Rod Blum, David Young lie to cover for reversal on health care bill

All three Iowa Republicans helped the American Health Care Act clear the U.S. House on May 4 with only one vote to spare. Representative Steve King (IA-04) has long called for repealing the 2010 health care reform law “root and branch” and came around to supporting the GOP replacement proposal in March. So nothing about his vote was surprising, aside from his awkward description of how former Representative Michele Bachmann’s “finger joined mine today to push my vote button to dismantle” Obamacare.

Unlike King, Representatives Rod Blum (IA-01) and David Young (IA-03) made a big show of opposing the AHCA in March. Blum pledged to insist on lower costs for consumers and helping “people who need the help.” Young repeatedly promised to protect people with pre-existing conditions while making sure the bill wouldn’t bring back caps on health benefits.

Feigning concern about the legislative process, Blum said in March, “I believe Congress should slow down and discuss in an open and transparent manner” how to address the “unsustainably high cost of healthcare in America.” Similarly, Young warned, “The ACA [Affordable Care Act] was rushed through Congress and to President Obama’s desk which resulted in a failed law that does not work for everyone [….] It is a fundamental principle that repeal, reforms and fixes to healthcare are done in the right way, for the right reasons, and in the right amount of time it takes to ensure we avoid the mistakes of the past. We need to be thoughtful and deliberate and get this right […].”

Over the past week, Blum studiously avoided comment as GOP leaders sought ways to give members cover for caving. Young’s staff told hundreds of callers he was still against the bill, even as late as Wednesday morning. The same day, he signed on as co-sponsor of an amendment that “comes nowhere close to meeting Republican commitments to people with pre-existing conditions.”

Self-styled deficit hawk Blum and “affordable for every patient” Young proceeded to vote for the bill without waiting for a Congressional Budget Office score to tell them “how many people it covers or how much it would cost.” It wasn’t the first time Young reversed his position on a matter of principle to please his party leaders.

In their comments on the House vote, Young and Blum tried to take credit for imaginary improvements in the AHCA. Their claims can’t withstand scrutiny.

FALSE PROMISES ON PREMIUMS AND PRE-EXISTING CONDITIONS

To read Thursday’s news releases from Blum and Young, you’d think every Iowan would be better off under the AHCA. Here’s the full statement from Blum (emphasis added):

Dubuque, IA – “Obamacare is collapsing. In Iowa the two largest insurers have already announced their departure from the market, and the third and final insurer is on the verge of leaving as well. This could leave over 70,000 Iowans with zero options for health insurance – it’s clear that something needs to be done.

The AHCA will stabilize the market, lower premiums for Iowans, increase choices, reduce taxes, and protect people who have pre-existing conditions. I withheld my support – against the wishes of my own party – until changes were made to ensure that premiums would come down and that we would take care of those who need help by setting aside over $120 billion to assist citizens with pre-existing conditions. After years of higher costs, fewer choices and broken promises under Obamacare, it’s time to enact a better system that actually works for Americans.”

Young made equally grand claims (emphasis added):

WASHINGTON, D.C. – My principles for strengthening health care have always remained the same. For a measure to receive my support it would have to achieve accessible, affordable and quality health care that works for all patients – not just some.

When the House’s health care proposal was first introduced, I announced I could not then support the bill as it was written. Over the past several weeks, the bill improved and was headed in a more promising direction, but still not something I could have supported.

Following today’s adoption by the House to support and include an amendment I cosponsored and worked on making health care costs lower for Iowans with pre-existing conditions – even lower than they pay under the current Affordable Care Act law – the health care bill satisfied the essential principles I hold on strengthening health care and I voted to move this critical issue and process forward.

This is not the final bill, but a first step and I’m committed to continue working to advance policies and solutions improving health care for all Iowans – not just some.

