Archive | August, 2009

Reining in health care costs now, really

31 Aug


The frustration in all this health care reform is that they are people who understand the problem, the real problem and yet they are largely ignored.  Many of these people are physicians or other health care professionals who see firsthand the real issues of costs and what is driving them.  Here is a good example of that How to Rein in Medical Costs Right Now.  Regardless of what you hear from the politicians, the problem is not the insurance companies and not even the uninsured, it is simply the way we practice medicine in America and the underlying belief that more is better or that every test and procedure adds value equal to or beyond its cost.  In addition, from the patient perspective we hear little about the risks and potential harm caused by many of these procedures. 

You might also want to read the writing of Ezekial Emanuel, Md, PhD, White House advsor on health care reform.

Cash me out

30 Aug

Cash for clunkers has ended and I am waiting for a thank you note from just one of my 700,000 fellow Americans for whom I helped buy a new car.

I admit to being on the conservative side (As regular readers may have surmised), but golly gee what political mindset thinks a one time limited program giving people money to buy a car is going to stimulate a trend? Most of the cars bought are foreign brands and while I understand some are made in America, the profits go elsewhere. With any luck they will buy US Treasury debt to help us fund the three billion this deal cost us.

What have we accomplished? Well 700,000 people got a good deal and 700,000 vehicles get better mileage and a few auto workers were called back to work very likely temporarily even though only one American car was in the top five sellers. The US government and taxpayers are further in debt. A slew of Americans who missed the mileage cutoff are pissed and the 700,000 who got the deal now have monthly payments when they had none on the clunker. Let’s hope the car payment doesn’t impair their ability to make the mortgage payment.

Call me cynical, but I never got cash for buying a house, or car. Last night I did get a senior discount at the movies perhaps I am sufficiently stimulated.

But wait, I have my eye on a new water heater and next year round two of this stimulation will get me (and you) a few hundred dollars back on new appliances.

If this keeps up soon we will all experience the joy of using food stamps too especially the car dealers waiting for their rebate checks.

Don’t confuse me with facts-spin baby spin

29 Aug

Gary Locke, the Secretary of Commerce has an op-ed piece in the August 28 Wall Street Journal “Fixing Health Care is Good for Business” 

Can I leave the corner if I say what you want me to say?

Can I leave the corner if I say what you want me to say?

I doubt that anyone would argue that fixing health care would indeed be good for business and everyone else, but where is the fix?  About the only positive in all this so far is that some cost shifting for the uninsured may be reduced, but that is likely offset by higher taxes, additional cost shifting from Medicare and perhaps a public option, not to mention additional benefit mandates and additional administrative burdens for employers.  The bottom line is that health care costs will continue to rise only from a higher base for at least the next ten years if the current version of “reform” is enacted. 

I sometimes wonder how otherwise intelligent people can get themselves to support the party line when they must know that what they are asked to say defies common sense and logic, not to mention the facts generated by other people equally as smart.

A deal is a deal…or so we thought

28 Aug


The trend continues, the defined benefit pension is dying a slow death and with its passing will come a changed society, a changed workforce and millions more Americans left on their own to fund and manage their retirement income.  Watson Wyatt reports that even among Fortune 1000 companies, the number sponsoring a defined benefit plan has dropped from 59% to 42% between 2004 and 2009 and more have eliminated them for new hires. 

You can imagine the reasons for all this, but it all comes down to one thing, earnings for the next quarter are more important than the employees who may have counted on these programs for the last several decades.  Just as pensions are funded over many decades so there should be a long-term commitment to workers, in some cases even before a commitment to shareholders who know or should know about these obligations before they invest.  One may make the case that when there is a true survival situation it is better to keep a Company going and freeze a pension plan and I can buy that, but otherwise, a deal is a deal in my view. 

If I'm late for the staff meeting one more time, I've had it.

I frequently sound the call of unintended consequences and this is a good example.  A myriad of laws and regulations related to funding, reporting, disclosure etc. intended in large part to protect plan participants, have in reality contributed significantly to the demise of the pension.  The same holds true for retiree medical, accounting rules designed for transparency, killed this coverage and while the majority of Americans never had this benefit, its elimination will have a profound impact on future generations and on the future workforce. 

