Room Visits Intervention Group: 1.2 fewer visits than the Usual Care Group

47 Nursing Home Days Intervention Group: 37% Usual Care Group: 63%

48 Survival with Intact Immunity
P = 0.04

49 For every 100 chronically homeless HIV positive individuals housed, there is a savings of a $1 million in public funds

50 The new world of USA health care NEEDS AIDS Housing to save $$$$$$$$$$$$$$$



53 Ways to Reduce Costs AIDS Housing Shared electronic medical records
Coordinated care for those with at least two chronic illnesses Outcome based treatment

54 IL Medicaid Health Homes
Care Coordination Entities (CCE) Will include FQHCs, hospitals, behavioral health centers, pharmacies... MOUs with permanent supportive housing organizations Will receive care coordination payments

55 Cost Breakdown – First 10 HIV positive

56 AIDS Housing: Reduces Costs
1/2 (50%) of spending on: Hospitalizations, Emergency room visits Nursing home stays CHHP Study: Significant $$$ Reduction and Suppressed Vital Loads

57 Care Coordination Role of Case Managers on Team
Low Barrier Appointment Access Monitoring Appointments Integration of Physical and Behavioral Health Electronic Health Records Monitoring Medication Compliance

58 Ways to Reduce Costs Coordinated care for those with living with chronic illnesses Shared electronic medical records Outcome based treatment Braided funding / AIDS Housing

59 Braided Funding HUD pays rental subsidy
PSH Project with 48 units / health homes: HUD pays rental subsidy Medicaid pays for some of case management / care coordination Other sources: SAMHSA, Ryan White,…….. Private dollars……

60 The marriage or engagement or hook-up of AIDS Housing with the ACA’s Health Homes, ACOs, or Other Health Plans WE HAVE MUCH ON OUR SIDE

61 Advocacy Needs in States Moving Forward with ACA Implementation and in States Refusing Medicaid Expansion

62 What’s Happening in Your State?

63 Cost Savings from ACA Implementation
Christine Campbell Housing Works

64 Housing Advocacy in NYS ACA Implementation: Engaging with the NYS Medicaid Redesign Process
Context: NYS process for major delivery system reform through the ACA health home option for chronically ill Medicaid recipients Goal: Housing as health care for persons living with HIV Funding for housing as a core component of the health home model Gain the support of Medicaid and Public Health agencies for housing advocacy Strategy: Cost analyses to demonstrate potential Medicaid saving from increased HIV housing resources

65 Overall Strategy: Support for ongoing housing campaigns
Compare housing costs and potential Medicaid savings to build support ongoing HIV housing advocacy campaigns: For a 30% rent cap affordability protection for disabled PLHWA receiving state/city rental assistance (to prevent housing loss in independent living) For expanded eligibility for existing HIV housing resources to all homeless HIV-positive persons, not just those with an AIDS diagnosis For state-wide access to proven HIV housing rental assistance program that is currently available only in New York City For housing as HIV prevention for homeless at risk LGBTQ youth

66 We Have the Facts: Projecting Savings from HIV Housing
Formula: annual housing costs compared to annual Medicaid savings Housing costs = per unit costs times unmet need Medicaid savings = better HIV health care utilization + savings from averted infections Medicaid savings – published research on housing & HIV outcomes: SF Department of Public Health data show a mean decrease of $15,000 per year in health care costs for each homeless PLWHA placed in housing (appropriate care increases while expensive crisis care & hospitalizations go down) Conservative estimate of 5% reduction in annual HIV transmissions for homeless PLWHA who get housed (rates range from 2.4 and 10.79, with unstably housed at the higher end) Lifetime healthcare costs of at least $370,000 for each new HIV infection Housing costs – local data on unmet need and per person costs: For rent cap, calculated the incremental cost as $175/month/person For other initiatives to expand HIV housing, estimated annual per unit cost at $14,400 (which includes a mix of rental subsidies and supportive housing units)