No health care policy expert agrees that the amendment Young co-sponsored would provide even minimal coverage for all Americans with pre-existing conditions, let alone at a lower cost than under current law. Avalere studies the health care system. Here’s what senior manager Chris Sloan had to say (emphasis added):

Approximately 2.2 million enrollees in the individual market today have some form of pre-existing chronic condition. Under the AHCA, states would be able to apply for a waiver to allow medical underwriting of individuals who do not maintain continuous coverage (i.e., let their insurance lapse for 63 days), provided the state sets up a program to provide some form of financial assistance to help high risk individuals or health plans who cover them. Medical underwriting based on health status would likely make health insurance coverage unaffordable for those individuals with pre-existing conditions, who would then require some form of public financial assistance. […]

The AHCA allocates $15 billion over nine years for states to establish high risk pools and cover patients who are underwritten, denied coverage, or unable to afford coverage as the result of that underwriting. The recent Upton amendment added $8 billion over five years to the Patient and State Stability Fund to assist with premiums and cost sharing for individuals with pre-existing conditions. Allocating this money equally over their timeframes provides $3.3 billion in funding for 2019, the first year such waivers would be available. This amount of money will only cover approximately 110,000 individuals with a pre-existing chronic condition.

Finally, the AHCA creates a $100 billion Patient and State Stability Fund. Funding is allocated to states per their share of insurance claims. The AHCA provides states with a variety of options for how to use the funds, including the creation of high risk pools. Under the AHCA, $15 billion of this fund is distributed to states in 2019. This amount of money, were it all allocated to covering individuals with a pre-existing chronic condition, will only cover 600,000 individuals.

The number of Americans with pre-existing conditions may vastly exceed the 2.2 million Avalere assumed. A Kaiser Family Foundation analysis published in December found,

27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA [Affordable Care Act] underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage.

The Kaiser Foundation data suggest that 24 percent of non-elderly Iowans, approximately 448,000 people, have some condition that could have been used to decline insurance coverage before the current health care reform law went into effect. Wellmark Blue Cross/Blue Shield used one emergency room visit for a routine childhood illness as an excuse to deny coverage to my friend’s son for all respiratory aliments for four years.

Speaking to Tom Murphy of the Associated Press, the Kaiser Foundation’s Larry Levitt said that under the AHCA, “Many people with pre-existing conditions will have a hard time maintaining coverage because it just won’t be affordable.”

Aviva Aron-Dine of the Center on Budget and Policy Priorities noted that the extra $8 billion “would restore less than 1 percent of the nearly $1 trillion the House bill cuts from programs that help people afford coverage.”

Moreover, according to news accounts, the additional funding would be available only to states that sought federal waivers of protections for people with pre-existing conditions.[3] If so, the new funding would create even stronger incentives than the current bill for states to drop these protections. That could make the bill even worse than before for people with serious health needs. […]

Some 84 percent of people age 55-64 have pre-existing health conditions.[8] Under the House bill, insurers could charge older consumers premiums that are five times higher than younger consumers, and older people would also receive smaller subsidies than they do today to help them afford insurance. For example, a 60-year-old woman with $22,000 of annual income who faced the national average benchmark premium would pay $8,200 more in premiums after tax credits than she does now.[9] The Congressional Budget Office projects that uninsured rates for people age 50-64 would double due to the House bill.[10]

Moreover, high-risk pools are only intended to serve those with the most serious health conditions. Many older people have pre-existing conditions like hypertension and asthma that likely would not qualify for high-risk pools.

By the way, Americans with employer-provided health insurance would not be fully protected for pre-existing conditions either, because the new AHCA would allow states to seek a waiver from a ban on lifetime caps for coverage. Welcome back to the days when cancer patients or those with expensive chronic conditions declared bankruptcy after exhausting lifetime limits of $1 million or $2 million.

Even the president of the health insurance industry’s trade group said after the House vote that the AHCA

needs important improvements to better protect low- and moderate-income families who rely on Medicaid or buy their own coverage. We stand ready to work with members of the Senate and all policymakers, offering our recommendations for how this bill can be improved to ensure the private market delivers affordable coverage for all Americans.

[…] The tax credit should be enhanced to reduce premiums and better meet the needs of people with low and modest incomes, are older, or live in areas with high health care costs.

Republicans often point to rising deductibles as proof of Obamacare’s flaws, but the Kaiser Foundation calculated that “the average deductible for a typical plan in the non-group market under the GOP plan would be about $1,550 higher in 2017 than it would have been under the Affordable Care Act.”

PRETENDING NOT TO KNOW IOWANS WOULD LOSE COVERAGE

Explaining why they could not support the AHCA in March, Blum said the bill “doesn’t do enough to lower premiums for hardworking Americans,” and Young called for a “common sense solution” that makes health insurance “affordable for every patient.”

