tag:blogger.com,1999:blog-15091878410336286602024-03-16T11:53:04.526-07:00Medicine and Social JusticeMy book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global prioritiesJosh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.comBlogger604125tag:blogger.com,1999:blog-1509187841033628660.post-20399866427921711852024-03-07T09:22:00.003-07:002024-03-07T09:22:35.827-07:00"Health care" Corporations are Evil. Most of the people who work for them are not. Fight back!<p><span style="font-family: verdana;">Usually, when I write a blog post, I start with something
that has happened or is happening, try to develop it and point out the
relationships between it and other things that are happening. Toward the end I
make an effort to form a conclusion, and, perhaps even make suggestions as to
how the problem(s) might be addressed. However, today I think I’ll lead with
the conclusion, so folks do not have to read too far: <br /></span></p>
<p class="MsoNormal"><i style="font-family: verdana;">All of the US healthcare industry (not system) is run by
corporations that are effectively evil.* They function for only one purpose: to
suck as much money, in the form of profits, stock price, and executive salaries
(the executives, who are people, are of course evil) from our economy under the
false flag of providing health care. They care not one whit about the health of
people, society, or community, nor about decency. They include insurance companies,
large hospital systems and provider groups (often owned by insurance companies
and -- the exemplar of morality-free rapacious profit -- private equity),
pharmaceutical companies and device companies, the large pharmacy chains (e.g.,
Walgreen’s, CVS) and the PBMs (pharmacy benefits managers) that control drug
distribution. </i></p>
<p class="MsoNormal"><span style="font-family: verdana;">*[I do not believe that corporations are people, despite the
scandalous Citizens United decision that decided that they were and that money
is speech, so are without human characteristics.]</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">I could end it there, and say “if you have any questions,
read my previous blogs, and the references I cite”, but I will go to talk about
a few recent events and actions that bolster this case. First, however, I want
to talk about people, the people who work in health care, the people who the
other people (called “patients”) seeking health care actually run into. Almost
uniformly, they are not the problem. From the higher-paid physicians and other
clinicians, including nurses, who provide clinical care, to the pharmacists and
pharmacy assistants who dispense medications, to those who answer the phones,
schedule appointments, take questions to be transmitted to the clinicians, and
even collect money, these are overwhelmingly hard-working people trying to do a
good job of serving you. They are almost all employed, however; even about 75%
of physicians (and growing) are employed by corporations. If your doctors seem
rushed and not to have enough time for you, if they are focused on computer screens,
if they don’t quickly call you back, this is not their choice, it is the mandate
of the corporation that employs them. It is essentially the same as the
traditional “speed up” for assembly line workers: to be “more efficient”, a euphemism
for “making more money for the corporation”. The same is true for the clerks
who may take a lot of time to answer the phone, or who are “unwilling” to cut
you some slack on your bill (when really they do not have the power to), or the
pharmacist who takes “too long” to fill a prescription or provide you with the
information that you need. These are, by and large, good people trapped in a
heartless system. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And, yet, because these are the people –physicians, nurses,
pharmacists, clerks – whom we, as patients, see and interact with, they are the
ones on whom we take out our frustrations when we feel we are not being treated
as we should be. When we are denied care when we are late because the bus was
delayed, or because we had to get our children off to school but the early
appointment was the only one available, or because we don’t get off work until
4:15 but the 3:30 appointment was the last available. Yes, like the rest of us,
all these people in healthcare want to work reasonable hours and get home on
time, but the rules that they are required to enforce are not made by them.
They are made by the corporate executives, those who have sold their souls, the
CPAs and MBAs (and occasionally MDs and RNs, but usually those also have MBAs) whose
expertise is in making money for the corporation, not in serving you, and who
are handsomely rewarded for it. They are the people who are responsible and to whom
your anger should be directed, but good luck getting to them. Maybe you can
reach the CEO of a small rural hospital (who will almost never be the real CEO,
since it is probably owned by a large hospital corporation) but not the heads
of the insurance companies and pharmaceutical companies and massive health
systems and private equity owners of all of these. More than the highest Mafia
dons, they are protected by layers and layers of others who keep them from
having to interact with you. But they ARE the evil people (even if, like those
Mafia dons, they are nice to their children), creating, maintaining, and
expanding an industry designed to extract as much money as possible from the
economy and mis-label it “health care”.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The idea that this skates close to the edge of what is legal
is disingenuous. It <i>is</i> often illegal; a huge part of the industry
regularly acts illegally. We want there to be laws against such abuse, but even
when there are they are irregularly, even rarely, enforced largely due to inadequate
funding for the regulators. This is on purpose; those huge corporations have
the money to buy – I mean donate to – congresspeople and also offer high-paid
jobs to former regulators who “behaved” in the revolving door system. And when
the rules are enforced, the fines are relatively low, and are just written off
as a “cost of doing business” <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Examples?</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">How about “<a href="https://kffhealthnews.org/news/article/whistleblower-upcoding-medicare-aledade-lawsuit-aco-accountable-care/?wpisrc=nl_health202">Whistleblower
Accuses Aledade, Largest US Independent Primary Care Network, of Medicare Fraud”</a>,
<i>KFF Health News</i> (March 5, 2024)? Using a practice known as “upcoding”,
the company employs large numbers of people to add additional diagnoses to the
one for which the person is being treated, increasing the reimbursement. This
practice results in greater fee-for-service payment, but is even better (for
the company) in increasing the “capitated payment” that they get for a
particular “covered life”, both in general managed care and in Medicare
Advantage programs. In this case, and in many hospitals, it is the provider who
is fiddling the data to get more money from the insurer (which, in the case of
Medicare Advantage, as well as Medicaid and some other programs, is the government
– that is, you, the taxpayer).</span></p><p class="MsoNormal"><span style="font-family: verdana;">But let’s not cry for the poor insurance companies, although
they would like you to think it is the doctors and hospitals who are at fault
for milking them. Even when something very bad happens, like the <a href="https://www.nytimes.com/2024/03/05/health/cyberattack-healthcare-cash.html">recent
cyberattack at the largest health insurer, UnitedHealth</a>, in which they may
have paid a $22M ransom, it is the providers who are not getting paid. UnitedHealth
is doing just fine, thank you. Not only is $22M not that much for them, but as
pointed out by former insurance executive and current whistleblower<a href="https://wendellpotter.substack.com/p/unitedhealth-group-vulnerable-and">
Wendell Potter in his substack</a></span> </p>
<p class="MsoNormal" style="margin-left: .5in;"><i style="font-family: verdana;">Keep in mind that while the
company is unable to pay thousands of the country’s doctors and hospitals for
who knows how long because of the hack, UnitedHealth will be able to hold on to
billions of dollars in premium income longer, and that will boost its
investment income, which is considerable on any day of the week.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">They have the system covered from all angles. UnitedHealth has
moved into owning practices directly, through Optum, a very large provider and
the source of a big percent of their profit. Along with their Medicare
Advantage products.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Indeed, as providers and insurers point the finger at each
other, and as pharmacies buy up the PBMs that control utilization, increasing
vertical integration, and as private equity companies buy up all of these,
there is one thing that you can be sure of: the benefit to the customer, consumer,
patient, person, society is the one thing not being considered. We are the collateral
damage in the fights among these amoral (at least, really immoral) behemoths. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">What can we do? It often seems like there is not much. Our
feeble cries are drowned out by the corporate contributions to our
congresspeople. But we can let our elected representatives know that we are on
to the abuses by those companies, and that we hold them responsible for holding
(or not holding) the corporations responsible. We can, for example, demand something
specific, that they sign on to the <a href="https://patientsoverprofits.org/">Patients
over Profits </a>pledge (initiated by National Nurses United, NNU, and now
sponsored by many patient and community groups):</span></p>
<p class="MsoNormal" style="margin-left: .5in;"><i style="font-family: verdana;">I pledge to put patients over
profits and not take contributions over $200 from the executives, lobbyists,
and PACs affiliated with the corporate health care industry, including private
insurers, pharma corporations, and private hospitals who are organizing to take
over our health care system.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">They won’t if just a few of us ask. But if LOTS of us do,
they just might.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And that’s a start.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-54891609740174366142024-02-12T09:39:00.003-07:002024-02-12T09:39:53.141-07:00Medicare Scams? The whole US health care "system" is a scam!<p><!--[if gte mso 9]><xml>
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</p><p class="MsoNormal"><span style="font-family: verdana;">In ‘<a href="https://www.nytimes.com/2024/02/09/health/medicare-billing-scam-catheters.html">Staggering
Rise in Catheter Bills Suggests Medicare Scam</a>’, Feb 9, 2024, the <i>NY
Times</i> suggests that up to 20% of federal spending on medical supplies may
be from 7 “high-volume” suppliers of catheters, including people -- like the
woman for whom Medicare paid $12,000 for 2000 catheters -- who don’t need them,
don’t want them, did not order them, and didn’t receive them. If true, this is
a totally illegal scam, something that we see all too frequently in the US,
with criminal parasites preying on our people and on a federal agency hamstrung
by budget cuts to their enforcement divisions. Perhaps “nursing homes” is what
first comes to the minds of many when inflated billing for shoddy care comes to
mind, and that is fair, but our medical supply companies and, of course,
pharmaceutical companies are right there with scams.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Unfortunately, the biggest scam is not the obviously-illegal
like catheter falsifying, but rather the skirting-the-law routine practice of
many (maybe not all) health insurance companies in denying necessary, and sometimes
legally-required, care to their clients. The most common method for doing so is
requiring “prior authorization” and then repeatedly denying it until the client
gets weary of fighting it, or recovers, or, maybe, dies from not having a procedure.
And it is not like these denials are wisely made by qualified physicians sagely
considering the issue; most of them are routinely denied by staff (sometimes,
but not always, nurses) following algorithms. Or, increasingly, by AI. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">I and others (e.g., <a href="https://wendellpotter.substack.com/p/the-great-medicare-advantage-marketing">https://wendellpotter.substack.com/p/the-great-medicare-advantage-marketing</a>)
have written about Medicare Advantage plans several times, which attract seniors
with lower out-of-pocket costs (compared to paying for Medicare Part B + a
supplement) and full coverage, including for some services not covered by Medicare
(glasses, hearing aids, etc.) My main point has been that this is great if you
are willing to use their limited network of doctors and hospitals -- until it
isn’t. Until they deny you care. Which can be illegal because they are required
by law to cover everything Medicare covers. But, using the “prior authorization”
and “repeated denials” techniques, many (maybe not all) often (but not always)
do. This is just as illegal as the catheter scam, but penalties have been
rarely incurred, and when they are, are low enough to be considered a “cost of
doing business”, essentially a slap on the wrist. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But it is not only Medicare Advantage (MA) that uses these
techniques (I’ll call them PA&RD) to effectively deny care to the people
who are paying their premiums. Indeed, the use of these strategies in MA plans
was developed for the insurance companies’ non-Medicare clients, those who have
coverage through employer-based plans or ACA. For a long time, the use of
PA&RD was common, if not ubiquitous, but possibly legal. Unethical, maybe.
Fatal for some, yes. But apparently legal. Some state legislatures stepped in to
prevent these abuses, requiring coverage for certain conditions, such as
diabetes, emergency care or reconstructive surgery for breast cancer. Indeed, <i>‘States
have passed hundreds of laws to protect people from wrongful insurance denials</i>’,
but as documented by ProPublica, ‘<a href="https://www.propublica.org/article/health-insurance-denials-breaking-state-laws">Health
Insurers Have Been Breaking State Laws for Years</a>’. How do they get away with
it? Again, lack of enforcers because of budget cuts and very powerful lobbies
for the insurers (they make lots of money and are careful to spend enough of it
in the “right” places!) Per ProPublica:</span></p>
<p class="MsoNormal" style="margin-left: .5in;"><i style="font-family: verdana;">State insurance departments are
responsible for enforcing these laws, but many are ill-equipped to do so,
researchers, consumer advocates and even some regulators say. These agencies
oversee all types of insurance, including plans covering cars, homes and
people’s health. Yet they employed less people last year than they did a decade
ago. <a href="https://content.naic.org/sites/default/files/publication-sta-bb-volume-one.pdf">Their
first priority is making sure plans remain solvent</a>; protecting consumers
from unlawful denials often takes a backseat.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">What are the results? One is that people stay sick, get
worse, and sometimes die from lack of health care. I hope we can agree that is
a bad thing. Another is that people are going broke more and more often from trying
to pay the bills that their insurance companies don’t (yes, those insurance
companies that they and/or their employers have been paying premiums to). The recent
study by KFF Health News and NPR, reported in the<i><a href="https://www.theguardian.com/us-news/2024/jan/11/hospital-debt-increase-people-with-insurance">
Guardian</a></i> and the <a href="https://healthjusticemonitor.org/2024/01/18/most-medical-debt-now-from-the-insured/">Health
Justice Monitor</a> and discussed by me recently (<a href="https://medicinesocialjustice.blogspot.com/2024/01/er-backups-and-poor-quality-but.html">ER
backups and poor-quality but expensive insurance: The American Way!</a>, Jan
24, 2024), but worth repeating, found that more than <b><i>100 million </i></b>Americans
have medical debt. More shockingly, (as reported by Kodiak Solutions, a billing
and accounting firm that covers 1800, nearly 1/3 of US hospitals) in just 4
short years the proportion of that debt owed by insured people has risen from
11% to 58%! Think about that – way back in 2018 most “bad debt” was owed by uninsured
people (almost all of whom were too low-income to be able to afford it) but by
2022 it was by insured people – meaning insurance companies were not doing what
they were contracted to do – paying people’s medical bills – even when required
to by state law. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">When the bad actions of health insurance companies are combined
with the bad actions of health care providers, now often owned by private equity
companies seeking only profit (see <a href="https://wendellpotter.substack.com/p/massachusetts-wakes-up-to-a-hospital?publication_id=255152&post_id=141494135&isFreemail=false&r=1q48vk">example
of Steward Health Care</a>, or <a href="https://portside.org/2024-02-06/casualties-failed-health-care-system">overcrowded
ERs in Massachusetts</a>, as well as Arizona) it is obvious that get real pain
being is being suffered by – really, inflicted upon -- the American people. On
the other hand, insurers like UnitedHealth (which also operates the largest
chain of physician practices, Optum), and private equity companies like that
which owns Steward Health Care, are doing just fine, thank you, making record
profits.<span style="mso-spacerun: yes;"> </span>And the<a href="https://www.commonwealthfund.org/blog/2023/how-medicare-negotiations-can-avoid-manufacturers-loopholes-and-save-consumers-money">
drug companies finding all the loopholes in laws to charge more</a> and t<a href="https://www.nytimes.com/2024/02/08/us/politics/senate-hearing-drug-prices.html">elling
Sen. Sanders and the health committee that sure they charge American consumers
more for drugs</a>, but, hey, why the heck not, since we’re allowed to here –
and, by the way, don’t change that – are continuing, as they always have, to
make out like, well, bandits, which they have always been. They argued to the
Senate that Americans get access to new drugs first as part of paying more, but
Sen. Sanders appropriately responded that this was of no help to people who
were unable to get the drugs because of their cost! Duh!</span></p><p class="MsoNormal"><span style="font-family: verdana;">There are those who think that the money we pay – in premiums,
taxes, co-pays, etc. – should be spent on delivering health care, not corporate
profits. But so far enough politicians have been willfully deaf and blind on
the issue to prevent really significant change to the system so that (as in
most countries) it does the latter.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">They need to hear from you to tell them that’s what matters.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-32208746754851096842024-01-25T10:04:00.004-07:002024-01-27T08:48:34.957-07:00ER backups and poor-quality but expensive insurance: The American Way!<p><span style="font-family: verdana;">The January 22 edition of the <i>Arizona Star </i>(Tucson) reprinted
a piece from the <i>Arizona Republic </i>(Phoenix) titled “<a href="https://www.azcentral.com/story/news/local/arizona-health/2024/01/20/ers-in-arizona-hospitals-are-extremely-busy-heres-why/72214630007/">'I've
never seen it this busy': Here's why Arizona emergency departments are jammed</a>”.