Better prepare for a “normal” retirement age of 80.  Are the halls wide enough for those mobile chairs?

OMG I was wrong-sort of

28 Aug


In my post regarding living on a fixed income I predicted that the AARP would be up in arms because there is no COLA for Social Security benefits in 2010, inflation or the lack thereof does not justify it and given that in 2009 the increase was 5.8% us seasoned citizens still have a pretty good deal.  Indeed the AARP does have it’s undies in a bunch and on top of that the WSJ reports that members of Congress want the COLA calculation reviewed, is there no shame? 

Ah, dodged another bullet

Ah, dodged another bullet

At a time when workers are being laid off, seeing pay cut or stay the same while trying to support their families, this so-called representative of older Americans wants more for the people in this country who already receive a disproportionate portion of our wealth  (and yes, at 66 and 70 my wife and I are among them- I’m the young one by the way).

Now here is where I was wrong, without checking my facts and naively believing there was some logic in all this I stated that the Medicare Part B premium would be rising in 2010 because of health care inflation and the fact that the premium is supposed to represent 25% of the cost.   Silly me.

In fact, there is a provision in the law that prevents an increase in the Part B premium in any year there is no increase in  Social Security benefits. There you go, more efficient cost management of health care by our Congress. 

The Medicare trust fund is in trouble starting when?

I agree with Ezekiel J. Emanuel, MD, PhD

27 Aug

Some of us have been saying from the start that expanding coverage before addressing the underlying cost of health care is a mistake.  Of course, some of us do not have a number of letters attached at the end of our name and thus we are going on gut instinct, in some cases such as mine accompanied by several decades of working with health benefits and the people who provide and use them.  I recall during the Clinton health care initiative going to a

"Free" healthcare available here

"Free" healthcare available here

public hearing and seeing one person after the other give horror stories about their medical care and the failure of their benefits to cover it all in full, but I heard not one word about the cost of the care of why a certain amount was charged for this or that service. 

White House advisor Ezekiel Emanuel has taken a lot of flak recently over the bogus flap about death panels, but if you read some of his past writings, you may take heart in his assessment of health care and its costs.  It is, however, very unfortunate that the politicians pushing their version of “reform” do not pay attention to the advice he is giving. 

Here are the first few words from an article he wrote in the Journal of the American Medical Association in February 2008 (even I could have written this): 

The Cost-Coverage Trade-off

“It’s Health Care Costs, Stupid”

Ezekiel J. Emanuel, MD, PhD

JAMA. 2008;299(8):947-949.

“According to recent polls, many Americans consider health care reform the No. 1 domestic issue.1 Presidential candidates, other politicians, health policy experts, labor leaders, business groups, and others have responded with numerous reform proposals. And somehow in the clamoring, health care reform has become equated exclusively with expanding coverage to the 47 million uninsured Americans.

This is a mistake. As serious as it is, the problems of the uninsured and lack of coverage are symptoms, not the underlying problem. Focusing on them is like treating a fever without addressing the causal infection. Instead, the diagnosis and treatment need to focus on health care costs. The fundamental problem arises because of a cost-coverage trade-off. Without controlling health care costs, any attempt at universal coverage will be transient. Sustainable expansion of coverage to all Americans requires credible changes in the rate of health care inflation—the slope of . . . “

He also wrote, “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely ‘lipstick’ cost control, more for show and public relations than for true change.”

Those among us who tell Americans that controlling health care costs will come about without fundamental change in the way we think about, delivery and reimburse for health care are dreamers or liars. Americans who want cost control should look at what it takes in other countries to achieve that.  Only then should we expand coverage to all Americans and by then hopefully Americans will understand they can’t have everything they want, when they want it and the cost be damned and along with that they may understand that high cost does not guarantee high quality.

2013 and Beyond-America’s Debt

27 Aug

You have heard this before, every wealthy country in the world provides health care to all its citizens except the United States. If $9 trillion in debt over the next ten years sounds like a wealthy country, you will also buy the idea that the couple who purchased a McMansion with no down payment and then furnished two of the ten rooms with used lawn furniture is wealthy as well.

You have also heard that controlling health care costs is essential to bringing down the federal deficit, that’s federal deficit remember as in:

“Beyond 2013, deficits will remain stubbornly high in large part because of spending on Medicare, Medicaid and Social Security. That isn’t tied to the recession, the CBO said: it will simply rise as baby boomers age.” As quoted in the August 26, WSJ.