The amendments that brought them and others on board didn’t change one of the Republican plan’s biggest shortcomings: insurance companies would be allowed to charge much higher rates to older policy-holders. Health care reporter Sarah Kliff wrote for Vox,

The Congressional Budget Office estimates that the average 40-year-old who earns $26,500 would see her tax credit fall from $4,800 to $3,650 under AHCA.

For an older Obamacare enrollee, the problem would be even more acute, because insurers would be allowed to charge the oldest enrollees five times as much as the youngest enrollees. This would have the result of raising premiums for Obamacare enrollees in their 60s.

CBO estimates that a 64-year-old earning $26,500 would see their annual tax credit decline from $13,600 to $4,900. The amount they pay out of pocket for their premiums, meanwhile, would go up from $1,700 in annual premiums under current law to $14,600 under AHCA. Right now, with the tax credit, that person spends very little of her own money on a premium. Under the new bill, she’d spend nearly half her annual income on health insurance.

The latest version of the AHCA doesn’t fix this problem, which is why the AARP, American Medical Association, and two major hospital groups all denounced the GOP bill. From an April 27 story by CNN’s Tami Luhby,

“Although the MacArthur amendment states that the ban on pre-existing conditions remains intact, this assurance may be illusory as health status underwriting could effectively make coverage completely unaffordable to people with preexisting conditions,” the AMA wrote in a letter Thursday to House Speaker Paul Ryan and Minority Leader Nancy Pelosi.

AARP slammed the amendment, saying it would put in place “backdoor cuts” to the protections and would create an “age tax.”

“This harmful legislation still puts an Age Tax on older Americans and puts vulnerable populations at risk through a series of backdoor deals that attempts to shift responsibility to states,” the influential lobbying group said in a statement Wednesday. “Older Americans need affordable health care services and prescriptions. This legislation still goes in the opposite direction, increasing insurance premiums for older Americans and not doing anything to lower drug costs.” […]

The hospital groups — the American Hospital Association and America’s Essential Hospitals — both voiced concerns that the amendment would not lessen the number of people expected to be left uninsured under the Republican bill. The Congressional Budget Office analysis of the original legislation found that 24 million more people could be left without coverage by 2026.

David Cutler and Emily Gee of the Center for American Progress tried to calculate in March how many people in each U.S. House district would lose coverage. (Click here to read their methodology.) Their best guess: the AHCA would cause a net loss of insurance coverage to 41,000 residents of Iowa’s first Congressional district, 43,800 people in IA-02, 45,400 in IA-03, and 40,900 in IA-04.

In addition to older people subjected to skyrocketing premiums, the group of newly uninsured Iowans would include many Medicaid recipients. From Aron-Dine’s analysis (epmhasis in original):

The House bill would cap and cut federal funding for virtually the entire Medicaid program, setting annual limits on federal funding per-enrollee that would grow more slowly than the need for that funding would rise, forcing states to make deeper cuts in their Medicaid programs with each passing year. Faced with these large cuts in federal Medicaid funding, many states would have to cut home- and community-based services, an optional Medicaid benefit that most states already limit based on available funds. These services, which include nursing and home health care and help with chores, meals, transportation, and other services, let people with serious health problems remain in their homes instead of having to be placed in a nursing home. Under the House bill, tens of millions of people with disabilities, seniors, and children with special health care needs and disabilities – all of them people with pre-existing conditions – would face the risk of losing coverage or going without needed care as states scaled back eligibility, covered benefits, and provider payments over time.

Here, as well, no adjustment that House Republicans make to the bill for people getting coverage in the individual market could resolve this: millions of Medicaid enrollees with pre-existing conditions would still be at substantial risk of losing critical health services.

Low-income people are among the biggest “losers” under the GOP bill, Kliff pointed out.

The bill would end the Medicaid expansion in 2020, a program that millions of Americans who earn less than 138 percent of the poverty line (about $15,000 for an individual) currently rely on. The end result would be that people eventually get moved into the individual market, where they would have to pay for private insurance coverage. They would get some help from AHCA’s tax credits, but likely not enough to afford to purchase a plan — keep in mind, these are people who are only earning $15,000 or less per year.

