No. 2 in an occasional series: Alex Tabarrok on France-US comparisons (with minor editorial changes)

by Henry on May 13, 2006

(see here for Tabarrok’s original; see here for No. 1 in this series)

The US has one of the most deplored health insurance systems in the world and one of the most admired veterans’ health care systems. Could the difference have something to do with the fact that America’s health insurance firms operate in a competitive market with lots of private suppliers while veterans’ health care is dominated by monopolistic, government provided hospitals?

What would our health system look like if it operated like the Veterans’ Administration?

Look to France for the answer. Healthcare in France is “mainly under state control … The state plans out hospitals, the allocation of specialized equipment, etc.” However, as Kevin Drum notes, this

works pretty well. French healthcare is excellent, waiting lists are short, the supply of doctors is high, overall costs are reasonable, and patient satisfaction levels are excellent. It couldn’t be transplanted whole into the United States, of course — doctors are paid considerably more here, for one thing — but it’s a pretty good model for what we could accomplish.



abb1 05.13.06 at 3:11 pm

The campus cafeterias close after lunch.

Duh. I dare you to find one restaurant anywhere in France with kitchen open between 2 and 7pm.


Kevin Donoghue 05.13.06 at 4:35 pm

I dare you to find one restaurant anywhere in France with kitchen open between 2 and 7pm.

You mean, apart from MacDonalds? Fair point, though, and one which may have a bearing on French health.


Mark Paul 05.13.06 at 4:56 pm

Although it hasn’t digitized medical records yet, Medicare works nearly as well as the VA system.

A few months ago, I interviewed Dr. Quentin Young about universal healthcare. Dr. Young was chairman of the Department of Internal Medicine at Cook County Hospital, and is now Clinical Professor of Preventive Medicine and Community Health at the University of Illinois Medical Center and Senior Attending Physician at Michael Reese Hospital.

Here’s an excerpt:
What’s the most common misconception about universal, single-payer?
“It’s ironic that people think you lose choice in a single-payer system. That might be true in a socialized system, like Cuba’s, but that’s not what we’re proposing. We advocate that the government be the insurer, and we already have such a single payer system in place for people over 65. It’s called Medicare.”

The obstacle to be overcome is the deep-pocketed and well-organized insurance companies, who have managed to enlist a large number of physicians as allies.

It’s difficult to imagine an efficient universal program in which insurance companies play a role, but they will not go away gently.

Nothing will happen until there’s a Democratic landslide of 1964 proportions.


Stephen M (Ethesis) 05.13.06 at 6:37 pm

Gee, I had no idea anyone admired the VA system.

That is a wake-up. Find a nurse you known and trust who lives in the US and ask them about the VA.

If that is a gold standard, I’m thinking (though I haven’t reached any conclusions that are firm).

But it justifies more thought.

I liked Paris when I visited, skipped the MickyD I saw, was surprised at just how friendly the Frence were. Doctors make only about $50k a year, according to the recruiter I had lunch with one day (she recruits for places in England, where they pay them as much as $100k for a specialist who works a lot of overtime).

They don’t use many CRNAs, which is too bad.


radek 05.13.06 at 9:02 pm

This one’s easy. The key word in ‘health insurance system’ is ‘insurance’. Insurance markets are generally prone to market failure (not that government attempts to fix this cannot be a greater failure) so it makes sense that government intervention could make it work better.

On the other hand university education should work better in a competitive system than when ran by a micromanaging government. While it generates research externalities and the like this is essentially an argument for some subsidies not outright control and regulation.

So US should have France’s health care system (if it could be transplanted) but France should have US’s university system.
No puzzle here.


Jor 05.13.06 at 9:18 pm

I dunno what the statistics say — but on the ground experience at the VA is abysmal. Whether your a doctor, researcher, or nurse. I never use to buy the stuff against govt. inefficiency until this past year when I briefly did a stint at the VA. Everyone I know there, just lamely accepts VA ineptitude and intractable beurocracy. Medicine is beurocratic enough — but govt. + medicine seems to be a nightmare.


b.rian 05.13.06 at 9:33 pm

is it possible that Americans as a whole lack the knack for socialism in any small or large sense of it? European countries seem to have a fair grasp of its idea and how to implement it in some circumstances, not to say that it doesnt fail at some points. America just seems to be caught in this Cold War vacuum, where 20 years later any sort of government control or implementation of social programs sets the conservatives off on a rampage.