 To accomplish health care reform the plan is for $622 billion in cuts to Medicare and Medicaid. Part of that is lowering payments to providers (think cost shifting) and part of that is cutting government payments for Medicare Advantage Plans, those are the private options available to Medicare beneficiaries and they operate as an HMO or POS, considerably reducing or in some cases eliminating out of pocket costs. Medicare out of pocket costs are an often overlooked issue.

Here is what the Medicare website says about Medicare Advantage Plans:

“Medicare Health Plans (like HMOs and PPOs)

These plans are approved by Medicare and run by private companies. When you join one of these plans, you are still in Medicare. Some of these plans require referrals to see specialists. They provide all of your Part A (hospital) and Part B (medical) coverage. They generally offer extra benefits, and many include prescription drug coverage. These plans often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.  In many cases, your costs for services can be lower than in Original Medicare, but it is important to check with the plan because the costs for services will vary.”

Cutting payments to Medicare Advnatage Plans most likely means higher costs for Medicare beneficiares in those options.

I don't understand why I'm not getting anywhere

So here is the point, costs are to come from Medicare and spent to expand health care for younger Americans.

That is not a net gain for the budget, it’s neutral, and so it does nothing to reduce total deficits. The hope is that by adding all Americans, many subsidized, to the health insurance roles somehow costs will be lowered for the government. At the same time costs for Medicare beneficiaries, all the people who currently have health insurance and employers who provide coverage to workers will rise (not counting the possible various taxes and penalties that are part of proposed legislation). We are told that other provisions in the law will lower the cost of care, things like implementing the results of comparative effectiveness studies, but even if that is accomplished it will not happen within the next ten years.

If by some miracle we do lower the base for health care costs, there is nothing being done that will lower the rate of increase going forward, unless of course, you believe that paying fully for health and wellness programs and preventive services will lower costs, but again, not in the next ten years.

While we are reducing the cost of health care to the federal government, proposals also include elimination of the Medicare Part D donut hole, adding long term care coverage as a default mandate (paid for by Americans, but adding a new bureaucracy) and virtually unlimited health benefits, nice to do stuff if you are really rich.

All of the above simply does not add up to controlling our debt. America may be a rich country, just like a friend of mine who has two mega homes and two Mercedes, but no money to retire is rich. While we control health care costs for Americans we tax them to pay off our growing debts…are you going to be better off?

Let us not forget that controlling health care costs should it ever be accomplished means that someone will be paid less, that someone is doctors, hospitals, insurance companies, drug makers, medical equipment manufacturers. The health care industry is the fastest growing segment of the economy (behind government I suspect) and that sector is adding jobs.

While striving for efficient quality health care is a valid and critical goal, we should not ignore the consequences of approaching that goal by merely waiving a political wand and taking from Peter to pay Paul.

The pensions you pay while trying to fund your 401(k)

26 Aug


maninrockingchairPension costs are on the minds of CFOs of those relatively few organizations that still have defined benefit plans, so much so that companies with long histories of providing a pension are chipping away at the benefit all in the name of the next earnings report.  While the traditional pension is fast disappearing for the private sector (a very bad strategy in my view but do not get me started on that one), it is still strong among public employees, strong but a growing problem.  CalPers is a good example.

Pension funds are in a bad way these days, and some are worse than others because they were underfunded and because they provide overly generous benefits that are very costly.  Again, public plans are a good example where in some cases the pension is based on the last years pay and where overtime is manipulated to provide a pension greater than the salary for active employment.  Early retirement is also generous when compared to the private sector.  How does this happen?  Well there are strong public unions and weak public politicians and a disconnect with the people paying for it all.  While the citizens of the various states bear the burden of these costs and in some cases mismanagement of the plans and the funds, the majority of citizens have no such benefits.  School taxes, property taxes, sales and income taxes are all reflective in part of the tremendous pension liabilities and expenses that our politicians promised to state workers . The public pays little attention, politicians have a short span of attention and no long term view and unions get politicians elected, it works quite well don’t you think?

There is nothing new about all this, but what is new is that the pension funds are caught with their pants down so to speak, as the markets revealed how precarious these promises can be.