In addition to threatening health care, Medicaid cuts would likely reduce access to special education in public schools. Erica Green reported for the New York Times,

The new law would cut Medicaid by $880 billion, or 25 percent, over 10 years and impose a “per-capita cap” on funding for certain groups of people, such as children and the elderly — a dramatic change that would convert Medicaid from an entitlement designed to cover any costs incurred to a more limited program.

AASA, an advocacy association for school superintendents, estimates that school districts receive about $4 billion in Medicaid reimbursements annually. In a January survey of nearly 1,000 district officials in 42 states, nearly 70 percent of districts reported that they used the money to pay the salaries of health care professionals who serve special education students. […]

The ability of school systems to provide services mandated under the federal Individuals With Disabilities Education Act would be strained. The law is supposed to ensure that students with disabilities receive high-quality educational services, but it has historically been underfunded.

Under a little-noticed provision of the health care bill, states would no longer have to consider schools eligible Medicaid providers, meaning they would not be entitled to reimbursements.

“School-based Medicaid programs serve as a lifeline to children who can’t access critical health care and health services outside of their school,” said the letter sent this week by the Save Medicaid in Schools Coalition, which consists of more than 50 organizations, including the American Civil Liberties Union, the Disability Rights Education and Defense Fund, and the School Superintendents Association.

Meeting with some knowledgeable and concerned constituents two weeks ago, Young tap-danced around questions about how the AHCA would affect Iowans who benefited from our state’s version of Medicaid expansion. That neither he nor Blum mentioned Medicaid in their May 4 statements suggests they are well aware the House bill would be terrible for some of the most vulnerable people they represent.

DOWNPLAYING A “MASSIVE TAX CUT FOR THE RICH”

Given the AHCA’s horrendous provisions, why would anyone support this “act of monstrous cruelty”?

Many commentators have noted that this bill is not so much a health care plan as a “massive tax cut for the rich, paid for by destroying health care for others.”

In their public statements about Thursday’s vote, Blum mentioned the AHCA’s tax provisions only in passing and Young not at all.

That’s because very few residents of Iowa’s first and third Congressional districts would benefit from “$600 billion in tax cuts that would save the wealthiest 0.1 percent of Americans, on average, $200,000 each.” Brandon DeBot explained in March that the AHCA “would eliminate, for 2017, two taxes that fall only on high-income filers: the additional Hospital Insurance (HI) payroll tax on high earners and the Medicare tax on unearned income.”

Repealing these taxes a year earlier would:

• Benefit only individuals with incomes above $200,000 and couples with incomes above $250,000 on top of the $275 billion in tax cuts over ten years that the Joint Committee on Taxation estimates they would have received starting in 2018 under the prior version of the bill, while doing nothing for low- and moderate-income people.

• Provide billions of dollars in the additional year of tax cuts for millionaires, who would receive 80 percent of the benefit and tax cuts of nearly $50,000 on average in 2017, the Tax Policy Center estimates. (See chart.)

• Provide another year of tax cuts of about $7 million apiece for the 400 highest-income households, we estimate using Internal Revenue Service statistics.

To visualize just how badly Iowa’s Republicans voted to gouge their non-wealthy constituents, here’s a chart drawing on data from the Urban Institute’s Health Policy Center and the Urban-Brookings Tax Policy Center.

If you’re a House Republican, the less said about that screw job, the better.

“IS THIS BILL GOOD? NO”

Not all House Republicans who flipped from “no” to “yes” on the AHCA were as dishonest as Blum and Young. Some admitted they just wanted a political victory and to kick the issue over to the Senate. Martha McSally of Arizona (a member of the “Tuesday group” of fake GOP moderates) “stood up in GOP conference meeting and said let’s get this ‘f*cking thing’ done.” Freedom Caucus member Mo Brooks of Alabama: “I would prefer to have it scored [by the CBO], but more than that I want it to pass.”

Paul Kane reported for the Washington Post,

“This bill is highly imperfect, imperfect, okay? There’s no doubt about that,” Rep. Mario Diaz-Balart said after supporting the legislation.

The Florida Republican — who represents a competitive district — waited until the last 24 hours to come on board. He cited conversations with senators who vowed to address his concerns about how to handle the tens of thousands of his constituents who are signed up for the ACA insurance exchanges.

