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Home > Covering Health Issues, 5th Ed. (2010) - Table of Contents > Chapter 5 - Individual Health Coverage

Chapter 5 - Individual Health Coverage

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Originally written by Karen Pollitz, Georgetown University Health Policy Institute. Revised May 2010 by Deborah Chollet and Allison Barrett, Mathematica Policy Research. This chapter was made possible by the Robert Wood Johnson Foundation.


  • 16.7 million people under age 65 were covered by an individual health insurance policy in 2008, according to the U.S. Census Bureau. 1
  • Over the next 10 years, this number expected to grow by 19 million due to provisions in the federal health reform law, the Patient Protection and Affordable Care Act (PPACA).2
  • Individual health insurance is different from job-based coverage. Currently, it is regulated differently, and those who buy individual coverage receive neither an employer contribution to coverage nor the same tax exemption of premiums as people with job-based coverage enjoy.
  • Currently, most individual policies are medically underwritten, meaning insurers can deny or restrict coverage, or charge higher premiums because of an applicant’s medical history.3 Rules governing medical underwriting differ from state to state.
  • PPACA will substantially change the individual coverage market in the U.S., eventually ending medical underwriting and eliminating higher premiums charged because of a person’s medical history.
  • Today, individual policies typically cost less than group health plans, but they provide less coverage. 4 High deductibles are the norm and some key benefits such as mental health, prescription drugs, or maternity care may be limited or not covered at all. The PPACA, when fully implemented in 2014, will change these practices.
  • Also starting in 2014, PPACA will require all Americans to have health insurance. Health insurance “exchanges” will help consumers compare prices and policies and obtain subsidies to buy coverage, if their income is less than four times the federal poverty level and they cannot get coverage from their employer or a public coverage plan, such as Medicaid.
  • Administrative expenses and profit for individual policies can account for a much larger share of premiums than in group plans.
  • As of early 2010, 34 states sponsored high-risk pools that make coverage available to people who have trouble buying individual coverage because they have health problems.5 PPACA creates a temporary, federally subsidized high risk program in every state, but only individuals who have been uninsured for at least six months can enroll.

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In 2008, 26.8 million people, including 16.7 million people under age 65, bought health insurance on their own in the individual market. 6 7 (See chart, "Sources of Health Insurance Coverage, 2008.") In general, people turn to the individual market for coverage when they don’t qualify for job-based health benefits or public programs. While only about 6 percent of all people under age 65 have individual health insurance in a given year,8 as many as one in four adults will seek coverage in this market over a three-year period.9

Young adults and the near-elderly participate disproportionately in this market. Currently, because insurers in most states can deny or restrict coverage, or charge a higher premium because of an applicant’s medical history (a practice called medical underwriting), people who buy individual health insurance tend to be in good health.10

Premiums for individual health insurance tend to be lower than for job-based health plans, in part because individual policies generally offer less coverage. One study of the individual market in 10 states found that individual policies paid 66 percent of medical costs for beneficiaries’ covered services in 2007, compared with 80 percent in employer-based plans.11

Another study found that individual market insurance policies in California paid for just 55 percent of the expenses for covered services in 2006, compared to 83 percent for small group health plans.12 Deductibles in individual policies were about three times as large as in employer-based plans.13 (See Glossary for the definition of “deductibles.”) Individuals can put money into tax-free health savings accounts (HSAs) to help pay out-of-pocket expenses, if their policy qualifies as a “high deductible health plan” under federal law. (See Chapter 4, “Employer-Sponsored Coverage,” for more on HSAs.)

In March 2010, the Patient Protection and Affordable Care Act (PPACA) was enacted, extending new protections and assistance to consumers buying individual coverage. Some of these start immediately; others will start in 2011 and 2014. See “Federal Reform of Individual Coverage” below for details.)