DD 05.13.06 at 9:35 pm

In his post, Alex Tabarrok wrote, “The United State’s has one of the most admired university systems in the world and one of the most deplored k-12 systems. Could the difference have something to do with the fact that universities operate in a competitive market with lots of private suppliers while k-12 is dominated by monopolistic, government provided schools?”

Here are some results from the PISA tests conducted by the OECD. The test measures how well teenagers can apply math skills to real-life problems.

Country: Score
S. Korea: 550
Japan: 547
Canada: 529
France: 519
Czech Rep.: 516
Germany: 513
Spain: 482
US: 477
Italy: 470
Mexico: 384
OECD average: 500

Don’t all of the countries that beat the U.S. have k-12 systems dominated by monopolistic, government provided schools?


trialsanderrors 05.13.06 at 10:40 pm

Methinks Tabarrok confuses the cream of the crop of American universities with the domestic postsecondary education overall. There is a tendency (including from European PoV’s) to look at Princeton and point out how overabundant resources are at American universities. Sadly, for the vast majority of students in the U.S. the reality of campus life is much closer to Paris XII than Princeton, at a significantly higher cost. If you want to compare the US system at its peak with the French system, you better looks at the grandes écoles.


Jor 05.13.06 at 11:34 pm

I went to a state university (not UC) for undergrad — and it didn’t seem anywhere nearly as dreary as the french system. I can’t imagine a computer without internet. Or a professor w/o office hours.


me2i81 05.14.06 at 1:21 am

I went to UC Berkeley, and it’s a lovely place, even though it sucks off the teat of the state.

And of course, private US research universities get piles of government grant money, so it’s hard to argue that they’re purely a capitalist enterprise. They somehow get away with charging higher grant overhead % than public universities, or at least they did when I worked on NCI-funded projects back in the day. You’re going to have a hard time arguing that Princeton is more “efficient” than UC Berkeley just because it’s private.

If you want to look at purely capitalist universities, you have to look at the for-profit sector (i.e. DeVry, Heald, U of Phoenix, etc.) Frankly I don’t think the people going to the grands écoles are too envious of those…


finnsense 05.14.06 at 1:37 am

France is not the only country with a fully state funded higher education system. Here in Finland we have one too and I can vouch that at all universities here we have hundreds if not thousands of fast PCs and everything works quite well.

I have gripes about the system here. Helsinki University is not Harvard (but I bet with a $13 billion endowment it could get pretty close). However, for most subjects it is comparable with top 10 British Universities, which are in turn comparable with most US universities outside the top 20.

Of course Europe has a problem with elite education because of the egalitarian system. We could probably do with a few first class private research universities (I read about a EIT recently being planned) but in terms of solid education and research there’s nothing wrong with a state funded system in principle.


nick s 05.14.06 at 2:53 am

If you want to look at purely capitalist universities, you have to look at the for-profit sector (i.e. DeVry, Heald, U of Phoenix, etc.) Frankly I don’t think the people going to the grands écoles are too envious of those…

Or the for-profit-and-Jebus sector (i.e. Fallwell’s Liberty University), which is a ‘pure product of America’ in the William Carlos Williams sense.

Anyway, Tabarrok’s ‘most admired… in the world’ line is more than somewhat vague in meaning. Most admired around the world, in the sense that US universities attract foreign students? Well, those foreign students getting visas aren’t going to community college. Nor are they enrolling for an undergraduate degree, for the most part: take Alex Tabarrok, for instance, who arrived at George Mason with a B.A. from Canada.

‘Most admired’ in terms of global criteria for enrollment and graduation? Well, again, we’re talking about American undergraduate degrees here. Define your terms, mate.

Of course Europe has a problem with elite education because of the egalitarian system.

Bwahahahahahahahahaha. If there’s a problem, it’s with the idea that an ‘elite education’ should come with an elite price-tag.


nick s 05.14.06 at 3:09 am

One more thing:

Amazingly, with just a few exceptions for the elites, students are required to attend the universities closest to their high schools. Sound familiar?

Actually, it sounds a lot like the US university system, more or less, given the difference between in-state and out-of-state tuition rates. Tabarrok writes as if he knows very little about the undergraduate system (or the high school system, for that matter) outside the elite institutions at which he has taught.