The article is paywalled, but you don’t really need to read it
since that headline basically is the story: all over the state, including its
two biggest cities, waits for non-emergencies (and sometimes emergencies) in
ERs is many hours to, sometimes, days! The article discusses some reasons,
including the increase this winter in respiratory diseases like flu, RSV, and,
yes COVID (despite everyone pretending it has gone away; see <i>NY Times</i> “<a href="https://www.nytimes.com/2024/01/21/us/covid-rules-california-oregon-cdc.html">California
and Oregon Ease Covid Isolation Rules, Breaking With C.D.C.”</a>). In fact, there
has been a lot of respiratory disease this winter, a<a href="https://yourlocalepidemiologist.substack.com/p/state-of-affairs-jan-23">nd
as reported by “Your Local Epidemiologist”, Katelyn Jetelina, and while it
seems to be declining, there could well be more peaks.</a></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The colder weather makes the most vulnerable, those without
housing, even more vulnerable. Also contributing to the ER backup in Arizona is
the increase in the number of “winter visitors” (also known as “snowbirds”) who
are coming back “after” the pandemic, who are often older and do not have a
regular source of care here. And, yes, also that too many of us who live here
year round do not have a regular source of care because, as in most places,
there are not enough primary care clinicians (see “<a href="https://medicinesocialjustice.blogspot.com/2023/09/primary-care-private-equity-and-profit.html">Primary
Care, Private Equity, and Profit: How to ensure poor quality care for the
American people</a>”, Sept 28, 2023 and “<a href="https://medicinesocialjustice.blogspot.com/2023/12/we-need-more-primary-care-to-serve-our.html">We
need more primary care to serve our people: Why do the medical schools lie?</a>”,
Dec 12, 2023). So people go to the emergency room, or to an urgent care center
where they are told to go to the emergency room “if it gets worse” or, when it
is serious enough, right away. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But there is something else going on here. That is the
breakdown of the American health care system, particularly the insurance system
and the ways people are covered (or not) for health care costs. It is breaking
down at all levels: there are not enough doctors, especially in primary care
(see the blog posts cited above), insurance companies and employers are
covering less and less of the cost of health care and requiring those who have
insurance to pay more and more, and private equity (see the referenced blog
above) has taken over many practices and is squeezing them for maximum profit
without regard to what it does to the quality of the “product”, which is our
health care. Private equity in the healthcare sector follows the same playbook it
follows everywhere: squeeze profit out, diminish services, and if it bankrupts the
company too bad; they already have theirs. And when it is insurance companies
that take over the practices (such as United Health Care owning Optum) the result
is about the same. No one is minding the people-serving part of the store. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Yes, there are plenty of uninsured people, including the
homeless, and those who are “too rich” (hah!) to get Medicaid, which in most
states requires an income far below (often way less than half) the poverty
level (<a href="https://www.medicaidplanningassistance.org/federal-poverty-guidelines/">which
is about $31,000 for a family of 4</a>), and anyway is also, in most states,
pretty much limited to women with small children and virtually never covers
single adults. But there are also the under-insured, those with terrible
insurance coverage because it is all they can afford, <a href="https://healthjusticemonitor.org/2024/01/20/growing-job-based-insurance-premiums-exacerbate-income-inequality/">as
employers cut back on their contributions and insurance companies raise their
rates and the financial burden on the insured including through copays,
deductibles, and denied care (kind of like both raising the price and shrinking
the size of a candy bar, except with much more serious outcomes)</a>. In
addition, the expenditures by employers on health insurance (even when it is inadequate)
is money that is not spent on wages, thereby increasing income inequality,<a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813927"> as
documented recently by Hager, Emanuel, and Mozaffarian in <i>JAMA Open Network.</i></a><i>
</i>And, since health insurance premiums are tax deductible for employers (although
not for employees!) they prefer it to paying higher wages. What is the result
of having insurance that doesn’t pay for what you hoped and expected it would when
you or a family member is seriously ill? You go into debt. So the proportion of
medical debt held by insured people as opposed to “self-pay” (uninsured,
virtually all poor) people,<a href="https://healthjusticemonitor.org/2024/01/18/most-medical-debt-now-from-the-insured/">
has risen from 11.1% to 57.6% in 4 short years, from 2018 to 2022</a>.
Quintupled. The system, to the extent that it can be called a system at all, is
broken.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But why? How? While there are still undoubtedly those,
including politicians, pundits, and health administrators (all of them
WELL-insured, you can be sure!) who blame it on some kind of “overuse” by
patients (the medical word for “people”), there are actually 2 real causes:</span></p><ol style="text-align: left;"><li class="MsoNormal"><span style="font-family: verdana;">Abuse, corruption, and illegal behavior by
insurance companies in pursuit of ever-more profit, and</span></li><li class="MsoNormal"><span style="font-family: verdana;">The failure of government entities to prevent
them from doing so, or to prosecute them when they do.</span></li></ol>
<p class="MsoNormal"><span style="font-family: verdana;">Really? Really. Not only are insurance companies
inadequately regulated, and able to effectively abstain from paying for care by
repeatedly denying it and creating other obstacles, they <i>frequently </i>simply
break the law, <a href="https://nonprofitquarterly.org/is-your-health-insurer-breaking-the-law/">as
documented in a study by <i>ProPublica </i>and reported by the <i>Nonprofit
Quarterl</i></a><i>y:</i></span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>‘The findings point not just to
bad behavior on the part of health insurance companies but also to a failure of
the state regulatory apparatuses that oversee health insurance coverage to
enforce laws already on the books:<span class="apple-converted-space"> …</span></i><i> If explicit laws on the
books, spelling out mandatory coverage requirements, aren’t enough to prevent
insurers from denying coverage, how are ordinary people to push back?</i></span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">The answer, <a href="https://www.propublica.org/article/how-to-appeal-insurance-denials-too-complicated" target="_blank">ProPublica’s Cheryl Clark found</a>, is that those fighting for
their own coverage are forced to navigate a “mind-boggling labyrinth” of
bureaucracies set up by insurers and often barely regulated.”</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">It’s pretty bad, and it’s getting worse. Poor and uninsured
people suffer the most, but employed and insured people are right behind them.
Their medical debt increases in part because they <i>think</i> they have
insurance and actually seek care, rather than avoiding it, as uninsured people often
do. Which is, of course, terrible – how can there possibly be any justification
at all for a “system” that encourages people to not seek care when they are
sick, that provides too few primary care doctors or other clinicians to care
for them, that makes them wait hours or days in ERs to be seen, and then
saddles them with unpayable – but of course credit-destroying -- medical debt
when they do get care?</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Who are the worse criminals? The insurance companies and
private equity firms who directly cause these problems by pursuing only maximum
profit? Or the politicians who allow it to happen, who at best tinker around
the edges, trying to limit (only occasionally with any success) the worst
abuses? Should we run our fire departments like that? Police? The answer is in
part tight regulation, prosecution of abuses and illegal activities including
putting senior executives in prison, and really, finally, creating a universal
coverage system in which each person has good coverage, can get good care, and
be treated as a human being.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Like the executives, politicians and pundits expect for
themselves.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com1tag:blogger.com,1999:blog-1509187841033628660.post-47192130014083935082024-01-06T11:19:00.004-07:002024-01-06T19:52:03.627-07:00Guns good? Depends on what you believe. Guns dangerous? No question.<p><span style="font-family: verdana;">People like guns.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">People hate guns.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">People are scared of guns.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Guns are good for sport, like hunting animals.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Guns are good for war.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Guns are good for self-protection, in case “they” come for
you.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Guns are good for going out and killing other people
because:</span></p>
<p class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>They might otherwise come for you.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>They are bad people because they are:</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">o<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>The wrong religion.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">o<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>The wrong race or ethnicity.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">o<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>Believe in abortion.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">o<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>Are liberals.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 1in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">o<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>Support restrictions on guns.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Guns are bad because they can be and are used for all of the
reasons above.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Whether guns or good or bad or dangerous or not is
irrelevant because “Second Amendment”. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If you like, substitute “automatic rifles” for guns in all
or any of the above.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">All the above are true.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">There are definitely people who are terrified that “they”
will be coming for them.<span style="mso-spacerun: yes;"> </span>“They” could be
the government (except when the government is on their side), or they could be,
you know, “them”, the other. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Probably not for deer hunting; 30 or 40 rounds of high-power
automatic rifle fire can really tear up the meat. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">It could be post-apocalyptic, where they are, like Mad Max,
fighting for survival. They believe that they need thousands of rounds of
ammunition for all their guns (after all, ammo stores might not be open after
the apocalypse) and high-capacity, high-speed automatic weapons are going to be
more effective in protecting themselves and their families from, well,
whatever. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Zombies. Or “them”. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If you believe this stuff, and your social circle and the
sites that you frequent on the Internet completely reinforce these beliefs,
there is no reason to doubt that it is true. Even if you used to not believe
them. (Remember, perfectly rational people from the Midwest have moved to
California and, after some time being among only Californians, have come to think
that it is normative to believe in the healing power of crystals.)</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If you do not believe this stuff, and your social circle and
the sites that you frequent on the Internet completely reinforce your non-belief,
you become convinced that the folks that do are both crazy and deluded. Which
they may be.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If you think that these people watch too many movies and
zombie TV shows, you’re right; the most important FACT is that there will be a much
more limited number of people who are alive to duke it out after a nuclear war;
let’s see, after nuclear winter, roughly ZERO!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If you think that there is a certain cognitive dissonance in
thinking that people on the left are pansy snowflakes and also fearing that
they’ll be coming after the heavily armed folks with the fears, you’re right,
but so what? </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Total logical contradictions have never been a problem for
them in the past (see, e.g., “Donald Trump – Christian”). </span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">There are a lot of folks in the “I
need more guns and ammo” camp who are strongly opposed to mass murder, although
there are pretty many (including in Congress) who are able to make arguments
(sure, weird syllogisms, but hey…) defending folks who go to peaceful demonstrations
with loaded weapons looking for other people to shoot. Charlottesville?
Kenosha? </span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">It is a “prevent defense”, I
guess. There are even more who are opposed to slaughtering children in school
(hardly anyone comes out specifically in favor of that), but are 100% against
any proposal that might make it more unlikely. </span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">Because, you know, if you make
psychotic minors unable to purchase an AR-15 without a waiting period, the next
thing will be government agents confiscating your deer rifle. Or Uzi.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">No one is in favor of school
shootings, but <a href="https://www.nytimes.com/2024/01/04/us/perry-iowa-school-shooting.html">we
have them almost every day</a>. In every state. We look at the news, open the
paper, hear our phones ding, and we see the newest one. And our Congress, and
our state legislatures, all of whom are against school shootings, can’t seem to
do anything to prevent them. Even though we – and they – know exactly what
would do it.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">Make guns very hard to get.
Especially for young people. The brain does not fully mature until at least the
mid-20s and the last part to develop is the frontal cortex where executive
function and judgement reside.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">Especially for automatic
weapons.<span style="mso-spacerun: yes;"> </span>Especially with those with
histories of violence. Yes, crazies but mainly not them. Mostly those who have
or have threatened to use violence. You see, shooting people, especially lots
of people, that may or may not be crazy, but it is for sure violence. Any
abuser of any kind, any barroom brawler, anyone who threatens violence.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">But of course they won’t. Maybe
because it would lose them votes, or maybe they just believe the same things.