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Regulation of Individual Health Insurance

Because states regulate individual insurance, consumer protections in this market currently depend largely on where one lives. Today, in most states, insurance companies can reject applicants, charge higher premiums based on their health status, or exclude coverage for certain conditions entirely. 14 Federal law requires insurers in every state to renew individual coverage regardless of the policyholder’s health status, but in some states insurers can employ various rating and marketing practices to raise the price of coverage for policyholders who get sick. In just five states – Maine, Massachusetts, New Jersey, New York and Vermont –individuals are protected against all underwriting actions both when they first apply for coverage and when they renew.

When applicants are denied individual coverage, charged higher premiums, or offered fewer benefits because of health problems, in 34 states they can turn to a state high-risk pool to buy coverage for premiums that are as much as 25 to 100 percent higher than premiums for private coverage. Although some high-risk pools offer income-scaled premium subsidies, premiums remain higher than many people can afford, and enrollment is much less than the number estimated to be eligible.15

As of June 2010, a federally-approved high risk program will be available in every state to individuals who are denied private coverage due to a health problem and have been uninsured at least six months. (See “Federal Reform of Individual Coverage” below).

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Many individuals who lack job-based health insurance are low-income. In 2003, more than half lived in a household below 200 percent of the poverty line.16

However, individual coverage is not subsidized like job-based coverage. Families must pay the entire premium, without employer contributions or extensive income tax breaks. The federal government provides a health coverage tax credit to subsidize individual coverage for a few thousand eligible early retirees and certain workers who lose their jobs because of foreign competition.17

Otherwise, just five states—Maine, Massachusetts, New York, Oregon, and Vermont—subsidize premiums to help low-income residents buy individual health insurance.18 Because PPACA allows states to extend Medicaid coverage to all residents under 133 percent of the poverty line (and requires all states to do so by 2014), these states may instead choose to offer Medicaid to many individuals in those programs.

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Federal Reform of Individual Coverage

PPACA establishes many new protections for consumers buying individual coverage. The first of these become effective in 2010 and 2011; others take effect in 2014. Ultimately, PPACA will fundamentally restructure the individual market in every state.

Changes effective in 2010-2011

In June 2010, a temporary federally approved high risk pool will open in every state for individuals who are denied coverage because of a health problem and have been uninsured at least six months. Enrollees in these high risk programs will pay the same premiums that healthy people would pay on the individual market and out-of-pocket costs will be limited, but premiums will not be scaled to income. 19

In September 2010, individuals will gain basic protections in both current and new policies:20

  • Insurers cannot cancel coverage retroactively when the policyholder becomes ill (a practice called “rescission”), except for nonpayment of premiums or fraud.
  • Insurers may not place lifetime limits on benefits paid for covered services, nor place unreasonable annual limits on covered benefits.
  • Insurers must cover pre-existing conditions for dependents under age 19, and dependent children may remain on a family policy until age 26.

In 2011, additional protections take effect:

  • Insurers can spend no more than 20 percent of individual premiums on administrative costs and profit, refunding any excess to policyholders.
  • Individual policies issued subsequent to PPACA’s enactment (March 23, 2010) must cover a standard set of preventive services without cost sharing.

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Changes effective in 2014

In 2014, the individual market will undergo major change:

  • Insurers must accept all applicants and cover pre-existing conditions for new and current policyholders. They can vary premiums only by the individual’s age, geographic location, and tobacco use, and for single versus family coverage.21
  • To prevent healthy people from waiting until they need health care to buy insurance, increasing premiums for everyone, nearly all U.S. residents will be required to maintain coverage. Exceptions will be given for financial hardship and religious objections, and to people in certain groups.22
  • States will create “exchanges” where individual consumers can compare premiums for policies of similar value and buy coverage.
  • Individuals who buy coverage through an exchange can qualify for a premium subsidy if their income is below four times the federal poverty line and they are ineligible for an employer plan or public program.23 These individuals will spend no more than 10 percent of income on premiums. (For an example of how subsidies would work, see table “Maximum premium payments for low- and middle-income households.”)
  • All new policies must cover “essential benefits” (including maternity and newborn care, mental health and substance abuse services, and prescription drugs), and annual out-of-pocket costs will be capped.24

Maximum premium payments for low- and middle-income households based on 2010 poverty guidelines

Income as percent of poverty

Maximum premium as percent of income

Maximum monthly premium by family size















































Source: Congressional Research Service (March 2010). “Private Health Insurance: Changes Made by H.R. 4872, the Health Care and Education Reconciliation Act of 2010” (R41126), Table 1.