John F. Opie 05.14.06 at 4:15 am


Sorry to be heretical here, but the European systems of universal health care insurance leave a lot to be desired.

Has everything to do with demographics and the declining number of people who can actually fund the system.

I live in Germany and have been in the system here for 20 of the last 24 years.

None, and I repeat none, of the European health care insurance systems are fundamentally fiscally sound. The basic problem is demographics and the fact that an increasingly older population is driving costs in such a way that only government limits on how much workers can be dunned prevents them from raising rates to where they need to be.

I’m a voluntary member of the state insurance system here, voluntary because I earn well above the maximum where I can opt out of the system and choose private insurance. I pay 528€/month, which my employer matches for a total insurance load of €1056/month. I am one of the people helping to finance the system here: I would have better coverage in the private sector, but I simply refuse to enter the private sector as a matter of principle, since I have good friends who work in the public sector and it is, fundamentally, a good idea that is slowly being destroyed by demographics.

For that €1056/month I get extremely basic coverage which does NOT include things like eye care or dentists. It once did (15 years ago), but now that’s been dropped. What I do is pay for people like my mother-in-law, who is paying virtually nothing for the same coverage I get.

The problem, to reiterate, is demographics. Whilst young folks generally get the care they need without much delay (including some elective surgeries), the health care for the elderly is severely rationed. Not that someone with a broken hip in their 80s doesn’t get helped: but the hip won’t be replaced, but rather pinned together and the patient put on a permanent regime of pain killers, because it’s simply not cost effective to give them a new hip.

I discussed two concrete cases with my doctor, a GP within the public sector, to see what he would be allowed to do under the circumstances. One is an 84 year old male who had a stroke, fell and broke a hip and three ribs. Under the German system, he would have ended up in a wheel chair, since the hip replacement is contraindicated beyond the age of 80. The other is a 70 year old male who has an increasing problem with scoliosis of the back and degneration problems with his backbone. He would have also ended up in a wheel chair, since the necessary operation(s) were contraindicated beyond the age of 65 (multiple rods in the back to correct the backbone problems).

Which would have meant that both my grandfather and father would’ve been in wheelchairs for the rest of their lives, instead of leading active and productive lives for another 10 years in the case of my grandfather (2 hip replacments) and continuing activity with my father.

Of course, these operations cost a sh*tload of money. My grandfather was insured by his previous employer and Medicare; my father as well.

To reiterate, under the German system they would’ve had this care rationed. That is, in reality, how the Germans are taking care of their increasingly elderly population, by rationing the health care in order to not bankrupt the system.

And interesting that no one here mentioned the 15000 deaths in France of their elderly there last summer when everyone in the country was on vacation.

So transplanting any sort of European health care insurance system means that you will need to talk about rationing health care to those who cause the greatest costs, the elderly. If you’re comfortable with that, go ahead, but explain to everyone in advance that it may well mean that grandma and grandpa won’t be getting some of the care they need because no one can afford to pay for it.

Just look at all the problems of the British system to see what at least could happen. On paper it looks great, in reality? Get real. There are real reasons why the NH is vilified in the UK. Having a heart attack? Get in line.

Check reality before making recomendations: while there are many who either chose not to have health insurance or who cannot afford it, the quality of care in the US is superior to that of Europe as a whole. Hospitals carry the cost of providing that and pass it on to the insured in the form of high costs for those who can afford it. But it’s a system that ensures that explicit rationing is NOT in place, which it is in Germany.


Tim Worstall 05.14.06 at 5:08 am

A slight disconnect on the health care systems? The VA is a single payer, single provider system. The French is a multiple payer (significant charges made to the individual receiving the care, for example) multiple provider one, with an extensive private insurance market.
Are these really the same thing?


Barry 05.14.06 at 7:50 am

Tim, for some people, it’s all the same – Evul Soshulizm.

dd – “Don’t all of the countries that beat the U.S. have k-12 systems dominated by monopolistic, government provided schools?”

Not only that, but how many of the countries which beat us have as large a proportion of private schools as the US does? I’d wager that at least some of the US-beaters are doing it with almost pure gov’t schools.