Maybe they believe their own stories.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">But, you know, you can kill people
with a knife. Or a baseball bat. Or a garotte. Of course, it is not easy to kill
a whole lot of people from 100 feet away with any of those.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">I would be remiss to not mention
suicide. <a href="https://usafacts.org/data-projects/firearms-suicides">They
constitute the majority of gun deaths</a>. Yes, suicide is an individual’s
choice, but it is not necessarily an unchangeable choice. The “successful”
suicide rate among teens and young adult males 16-24 is TEN TIMES higher in the
states with the loosest gun laws as in those with the most restrictive. Are
young men in, say, Montana more depressed than those in, say, Connecticut? I
don’t know, but <a href="https://www.hsph.harvard.edu/means-matter/means-matter/intent/">suicide
attempts, especially in young people, are very often impulsive, and the easy availability
of a gun makes that impulse easier to follow. And attempts at suicide by gun are
much more likely to be “successful” (called lethality) than those by poison, or
gas, or hitting yourself on the head with<span style="mso-spacerun: yes;">
</span>brick</a>. </span></p><p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">In the US it is often people in poor and minority communities who suffer the most random death. But it is older white men who commit suicide most. Often with guns that they had right there. <br /></span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">If you think we should make guns,
especially automatic weapons, less easily available, especially to those most likely
to use them for killing people, great. But lots of others do not agree. Of
course, they include those most likely to use them for killing people.</span></p><p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0CWEb2HR5Mb1QFCfcjhf-XAVBNbj6KGD7dQQdVqBSr4zbbgsUaEjA3NcU5wt5kwMLAuOW1sLpTyrvPqwNg4Q9gALSZDo0bn3hkg2M1wMgBbZmocskjhQHn8bK9KCR0A0Y4_klkrUvXJb1OyKTlnpWwkeQaodVzlIrFz517j2wGgh2oSElu5tI7lz7poTT/s2199/Gun%20deaths%20international.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1124" data-original-width="2199" height="329" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0CWEb2HR5Mb1QFCfcjhf-XAVBNbj6KGD7dQQdVqBSr4zbbgsUaEjA3NcU5wt5kwMLAuOW1sLpTyrvPqwNg4Q9gALSZDo0bn3hkg2M1wMgBbZmocskjhQHn8bK9KCR0A0Y4_klkrUvXJb1OyKTlnpWwkeQaodVzlIrFz517j2wGgh2oSElu5tI7lz7poTT/w640-h329/Gun%20deaths%20international.JPG" width="640" /></a></div><br /> <p></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">The rest of the wealthy world
could provide an example of what to do, but you know what? They are not
Americans. <a href="https://worldpopulationreview.com/country-rankings/gun-deaths-by-country">A
number of countries have higher gun-death rates than the US, mostly those at
war (e.g., Ukraine) or in the midst of narco terrorism</a>. We are not. </span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">But we have a lot of guns, and
that helps us make up the difference.</span></p>
<p class="MsoNormal" style="margin-top: 12pt;"><span style="mso-no-proof: yes;"><br /></span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2tag:blogger.com,1999:blog-1509187841033628660.post-39544636027640486822023-12-12T08:59:00.001-07:002023-12-12T08:59:22.937-07:00We need more primary care to serve our people: Why do the medical schools lie? (reposted from April 5, 2021)<p>I recently re-read this blog post from 2-1/2 years ago, and decided that it was still important as well as relevant and accurate. So, in a "first" I am reposting it, since some folks may have missed it:</p><p><br /></p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;">Every year the nation’s medical schools graduate thousands of people with MD and DO degrees. But this is just the start of becoming a practicing physician; they now need to complete residency programs in a specialty area, ranging from 3 to as many as 8 years, to become family physicians, surgeons, radiologists, dermatologists, orthopedists, etc. Indeed, for many physicians this “postgraduate” training (meaning post-medical school, since medical school itself is post-graduate, requiring a bachelor’s degree for entrance) can have two components as well. First there is the primary residency program, say an internal medicine residency of 3 years, and then there is subspecialty training, usually called “fellowship”, where that internist becomes a cardiologist, or endocrinologist, or pulmonary medicine physician. While the internist who completes 3-year residency may practice general internal medicine and thus become a primary care physician for adults, those subspecialists do not. A similar process exists for pediatrics. Family physicians completing their 3 year residencies can also do fellowships in a limited number of areas, and some limit their practices to sports medicine or geriatrics or adolescent medicine, but most add these skills to their primary care practice. And, of course, geriatrics and adolescent medicine are, like general internal medicine or general pediatrics, primary care for a particular population.</p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;">This is important. Primary care doctors provide care for their patients that is comprehensive and unrestricted, other than by age for pediatrics, internal medicine, and geriatrics. They meet the World Health Organization (WHO) criteria for primary care, providing continuous, comprehensive, community-and-family-centered care. Distilled down, this means that primary care physicians see their patients for everything, whatever concerns them, referring when needed. They are the doctors for their people, not for a particular disease or set of diseases. The lack of sufficient numbers of primary care doctors has significant negative impact on the health of our people. Of course, it falls hardest on those who are always most disadvantaged – the poor, members of minority groups, and rural residents. But it also has negative impact upon the health of privileged people who see lots of subspecialists, in two ways. One is that the specialist may be expert in their field, but miss appropriate treatments, and especially preventive measures, outside it. The other is that many specialties and subspecialties rely on and extensively use care that is very high-tech and expensive, which can lead to people getting tests and treatments that are not only costly but may not be of any benefit, and indeed may lead to harm.</p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;"> So, when a medical school claims that it is good at producing primary care physicians, this is serious, and should be accurate. But it usually is not, because schools want to look as good as possible so establish criteria that make them look good, counting a wide variety of specialties that their graduates might enter as “primary care”. The biggest “offender” in this regard is counting all graduates entering internal medicine residency programs as entering primary care. As described above, some of these end up doing fellowships to become subspecialists and do not practice primary care; indeed, “some” is an understatement as it is about 80%. In addition, about half the rest end up practicing as “hospitalists”, taking care of hospitalized patients only, rather than practicing primary care. So an approximation would be to assume about 10% of those entering internal medicine residencies will practice primary care. In pediatrics, continuing as a general pediatrician is much more common; the appropriate multiplier is probably 60%, and for family medicine as much as 95%. There are also residency programs in a combination of medicine and pediatrics (Med/Peds) which can produce primary care doctors, and whose graduates are less likely to pursue subspecialty training; however, they are very likely to choose only one of those areas (adult medicine or pediatrics) and also to become hospitalists.</p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;">In addition, some (or many) schools include in the primary care numbers specialties that are simply not primary care at all. Most commonly, they include emergency medicine and obstetrics/gynecology. Emergency medicine does indeed provide first-contact care, but it does not provide continuity. Obstetrics/gynecology can provide some aspects of primary care (and indeed OBGyns may be the only doctors some young women see) but it is limited in that it is not comprehensive; women are more than their reproductive tracts, and they can have a variety of conditions OBGYN does not care for (diabetes, hypertension, heart disease, depression, arthritis, asthma and other lung problems, substance abuse, etc., to name a few). Perhaps the most egregious abuse is counting all students who enter internal medicine “transitional” or “preliminary” years. Such one-year programs, which have replaced the old “rotating internships”, are required for many specialties such as neurology, anesthesiology, radiology, ophthalmology, dermatology, and others, whose practitioners do not do primary care at all.</p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;">If we want to know how well a school is doing in graduating students who actually practice primary care at the end of their residency and fellowship training, these inflated numbers do not inform us. Fortunately, one of the most popular sources of information on medical (and other) schools, <i>US News,</i> has worked with the Robert Graham Center, the policy center of the American Academy of Family Physicians (AAFP) to develop and publish a metric that does show which schools actually produce primary care physicians, available at <a href="https://www.usnews.com/best-graduate-schools/top-medical-schools/graduates-practicing-primary-care-rankings" style="color: #992211; text-decoration-line: none;">https://www.usnews.com/best-graduate-schools/top-medical-schools/graduates-practicing-primary-care-rankings</a>. The top of this list is dominated by schools of osteopathic medicine, which consistently graduate higher numbers of primary care physicians, and, among the allopathic schools, the mainly public schools who have been doing well in this area for a long time. The private, largely northeastern, schools that usually top rank lists are nowhere to be found.</p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;">It is important to look at this list, not the list of “Top Primary Care Schools”, to get accurate data on production of primary care physicians. The metric on percent of students going into primary care has also been fixed in the <a href="https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings" style="color: #992211; text-decoration-line: none;">“Top Primary Care” rankings</a>, so it is better, but it still <a href="https://www.usnews.com/education/best-graduate-schools/articles/medical-schools-methodology" style="color: #992211; text-decoration-line: none;">only accounts for 40% of that ranking.</a> “Peer Assessment” (subjective rankings) account for 30%, half from medical school deans and other leaders, and half from residency directors. The other 30% is half “faculty resources” (largely faculty ratio) which may be skewed to the advantage of research-intensive schools, because it includes faculty who are mostly in laboratories and not teaching, and half “student selectivity” (based on student grades and MCAT scores), which is actually negatively associated with entry into primary care. This doesn’t mean the students that enter primary care are not as smart; it means that the cachet of attending a research-intensive school makes the competition greater. Unsurprisingly, adding these other criteria does affect the rankings; Harvard, for example, is now #8 in “best primary care schools”, although it ranks #141 of 159 schools in percent of graduates practicing primary care. (In contrast, the University of Kansas, which ranks #9 in primary care, below Harvard, ranks #17 in graduates practicing primary care, at 37.8%). Reputation affects peer assessments in at least 3 ways. One is spillover effect -- well, it’s Harvard, and good in everything so it must be good in primary care. A second is the ignorance of non-primary care deans and residency directors about what kinds of doctors the school produces. Finally, the fact that “good in primary care” can mean things other than what specialties the graduates enter can have an effect; there are schools in which the family medicine and other primary care faculty are well-known for their research and leadership in national organizations, but which do not graduate very many students into primary care disciplines.</p><p class="MsoNormal" style="background-color: white; color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 14.85px;">The fact remains, though, that the US very short of the primary care doctors it needs to provide quality health care to the American people. The way to begin to change that is to stop deceiving ourselves. Then we can start the process of producing a higher percentage, in every school.</p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com1tag:blogger.com,1999:blog-1509187841033628660.post-1674639576996163202023-12-01T19:56:00.000-07:002023-12-01T19:56:00.842-07:00The insurance company mafia and Medicare Advantage: Taking your money and denying you care<p class="MsoNormal"><span style="font-family: verdana;">If the government were considering ways of making small
businesses function more effectively to meet the needs of their customers and
make a reasonable living for their owners, they would consider the
stakeholders. Those might reasonably be the owners, the customers, and perhaps
the suppliers. And, of course the gangsters who supplied “protection" to the
owners – that is, protecting them from damage that might occur if the owners
didn’t pay up. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Oh. You don’t think so? Why would we include the gangsters
who just prey upon these businesses, drive up costs and thus probably prices,
and threaten bodily harm to innocent people? Well, why not? After all, they
have a stake in those businesses as well. If this seems like a ridiculous idea,
consider the fact that we do it whenever we consider changes to our healthcare
system in the United States. Except, in that case, it is the health insurance,
a huge parasitic industry that preys on the health of the American people by
sucking out billions in profit from funds intended to pay for our actual health
care. We not only allow it, we encourage it!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The patchwork nature of health insurance coverage in the US
is incredible. Many folks are coverage by policies held by their employers, or
the employers of family members, but the employer contribution has been
decreasing with increases in what employees have to pay in premiums, co-pays,
and co-insurance. Others are covered by government programs – indeed, when
considering all of these including Medicare, Medicaid, military families and
retirees, employees and families of federal, state, and local government –
public funds are more than half our health expenditures, rising to about 60% if
the taxes foregone by the government because (unlike wages) employer
contributions but not employee contributions) to health insurance are tax free.