67 NY Housing Proposals – Annual Costs vs. Savings

68 Activities & Outcomes to Date (Some progress but much more to be done)
Establishment of a Housing Workgroup as part of the State’s ongoing Medicaid Redesign process Active and ongoing involvement of HIV providers and advocates in the Redesign process, including the Housing & Medical Disparities Workgroups Circulation of an HIV housing briefing paper with research findings on housing & HIV health and the HIV housing cost analyses presented here A requirement that NYS networks of health home providers include partnerships with housing agencies Specific plans to invest Medicaid savings in housing are included in a NYS request to reinvest up to $10 billion of the anticipated federal savings from the State’s health home initiative

69 Ryan White and HOPWA The Perfect Marriage?
Kathie Hiers CEO, AIDS Alabama

70 Ryan White Reauthorization: September 30, 2013
Ryan White doesn’t “sunset” or end, but appropriations must be approved by Congress The Administration has already indicated that the Ryan White money for ADAP will be needed to offset costs of Affordable Care Act (ACA) In best-case scenario, many will be left out of ACA coverage

71 States Positions on the ACA Supreme Court Case

72 ACA Implementation Looks Different In Every State
ACA Statute Federal Regulations or Guidance State Flexibility

73 So Who Will Not Benefit from ACA?
Undocumented Legal immigrants in U.S. less than five years Those eligible for Medicaid who were not enrolled People in states that do not expand Medicaid People who fall victim to co-pays that are out of reach People who need dental services People who fall through the cracks!

74 Medicaid Expansion: State Planning in the Midst of Uncertainty
What happens in a state that does not expand? Greater role for Ryan White Program/ADAP

75 Essential Health Benefits (EHB): What We Know
States selecting from ten benchmark options to set the standard for their EHB State benchmark selection due Sept 30th Largest small group plan in the state is the default Generally lowest cost option, more service limits, etc. Regulations delayed…until after elections?

76 Essential Health Benefits: Will Private Insurance Benchmark Plan Cover Necessary Care and Treatment?

77 Essential Health Benefits: Will Medicaid Benchmark Plan Cover Necessary Care and Treatment?
Medicaid benchmark plans have been used by states to offer slimmer benefits packages: Wisconsin BadgerCare Core Plan: Restricted formulary No branded ARVs Co-payments Service limits

78 Exchange Activity: Where the States Are

79 Ryan White Continues to be Critical
Most Ryan White recipients are low income Wraparound services allow people to remain in care Without stable housing, transportation, non-medical case management, and other services, stable medical care is impossible Ryan White could become the safety net that the legislation was meant to be Will the 75% core medical/25% support services still be appropriate?

80 HIV Community Must Unite to Keep Ryan White Funded

81 How Much Pressure Can Ryan White Take
How Much Pressure Can Ryan White Take? How Much Will Be Left for Housing?

82 HOPWA Formula: The Glue That Holds It All Together
HOPWA funds may be used for…. A wide range of housing, social services, program planning, and development costs, including acquisition, rehabilitation, or new construction of housing units; costs for facility operations; rental assistance; and short-term payments to prevent homelessness. Also mental health services, chemical dependency treatment, nutritional services, case management, assistance with daily living, and other supportive services.

83 HUD’s Housing Opportunities for Persons With AIDS (HOPWA)
HOPWA Formula Program uses a statutory method to allocate HOPWA funds to eligible states and cities on behalf of their metropolitan areas (90% of funding). HOPWA Competitive Program is a national competition to select model projects or programs (10% of funding). HOPWA Technical Assistance is now provided along with other more mainstream HUD housing programs.

84 HOPWA Formula: Rental Assistance
Low income and HIV/AIDS Tenant- or project-based assistance Based on action plans approved in City and State Consolidated Plans Funding based on annual allocation from HUD (three-year use period) HOPWA may provide short term (STRMU) assistance (up to 21 weeks) to prevent homelessness HOPWA may provide long-term, tenant-based rental assistance (TBRA) for eligible tenants with constant need

85 Every State Is Different!
AIDS Alabama provides assistance to all 67 counties through a partnership with the AIDS Service Organizations. Some states don’t help in rural areas. Some states offer long-term help; some don’t. Who runs your HOPWA program?