“Is this bill good? No, I don’t like it,” Diaz-Balart said. But he suggested that voting for the bill would allow him to be part of future negotiations: “So my decision was, how do I stay involved?” […]

[Carlos] Curbelo [of Florida] held out until Thursday afternoon to decide how he would vote. […] Like many other late-deciding Republicans, he placed his bet on the Senate after conversations with Sen. Marco Rubio (R-Fla.) about his concerns that the tax credits in the House bill are not generous enough to help older workers who aren’t yet eligible for Medicare.

“I want as much of a guarantee as I can get from Senate offices that is a major priority, and that it’s going to get done,” he said Thursday morning.

Every House member who voted for this bill deserves contempt, but at least some admit they made the call based on political expedience rather than substance.

Meanwhile, Blum and Young push a fairy tale about lower costs and full protection for people with pre-existing conditions.

BUT WHAT ABOUT IOWA’S FAILED MARKETPLACE?

To bolster their case for replacing Obamacare, Blum, Young, House Speaker Paul Ryan, and other prominent Republicans cited the implosion of Iowa’s individual health insurance market. None of the companies selling individual policies in most of the state will stay here for 2018. Some 70,000 people including my family could be left with no way to purchase health insurance.

Nothing in the AHCA solves that problem.

Nothing in the bill would make Iowa more attractive for the two companies that already confirmed plans to pull out, or for the third which has one foot out the door. The health insurance industry recognizes that this bill wouldn’t stabilize the market.

Some of the problems on the Iowa exchange stem from one individual whose medical care costs $1 million per month. No company can make a profit covering him.

Rates have to be high enough to cover this individual’s costs. […] If they set their rates low enough to be attractive to healthy people, they lose money on the catastrophic expected claims. If they set the rates high enough to cover a $12,000,000 claim, no one buys their product.

In other words, “This has made the entire state an undesirable market for health plans, which know that if they’re the last man standing, they will end up with that extremely high-cost patient.”

Also worth noting, but rarely acknowledged in coverage of the marketplace collapse: if Iowa House Republicans and Governor Terry Branstad had agreed to create a fully state-run insurance exchange, as state Senate Democrats and Iowa’s then insurance commissioner Susan Voss proposed, the Iowa Insurance Division would have had the authority force companies controlling a certain percentage of the market to offer policies there. Wellmark Blue Cross/Blue Shield has a near-monopoly in our state, but the insurance commissioner can’t require the company to participate, because Republicans refused to establish a state-run exchange.

Wellmark’s refusal to sell policies on the new exchange hurt the non-profit cooperative created for Iowa and Nebraska. That venture failed partly because its members were sicker than anticipated and partly because Congress rescinded most of the promised funds to support the new health insurance co-ops envisioned under the Affordable Care Act.

POSSIBLE POLITICAL FALLOUT

Nate Silver commented on May 4, “Academic studies found that [Democratic] incumbents who voted for Obamacare lost 10-15 points of vote margin in the 2010 midterms. A massive effect.” Silver added, “although Obamacare was an unpopular bill, the AHCA is really, really, REALLY unpopular.”

According to this Roper Center analysis of polling data, the AHCA has the lowest support among more than a dozen major bills Congress has approved since 1990.

Blum and Young won re-election in 2016 with 53.7 percent and 53.4 percent of the vote, respectively. A shift on the scale of what House Democrats experienced in 2010 would threaten their careers. Both IA-01 and IA-03 will be targeted races next year.

Democratic challengers appear ready to make health care a central part of their case.

Blum’s opponent Courtney Rowe posted on Facebook yesterday,

#Blum, who told Iowans last month that the reason he did not support the #AHCA in April, was because he wasn’t sure it would save Iowans money and didn’t think the bill should be rushed. He just voted yes on this bill, which was rushed through the House, before the CBO (Congressional Budget Office) could make a report on the cost/savings of this bill. The CBO’s early indications are that over 20 million people will loose their healthcare, and that millions of our poorest Americans will pay more money for healthcare. #IA01
This bill strips protections for pre-existing conditions, makes being a woman a pre-existing condition, strips coverage for mental health care, and strips care for veterans.
Iowans in district 1 deserve better than a bold face liar.
Here’s a link to his vote:
https://www.nytimes.com/…/house-vote-republican-health-care…
Here’s a link to his press release in April:
https://blum.house.gov/…/congressman-blums-statement-pullin…
Make sure you register for his town hall. You can’t enter without preregistering and bringing a photo ID with the correct address, because he is afraid of the people living in his district.
https://blum.house.gov/about/events

Blum’s other declared challenger, Abby Finkenauer, released this statement:

FINKENAUER: “Taking healthcare away from 24 million Americans is why Rod Blum should no longer represent the 1st District in Congress.”