And still others have insurance through the ACA (Obamacare) or actually pay
their whole cost. And, of course, lots and lots of people are uninsured. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And the coverage for those who are insured varies
tremendously, from plan to plan, insurer to insurer, employer to employer. Many
policies are so bad that those who have them are almost as bad off as the uninsured
– but they are paying for it. People get low-cost policies because this is what
they can afford, <span style="mso-spacerun: yes;"> </span>but pay the price when
they find out they are sick. It is bad, bad, bad, inefficient, incredibly
expensive, and, like all “protection” plans, beneficial only to the insurance
company mafia. But it is even, in a way, more egregious when we consider how it
has cannibalized Medicare, the federal program that is supposed to cover the
aged, blind, and disabled. Not that it is ok to screw the younger, non-blind or
disabled portion of our population, but Medicare, passed in 1965, was supposed
to ensure health care for the elderly, who are, in fact, more likely to be
sick.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But then we get “Medicare Advantage” (also known as Medicare
Part C), pushed by successive Republican administrations and assented to by the
Democrats who seem to believe the hype. Let’s be clear about what MA is and is
not. It is NOT Medicare, the program funded by your Medicare taxes from your
paycheck (Part A) or general revenue + you (Part B). It is private health insurance
being paid for with Medicare dollars (and the MA insurers get more, per capita
than Medicare itself). It is usually a PPO or HMO plan, which can (and does,
its essential character) restrict the health care providers (doctors,
hospitals, etc.) you can use, and can and does make it more difficult to get
care by denying payment (illegal as such; it is supposed to cover, by law,
everything Medicare does, but it can delay and delay by repeated denials) or
requiring prior authorization for – everything. Sometimes until it is too late
and you die. We’ll look at some examples. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">In a piece subtly titled <a href="https://www.nbcnews.com/news/amp/rcna121012">“Deny, deny, deny”</a>, NBC
News on Oct 31, 2023 describes how rural hospitals, usually the sole community
provider, are losing so much money from MA plans denying their claims that they
are either in danger of closing or at least will no longer accept MA. That, of
course, creates major problems for their patients covered by MA plans –
remember, they are not a problem until you get sick! ‘<i>Rose Stone of Holly
Springs, Miss., said she stopped going to her doctor after her Medicare
Advantage plan wouldn't pay for the visits. “It was a mess,” Stone told NBC
News. “I didn’t go to the doctor because I was going to have to pay
out-of-pocket money I didn’t have.”</i>’ </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The Washington Post, on Nov 29, 2023, in <a href="https://www.washingtonpost.com/politics/2023/11/29/theres-growing-friction-over-prior-approval/">Hospitals
and doctors are fed up with Medicare Advantage</a>, discusses that they are not
only fed up, but they are refusing to accept MA plans because it does not pay
them for the services that they provide. Scripps Health in San Diego joined
Mayo Clinic and many other facilities in not taking any MA plans. The problem
with the article is it can be read to imply that doctors and hospitals are
greedy, since <i>‘Medicare Advantage plans are pretty popular with both
lawmakers and ordinary Americans — they now enroll about 31 million people,
representing just over half of everyone in Medicare, by KFF’s (Kaiser
Family<span style="mso-spacerun: yes;"> </span>Foundation) count.’ </i>Popular
with lawmakers because, a lot, they are heavily lobbied by insurers and get
campaign contributions from them. Popular with ordinary Americans in the same
way that a lot of things are popular – they are heavily advertised and cheaper
on the front end than having to buy a Medicare Supplement plan because Medicare
only pays 80% of the money it approves for covered services. And they provide
glasses, and dental, and often drugs without a separate Part D plan, and even
gym memberships! Great! Until you really need care…like Ms. Stone. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Or like the woman who was denied coverage by Cigna for a
lung transplant and died, as discussed by former insurance executive and
current whistleblower Wendell Potter in his <a href="https://wendellpotter.substack.com/p/cigna-denied-a-double-lung-transplant?r=1q48vk">substack,
“Health Care Un-Covered”, on Nov 27, 2023.</a> Or the reports of massive
denials, <a href="https://www.propublica.org/article/health-insurance-denials-breaking-state-laws?wpisrc=nl_health202">including
those that break the law,</a> identified by <a href="https://www.propublica.org/article/priority-health-michigan-cart-insurance-vanpatten-denials">ProPublica</a>
in partnership with Scripps News and <a href="https://wendellpotter.substack.com/p/thanks-to-reporters-at-propublica">reported
by Potter on Nov 30, 2023</a>. These are not isolated stories; they occur all
the time.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Potter also testified in favor of retirees from Cortland
County,<span style="mso-spacerun: yes;"> </span>NY, when the county was trying
to push them all into an MA plan run by UnitedHealth. For this year, at least,
they were successful, arguing basically about how Prior Authorizations (PAs)
required by UnitedHealth would limit their care. At the last minute, under
discovery, they obtained <a href="https://wendellpotter.substack.com/p/retirees-in-cortland-county-new-york">a
(possibly incomplete) list of services requiring PA</a>…essentially everything
(see the list at the end of this post)! And if anyone is worried that these doctors
and hospitals wanting to be paid for the work that they actually do for people’s
health (remember – insurance companies do ZERO of this!) will bankrupt the MA
plans, we can look at their profits. In a piece Potter wrote looking at <a href="https://wendellpotter.substack.com/p/cigna-said-to-be-going-after-humana">how
Cigna is trying to acquire Humana to get a piece of the MA market</a> he
provides the profit made by the largest players in the industry: Cigna $7.28B on
revenues of $181B, Humana $4.2B on revenues of $93B, and industry leader
UnitedHealth $28.4B on revenues of $324B – nearly 9%! ALL of this is on money
that was intended to be spent on providing health care to Medicare recipients!
No wonder they can pay for your gym membership! They sure ain’t hurting! <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Other countries have much less complex and arcane coverage
systems. You’re born, you’re covered. Everyone is in, no one is out. Pretty
much everyone is in the same plan. That is what we could have if we had an
expanded (to everyone) and improved (covering 100%, not 80%, of ALL necessary
services, including mental health, dental, vision, hearing, drugs, long-term
care) Medicare for All. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But the insurance company mafia stands in the way. Contact
your senators and congresspeople! </span></p><p class="MsoNormal"><br /></p>
<p class="MsoNormal"><i><span> </span>From Wendell Potter, list of services (possibly incomplete)
requiring PA from UnitedHealth:</i></p>
<p class="MsoNormal"><i>The list includes:</i></p>
<ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Cardiac
rehabilitation services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Intensive
cardiac rehabilitation services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Chiropractic
services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
diagnostic colonoscopy</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Supplies
to monitor blood glucose</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Continuous
glucose monitors</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Therapeutic
shoes for people with diabetes</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Durable
medical equipment</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Diagnostic
hearing and balance evaluations</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Home
infusion therapy</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Inpatient
services in a psychiatric hospital</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Medicare
Part B drugs and non-chemotherapy drugs to treat cancer</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Medicare-covered
chemotherapy drugs to treat cancer and the administration of that drug</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Opioid
treatment services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
diagnostic tests and therapeutic services and supplies, including x-rays
and other radiation therapies</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Lab
tests and other diagnostic tests</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
mental health care</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
rehabilitation services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
substance abuse services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
surgery and other medical services at hospital outpatient and ambulatory
surgical centers</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Partial
hospitalization services and intensive outpatient services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Basic
hearing and balance exams</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Some
telehealth services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Second
opinions prior to surgery</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Non-routine
dental care</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Monitoring
services in a physician’s office or outpatient setting</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Medically
necessary medical and surgical services that are provided at home or
nursing home</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Prosthetic
devices</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Pulmonary
rehabilitation services</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Skilled
nursing care</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Supervised
exercise therapy</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Outpatient
services provided by an ophthalmologist or optometrist</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;"><i>Eye
exams for people with diabetes</i></li></ul>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2tag:blogger.com,1999:blog-1509187841033628660.post-51387994263980455932023-11-21T09:46:00.003-07:002023-11-21T18:09:29.949-07:00Running and Depression: Be careful about spreading the results of research until you understand it.<p><span style="font-family: verdana;">During the COVID pandemic, a great deal of scientific and
medical literature was published on line without going through the normal
peer-review process. The justification was that things were happening so fast
that scientists and doctors needed quicker access to the information being
discovered to be able to implement prevention and treatment strategies.<span style="mso-spacerun: yes;"> </span>Many of these were published on sites like
MedRxiv (<a href="https://www.medrxiv.org/content/about-medrxiv">https://www.medrxiv.org/content/about-medrxiv</a>),
with little or no peer review. Some of these articles were later shown to be
flawed, either in terms of the science of the research methods or in the
presentation of the conclusions to be drawn from that research. In a number of
cases, these articles, which would likely not have been published in normal
(peer-review) circumstances were “taken down”, “unpublished” if you will. This
was criticized by many during the pandemic, such as <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-01650-6">Rapid
publications risk the integrity of science in the era of COVID-19</a>, by
Bagdasarian, Cross and Fisher.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Except, of course, nothing can truly be “taken down” from
the internet. If it is out there, it can be copied, saved, reposted. Certainly
this has been shown to be true on social media, where embarrassing posts (e.g.,
sexual, racist, etc.) have continued with lives of their own even after the
original was taken down. In the case of medical and scientific articles, the
information is out there, and the study can be referred to and cited by others.
And with the thousands and thousand of such articles published on line, only a
small percent are ever taken down, even if the methods used in the research are
flawed, and the conclusions presented are inaccurate. This was the source of a
lot of misinformation during the pandemic, transmitted on social media because
it was “in a scientific journal”. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Hopefully we are past that (fingers crossed!), but we are
still not without other misleading research being reported. As with almost
everything, on line or in print or conveyed by mouth, people are more likely to
believe things that reinforce what they already believe (“confirmation bias”),
and in general, regarding medical and scientific information, most people are
willing to read just the “bottom line” (is “X” good for you? Is “Y” better than
“Z” for “A”?), which is usually far too simplistic. This is not limited to
laypeople, few of whom have the expertise to actually read and interpret a
research study; many doctors (and sadly residents and medical students) read
only the Abstract or at best the Conclusion, skipping or skimming over the only
important parts of a research paper, the Methods and Results. Reading the
Abstract may be adequate to decide whether to read the whole article (“if they
actually found what they say they found, do I care?”) but should never be
conflated with actually having read it, and thought about it.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And while peer review should ensure that the methods,
probably, were legitimate and that therefore the results are accurate, it does
not always flag potential problems, particularly with regard to overstating the
significance of the results in the conclusion -- or a one-sentence abbreviated
conclusion. A recent study (and I pick on it not because it is more egregious
than most, but because it was brought to my attention by<a href="https://www.medscape.com/viewarticle/997236?form=fpf"> <i>Medscape, </i>reporting
on its presentation at an international conference</a><span class="MsoHyperlink">)</span>,
is ” <a href="https://www.sciencedirect.com/science/article/pii/S0165032723002239">Antidepressants
or running therapy: Comparing effects on mental and physical health in patients
with depression and anxiety disorders”</a>, published in the <i>Journal of
Affective Disorders</i>, May 2023. The study, done by a group of researchers in
the Netherlands, in fact showed, as <i>Medscape </i>reports, that while both
anti-depressant medications and running helped depression, running was better
for overall physical health. That is good news if you are a runner, I guess, or
if you have been wondering if taking up running would be good for your depression.
But if your take-away is something like “See? Natural things – like running –
are better for you than drugs!”, there are some details you need to pay
attention to. Like who was studied. In any study, it is critical to see if the
population studied is similar to you (or your patient, if you are a health care
clinician). In this case the average age of participants was about 38. So if
you are in that age range, it could apply to you. If you’re 70, the age of the
oldest participants, maybe taking up running might not be the best idea. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But a much more important flaw in this study is illustrated
by saying “taking up running”: it has to do with the allocation of people to
the different treatments, running or medication. In a good study, participants
are <i>randomized</i> to one treatment or another. In this study, people <i>chose
</i>the treatment they wanted to try, with only those left over allocated to one
treatment or another. 83 people <i>chose </i>running with another 13 assigned
to it; 36 people <i>chose </i>medication, with another 9 assigned to it. So of
the 141 participants, 83, 59%, <i>chose</i> running. Although those already
exercising more than once a week were excluded, it is still possible, if not
likely, that many of that 59% were, at least in the past, runners, or people who
wanted to run. This is what is called a potential <i>confounder</i>, something
that is associated with the treatment and the result, and leads to results that
are much less convincing than does random allocation.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">So does this mean running is <i>not </i>as good or better
than drugs for treatment of depression? No (although obviously it requires the
physical capability of being able to run). This study provides evidence that in
a group of 141 people, average age 38, 58% female, 59% of who chose to be in the
running “arm” of the study, it worked as well. But those are important caveats
that make the study weaker, and less likely to work for someone who doesn’t fit
the profile. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Enough of this study. I chose it because it came to my
attention, but also because it was published in a reputable, peer-reviewed
journal, and it is not totally worthless – but to draw the conclusion that
“running is as good as drugs for depression and better for your overall health”
is true for anyone, for you, could be inaccurate. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The impression that one can take away from hearing from
someone that “a scientific study showed that…” (and tell me you never hear
that!) can be a little, a lot, or completely wrong unless you both read the
whole study and have enough background to understand what it does not say as
well as what it does. Beyond “was this a well-done study?” and “was it
published by reputable scientists in a reputable journal?”, the questions of
“to whom are the results most likely to apply?” is also important. You may
think yourself healthy and in good shape for your age, but a study of, say, 25
year olds, may not apply to you if you’re 65. The most reliable characteristic
is replication of the results by other well-designed studies. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Is there a social justice issue here? I do not know.
Probably well-off people have better access to doctors and other professionals,
but they also have more choice and are able to choose the ones that they know
have the same beliefs (or biases) that they do; for example, exercise is good,
drugs are bad, natural is good, etc. My personal (not statistically valid!)
experience is that people who are likely to believe something because it shows
what they <i>want</i> to be true and to discount studies that show what they <i>don’t
want </i><span style="mso-spacerun: yes;"> </span>to be true, come from all
socioeconomic, ethnic, and other groups.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But my advice is to take a deep breath, and not believe
everything you hear, or read, is 100% true, and certainly not that it is more
broadly applicable that whatever the research showed. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Even if you want to.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2tag:blogger.com,1999:blog-1509187841033628660.post-51921014520983704132023-11-01T09:33:00.002-07:002023-11-01T09:33:39.936-07:00People are more important than profit. Period.<p><span style="font-family: verdana;">In his recent piece, <a href="https://armoxon.substack.com/p/an-appropriate-anger?r=23cox">‘An
Appropriate Anger’ on his Substack “The Reframe”</a>, writer AR Moxon states
that <i>“All people have an intrinsic and indestructible worth that cannot be
measured</i>”. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">He notes: <span style="mso-spacerun: yes;"> </span>“That’s not
true of everything, you know. If a car stops functioning properly, it’s no
longer as valuable as it was when it was functioning properly…[but] It’s not
that way with people who, as it so happens, are not things.” </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">I happen to agree with that, and honestly believe that most
people do. But not everyone does. Moxon has some things to say about the businesses,
and the people who hide behind the corporate logo, who clearly think that profit
is more important than people and act on it. He particularly focuses on
healthcare as he had a very scary event with a person close to him. But
healthcare is a particularly good example of the core problem that he cites.