Tim Worstall 05.14.06 at 8:36 am

Barry, my point is rather the other way around. Many would indeed like to have a more socialized medical system and France is often held up as a decent model of such. But it isn’t actually quite as “socialist” as many think: it is far less so than either the Canadian or UK models, for example.
It is (at least arguably) less socialist than Medicare: I don’t think that system has 25% co-pays does it?


harry b 05.14.06 at 8:47 am

Barry, take the private schools out of the US system and not much would change; elite k-12 schooling in the US is mainly provided through government-run schools (in very welathy suburbs); the private school system deals with religious kids, at-risk middle class kids, and others; the “elite” is a tiny percentage of the private system. France relies heavily on private (but government funded schools); Canada has a very complex system of choice which is in effect heavily privatised (but again, government funded). The general points here all stand though; it is the research and graduate element of US universities that is widely admired, not undergrad education, and anyway its mostly heavily funded and regulated by the Feds and/or the States.


Dr. Weevil 05.14.06 at 9:20 am

‘nick s’ thinks that requiring studentds to attend the universities closest to their high schools “sounds a lot like the US university system, more or less, given the difference between in-state and out-of-state tuition rates”.

That only applies to the very few students who live in states with only a single state university campus. I don’t have time to check the list, but I believe that would be around three or four states, most likely Vermont, Rhode Island, Delaware, and Wyoming. Even the Dakotas have multiple state university campuses. A medium-sized state like North Carolina has over a dozen choices for in-state tution: my tiny high school in Raleigh sends graduates to N.C. State, which is indeed the closest university, but also 150+ miles west to U.N.C. Asheville and West Carolina, and 100+ miles southeast to U.N.C. Wilmington. If you like the mountains or the seashore, you can easily go there for in-state tuition. If it’s true that French students are required to attend the nearest campus, the situation there is entirely different.


Cian 05.14.06 at 10:12 am

I have a real problem with these kinds of debates, as different things are being compared. To give a few examples. Yes there are real problems with the NHS, but then it is a healthcare system done on the cheap (both the US and Europe spend significantly more on their systems), where doctors effectively operate a cartel on how many new doctors can be trained (whereas France and Germany have a surplus of doctors), one reason for the waiting lists and higher salaries. Simplistic arguments about private vs public are meaningless in this context. Many of these arguments tend to come down to complaints about inefficient bureacracy – but that can be as bad in private sectors (such as the insurance claim system in the US).

John F. Opie argues that the German system has a problem with demographics – there are not enough young people to pay for the system. Quite possibly, but that’s not going to change by privatising it, so I’m not quite sure what his argument is supposed to be there. Yes, the US system is wonderful if you have good insurance – most people don’t. Health care in Germany might be rationed, but then it is in the US based on ability to pay. There are plenty of old people in the US who won’t get hip replacements either, and probably can’t afford the painkillers either.

Similarly comparing US and European universities is similarly simplistic. It depends upon what purpose is required from the university system. Is it for research, or teaching? Should it being teaching an elite very well at the expense of the rest, or should the money be distributed more equitably? And anyway, is this particularly relevant given the inadequacies of the tertiary schooling system in the US?


nick s 05.14.06 at 11:05 am

That only applies to the very few students who live in states with only a single state university campus.

I’m very well aware that states do, indeed, have more than one institution that offers in-state tuition rates. Hence the ‘more or less’. My point was that the decision is often subject to economic restrictions which extend to the choice of one in-state location over another. My wider point is that Alex Tabarrok, who entered the US system as a postgraduate, doesn’t show possession of much clue about the brain-blending choices that most high-school graduates have to make.

Anyway. There’s ultimate something of an apples-oranges comparison here, given that the time-honoured practice of the French university system was to admit large numbers of students, then flunk a sizeable chunk of them halfway through the year and pocket the cash from the state. In contrast, the time-honoured practice of the American university system is to churn out thousands of ABs at break-even or thereabouts, and make the real profits on postgraduate tuition.


eudoxis 05.14.06 at 11:20 am

The US has one of the most deplored health insurance systems in the world and one of the most admired veterans’ health care systems.