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Individual Mandate

PPACA’s requirement that individuals maintain health insurance coverage is an essential component of individual market reform. As of 2014, insurers must accept all applicants and cannot use medical underwriting, waiting periods for pre-existing conditions, or coverage exclusions.

If not required to buy health insurance, individuals will be very tempted to buy coverage in this market only when they are sick. If this happens, premiums will be higher for everyone, making it harder for individuals and families to afford coverage and more costly for government to subsidize premiums. Critics of the individual mandate worry that it will establish a precedent for social policy more generally.

Even though health reform is now law, the individual mandate remains controversial. Virginia, Idaho and Utah have passed state laws declaring that the mandate does now apply to their citizens. The attorneys general of 20 states have filed a suit challenging the constitutionality of the reform law. 25
Impact of reform on individual premiums

PPACA will change the way insurers set individual premiums. Premiums will no longer reflect individual health status, and the oldest individuals will pay no more than three times what the youngest pay for the same policy. In most states, where insurers are allowed to charge a higher premium for those in poorer health and greater variation in premiums based on age are currently allowed, premiums for young and healthy individuals might increase in 2014, if their income is too high to qualify for the premium subsidy. Other requirements – that insurers accept all applicants, establish reasonable annual limits on coverage, and eliminate lifetime limits, preexisting-condition waiting periods, and benefit exclusions – are likely to further increase premiums for the youngest and healthiest individuals.

Advocates of these reforms (when taken together with income-scaled premium subsidies) see them as essential components of an individual insurance market that is accessible, affordable, and fair over the course of individuals’ lifetimes. Critics are concerned that these reforms create a market that relies too heavily on government to make it work.


  • Keep in mind differences between individual and group health coverage. If you haven’t reviewed the employer-sponsored coverage chapter of this sourcebook, you will find that useful.
  • Probe averages. The sickest 5 percent of the population accounts for half of health care spending. 26 Averages or per capita statistics can mask the experience of the small proportion of policyholders who make large claims in any given year. How does health insurance work for consumers, not just most of the time, but when they get sick?
  • Expand time horizons. Snapshots reveal differences in health insurance products and prices at a point in time, but this can change. Are the low premiums offered for some policies stable, or do they increase over time? Do covered benefits and deductibles change?
  • You will find a good overview of current state regulation of health insurance, including individual coverage, at this Alliance for Health Reform site, Remember that some new federal reforms of the individual market may already be in effect.
  • Personal stories of people who have had problems with their health insurance will help you understand the motivation for PPACA’s individual market reforms.Try the Families USA Consumer Story Bank (call 202-628-3030, or e-mail The Alliance for Health Reform’s Find-an-Expert service also can help reporters find such individuals ( or 202-789-2300).

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  • Self-employed workers and early retirees –What is the experience of self-employed workers and early retirees who rely on individual health insurance? How does medical underwriting work? Which benefits are covered, and which are excluded? What does the coverage cost when first purchased? Does this change over time, especially when they get sick or age into a higher rate class?
  • Renewal practices – What happens when individuals renew their policies? Do insurers in your market use “durational rating,” so that the same policy costs more to renew than to purchase initially? Do policyholders try to moderate premium increases by increasing deductibles or dropping important benefits?
  • Explore medical underwriting practices – Ask insurers/agents about conditions that are “uninsurable.” Are policies routinely offered to applicants who are pregnant? Cancer survivors? Depressed? 20 pounds overweight?
  • Explore coverage adequacy – How well do different policies pay for medical bills of policyholders who become sick, injured, or pregnant? What do providers do when a patient’s insurance doesn’t cover a needed service?
  • Regulatory capacity – Who is your state insurance commissioner? How many staff work for her/him to regulate health insurance? Does the insurance commissioner review and question insurers about proposed premiums or premium increases? Does s/he approve rates, or can insurers charge premiums without approval?
  • Risk pool plans – How is your state reacting to the requirement in the new health reform law that everyone uninsured for at least six months and who has been denied coverage will have access to a high risk pool charging regular non-group market premiums? How can eligible citizens in your state take advantage of the program – run either by the state or, if your state is resisting the requirement, by the federal government?