Healthcare is a system which people want to believe, and often in the face of
powerful evidence to the contrary <i>do </i>believe, exists to help them. In
fact, it is actually an incredibly efficient and effective producer of profit
for the industry, often at the expense of the health of the people it
ostensibly exists to help. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">What makes this worth
continuing to comment upon is the ongoing, aggressive, and accelerating rate at
which it is happening. No sooner can one say “well, this is bad, but at least we
have X as an alternative” than X is taken away or modified into a profit-producing
structure that decreases availability and quality of care for people while increasing
their costs. And, as a result, harming their health. (Just in recent blogs I
have written about ‘<a href="https://medicinesocialjustice.blogspot.com/2023/07/why-are-we-paying-wealthy-corporations.html">Why
are we paying wealthy corporations billions to limit our healthcare?</a>, July
23, 2023; ‘<a href="https://medicinesocialjustice.blogspot.com/2023/08/older-adults-cannot-afford-healthcare.html">Older
adults cannot afford healthcare even if they are insured: Time for a new
system!</a>’, Aug 22, 2023; ‘<a href="https://medicinesocialjustice.blogspot.com/2023/09/the-problems-with-our-us-healthcare.html">The
problems with our US 'Healthcare' system are well documented. We need to start
with the solution!</a>’, Sept 3, 2023; <span style="mso-spacerun: yes;"> </span>‘<a href="https://medicinesocialjustice.blogspot.com/2023/09/primary-care-private-equity-and-profit.html">Primary
Care, Private Equity, and Profit: How to ensure poor quality care for the
American people</a>’, Sept 28, 2023).<span style="mso-spacerun: yes;">
</span>The perpetrators of these evils – and they are evils -- are corporations
including insurance companies, health care providers, and pharmaceutical
companies, often now overlapping in a vertical integration, as for example with
UnitedHealth’s ownership of the physician group Optum that now provides more
income and profit than its insurance business! But the perpetrators are also
the <i>people</i> that run those corporations and make their decisions.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Groups that study
the healthcare system, such as the Commonwealth Fund and the Kaiser Family
Foundation, continue to issue increasingly distressing, indeed terrifying,
reports about the state of US healthcare, the access people have to it (or not),
and the impact that this has upon their health. The Commonwealth Fund in
particular has published a series of pieces that, although written in a calm
manner, create great alarm in me because of their content. ‘<a href="https://www.commonwealthfund.org/publications/issue-briefs/2023/oct/high-us-health-care-spending-where-is-it-all-going">High
U.S. Health Care Spending: Where Is It All Going?</a>’, Oct 4, 2023, notes that
‘The United States spends twice as much per person on health as peer
nations’ and concludes<span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> that </span></span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">More than half of excess U.S.
health spending was associated with factors likely reflected in higher prices,
including more spending on: administrative costs of insurance (~15% of the
excess), administrative costs borne by providers (~15%), prescription drugs
(~10%), wages for physicians (~10%) and registered nurses (~5%), and medical
machinery and equipment (less than 5%). Reductions in administrative burdens
and drug costs could substantially reduce the difference between U.S. and peer
nation health spending.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">[Note that wages for physicians and nurses is on 15% of this
total!] <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The ‘<span class="publication-herosubtitle">Findings from the
Commonwealth Fund 2023 Health Care Affordability Survey’ are reflected in its
title, ‘</span><a href="https://www.commonwealthfund.org/publications/surveys/2023/oct/paying-for-it-costs-debt-americans-sicker-poorer-2023-affordability-survey?_hsmi=280428380&_hsenc=p2ANqtz-_k_IXSzShn8cVuEsL9azD6k1HZPDh_U_zE-FWZNpg3axBBhLbgzymEJrVSQ9xNWdg_DyyWY57XyeQRZFHZzVUhrqwlog">How
Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer</a>’.
Those findings demonstrate that they are, and it is getting worse, and although
the greatest impact is in those already marginalized (particularly Black Americans
and those already poor), it is affecting more than half of the US population,
those insured and uninsured:</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">Large shares of insured
working-age adults surveyed said it was very or somewhat difficult to afford
their health care: 43 percent of those with employer coverage, 57 percent with
marketplace or individual-market plans, 45 percent with Medicaid, and 51 and
percent with Medicare.</i></p>
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUVFXvPJ1TlToPzkDxBROueATvG23O0NHZCsNaBgBCQofOYEZ5q-RnetxYoLHL9GQhSQmM4IyAKUH4j2NkV7f7jRp3VJWdRbTJFnM-ND-vrxtxObXqyMUibl_Th3_UCRJyOWzI1xxhwB3obqkf6AdJJsJEdb7wZgGisSDXf0f_FHqPTjAfShbLsvyejNmW/s1845/CommFund%20Afford%20Oct%202023.JPG" style="font-family: verdana; margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1111" data-original-width="1845" height="274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUVFXvPJ1TlToPzkDxBROueATvG23O0NHZCsNaBgBCQofOYEZ5q-RnetxYoLHL9GQhSQmM4IyAKUH4j2NkV7f7jRp3VJWdRbTJFnM-ND-vrxtxObXqyMUibl_Th3_UCRJyOWzI1xxhwB3obqkf6AdJJsJEdb7wZgGisSDXf0f_FHqPTjAfShbLsvyejNmW/w454-h274/CommFund%20Afford%20Oct%202023.JPG" width="454" /></a></div><span style="font-family: verdana;"><br /></span>
<p class="MsoNormal"><b style="font-family: verdana;"><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;"> </span></b></p>
<p class="MsoNormal"><span style="font-family: verdana;">Commonwealth also
had a series of reports, appearing every year or two, called “Mirror, Mirror on
the Wall” which compared US health care costs and outcomes to other comparable
(wealthy) countries. The US always did worst (see ‘<a href="https://medicinesocialjustice.blogspot.com/2017/06/us-health-rankings-remain-low-and.html">US
Health Rankings remain low and #Trumpcare will make them worse!</a>’, June 18,
2017, which includes scary data tables comparing US health system performance
to others). The most recent report, from 2022, has a different title that is even
scarier:<a href="https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022">
U.S. Health Care from a Global Perspective, 2022: Accelerating Spending,
Worsening Outcomes</a>. It includes as “highlights” (or lowlights)</span></p>
<p class="MsoListParagraphCxSpFirst" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span><i><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">Health
care spending, both per person and as a share of GDP, continues to be far
higher in the United States than in other high-income countries. Yet the U.S.
is the only country that doesn’t have universal health coverage. </span></i></span></p>
<p class="MsoListParagraphCxSpLast" style="margin-left: 0.75in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span><i><span style="mso-ascii-font-family: Calibri; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-hansi-font-family: Calibri; mso-hansi-theme-font: minor-latin;">The
U.S. has the lowest life expectancy at birth, the highest death rates for
avoidable or treatable conditions, the highest maternal and infant mortality,
and among the highest suicide rates.</span></i></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Comment: These
are not good things.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"> It is also easy
to lose health insurance. It can happen intentionally when insurance companies seek
to offload high-cost individuals (ie., the sick people). This procedure (“lemon
dropping”) is common in Medicare-substitute programs like Medicare Advantage and
push them into regular Medicare. It is the complement to efforts to enroll only
healthy seniors (“cherry picking”). The ideal insurance client, from the point
of view of maximizing profit (is there another point of view?) is one who pays
premiums and never uses care. Of course, if you are not yet on Medicare, you
can be dropped and – that’s that. You are uninsured.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But you can also
lose insurance coverage by mistake or oversight; in her Oct 25, 2023 essay ‘<a href="https://www.nytimes.com/2023/10/25/opinion/open-enrollment-health-insurance.html">It
Shouldn’t Be This Easy to Lose Your Health Insurance’</a> in the <i>New York
Times</i>, physician Danielle Ofri describes how she lost coverage because the
notification for “open enrollment” from her own HR department was collected by
her spam filter, and she was put into the “basic” plan – without coverage for
her family. Why does she have to re-enroll every year? And why do Medicaid patients?</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">The stated reason for this
bureaucratic merry-go-round is that eligibility must be ascertained every year
so as not to allot services to someone who doesn’t qualify. But the process of
determining eligibility is highly flawed. Only some disenrolled Medicaid
patients, for example, are truly ineligible; according to KFF, a health policy
research organization, a majority of people (more than 90 percent in some
states) were disenrolled for procedural reasons, such as missed deadlines,
paperwork issues and outdated contact information. Many of these people are
eligible for insurance but lose coverage because of the byzantine logistics.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">Yes. Dr. Ofri was able to reinstate her coverage but not
everyone can; she is not only highly educated but a physician: “For me, it took
endless phone calls to fix the problem and a miserable week in which I was
convinced that I’d failed my family. For millions of Americans, the system is
simply unnavigable.” Especially for those Medicaid patients.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Dr. Ofri concludes with the key point: </span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>Of course, none of this would be
necessary if the only requirement for getting insurance was — as it is in many
countries — being born.</i><span style="mso-spacerun: yes;"> </span></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Think about that. Everybody is insured – and coverage is the
same – for every person in the country. There is no enrollment or
disenrollment, no coverage lapse, no inability to afford it. Everyone is
covered. And it costs less – all of those countries spend less, overall and <i>per
capita</i>, than does the US. It is administratively simpler, less costly, more
effective, and results in better health status for the population. It has been
adopted by every other well-to-do (and many much less well-to-do) country in
the world. The US is an outlier, <i>not </i>in a good way, in being the only
nation that doesn’t.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But American insurance companies and health care providers make
huge amounts of money, money that is intended (often by the government) to be
spent on providing health care but instead ends up on the positive side of a
corporate balance sheet. That can be seen as a good thing, if you are a
corporate executive, a completely heartless and unempathetic bastard, and, of
course, you are certain that the negative impact will never affect you. We need
to change that, i.e., make it affect them.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Moxon goes on at great length documenting how the “profit
motive”, which can have positive effects on a society, has been so perverting
by being the ONLY thing that is considered to matter (“the profit motive
doesn’t care about enriching the lives of people, and it never will, any more
than a garden trowel cares about the state of your garden”) that it leads to
mass suffering, in health care and<span style="mso-spacerun: yes;"> </span>“with
justice, and with education, and public safety, and housing, and transport, and
recreation, and water, and the arts, and elder care, and on and on and on.”</span></p><p class="MsoNormal"><span style="font-family: verdana;">What is amazing is that so many of us have drunk enough of the
Kool-Aid to believe that, while <span style="mso-spacerun: yes;"> </span>these
are not good things, we think it is inevitable and the way that things have to
be. Of course, there are also those who in fact believe, either because they are
ideologues or are getting rich from the corporations they control or both, or
are politicians being paid from the lobbying arms of those corporations, that
profit is in fact more important than people. They should voluntarily (or not) sign
up on the list of people who will not get care because that would decrease
profit. They are welcome to live out their principles. Until they can’t because
they aren’t getting health care.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">As long as the rest of us do not continue to have to
sacrifice our health to their profit.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-32564497712585967792023-10-13T09:59:00.007-07:002023-10-26T08:34:07.204-07:00Self-centered Syllogism: Bad in public health, bad anywhere<p><span style="font-family: verdana;">I recently met someone who had seen a couple of my blog
posts, was interested in public health, and asked a few interesting questions.
My answers – or, really, comments – were things I have said and written about
before, but his questions forced me to put them together, and in my opinion,
the issues bear repeating.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The first question he asked was “why do we put so much emphasis
on smoking but not on alcohol? After all, smoking never caused someone to beat
their children or spouse, or to drive impaired and have an accident, or get
into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises
the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the
real answer is the incredible mortality caused by smoking. The <a href="https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm">CDC
page</a> identifies tobacco as the cause of nearly a half-million deaths in the
US annually. While the data is from 15-20 years ago, and (hopefully) the
mortality rate from tobacco has decreased as its usage has decreased, this is
an astonishing statistic. Deaths from tobacco exceeded the total of deaths from
alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It
remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco
is the leading cause of preventable mortality in the United States”. It was,
therefore, the focus of public health efforts because of its tremendous impact
on mortality.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">However, of course, alcohol is also a major problem, causing
both death and severe morbidity (bad outcomes besides death). It is, as my
questioner noted, highly associated with violence against both family members
and strangers, with automobile deaths, with homicide and not-homicide violence.
It also, of course, kills people who use it, from diseases such as cirrhosis
and heart disease as well as many cancers that are more common in heavy
drinkers. We all have heard someone who did something very bad (commit violence
against family members or strangers, have a car wreck, etc.) say “It was the
alcohol. I wouldn’t have done it if I were sober”. But they were not sober,
they had been drinking, and probably had often been.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The<a href="https://alcohol.org/health-effects/drinking-and-fighting/"> American
Addiction Centers alcohol.org</a> estimate that 88,000 people die from alcohol-related
violence and abuse and accidents. The site also notes that “The American
Society of Addiction Medicine notes that between 28% and 43% of violent
injuries, and 47% of homicides, alcohol has been estimated to be involved.”
That is a lot, and it could be an underestimate, but it is the closest I can
get to quantifying the attributable risk for violence from alcohol. The concept
of “attributable risk” in public health can be understood as the percentage of “bad
outcome X” that would go away if “risky behavior Y” went away. This is
different from the amount that it increases an individual’s risk; some behavior
“Y” may increase your risk a lot but, because it is relatively uncommon,
account for less attributable risk. Examples include asbestos and lung cancer
(very high increase in risk but a lower percent of cases, compared to smoking).
Or, looking at it inversely in terms of what disease a risk factor causes, smoking
and lung cancer vs. heart disease. Smoking increases the risk of lung cancer
more than it does heart disease, but because heart disease is so much more
common, the attributable risk from smoking, the number of lives that would not
be lost if people didn’t smoke, would be more from heart disease than lung
cancer. An example of “smaller percentages of larger numbers can be greater
than larger percentages of smaller numbers”.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">So what did I say about alcohol? He identified the fact that
there is a very large industry of alcohol manufacturers and sellers, which have
great influence. I noted that there was (is) also a great industry of tobacco
manufacturers and sellers. He said that in addition to the manufacturers, there
were also many businesses, restaurants and bars whose existence depended on the
sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t
drink too much”, a common “PSA” from alcohol manufacturers. The implicit
message, however, is “do drink!”. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">I think most of the members of our society, including many
of those still smoking, recognize that any amount of smoking is bad for you, and
more is worse, but I do not think that the same is true for alcohol use. The general
attitude, even among medical and public health professionals, seems to be “a
lot of drinking is obviously bad, for you and for others, but a little – <i>like
I do – </i>is not.” What could be wrong with a couple of beers? A couple of
glasses of wine? Especially if you’re not driving? Aren’t there studies that
show a little red wine is good for you?</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">There are such studies but they are dated, poorly done, and
wrong. Pretty much, while more is worse, there is no amount of alcohol
consumption that is good for your health, and any amount is somewhat bad. We disparage
those who use other drugs (heroin, cocaine, crack, meth, even still cannabis)
for entertainment, but much of our society is actually built around alcohol as
the “social lubricant”. Restaurants, bars, parties. Family events like weddings
and funerals. Most of such entertainment revolves around alcohol. Perhaps the
only place where alcohol is not the key component of “having fun” would be at
an AA meeting! This issue is seriously joined by Holly Whitaker in her book “<a href="https://www.penguinrandomhouse.com/books/605025/quit-like-a-woman-by-holly-whitaker/">Quit
Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”</a>.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The key here is that so many people drink (if “responsibly”,
by which they usually mean “not too much” and “not when driving”) that they
have to justify themselves by saying it is OK. I call this the “Dirk Gently
Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”.