The pension debacle faced by many states is just one example of a public plan in action and nobody is minding the store.

Fixed income aint no joke

26 Aug

For the first time in a generation the Social Security monthly check will not increase next January, the victim of low inflation. This should not be a surprise to anyone, but wait. I can just see the critical response team at AARP figuring out to make the case for an exception – economic stimulus and all that you know. Hey, we can help people buy cars, why not food? I suspect the Medicare premium will increase and well it should as cost rise and financial trouble looms.

The hard reality of retirement as I a learning after only a year in this state is that the fixed income deal is real and if you plan on retiring…ever, you better figure a way to cope. As we now know you can’t even rely on your uncle any more.

Is our public option “affordable?”

24 Aug


Much of the discussion around health care reform centers on one word, “affordable.”  We strive for affordable, high quality health care although I have yet to meet anyone who knows exactly what either means.  To some people neither is achievable without a public option so I decided to look at the one public option we have in place, Medicare.  If Medicare is the model for affordable health care, we better check with the elderly and see what they think.

The average family income in the U.S. is slightly under $50,000 a year, the average income for seniors is considerably less at around $34,000 as best I could find.  The older the individual,  the lower the income level so when you reach the age 85 and over group the income level is slightly more than $21,000.

Hmmm, a few more and I cover my last office visit coinsurance

Hmmm, a few more and I cover my last office visit coinsurance

Now let’s talk about affordability for health care.  The Medicare hospital deductible is $1,068 applicable to the first 60 days after that there is a daily co-payment.  The Part B deductible is $135. After the deductible is met, the beneficiary pays 20% of the allowable cost with no cap or out of pocket limit.  Of course, any prescription drug expenses are additional. For this Part B each person currently pays $96.40 (higher income people pay more).  To add Part D is in the area of $35 per month.

The Commonwealth Fund estimates the out of pocket cost as follows:

Medicare’s benefit structure leaves beneficiaries with significant out-of-pocket costs, particularly if they lack supplemental coverage. Out-of-pocket costs disproportionately affect low-income, old, and chronically ill Medicare beneficiaries: in 2003, the elderly with incomes under 135 percent of federal poverty level (FPL) spent one-third of their income on uncovered medical care, on average. Individuals of all incomes with fair or poor health status or age 85 and older spent almost 30 percent. (The 2007 Federal Poverty Level for a non-elderly adult is $10,787, and it is $9,944 for an elderly adult.) Although Medicare added an outpatient prescription drug benefit in 2006, poor and sick beneficiaries still face a substantial cost burden.

The average Medicare beneficiary and spouse pay $ 263.40 for Part B and D of Medicare that is $3160.80 per year, nearly 10% of income and more for the oldest Medicare recipients.  Of course, out of pocket expenses are in addition to that as noted above.  To avoid most of these out of pocket costs supplemental coverage is available.  The AARP option J that provides the broadest coverage costs $266.75 per month; $533.50 per couple or $6004.00 per year which is nearly 20% of average income. 

One could argue that we have yet to provide “affordable” health care to those in America over age 65. Medicare costs are increasing as fast or faster than other medical costs, Medicare is headed for financial trouble in only eight years.  With all this, how then can we expect that another public option will do any better controlling costs or making health care affordable?  It is also interesting to note that despite the Medicare experience, pending health care reform legislation calls for use of co-pays over coinsurance, has no limits on coverage, and seeks to add additional services without out of pocket costs.

Sometimes health care should be rationed

24 Aug


The answer to the question of whether health care will be rationed under health care reform depends on how you define rationing.  Congressional staff have admitted to me that once all the effectiveness research is complete (to be conducted using the Medicare population experience), there will be treatment guidelines that will result in recommendations that certain care at certain times under certain circumstances may not be warranted and ultimately not paid for by government programs.  Therefore, the short answer is yes, health care will eventually be ” rationed.”

The people working on this legislation know this, experts in the field know this, but they do not trust the American people to accept or understand it.  Frankly I do not think that is an unreasonable position  nor do I think the objective is a bad one.  The flap over a section of the legislation that would provide for end of life counseling as a reimbursable expense under Medicare is ample proof of the sometimes-irrational reaction to health care that we all have (more recently the airwaves a full of chatter about the “Death Booklet” from the VA). Of course, if I was 97 years old and knew I needed a pacemaker but was not going to receive it, I may feel differently.  On the othe rhand, if I was 97 and knew anything I would be happy.