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Stuart Altman , Professor of National Health Policy, Brandeis University, 781/736-3804,

Drew Altman , President and CEO, Kaiser Family Foundation, 650/854-9400

Joseph Antos , Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute, 202/862-5938,

Katherine Baicker , Professor of Health Economics, Department of Health Policy and Management, Harvard University School of Public Health, 617/432-5209

Brian Biles , Professor, Department of Health Policy, George Washington University, 202/416- 0066

Linda Blumberg , Principal Research Associate, Urban Institute, 202/261-5769

Michael Cannon , Director of Health Policy Studies, Cato Institute, 202/789-5200,

Deborah Chollet , Senior Fellow, Mathematica Policy Research, 202/554-7528,

Gary Claxton , Vice President/Director, Health Care Marketplace Project, Kaiser Family Foundation, 202/347-5270

Sara CollinsVice President, Affordable Health Insurance, The Commonwealth Fund, 212-606-3838,

Richard Curtis , President, Institute for Health Policy Solutions, 202/789-1491,

Michelle Doty , Associate Director of Research, The Commonwealth Fund, 212/606-3800,

Jon Gabel , Senior Fellow, National Opinion Research Center, 301-634-9313,

John Goodman , President, National Center for Policy Analysis, 972/308-6472,

Edmund Haislmaier , Research Fellow, The Heritage Foundation, 202/546-4400

Robert Helms , Resident Scholar, American Enterprise Institute, 202/862-5877,

Robert Laszewski , President, Health Policy and Strategy Associates, 703/727-9517

Barbara Lyons , Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202-347-5270,

Roland McDevitt , Director of Health Care Research, Towers Watson, 703/258-8000,

Jack Meyer , Principal, Health Management Associates, (202)785-3669,

Tom Miller , Resident Fellow, American Enterprise Institute, 202/862-5886,

Robert Moffit , Director, Center for Health Policy Studies, The Heritage Foundation, 202/546-4400

Len Nichols , Professor and Director, Center for Health Policy Research and Ethics, George Mason University, 703/993-1978,

Edwin Park , Co-Director of Health Policy, Center on Budget and Policy Priorities, 510/524-8033

Ron Pollack , Executive Director, Families USA, 202/628-3030, Communications Director: David Lemmon --

Uwe Reinhardt , James Madison Professor of Political Economy, Princeton University, 609/258- 4781

Jack Rodgers , Director, Economic Policy Analysis Group, PricewaterhouseCoopers, 202/414-1646

Diane Rowland , Executive Vice President, Kaiser Family Foundation, 202/347-5270,

William Scanlon , Senior Policy Advisor, Health Policy R & D, 202/624-3975

Cathy Schoen , Senior Vice President, Research and Evaluation, The Commonwealth Fund, 212/606-3800,

Ken Thorpe , Professor and Chair, Rollins School of Public Health; Executive Director, Partnership to Fight Chronic Disease Advisory Board, Emory University, 404/727-3373

Grace-Marie Turner , President, Galen Institute, 703/299-8900

Judy Waxman , Vice President for Health and Reproductive Rights, National Women's Law Center, 202/588-5180,

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John Dicken , Director, Health Care, Government Accountability Office, 202/512-7043,

Jean Hearne , Specialist in Social Legislation, Congressional Research Service, 202/707-7362

Mila Kofman , Superintendent of Insurance, Maine Bureau of Insurance, 207/624-8550,

Richard Rimkunas , Head, Health Insurance and Financing, Congressional Research Service, 202/707-7334

Brian Webb , Manager, Health Policy and Legislation, National Association of Insurance Commissioners, 202/471-3990,