86 HOPWA Formula: Modernize to HIV
National HIV/AIDS Strategy action during 2011: HUD will work with Congress to develop a plan (including seeking statutory changes if necessary) to shift to HIV/AIDS case reporting as a basis for formula grants for HOPWA funding. 1. Action needed to shift HOPWA data source to HIV case reports # of persons living with HIV seen as the best measure of the epidemic’s burden by area (852,982 persons, year end 2008), expectation of more mature HIV reporting nationally by 2013. Data on HIV now available from the Centers for Disease Control and Prevention, CDC. Current HOPWA formula uses cumulative AIDS cases (e.g. cases since 1981) – weighted for 75% of funds. FY 2011 was based on 1,107,329 cumulative AIDS cases as of , statutory date. The cumulative data includes case reporting on 608,288 deaths. Amounts (75% of formula amounts, $ million) shared in direct proportion for all 134 eligible areas based on CDC data


88 HOPWA Formula: Modernize to HIV
2. Current formula also uses AIDS incidence (e.g. new cases and population reported in last three years) – weighted at 25% of funds FY 2011 was based on 90,737 cases of AIDS reported ( ) as included in cumulative data. Used to determine area incidence per updated population to identify metropolitan areas with higher than average incidence of AIDS. At 25% of funding ($ million), this factor is shared by 31 of 84 MSAs with the 41 states/PR also not eligible; Initial year 1992 involved $11 million and 14 cities. Distributed based on number of cases in “excess” above average, with 7,425 cases used in this factor’s distribution (i.e. 8.2% of this recent AIDS case subset, only 0.6% of overall AIDS data). Super-targeted as largest 7 of 31 MSA receive 72% of this factor (top 3 with 48.6%) with per case impact at $10,030 compared to cumulative case impact at $202 per grantee.

89 HOPWA ideas for targeting
3. Targeting to needs along with greater equity for households by addressing housing costs & community resources – consider how to target, such as: Fair Market Rents (FMR) Recognize differences in housing costs in area rents, as reflected in HUD FMR standards, annual updates (e.g. range of $1,833 in SF to $574 in AR; $468 in PR) Poverty Recognize difficulties in service delivery in areas of concentrated poverty (e.g. range of 5.08 % in Islip to 26.6% in El Paso; 52.6% in PR) Consider if incidence or prevalence is useful in targeting, or that the number of persons living with HIV is more relevant to reflect the national impact of HIV along with associated housing service delivery costs & burdens



92 Will Housing Opportunities for Persons with AIDS (HOPWA) Distribution Methodology Ever Be Updated?
Appropriates 25% of formula dollars as bonus to limited number of large urban areas with highest AIDS incidence Distributes balance of formula dollars to all jurisdictions, including bonus recipients, based only on cumulative AIDS cases, including 610,000 deceased persons Does not utilize HIV cases, which punishes the South and other areas of the country with a newer epidemic and a higher HIV to AIDS ratio Must be changed by Congress NHAS Implementation Plan tells HUD to get it done by end of 2011!

93 Advocate! Never underestimate the power of a small group of committed people to change the world. In fact, it is the only thing that ever has. - Margaret Mead

94 The Squeaky Wheel Gets the Oil
Become that squeaky wheel! Be respectful, but never go away. Develop grassroots networks locally, statewide, regionally, and federally. Your voice and your story are just as important as anyone else’s.

95 Affordable Care Act Implementation
Nancy Bernstine National AIDS Housing Coalition

96 Health Care Reform Implementation
2013 2014 Closing the Medicare Drug Coverage Gap Medicaid Coverage of Preventive Services Medicaid Payments for Primary Care Expanded Medicaid Coverage Individual Requirement to Have Insurance Health Insurance Exchanges Health Insurance Premiums and Cost Sharing Subsidies Guaranteed Availability of Insurance No Annual Limits on Coverage Essential Health Benefits Basic Health Plan

97 Essential Advocacy to Ensure Housing is Part of the Future
Christine Campbell Housing Works

98 Thank You for Joining Us!

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