Dubuque, IA – Following today’s vote by Rep. Rod Blum on the latest Republican plan to repeal the Affordable Care Act, Abby Finkenauer released the following statement:

“Rod Blum has shown Iowans exactly where his priorities are – with drug companies and insurance executives. This unconscionable plan hurts regular Iowans. It puts an Age Tax on our seniors and will pull the rug out from under thousands of Iowa families – many with pre-existing conditions – who are one healthcare emergency away from financial ruin. Taking health care away from 24 million Americans is why Rod Blum should no longer represent the 1st District in Congress.”

The Republican Health Care Bill would result in:
· 24,000,000 Americans losing health care coverage
· States being allowed to end essential health benefits
· Insurance companies will be allowed to charge more for pre-existing conditions
· A woman who completed her pregnancy with minor or no complications could see a whopping $17,320 premium surcharge.
· Experts have concluded a 40-year-old with Asthma could be saddled with a $4,340 premium surcharge.
· Diabetes without complications could cost a 40-year-old individual $5,600.

Pete D’Alessandro, who is exploring a campaign in IA-03, commented after the House vote,

This afternoon David Young made clear what many Iowans in the Third District already know: He is willing to place the needs of corporations and the wealthiest amongst us ahead of what’s best for his constituents that depend on quality and affordable health care coverage. Instead of standing up for the hardworking Iowans who have real healthcare needs, David Young has once again shown an utter disregard for them. The only thing this bill accomplishes is higher premiums for working Iowans and an increase in those without healthcare coverage.

Steve King never pretended to be committed to preserving any part of the Affordable Care Act. Blum and Young did, which makes their betrayal of Iowans even more reprehensible.

UPDATE: The Cook Political Report changed its rating on IA-03 from “likely Republican” to “lean Republican.” The AHCA vote prompted revised ratings in 20 districts, because “House Republicans’ willingness to spend political capital on a proposal that garnered the support of just 17 percent of the public in a March Quinnipiac poll is consistent with past scenarios that have generated a midterm wave.”

  • Don't wait, start running attack ads now

    I think Iowa Democrats should start running ads now to label republicans like Blum and Young. There’s no challenger yet that they can respond to. The airwaves are free of other political ads, so it won’t be as likely to get drowned out. It’s early enough in the process that if Democrats can sway public opinion of these candidates now, those ill feelings may stick for the folks who don’t otherwise pay much attention until right before an election. Negative impressions of people tend to stick.

    Imagine an ad with a mother w/ a pre-existing condition talking about her reliance on the ACA. Video of her going about her day (making breakfast, playing with her kids, getting ready for work), all while she narrates about the impact of her illness and her fear of losing health insurance. Or parents of a child cancer survivor talking about their fear that the cancer could return and bankrupt them. Imagine an ad that ends with the patient saying that, for David Young or Rod Blum or even Steve King, the only value their life had was to provide a tax break for an already obscenely wealthy person. It may sound harsh, but that’s the reality for millions of people in this country. They’re scared to death, and the ads this upcoming cycle need to reflect that because for people who have good insurance, that’s a hard concept to understand. Sorry for the long fake commercial, but messaging and videos are kind of what I do 🙂

  • Japanese system

    I know a Japanese-American family of four who have lived in Japan for forty years and used the Japanese health care system. It’s not perfect by any means. But Japanese citizens don’t live in terror that they’ll lose access to health care.

    One member of the family needed an eye operation. He shared a modest hospital room with three other patients. But his surgery was good and paid for by the system.

    I wonder if anyone has ever measured the psychological security of knowing that one lives in a country where everyone has access to at least moderately-good health care, whether one is rich or poor. Conversely, I wonder if anyone has ever measured the stress of living in a country where that is not the case.

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