However, the real point is that to achieve that illusive “affordable” health care system something has to be done that requires the best use of resources.  The other problem of course, and this is true in England, is that those who can afford the care anyway or can afford to buy supplemental coverage will receive the care denied to others who are not able to afford more than a public system.  In other words, a two tiered system (which I assume is not the objective of our liberal friends).

As further evidence of the sometimes-skewed view of health care value and cost, many employer plans and the House bill HR 3200 provide full reimbursement for wellness and preventive services.  In a rational environment, one would expect that routine expenses, generally modest expenses and things that we should do to protect our families and ourselves are not insurable events.  When I was raising my children in the 1970s, my health benefits did not pay for well baby care,  immunizations, or orthodontics but providing them was a no brainer. If I had trouble paying for them, something else was not purchased; there was no question or discussion about it (which may explain why my four adult children still remind me that I never took them to Disneyworld).  Today, we seem to believe that every penny of incurred expense for health care no matter how minor or whether medically justified is somebody else’s responsibility.  On the other hand, there are well over 150 million cell phones in the US with an average bill of $53.00 (2002 data), so there must be many average Americans who cannot afford a flu shot for the kids, but can afford a cell phone.  There is every reason to believe that Americans cannot make rational decisions when it comes to health care nor do they understand the complexity of the system.

The bottom line is that unless we find a way to ethically ration certain health care services or more correctly, assure that we provide only appropriate services for the circumstances, we have no hope of affording health care. 

There are many concerns with the current health reform initiative starting with the bogus need for a public option, but comparative effectiveness research and its possible outcomes is not one of them.

It depends on your point of view and where you are pointing

23 Aug
We voted for Ralph

We voted for Ralph

I find politics and politicians a fascinating subject, almost as fascinating as finding the meaning of life although I suspect that some day we will find that the latter has an easier resolution.  In any case, there are those who are far better at deciphering political behavior than I.  In this case, it happens to be pointed at the Democrats, but I am certain there are those equally qualified to point a finger in the other direction.

Plug It in Plug It In

22 Aug


I rushed out of the house the other day and when I went to use my cell phone the battery was dead, I forgot to plug it in.

My coffee this morning was non-existent, I put the grounds in the pot, added the water, turned it on…but it was not plugged in.

My Kindle died in the middle of an exciting editorial in the New York Times (ok, I am kidding about that part), I forget to plug it in the night before.

I have a plugging it in problem, I admit it.

My grandfather drove Thomas Edison's first electric car from Maine to New Jersey and that's the truth

My grandfather drove Thomas Edison's first electric car from Maine to New Jersey and that's the truth

Now I am thinking to myself, what if I had to plug in something really important LIKE MY CAR.  Oh my, those of us with plugging it in problems really will have a problem, especially when you need an eight-hour lead-time.  It is a good thing I am retired or I could see me standing in front of the boss.  “Sorry I’m six hours late, I didn’t get a full charge last night.”  And, just imagine if the power goes out for a few hours in the evening, do you think they will put one of those cranking starting things in the front of the car?

By the time I get home this milk will be cocttage cheese

By the time I get home this milk will be cocttage cheese

I can just hear it now, “Dear will you run to the store for some milk?”  What’s my excuse for not going, I forgot to plug in the Volt?  She will never buy that; I will actually be running to the store it seems.

Look I can handle my iPhone ®, Blackberry ®, my Kindle®.  I’m a hip seasoned citizen, but plugging in my car, real men are not meant to plug in cars.  I am curious about one thing, we hear it takes several hours to recharge an electric car and we hear one of the problems with expanding the use of electric cars is the shortage of “filling stations.”  So, what I want to know is if my car needs to stop at one of these new plug in stations to recharge will it now take me 16 hours to drive to Cape Cod instead of the normal 5?  What am I going to do while I wait for my car to charge on the road?

There is one bright spot in all this, the Howard Johnson restaurant business model will be back in vogue because people will have plenty of time to dine and sample twenty –eight flavors while they wait for their car to charge.  Let us just hope they don’t put those plug in stations at the mall.