David Abernethy , Senior Vice President, HIP Health Plans, 202/393-0660,

Brenda Craine , Director, Washington Media Relations, American Medical Association, 202/789-7447,

Alissa Fox , Senior Vice President, Office of Policy and Representation, Blue Cross Blue Shield Association, 202/626-8681,

George Halvorson , Chairman and CEO, Kaiser Permanente, 510/271-5660

Angela Hunter , Director of Federal Affairs, Council for Affordable Health Insurance, 703/836- 6200x387,

Karen Ignagni , President and CEO, America's Health Insurance Plans, 202/778-3200,

Charles Kahn , President, Federation of American Hospitals, 202/624-1500

Jeff Lemieux , Senior Vice President, Center for Policy and Research, America's Health Insurance Plans, 202/778-3200,

Frank McArdle , Principal, Hewitt Associates LLC, 202/331-2034

Janet Trautwein , Executive Vice President and CEO, National Association of Health Underwriters, 703/276-3806

Reed Tuckson , Senior Vice President, UnitedHealth Group, 952-936-1253,

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Alliance for Health Reform
Alliance of Community Health Plans
American Enterprise Insititute
American Medical Association
America's Health Insurance Plans
Blue Cross Blue Shield Association
Cato Institute
Center for Studying Health System Change

Center on Budget and Policy Priorities

The Commonwealth Fund

Consumers for Health Care Choice

Council for Affordable Health Insurance

Employee Benefit Research Institute

Families USA

Federation of American Hospitals

Galen Institute

George Washington University Department of Health Policy

Georgetown University Health Policy Institute

Georgia State University Department of Risk Management and Insurance

Government Accountability Office

Health Policy and Strategy Associates

Health Policy R & D

Health Research and Educational Trust

Heritage Foundation

Institute for Health Policy Solutions

Kaiser Family Foundation

Kaiser Foundation Health Plan Inc.

Mathematica Policy Research

National Association of Health Underwriters

National Association of Insurance Commissioners

National Center for Policy Analysis

National Coalition on Health Care

National Women's Law Center

New America Foundation

Rollins School of Public Health, Emory University

UnitedHealth Group

Urban Institute

U.S. Census Bureau, Health Insurance Data  


1 U.S. Census Bureau (2009). "Table HIA-6. Health Insurance Coverage Status and Type of Coverage by State – Persons Under 65: 1999 to 2008." (

Most researchers believe Census data overstate the number of individual market participants, for example, by including in the count people with multiple sources of coverage. Others estimate the individual market to cover only about 14 million people. See, for example, “How Private Health Coverage Works: A Primer, 2008 Update” by the Kaiser Family Foundation at

2 Congressional Budget Office and Joint Committee on Taxation. Cited it: Elemendorf, Douglas W. (March 20, 2010). Letter to Honorable Nancy Pelosi (’sAmendment toReconciliationProposal.pdf ).

3 Medical underwriting is the process by which insurers assess the health and risk status of applicants. Applicants for a medically underwritten individual health insurance policy might be turned down, charged more, or offered a policy that permanently excludes coverage for their pre-existing condition.

4 McDevitt, Roland, Jon Gabel, Ryan Lore et al. (2010). “Group Insurance: A Better Deal For Most People Than Individual Plans.” Health Affairs, January 2010, pp. 156-164.

5 Schwartz, Tanya (2010). “State High-Risk Pools: An Overview.” Kaiser Family Foundation. ( 35 high risk pools are in operation, but Florida’s high risk pool has been closed to new enrollment since 1991. California’s high risk pool has a waiting list for most applicants.

6 U.S. Census Bureau (2009). "Table HIA-1. Health Insurance Coverage Status and Type of Coverage by Sex, Race and Hispanic Origin: 1999 to 2008." (

7 U.S. Census Bureau (2009). "Table HIA-6. Health Insurance Coverage Status and Type of Coverage by State – Persons Under 65: 1999 to 2008." (

8 U.S. Census Bureau (2009). "Table HIA-6. Health Insurance Coverage Status and Type of Coverage by State – Persons Under 65: 1999 to 2008." (

9 Duchon, Lisa, and Cathy Schoen (2001). “Experience of working-age adults in the individual insurance market: Findings from the Commonwealth Fund 2001 Health Insurance Survey” (Issue Brief No. 514). The Commonwealth Fund, December, p.1. ( ).