Donald Johnson 05.14.06 at 1:25 pm

I was a little surprised myself to hear that US veteran’s health care is widely admired. Not that I know anything about it, but I’d always heard bad things about the VA.


eudoxis 05.14.06 at 4:22 pm

The VHA has made a tremendous turnaround from it’s low point in the early 90’s. I did some research at the VA in LA and clearly remember the rows of nodding old men lined up in the hallways in wheelchairs, jacked up on demerol, and … smoking. The changes were forced by the possibility of being doomed to obsolescence. The changes can’t be causally attributed to the method of payment administration. The government was the single payer when these VA hospitals were at their worst and now, at their best. Nevertheless, the naysayers who claim that comprehensive health systems can not be run well under a government single payer system are wrong.

There are other, premier medical centers that run equally well or better than VA medical centers. They are non-commercial institutions (like Mayo) that use a mixture of payers from private insurance to Medicare. Obviously, private systems can and do work. They end up costing more in the long run. And that’s reason enough to change to a government-run single payer system.

In the final analysis, the medical model is what ensures quality of care. The VHA adopted a value driven, patient centered medical model much like that of the Mayo Clinic. And it worked.


Barry 05.14.06 at 5:16 pm

“The VHA has made a tremendous turnaround from it’s low point in the early 90’s. “

Hmmmm. Just like FEMA. I wonder what happened in the early 1990’s, in the federal government, which could have caused two such programs to improve so dramatically.


jet 05.14.06 at 10:38 pm

The VHA may have made a tremendous turnaround from the early 90’s, but it is still below par. The VHA relies heavily upon non-VA hospitals and then pays VA rates for the service. This can take months to schedule and then years to negotiate the final price, and which the patient will carry the debt until the VA pays.

From the veterans I know (yeah yeah yeah, antedote doesn’t make date), I’d be extremely skeptical of any study claiming the VHA was doing a better than the over all system. Probably rigged anyway, with the VHA being compared to an elite (expensive) set of hospitals catering to old rich people.


Barry 05.15.06 at 6:09 am

jet, as usual you’re a bi, uh, jet-like in your logic. To rig a study to prove the VHA better, one would compare it to the worst hospitals available, not the best. In addition, it’d still make sense for the VHA to contract out some things, unless it was necessary to build those capacities into the system.


SamChevre 05.15.06 at 8:06 am

Comment #4 is key; doctors in the US make a LOT more than doctors in other countries (IIRC, average income for a Primary Care Provider in the US is 2.5x that of a PCP in France, and the disconnect is even greater for specialists.)


jet 05.15.06 at 9:22 am

If they compared it against expensive hospitals who’s clientale were usually older, then it would look like very expensive treatment was being given whith worse results. If they were going to compare it to the worst hospitals available, they’d compare it to BIA hospitals, another government ran, single payer, health care system. And I’m sure the BIA hospitals would make even VHA healthcare look like a healthcare utopia.


eudoxis 05.15.06 at 10:03 am

Because the US does not have a single universal health care system, it is ludicrous to compare the aggregate of US health systems to individual health care systems in Europe. Single models in the US should be compared to single models in Europe. Just the first sentence in Henry’s post highlights the strange comparisons so common in these discussions. First, comparing insurance systems to health care systems, and, second, comparing the whole “most deplored health insurance systems in the world” to the VHA which happens to be part of that whole.

Jet, comparison studies in quality of care have been done between the VHA and commercial managed care systems. That’s a far cry from comparing the VHA to premier US medical centers. Hospital ratings that include all hospitals don’t have VA hospitals high on the list.

The patient satisfaction surveys are not rigged; they are just not properly controlled. Crudely put, VA patients are a different population from the general population. Still, the VHA has improved dramatically compared to 15 years ago. Canada, for instance, looks to the VHA to see how they can improve their health care system.


lemuel pitkin 05.15.06 at 10:26 am

On teh VA:

1. Costs, particularly administrative costs, are very low compared with the rest of the health care system. The fact that doctors and other professionals who are very highly compensated by the private systehm would prefer not to work for the VA is not, in my mind, a strike against it. The opposite, even.

2. The vets I know are generally happy with the care they get through the VA.

On K-12:

If you know anything at all about K-12 education in the US, you know that the very best schools are public schools in affleunt suburbs. By any metric, the quality of education in a good public school system is higher tahn at any but a tiny handful of the most elite private schools. Various commetners have noted that the difference between good and bad universities in America does not track the public-private divide. The same thing is even more true of K-12.