The lead character, who dies on the first page, was a millionaire who made his money
by essentially developing syllogisms that took you from the data you had to the
conclusion you had foreordained (his biggest client was the US Department of
Defense). This is pretty much what we do in lots of areas, including alcohol
use; we decide on what we want the answer to be and then look for evidence that
supports it.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">My new friend noted his son had been in a public health
program a few years ago when the big emphasis was on obesity and its health
effects. I nodded, but it not so much any more. Obesity has big health effects,
yes, but it is also easy to disparage people who are overweight. This is a
manifestation of another common tendency among people (including among health
professionals): to be critical of people who do (or don’t do) things that come
easily to <i>you</i> to do or not do, and conversely minimize the significance
of the negative behaviors that you do (or don’t do). If you are naturally thin and
have an no difficulty keeping weight off, it is easy to criticize those who are
overweight. However, if you like your fancy wine or craft beer or expensive
single-malt scotch, you don’t think drinking is such a bad thing. Or, for that
matter, being self-righteous.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Public health is good and important. In the US, it is grossly
underfunded compared to individual medical care (about 1% of health care
dollars). But, like much of medicine it is also subspecialized. To a large
degree, public health researchers go where the money is available for grants – in
obesity, or smoking, or violence prevention, etc., and become specialists in that
area. It is (or should be) different in primary care. As a family doctor, I can
measure and counsel you on your blood pressure, but I cannot ignore your
diabetes or lung disease and just refer you to another specialist. Similarly, while
public health specialists “do obesity” or “do child seats”, this is not an
option for the family physician. I need to help you to stop smoking, but cannot
ignore that you need to use a seatbelt. Or get vaccinated. Or would have a
greater probability of better health outcomes if you lost some weight. Or did not
drink so much. Or at all.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Judging others for doing (or not doing) what we find it easy
to not do (or do) and minimizing the damage caused by what we ourselves do is a
big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive,
appropriate, or helpful or good for anyone, and are especially dangerous coming
from medical or public health professionals.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com4tag:blogger.com,1999:blog-1509187841033628660.post-16976335231624708072023-09-28T09:51:00.001-07:002023-09-28T09:53:07.375-07:00Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people<p> <span style="font-family: verdana; font-weight: normal;">I -- and many
others -- have written (frequently and recently) about the abuses of for-profit
companies, and especially private equity companies, and “non-profits” that act
like for-profits in health care (<a href="https://medicinesocialjustice.blogspot.com/2023/05/private-equity-private-profit-medicare.html">Private
equity, private profit, Medicare and your health: They are incompatible</a>, May
11, 2023; <a href="https://medicinesocialjustice.blogspot.com/2023/01/privatizing-medicare-through-medicare.html">Privatizing
Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!</a>,
Jan 20, 2023; </span><span style="color: windowtext; font-family: verdana; font-weight: normal;"><a href="https://medicinesocialjustice.blogspot.com/2022/09/private-equity-profiteers-in-nursing.html"><span style="mso-bidi-font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">"Private Equity": Profiteers in
nursing homes, Medicare Advantage, DCEs, and all of healthcare</span></a></span><span style="font-family: verdana; font-weight: normal;">, Sept 16,
2022). But despite our efforts, it doesn’t get any better. Indeed it gets
worse.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Drs. David Himmelstein, Steffie Woolhandler, Adam Gaffney,
Don McCanne, and John Geyman, have been leaders in the campaign for a national
health insurance plan (e.g., Medicare for All), published an article 18 months
ago in ‘The Nation’ (March 31, 2022) titled <a href="https://www.thenation.com/article/economy/healthcare-corporations-private-equity/">‘Medicare
for All is Not Enough’</a>. They go through the ways in which the ownership of
our health system has changed, particularly over the last decade, to focus on
profit for the private owners rather than “health care”. That is to say, while
a single-payer Medicare for All program would be a great thing and would limit
the negative impact that for-profit insurance companies wreak on our collective
health – which is considerable – as long as for-profit companies continue to
own, and to increase their share of, our actual health delivery systems
(hospitals, nursing homes, pharmacies, and physician practices) there will be
terrible consequences, with those single-payer dollars flooding into investors’
pockets rather than patient care.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Insurance companies like United Health and giant pharmacy
firms like CVS own large portions of our practice and health delivery sector. And
the role of private equity companies and investors, with their “buy ‘em and
burn ‘em” approach to acquisition and profit, in taking over our delivery
system is at least as terrifying. As the authors state:</span></p>
<p class="MsoNormal" style="margin-left: .5in;"><i style="font-family: verdana;">At least UnitedHealth and CVS
plan to stay in business for the foreseeable future, and may be constrained by
the worry that substandard care will damage their reputation. Private equity
companies face no such constraints. They promise investors quick profits, and
often sell off the businesses they’ve bought within five years, often after
stripping their assets and loading them with debts that hobble future
operations.</i></p>
<p class="MsoNormal"></p><p class="MsoNormal"><span style="font-family: verdana;"></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">On top of who will <i>own</i> our care provision, there also
is the issue of who will provide the care. Most developed countries, with more
rational health delivery systems, rely on primary care physicians and other
clinicians far more than the US does. In those other countries primary care is
at least 30-40% of the physician workforce, while here it is closer to 20% and
dropping, an issue I have written about often (see, for example, <a href="https://medicinesocialjustice.blogspot.com/2022/03/what-is-problem-with-primary-care-us.html">What
is the problem with Primary Care? The US health system!</a>, March 22, 2022).<span style="mso-spacerun: yes;"> </span>Primary care clinicians – family physicians,
pediatricians, and general internists, and the NPs and PAs who work with them –
can provide not only cost-effective care but care that is comprehensive, continuous,
and reassuring to people and families because they know the person who is providing
it and have a relationship with them. And the cost-effectiveness is not (only)
about the fact that they earn less money (see below) but because they are in a
position, as a result of taking care of the “whole person” and having a long
term relationship, to more wisely utilize resources when necessary. Nonetheless,
there is a definite shortage of primary care clinicians, as anyone who has
tried to find one recently, because they moved, or their physicians retired or had
their practice bought out by a large company like Optum (a subsidiary of United
Health Care, which has become UHC’s major profit center as documented by former
insurance executive Wendell Potter in his “<a href="https://wendellpotter.substack.com/p/first-half-of-2023-7-big-health-insurers">Health
Care Un-covered</a>” substack) or, sometimes in response, went into a “concierge”
or “boutique” practice, can testify. Elisabeth Rosenthal, editor of Kaiser
Health News, documents this in a recent piece in the Washington Post, <a href="https://www.washingtonpost.com/opinions/2023/09/05/lack-primary-care-tipping-point/">“The
Shrinking Number of Primary Care Physicians is Reaching a Tipping Point”</a>. She
notes that “fewer medical students are choosing a field that once attracted
some of the best and brightest because of its diagnostic challenges and the
emotional gratification of deep relationships with patients.” And she makes the
important point that</span></p>
<p class="MsoNormal" style="margin-left: .5in;"><i style="font-family: verdana;">One explanation for the
disappearing primary-care doctor is financial. The payment structure in the
U.S. health system has long rewarded surgeries and procedures while
shortchanging the diagnostic, prescriptive and preventive work that is the
province of primary care.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">Don’t forget that one. Rosenthal discusses the terrible experience
of colleague Bob Morrow, MD, who, under financial pressure, finally had to sell
his decades-old practice, and then, watching how the new owner ran it (suffice
it to say, not in the best interests of the patients), leave medicine. Morrow
is not a depressed person, but reading about what has happened to him and
thousand of other primary care doctors is enough to make you depressed.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">In a data-driven <a href="https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/">“Report
Card” on primary care in the US</a>, the Milbank Memorial Fund ranks it poorly
on all front, although not on the quality of the physicians:</span></p>
<p class="MsoNormal" style="margin-left: .25in;"><i style="font-family: verdana;">This first national primary
care scorecard finds a chronic lack of adequate support for the implementation
of high-quality primary care in the United States across all measures, although
performance varies across states. The scorecard finds:</i></p>
<p class="MsoNormal" style="margin-left: .75in; mso-list: l1 level1 lfo1; tab-stops: list .75in; text-indent: -.25in;"><span style="font-family: verdana;"><i><span style="mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">1.<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"> </span></span></span></i><i>Financing:
The United States is systemically underinvesting in primary care.</i></span></p>
<p class="MsoNormal" style="margin-left: .75in; mso-list: l1 level1 lfo1; tab-stops: list .75in; text-indent: -.25in;"><span style="font-family: verdana;"><i><span style="mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">2.<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"> </span></span></span></i><i>Workforce:
The primary care physician workforce is shrinking and gaps in access to care
appear to be growing.</i></span></p>
<p class="MsoNormal" style="margin-left: .75in; mso-list: l1 level1 lfo1; tab-stops: list .75in; text-indent: -.25in;"><span style="font-family: verdana;"><i><span style="mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">3.<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"> </span></span></span></i><i>Access:
The percentage of adults reporting they do not have a usual source of care is
increasing.</i></span></p>
<p class="MsoNormal" style="margin-left: .75in; mso-list: l1 level1 lfo1; tab-stops: list .75in; text-indent: -.25in;"><span style="font-family: verdana;"><i><span style="mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">4.<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"> </span></span></span></i><i>Training:
Too few physicians are being trained in community settings, where most primary
care takes place.</i></span></p>
<p class="MsoNormal" style="margin-left: .75in; mso-list: l1 level1 lfo1; tab-stops: list .75in; text-indent: -.25in;"><span style="font-family: verdana;"><i><span style="mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">5.<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;"> </span></span></span></i><i>Research:
There is almost no federal funding available for primary care research. </i></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The <span style="mso-spacerun: yes;"> </span>report card,
created for Milbank by the Robert Graham Center (the policy arm of the American
Academy of Family Physicians, AAFP), not only identifies these deficits, but
also the importance of solving them for the health of the American people.
100,000,000 people without a primary care doctor, only able to see a physician
(if they can see <i>any</i> physician) who has a narrowly focused,
disease-based practice is a real problem. We need those specialists for when we
are diagnosed with a particular condition that requires their expertise, but
they are often not knowledgeable about conditions outside it. Moreover, the
primary care clinician does not only care for many conditions; much more
important is that they care for the <i>person</i> who has those conditions.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The report also endorses the conclusions from the National Academy
of Science, Engineering, and Medicine (NASEM) from 2021, recommending that the
US:</span></p>
<ol start="1" style="margin-top: 0in;" type="1"><li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;"><i style="font-family: verdana;">Pay
for primary care teams to care for people, not doctors to deliver
services.</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;"><i style="font-family: verdana;">Ensure
that high-quality primary care is available to every individual and family
in every community.</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;"><i style="font-family: verdana;">Train
primary care teams where people live and work.</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;"><i style="font-family: verdana;">Design
information technology that serves the patient, family, and
interprofessional care team.</i></li><li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;"><i style="font-family: verdana;">Ensure
that high-quality primary care is implemented in the United States.</i></li></ol>
<p class="MsoNormal"><span style="font-family: verdana;">Finally, for the moment, an effort is actually being made in
Congress to try to increase the number of primary care clinicians. <span style="mso-spacerun: yes;"> </span>In an uncommon bipartisan effort, the bill is
cosponsored by Bernie Sanders (I, VT), chair of the Senate HELP Committee and Roger
Marshall, MD, an OB/GYN and conservative Republican from Kansa<a href="https://www.commondreams.org/news/sanders-primary-care">s, as reported by
Jake Johnson in Common Dreams</a>, Sept 14, 2023. It’s a good thing to have
bipartisan support, but it is, sadly, unlikely to have a major effect on increasing
the primary care physician supply. Funding in the bill – about $6 billion -- goes
mainly to Community Health Centers (CHCs), especially Federally-Qualified
Health Centers (FQHCs). These centers can be, and usually are, good. They provide
care to lower-income people and communities where access to other clinicians is
difficult. Republicans like them because they are not actually “government”
programs, but responsible only to their boards of directors. But, while they
often rely heavily on primary care, and expanding them will increase the number
of jobs for primary care clinicians, it does nothing to increase the supply of
those clinicians, to convince medical students to enter family medicine, pediatrics,
and general internal medicine instead of much higher-paying subspecialties.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">I mention money, the Milbank report mentions money. It is a
lot about money. It is increasingly difficult to convince students to enter
fields where their income is likely to be a fraction of that of subspecialists
(even if much better than that of most Americans), especially in the context of
huge educational debt (frequently over $250K), and the lack of respect given by
the medical profession and often the society at large to primary care. And, not
at all to be minimized, the takeover of so many practices by for-profit
corporations and private equity, with situations like Dr. Morrow’s becoming the
norm rather than the exception. <a href="https://www.healthgrades.com/pro/highest-and-lowest-physician-salaries-by-specialty">Some
subspecialties make 2-3 or more times that of primary care doctors</a>, which
makes it increasingly difficult for students to decide to enter primary care.