Do we have a conflict of interest here or just a mixed message?

21 Aug


Do you recognize any of these insurance companies?  These are some of the organizations that cause health care costs to be so high, that have low loss ratios, the ones who need more competition from a public plan, the ones who have high administrative costs and are inefficient…oops,

this is actually a list of the organizations that process Medicare claims too.


Sorry, please call our single number, explain the problem to them and they will explain it to us and then someday someone will get back to you

Sorry, please call our single number, explain the problem to them and they will explain it to us and then someday someone will get back to you























However, if you are on Medicare do not try to call them about a claim problem, they don’t take calls. Imagine if you told your employees they could no longer call your health plan with a claim problem

If you want a donut hole after 2011, you will have to go to Dunkin Donuts (r)

21 Aug


Thank heaven I will soon be "hole" again

Thank heaven I will soon be "hole" again

Buried within the current version of HR 3200, the House health care reform bill, is the gradual elimination of the so-called donut hole for prescription coverage under Part D of Medicare.  You know, that is the program where there was no coverage for prescription drugs, coverage was added, but with limited benefits so the participants got a raw deal.  In any case, following is a cut and paste from the legislation.  While I sympathize with seniors who rely on this coverage, is a health care reform bill that is supposed to control costs the place to add substantial additional costs especially to a program that is already headed for financial disaster?  

Isn’t it curious that there has been virtually no coverage of this section of the legislation?  On the other hand, it could also be because no one is able to decipher what the heck they are saying



20  GAP.—

21 ‘‘(A) IN GENERAL.—For each year begin

22  ning with 2011, the Secretary shall consistent

23 with this paragraph progressively increase the

24 initial coverage limit (described in subsection

25 (b)(3)) and decrease the annual out-of-pocket

VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00355 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC


1 threshold from the amounts otherwise computed

2 until there is a continuation of coverage from

3 the initial coverage limit for expenditures in

4 curred through the total amount of expendi

5 tures at which benefits are available under

6 paragraph (4).


8 LIMIT.—For a year beginning with 2011, the

9 initial coverage limit otherwise computed with

10 out regard to this paragraph shall be increased

11 by 1⁄2 of the cumulative phase-in percentage (as

12 defined in subparagraph (D)(ii) for the year)

13 times the out-of-pocket gap amount (as defined

14 in subparagraph (E)) for the year.


16  ET THRESHOLD.—For a year beginning with

17 2011, the annual out-of-pocket threshold other

18 wise computed without regard to this paragraph

19 shall be decreased by 1⁄2 of the cumulative

20 phase-in percentage of the out-of-pocket gap

21 amount for the year multiplied by 1.75.

22 ‘‘(D) PHASE–IN.—For purposes of this

23 paragraph:

VerDate Nov 24 2008 12:51 Jul 14, 2009 Jkt 000000 PO 00000 Frm 00356 Fmt 6652 Sfmt 6201 C:\TEMP\AAHCA0~1.XML HOLCPC



AGE.—The term ‘annual phase-in percent

3 age’ means—

4 ‘‘(I) for 2011, 13 percent;

5 ‘‘(II) for 2012, 2013, 2014, and

6 2015, 5 percent;

7 ‘‘(III) for 2016 through 2018,

8 7.5 percent; and

9 ‘‘(IV) for 2019 and each subse

10 quent year, 10 percent.


12  CENTAGE.—The term ‘cumulative phase-in

13 percentage’ means for a year the sum of

14 the annual phase-in percentage for the

15 year and the annual phase-in percentages

16 for each previous year beginning with

17 2011, but in no case more than 100 per

18 cent.


20  purposes of this paragraph, the term ‘out-of

21 pocket gap amount’ means for a year the

22 amount by which—

23 ‘‘(i) the annual out-of-pocket thresh

24 old specified in paragraph (4)(B) for the


1 year (as determined as if this paragraph

2 did not apply), exceeds

3 ‘‘(ii) the sum of—

4 ‘‘(I) the annual deductible under

5 paragraph (1) for the year; and

6 ‘‘(II) 1⁄4 of the amount by which

7 the initial coverage limit under para

8 graph (3) for the year (as determined

9 as if this paragraph did not apply) ex

10 ceeds such annual deductible.’’.

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