Sebastian Holsclaw 05.15.06 at 11:06 am

I can think of a relatively easy way to measure patient satisfaction with the VA. The VA provides care to veterans and their dependents. For people who can choose between the VA and other health care plans (which is to say most veterans with full time jobs), find out if they use the VA (which they have largely already paid for by military service) or if they use their job’s health care (which if they have dependents they have to pay much more for). Anecdote not data of course, but in San Diego (with a good VA hospital closely affiliated with the well respected UCSD Medical School) with veterans whose medical choices I have some idea about (four) all prefer to use the insurance provided by their companies instead. Two have Scripps which makes it understandable, but two have Kaiser which despite their rather slick marketing campaign, at least in San Diego (local health insurance markets may vary so I figure I will give as much information as possible), has a not-so-thrilling reputation for being stingy and otherwise annoying. It seems to me that if people who have a choice and have experienced both choices consistently choose the non-VA option, that should be a good hint that the VA isn’t so wonderful. Is there somewhere we can get such statistics on a large scale? If not, maybe one of our academic friends could get a grant. :)


eudoxis 05.15.06 at 12:03 pm

“with a good VA hospital closely affiliated with the well respected UCSD Medical School”

Most VA medical centers are associated with large, academic teaching institutions. The VA Medical system in Los Angeles, for example, is associated with, among others, UCLA. Staff from UCLA rotates through the VA. In effect, cost containment and quality at the VA is sustained with subsidy from other health care providers. (Just as low cost Canadian pharmaceuticals are subsidized by higher prescription prices in the US.)


Sebastian Holsclaw 05.15.06 at 1:11 pm

“In effect, cost containment and quality at the VA is sustained with subsidy from other health care providers.”

I would be completely unshocked to find that is true. But my point in mentioning UCSD was that the VA here should not be thought of as some out-of-the-way awful old institution. It is modern, has access to excellent doctors and nevertheless appears not to be preferred.


james 05.15.06 at 2:04 pm

It would be interesting to know how the US health care would compare with European systems if both systems paid the same costs. Is it possible that the US system costs more, not because of inefficiency, but because it simply pays more for the same goods and services? How much does the US system save if the cost of wages, services, and drugs are fixed to the prices paid in say France? Could the French system stay solvent and pay US prices? Single payer vs. the US mess does very little to address the actual costs of healthcare.


glenn 05.16.06 at 5:38 am

This is a pretty absurd debate. I’ve lived in the US and I now live in Italy. I’ve been to hospitals in both, but if I were sick, I’d much prefer to get treatment in the US (in fact, just the threat of having to go to an Italian hospital has made me live more healthily. But I will say that the main failings are with the infrastructure; the doctors here seem excellent).

That being said, there are pros and cons to each system. There is no ‘one best’ system; there are just different failings in each.

While being far from an expert, I’ve been spendng an inordinate amout of time thinking about healthcare systems and increasingly I’m of the mind that the healthcare system is inconsistent with capitalism. That is not to say, though, that all aspect of healthcare should under control of the government, and it’s not even the same as saying the government could do the best job.

Which country has THE BEST healthcare system in the world? Let’s start with that, and then improve upon it…


Victoria Férauge 05.16.06 at 2:26 pm

To determine what is “best” we would all have to agree upon on how to rank the different healthcare systems. Yes, we can look at mortality rates, cost, and so on but I doubt that it would satisfy us all. The previous post talked about infrastructure problems in the Italien system, I can speak to the French system which has both infrastructure problems (check out the public hospital in Nanterre, near Paris) and incentive problems. The system is not really set up to encourage the average person to be a partner in his/her well-being. In some ways it’s glorious for someone like me who smokes like a chimney and really enjoys a two hour lunch with a very rare steak, a glass of Bordeaux and a “Fondant au chocolat” to top it all off. And rarely a word from my doctor who simply (and mildly) counsels me to practice a bit more “moderation” in my vices…

Would I trade this system for an American doctor who would tell me that it’s really time for me at 40 to stop smoking and watch the alcohol and cholesterol intake and who, at the first sign of trouble, slaps a “pre-existing” condition on my medical file?

Of course not.


theCoach 05.17.06 at 2:31 pm

Let’s think of a metric for the overall effect of the education system.

My guess would be productivity/hour.


glenn 05.18.06 at 6:05 am

Victoria – is there any other way to have a steak?
Otherwise, you’re eating charcoal…

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