10 Collins, Sara, Jennifer L. Kriss, Karen Davis, et al. (2006). “Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families.” The Commonwealth Fund, September, p. 3. ( ).

11 McDevitt, Roland; Jon Gabel, Ryan Lore, et al. (2010). “Group Insurance: A Better Deal For Most People Than Individual Plans.” Health Affairs, January, pp. 156-164.

12 Gabel, Jon, Jeremy Pickreign, Roland McDevitt, et al. (2007). “Trends In The GoldenState: Small-Group Premiums Rise Sharply While Actuarial Values For Individual Coverage Plummet.” Health Affairs Web Exclusive, July/August. (

13 McDevitt, Roland, Jon Gabel, Ryan Lore, et al. (2010). “Group Insurance: A Better Deal For Most People Than Individual Plans.” Health Affairs, January, pp. 156-164.

14 Kaiser Family Foundation (2007). “Individual Market Guaranteed Issue.” (

15 Schwartz, Tanya (2010). “State High-Risk Pools: An Overview.” Kaiser Family Foundation. (

16 Buntin, Melina, M. Susan Marquis, and Jill Yegian (2004). “The Role of the Individual Health Insurance Market and Prospects for Change.” Health Affairs, November/December, pp. 79-90.

17 The early retirees are those ages 55 to 64 who receive pension payments from the federal Pension Benefit Guaranty Corporation because their former employers went bankrupt or for other reasons can no longer pay these pensions. The trade-dislocated workers are those certified by the U.S. Department of Labor as having lost their jobs because of competition by foreign firms and who either receive Trade Adjustment Assistance cash payments or would qualify for such payments were it not for their receipt of unemployment insurance payments. See: Dorn, Stan (February 2008). “Health Coverage Tax Credits: A Small Program Offering Large Policy Lessons,” Urban Institute. (

18 For information about subsidized individual policies in these jurisdictions, see (Maine); (Massachusetts); (New York); (Oregon); (Vermont).

19 Kaiser Family Foundation (2010). “Explaining Health Care Reform: Questions About the Temporary High-Risk Pool.” (

20 The Commonwealth Fund (2010). “Timeline for Health Care Reform Implementation: Health Insurance Provisions.” ( Coverage_040110_v4.pdf)

21 Plans would also be allowed to offer a premium discount if enrollees participate in wellness programs. Congressional Research Service (2010), “Private Health Insurance Provisions in Senate-Passed H.R. 3590, the Patient Protection and Affordable Care Act,” March 12.

22 The exempt groups include American Indians, people who have been uninsured for less than three months, those for whom the lowest cost health plan exceeds 8 percent of income, and those with an income below the tax filing threshold ($9,350 for an individual and $18,700 for a married couple in 2009).  Kaiser Family Foundation (2010). “Summary of Coverage Provisions in the Patient Protection and Affordable Coverage Act.” April 28. (

23 The Commonwealth Fund (2010). “Timeline for Health Care Reform Implementation: Health Insurance Provisions.” ( Coverage_040110_v4.pdf)

24 The cap will be set equal to the maximum amount allowed in a health savings account, currently set at $5,950 for individuals and $11,900 for families. Commonwealth Fund (2010). “Timeline for Health Care Reform Implementation: Health Insurance Provisions.”

25 Kevin Arts (2010). “Legal Challenges to Health Reform.” Toolkit from the Alliance for Health Reform, May 18. ( )

26 Berk, Marc, and Alan Monheit (2001). “The Concentration of Health Care Expenses, Revisited.” Health Affairs, March/April, Exhibit 1. (

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Graphics for This Chapter

Sources of Health Insurance Coverage 2008


This sourcebook for journalists was made possible with the support of the Robert Wood Johnson Foundation.

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