And while some of these subspecialties have grueling work hours (e.g., general
surgery) others have much more circumscribed work hours, often shift work and
little call.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">There IS certainly something the federal government could
do. The Center for Medicare and Medicaid Services (CMS) sets the relative
reimbursement for physician services (office visits, procedures, etc.) and virtually
all private insurance companies reimburse based on multiples of the Medicare
rate (traditionally more, but now often less). So all CMS has to do is to
revise its fee schedule, increasing the relative value of primary care visits
relative to procedures. Of course, there will be great opposition from other
specialists; indeed the “RUC”, a non-government committee that advises CMS on
this ratio is completely dominated by subspecialists (<a href="https://medicinesocialjustice.blogspot.com/2013/07/changes-in-ruc-none-how-come-we-let.html">Changes
in the RUC: None.. How come we let a bunch of self-interested doctors decide
what they get paid?</a>, July 21, 2013). CMS is not required to follow the
recommendations of the RUC although it usually does; CMS could ignore or adjust
what the RUC recommends, or reconstitute the membership of the RUC to have more
primary care doctors. Primary care physicians do not need to make as much as
the highest-paid subspecialists (indeed neither do those subspecialists!) but
the difference needs to be decreased. Studies have indicated that if primary
care doctors earned 70% of what subspecialists do, income would no longer be a
significant factor in specialty choice.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Addressing this income gap is critical for increasing the
number of primary care clinicians. Then there is a lot else to do, like getting
for-profit corporations and private equity out of healthcare altogether.</span></p>
<p class="MsoNormal"><b style="font-family: verdana;"> </b></p>
<p class="MsoNormal"><i><span style="font-family: verdana;">For a “humorous” depiction of the takeover of primary
care by for-profit companies like Optum, check out this short piece by the brilliant
Dr. Glaucomflecken: <a href="https://twitter.com/i/status/1706339952857149895">https://twitter.com/i/status/1706339952857149895</a></span>
</i></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com1tag:blogger.com,1999:blog-1509187841033628660.post-7346477907109068612023-09-03T09:37:00.002-07:002023-09-03T09:37:41.984-07:00The problems with our US 'Healthcare' system are well documented. We need to start with the solution!<p><span style="font-family: verdana;">Many sources of news have provided information that should
be shocking on the abuses of the US “healthcare” industry. They include newspapers
like the <i>New York Times,</i> <i>Washington Post </i>and the <i>Guardian, </i>non-profit
policy organizations like the Commonwealth Fund and the Kaiser Family Foundation
(KFF), and many smaller podcasts, substacks, and blogs (well, like this one). The
rapacious profit-taking by corporations from dollars ostensibly allocated to provide
our healthcare by the federal and state governments (through Medicare and
Medicaid), our employers and, not least, ourselves, is regularly siphoned off
for profits and administrative costs (like multi-million dollar C-suite salaries).
</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">That this continues to happen and is built into the way our “system”
(or better “non-system”) works seems to completely mystify our government and
policy wonks. Their response is a hodge-podge of regulations that seek to try
in some way to limit the negative health effects of our system, and to limit
the number of people who are unable to access care because they have little
money, no insurance, poor quality insurance, or have been excluded for reasons
such as prior disease. The obvious solution – one single-payer health insurance
system that automatically includes every single person of every age – has been
anathema to them, despite the overwhelming evidence of it being pretty successful
in every other developed country. And, even when far from perfect, always
better than the US in terms of health access, health outcomes, and cost. We
presume the reason is, essentially, corruption – that, as a result of getting
fat and wealthy at the public (and our private) trough, these corporations give
lots of money to politicians. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Just a few recent examples of what is wrong with not having
single payer:</span></p>
<p class="MsoListParagraph" style="margin-left: 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>The<a href="https://www.nytimes.com/2023/08/30/health/medicaid-children.html"> <i>NY
Times</i> reports on a “glitch” in many states incorrectly disenrolling
children from Medicaid</a>. Whoops.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"> </span></p>
<p class="MsoListParagraphCxSpFirst" style="margin-left: 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>The <a href="https://wendellpotter.substack.com/p/the-seismic-shift-in-us-health-care">Healthcare
Un-Covered substack</a> takes a good long look a the practices of health
insurance companies. </span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; mso-add-space: auto;"><i style="font-family: verdana;">In the “good old days”–let’s call that period pre-2008–the majority of
commercial insurance was full-risk: increases came out of payor profitability
rather than employers’ and consumers’ pockets, and patients were protected from
high out-of-network/out-of-pocket costs. In 15-20 years, everything has
changed. A lot.</i></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.25in; mso-add-space: auto;"><span style="font-family: verdana;">Sure has. Its “poster child”, United Health Group, makes lots of money on
its insurance business per se, denying people (whether on “regular” insurance or
on Medicare-substitute plans like Medicare Advantage). Even more, it is making its
most money on its owned physician practice subsidiary, Optum, as well as their
pharmacy benefit mangers, using what is called “intercompany eliminations” to
have one of its subsidiaries pay more to another of its subsidiaries than to competitors.
Plus the Optum practice groups do not have the caps and regulations affecting
the insurance group.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.75in; mso-add-space: auto;"><i style="font-family: verdana;">Practically, this means UnitedHealth Networks can pay its own
physicians, UCCs, ASCs and the care delivery sites it owns above market
rates–through something called intercompany elimination–then starve other providers
with low rates. This accomplishes two things: it makes the starving
providers more likely to sell their practices to Optum, and it allows
UnitedHealth to post amazing profitability and stay under federal MLR caps.
This is what we call “a good problem” in business.</i></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.25in; mso-add-space: auto;"><span style="font-family: verdana;">Good problem for United Health. Big, bad problem for everyone else,
including the providers in other groups and mostly the people (that is the
English word for “patients”) who seek care.</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.25in; mso-add-space: auto; mso-list: l1 level1 lfo2; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span><a href="https://www.nytimes.com/2023/08/29/us/politics/medicare-drug-pricing-negotiations.html">The
administration announces the first 10 incredibly-overpriced drugs that Medicare
will negotiate the prices of.</a><span style="mso-spacerun: yes;"> </span>Allowing
Medicare to negotiate drug prices is one of the most popular issues in the US,
across party lines; KFF found ‘i<i>n <a href="https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-december-2022/" target="_blank">a survey</a> late last year, 89 percent of Democrats and 77
percent of Republicans said they favored the plank of the Inflation Reduction
Act that authorizes negotiations.’</i> Pharmaceutical companies of course push
back, with completely bullshit claims that it will limit the number of new
drugs. What it will, of course, threaten, is not whether they make a profit,
but only the incredibly amount of money these companies are raking out of the
economy in grossly excess profit. One good example of the vicious, avaricious
abuses is found in<i> The Lever</i>, <a href="https://www.levernews.com/big-pharmas-american-con/">“Big Pharma’s
American Con”</a>, documenting how they rip us off while charging much less in
the regulated environments in other countries. </span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>T<a href="https://www.nytimes.com/2023/09/01/health/nursing-home-staffing-cms.html">he
new administration regulations on nursing home staffing </a>have angered both the
operators (whose costs will go up, and also have trouble finding staff – at the
salaries they pay) and the patient-advocacy groups who point out that they are
far too little (patients have to be seen by <i>someone</i> 33 min a day??).</span></p>
<p class="MsoListParagraphCxSpMiddle" style="margin-left: 0.25in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><span style="font-family: verdana;">·<span style="font-feature-settings: normal; font-kerning: auto; font-language-override: normal; font-optical-sizing: auto; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-variation-settings: normal; font-weight: normal; line-height: normal;">
</span>And on and on. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">What do all these issues – and many more -- have in common? Well,
of course, they are manifestations of insatiable and unregulated greed by
corporations, and the willingness of our government to allow money that is
supposed to be for our health go into corporate pockets. But they also have in
common the fact that they can only exist in the absence of a single, rational,
health insurance system for the American people. What can we do? We can – and I
have, in this post and in many others – document and decry the absolute ripoff
of the American people. For example, Medicare Advantage, which is great if you
are pretty healthy and doing well, but not so much if you are sick and they
deny you care, that are funded (even overfunded, paid more per recipient than
is given to traditional Medicare) with the dollars that you have contributed
over your working life to the Medicare trust fund. Of course, it is facilitated
by the revolving door with government functionaries who are supposed to be
regulating them but don’t, and facilitate their greed, and are rewarded by
leaving the government and going to work for them for <i>beaucoup </i>bucks.
One example is<a href="https://sunlightfoundation.com/2010/02/12/the-legacy-of-billy-tauzin-the-white-house-phrma-deal/">
Billy Tauzin, the former Louisiana congressmen who chaired the committee that
passed Medicare Part D and included a prohibition on Medicare negotiating drug
prices, who became CEO of PhRMA</a>. Or Tom Scully, the Center for Medicare and
Medicaid Service director who oversaw<span style="mso-spacerun: yes;">
</span>the development of privatized Medicare, who went on to join a major
health private-equity firm and made out like the bandits he and they are, as <a href="https://prospect.org/health/2023-08-01-patient-zero-tom-scully/">detailed
in American Prospect.</a> The list of what is wrong seems endless.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">So, I think, it is time to stop leading with all the
skullduggery, rapacious, thievery, failure of public trust, and outright
killing of people, and start with the solution. A single-payer health system.
Everybody in, nobody out. Birth to death. No one is excluded, and no one can be
“thrown out”. It covers the same things for everyone, regardless of income. If
it is something people need for their health, it is covered; if it is unneeded,
frivolous, or harmful it is not. Glasses, hearing aids, mental health, dental,
long-term care. No out of pocket costs.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">How can we pay for this? See above, all the money going to
not-health-care. It would cost much less! Do not let your legislators off the
hook. For example, Phoenix congressmen Ruben Gallego has co-sponsored Medicare
for All legislation for years. Now he is running for Senate against
wolf-in-sheep’s-clothing Democrat-turned-Independent Kysten Sinema and whatever
yahoo the GOP drags up. But this year he has not signed on to the Medicare for
All bill, HR 3421. I have made it clear in response to his daily solicitations
that unless he does, no more money from me. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Demand a universal healthcare insurance system. Now.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com4tag:blogger.com,1999:blog-1509187841033628660.post-37769227508895882692023-08-22T09:30:00.000-07:002023-08-22T09:30:05.345-07:00Older adults cannot afford healthcare even if they are insured: Time for a new system!<p><span style="font-family: verdana;">Are health insurance companies the real enemy of Americans’
health? A strong argument can, and has been, made by myself and others that they
are. More broadly, however, the enemy is all the companies that pursue making money
as their primary goal, with providing healthcare a sideline (albeit a costly
one). So many corporations are involved and responsible that it is hard to be
sure that insurance companies are the main ones at fault. “Even” actual health
care providers – mainly hospitals and “health systems” – try to squeeze out the
poor and poorly insured and greatly prefer to deliver only the most high-profit-margin
care. And, certainly, one cannot leave out the drug companies, making gigantic
profits at the cost of our health (they remain #1 in profits, every year), or
the less-well-known but also very dangerous “PBMs”, pharmacy benefit managers,
who bundle our drug plans, and act as middlemen between the insurers and the
drug companies and the providers. (You notice I didn’t say “consumer” or “patient”;
they are no more than grist for the profit mill!) <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But one can still make a strong case for insurance companies
being at least a major cornerstone of the evil empire, sucking money out of
government coffers, employer contributions, and, yes, your pockets, for the
privilege of denying you care and padding their bottom lines. Long noted for their
unwillingness to cover everyone, the insurance industry is moving the needle by
providing poor coverage even to those it does insure. Two recent studies have
looked at the financial burden on older adults provided by health care, one at
those with private insurance and the other at those with Medicare. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The Commonwealth Fund looked at the coverage and costs for
older-but-not-yet-Medicare adults 50-64 in ‘<a href="https://healthjusticemonitor.us1.list-manage.com/track/click?u=cae609fd2236fc0891447739d&id=de89c71243&e=a87055fd83" target="_blank">Can Older Adults with Employer Coverage Afford Their Health
Care?</a>’ by Lauren A. Hayes and Sara R. Collins (August 10, 2023). A majority
of these folks have private insurance through their employers (55%) with higher
income (>400% of the Federal Poverty Level, FPL) at 82% and low income
(<200% FPL) at 22%. It wasn’t enough. More than half of low-income and more
than 1/3 of middle income (200-400% FPL) people had difficulty paying their
premiums and didn’t get adequate medical care because of the cost.
Unsurprisingly, those worst affected were not only low-income but sick; the
issue of paying for health care is greatest when one has health problems. <br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAzTY7ySZ2ylaUSL1AG_xSDY_TIPXpyNM5mdkRA0_0gH0CGTPPSJNFje0RxjpDExifgD5IzhnPfSiXXOtfSSZ8KEX6cDs_8KeYK8S8PMy7Av4YSemzk1B3dh8LAPdEyUvMYzA03hOijFRk-Kbo_7_DKbO2DtiJl7ei7h9YaEMk0s3kLiv6U9PQFhs3kFhY/s2025/Underinsured%20Commonwealth.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="954" data-original-width="2025" height="199" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAzTY7ySZ2ylaUSL1AG_xSDY_TIPXpyNM5mdkRA0_0gH0CGTPPSJNFje0RxjpDExifgD5IzhnPfSiXXOtfSSZ8KEX6cDs_8KeYK8S8PMy7Av4YSemzk1B3dh8LAPdEyUvMYzA03hOijFRk-Kbo_7_DKbO2DtiJl7ei7h9YaEMk0s3kLiv6U9PQFhs3kFhY/w422-h199/Underinsured%20Commonwealth.JPG" width="422" /></a></div><p></p>
<p class="MsoNormal"><span style="font-family: verdana;"><br /></span></p>
<br />
<p class="MsoNormal"><span style="font-family: verdana;">The Kaiser Family Foundation study, ‘<a href="https://healthjusticemonitor.us1.list-manage.com/track/click?u=cae609fd2236fc0891447739d&id=c34677a86b&e=a87055fd83" target="_blank">Medicare Households Spend More on Health Care Than Other
Households</a>’, by Nancy Ochieng, Juliette Cubanski, & Anthony Damico
(July 19, 2023) examined adults over 65, those on Medicare. They found – well,
what the title says. Again, not surprising; older people are sicker, and sicker
people use more healthcare (duh!) and it costs them more. While Medicare is a federal
government program, there are still out-of-pocket costs associated with it. For
hospital care (Medicare Part A, funded by your paycheck deduction), traditional
Medicare (TM) pays only 80% of approved charges, which means sick Medicare
recipients have to come up with the other 20% (which can be a huge amount of money)
or have a Medicare-supplement policy to cover it, which of course costs additional
premiums. Medicare recipients also have to pay a monthly fee for Medicare “Part
B” (the “outpatient” portion) which usually is deducted from their Social
Security payments. At least this is tiered, so higher income people pay more
and lower income less (or sometimes nothing). Also they have to pay for a drug
plan (Part D). </span></p><p class="MsoNormal"><span style="font-family: verdana;"><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiXOZ2uanR8nA2rqBKaJuGUZbHJ8LOe4Ah_DPWX_VJGbVIZtBOFp1RUhe1Wv5aLAjf8xqsHbI2FGxDAVlKFtBr7dvcZzsZKSIz5oc5lJlahZl0E0qgqbWTp6sei_e75XC6ALLznvByxec3crrSCg9QKJlqNspStJEFZpdJNZwVDbd_XzIkq4oNqFuHrogW0/s1415/Medicare_KFF.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1219" data-original-width="1415" height="336" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiXOZ2uanR8nA2rqBKaJuGUZbHJ8LOe4Ah_DPWX_VJGbVIZtBOFp1RUhe1Wv5aLAjf8xqsHbI2FGxDAVlKFtBr7dvcZzsZKSIz5oc5lJlahZl0E0qgqbWTp6sei_e75XC6ALLznvByxec3crrSCg9QKJlqNspStJEFZpdJNZwVDbd_XzIkq4oNqFuHrogW0/w389-h336/Medicare_KFF.JPG" width="389" /></a></div><p></p>
<p class="MsoNormal"><span style="font-family: verdana;">About half of Medicare recipients are now in “Medicare
Advantage” (MA) plans, which are essentially HMOs. I have written about them
previously, but because they are not actually Medicare (although paid for with
Medicare dollars) but private insurance, they have the ability to deny coverage
altogether. They have good perks if you don’t need expensive care (often no co-pays,
no 20% coinsurance, drug coverage so no need for a separate Part D plan, coverage
for some things TM doesn’t cover like glasses and hearing aids) which make them
attractive to healthier seniors. But while TM covers (if only at 80%) the
things it says it covers, and doesn’t deny individuals, MA can and does. So
while Medicare Advantage can be advantageous for some seniors, its greatest
advantage is to the insurance companies.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Indeed, that some people are better off with one type of
plan and others with a different one is both understandable and OK. But that
the difference is whether you are sick or not is dangerous, since the non-sick
can quickly become sick, especially if they are elderly. That we try to segment
public opinion by pitting the sick against the not-yet-sick (“I’m doing ok, and
can afford my premiums and healthcare, for now”) is what is truly sick, and
intolerable. It is a marker of a reprehensibly designed system. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The authors of the Commonwealth Fund report have a number of
suggestions for addressing the problems that they identify, all of which are
tweaks to our current system, and, in the unlikely event that they were
implemented, would immediately be “gamed” by the power players – the insurance
companies and the health systems – to ensure that there would still be lots of
people left out, lots of people suffering. Their suggestions do not entail
scrapping the entire for-profit insurance system that strangles the health of
our people in favor of an adequately-funded single payer system, but rather the
creation of new programs, and new rules to <i>try</i> to limit the damage
caused to the health of older Americans by a system that simply should not
exist <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Seniors can be attracted to MA plans because of the costs TM
doesn’t cover, especially the 20% of hospital bills. Those in MA plans, as well
as those “younger” – still employed – older people in employer-based insurance
plans can be financially screwed because those plans are operating with the goal
of making money for the companies, not ensuring health care. The fact is that
both problems could be addressed together – by getting rid of the profits and
costs of insurance companies, enough money could be saved to cover 100% of all
health care needs for Medicare recipients. One could say this is “ironic”, if
it weren’t for the fact that irony implies lack of intentionality, and this criminally
flawed and abusive system is clearly intentionally structured.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Dr. Don McCanne, who reported on this in his recent “<a href="http://healthjusticemonitor.org/">Health Justice Monitor</a>”, writes</span></p>
<p class="MsoNormal" style="margin-left: .5in;"><span style="font-family: verdana;"><i>“<span style="color: black;">Should
that be the primary mission of our health care administrators? Of course not!
Their primary mission should be to move health care to the people, the
patients, all of the patients, and they need to use our health care dollars to
do that. Our current system has demonstrated beyond any doubt whatsoever that
private administrators have been and always will be on the wrong mission, and
we need to replace them with public administrators who will always pursue a
mission for the public good.”</span></i><span style="color: black;"></span> <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Yes. Stop trying to make deals with the devil. Those companies,
including insurance companies, taking money intended to provide healthcare as
salaries and profit are evil, and it is hard to think of the legislators and
executive-branch functionaries who facilitate and enable this as anything else.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Our government should use its (ie, our) money to fund our
promises for healthcare to our seniors, not insurance companies who pay them
back with graft. </span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-46775393786306813722023-08-02T09:13:00.005-07:002023-08-03T11:37:34.603-07:00US Maternal Mortality Rate Exemplifies Moral Bankruptcy of Our Health System<p><span style="font-family: verdana;">My friend, Dr. Don Frey, recently published <a href="https://afamilydoctorlooksattheworld.com/americas-dwp-crisis-dying-while-pregnant/">America’s
DWP Crisis: Dying While Pregnant</a> (DWP) on his blog, “A Family Doctor Looks
at the World”. It leads with shocking and distressing statistics about the US
maternal mortality rate, which has long been the highest in the “developed
world” and has been steadily <i>increasing. </i>Citing a recent article in <i>JAMA,
</i><a href="https://jamanetwork.com/journals/jama/article-abstract/2806661">Trends
in State-Level Maternal Mortality by Racial and Ethnic Group in the United
States</a><b> </b>(LG Fleszar, AG Bryant, CO Johnson, July 3, 2023), he <span style="mso-spacerun: yes;"> </span>points out that in the 20 years from 1999 to
2019 US maternal mortality <i>more than doubled </i>(it actually went up 2.5
times):</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><b><i>In every corner of the
country, for every ethnic group, outcomes worsened.</i></b><i> By 2019,
deaths per 100,000 pregnancies (the benchmark measure) had increased from 12.7
to 32.2. For Black and American Indian women, the picture was much
worse. Their mortality skyrocketed to 55.4 and 49.2, respectively.</i></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And this doesn’t even include deaths from accidents and<a href="https://www.hsph.harvard.edu/news/hsph-in-the-news/homicide-leading-cause-of-death-for-pregnant-women-in-u-s/">
homicide – the latter being the #1 cause of death for pregnant women</a> in the
US!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Let’s stop and think about that. In the rest of the <a href="https://stats.oecd.org/index.aspx?queryid=30116">OECD (Organization for
Economic Cooperation and Development, = wealthy) countries maternal mortality is
going down. For the most recent reported years, it ranges from about 1.6 to
8.8, with most below 5</a>. When we were at 12.7 we were way out of the
picture. Now we are at <i>32.2! </i>And our rates for minority women are like
poor countries! Even though the maternal mortality rate is high and rising for all
races and ethnicities, it is made even higher by the ridiculously high rates
for some populations. In what conceivable way could this be compatible with the
US having “the best healthcare in the world”, or anything approaching it? Only
if you accept the definition of “well, the best healthcare is available for
some people, who can afford it, but not even for most Americans”.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Dr. Frey points to several reasons why our “DWP” (and our
dying-while-recently-pregnant, ie, post-partum) rate is so high, and they are
valid, and addressing them would certainly significantly lower it. The major
one is what we often refer to as “the social determinants of health”. This is a
fine term, except it has almost become routine to cite them while we, as a
country, continue to do little or nothing to address them. People are much more
likely to have poor health status if they are financially poor, poorly
nourished, poorly housed, poorly educated and live with ongoing danger and the fear
that comes from it. And when those bad things happen in childhood, their risk continues
higher for the rest of their lives. We call this “ACEs”, Adverse Childhood
Events, and the higher number and degree of ACEs, the worse the outcome for not
only those children but for the adults that they will become. Thus a person who
grew up poor is likely to have worse health status as an adult than a neighbor
who did not grow up poor, even if they end up with similar incomes and lifestyles.
In addition to the ACEs that have their origin in poverty, there are others, ranging
from growing up in a family with adults who abuse alcohol and other drugs, to parents’
divorce, to death of a parent, to physical and sexual abuse, that can occur in
any socioeconomic group.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Dr. Frey also cites the number of states that have passed –
and implemented – “anti-woman” laws, usually under the guise of being “anti-abortion”.
While the legislators who propose and vote for them, and the state governments
implementing them, would deny that they are anti-woman, the facts speak
otherwise. A good example that Dr. Frey discusses, is </span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">Last year in <a href="https://www.today.com/parents/moms/ectopic-pregnancies-missouri-bill-rcna19683">Missouri</a>,
for example, the legislature debated whether to outlaw surgery for ectopic
pregnancies (an embryo that implants in the fallopian tube instead of the
uterus), even though such pregnancies are 100% non-viable. Apparently,
the near-certainty of a mother’s tubal rupture, internal bleeding, sepsis, and
death, wasn’t particularly important.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">That law has not passed (so far) but many others have so
limited access to abortion that women have to travel <i>very</i> far, have waiting
periods, get illegal abortions, and otherwise risk their lives. Despite the ostensible
justification for anti-abortion laws is to protect the “unborn”, the result is
to increase the risk to fetuses, newborns, and their mothers. Dramatically.</span></p>
<p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiozZVNFVkaWC84tvj74cIZSvy1tzVJncKBPDWVoOfh69QCmZvDhYbciYSgGnFvAF7WQrWZP-OHvxTlJLJ16QhYc-DlIlUDtpzSndCq4zT1lQktuflH_lC6eHVTZisc8tDnWDhv7oNc4vYG9pzyO4sxkSu6G2NyBQHVjdXBj0EcPoa_SoymIKD3WYYciTm6/s1048/guns-abortion%20access.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1048" data-original-width="838" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiozZVNFVkaWC84tvj74cIZSvy1tzVJncKBPDWVoOfh69QCmZvDhYbciYSgGnFvAF7WQrWZP-OHvxTlJLJ16QhYc-DlIlUDtpzSndCq4zT1lQktuflH_lC6eHVTZisc8tDnWDhv7oNc4vYG9pzyO4sxkSu6G2NyBQHVjdXBj0EcPoa_SoymIKD3WYYciTm6/s320/guns-abortion%20access.jpg" width="256" /></a></div><span style="font-family: verdana;"><br /></span><p></p>
<p class="MsoNormal"><span style="font-family: verdana;">There are also medical and healthcare factors that
contribute to the maternal mortality rate in this country. As much as the social
determinants of health, and anti-abortion anti-woman laws, contribute to the
problem, medical care can make a difference. But too many women are not able to
access good medical care for their pregnancies and births, in the prenatal and especially
in the post-partum period. Among the important factors are the number and type
of providers, geographic distribution of those providers, preference of providers
for the kind of care that they want to do (or not do), and the ownership of
practices and hospital by corporations that are interested mainly in money-making.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Let’s look at providers. Usually we think of obstetricians
(OB-GYNs) as the people who deliver babies. And they do. Or at least many of
them do. Actually, a minority, decreasing in % as they age. Doing gynecologic
surgery is much more lucrative, and doesn’t require getting up at all hours to
do deliveries. Plus, like most specialists, they are concentrated in urban (but
not poor or inner-city) and suburban areas. So access to them is limited,
especially geographically and financially. Certified Nurse-Midwives (CNMs) and
family physicians also deliver babies, but often have the same “lifestyle”
disincentives. Nurse-midwives are by definition about delivering (or “catching”)
babies but usually are subservient to the dictates of the OB-GYN community. OBs
probably do not mind if CNMs -- or family physicians -- deliver babies where
the OBs do not want to be (rural and inner-city areas) but training programs may
not have enough deliveries to allow them to learn. While nurse-midwives are a separate
profession, their training may not strongly encourage them to assert themselves
in practice. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And there is huge gap is in post-partum care. It is not
uncommon for OBs (and, perhaps, others) to believe their job is done when the
baby emerges, or at least when the woman is discharged. But as Dr. Frey’s piece
points out, a very large number of maternal deaths take place in the post-partum
period, up to 6 weeks after delivery, from bleeding, infection, and other
causes that could be identified with the kind of close follow-up that too frequently
does not occur. Not to mention identifying the risks for homicide (and suicide)
in the situation in which the women lives.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Finally, but far from least important, is the structure of
the medical care system. I have written extensively in previous blog posts
about how hospitals and medical practices are run as businesses, to make money,
rather than as facilities dedicated to improving the health of communities and
the people in them. Birth, and the accompanying circumstances including
maternal mortality, make a particular case. The businesses, as well as the
physicians who work for them, are interested mainly in providing care when and
where it is relatively easy and most profitable. This is understandable, but it
is unacceptable. It is, at bottom, the cause of all the other problems. Receiving
care for childbirth –including the prenatal and postpartum periods, as with all
necessary medical services, should not be treated as luxury goods. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">It may be OK that some people have a Lexus or Tesla, others
a Toyota or Chevy, and still others an old clunker, while many have to walk or
ride the bus. But it is not ok for healthcare, and specifically not childbirth.
Women need to have access to excellent care no matter how much money they have
or where they live. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">That they do not is yet another indictment of a system built
on profit rather than health.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com4tag:blogger.com,1999:blog-1509187841033628660.post-20999241647143439252023-07-23T11:21:00.004-07:002023-07-23T21:44:34.556-07:00Why are we paying wealthy corporations billions to limit our healthcare?<p><!--[if gte mso 9]><xml>
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</p><p class="MsoNormal" style="margin-top: 12pt;"><span style="font-family: verdana;">In an excellent “Guest Essay” in
the <i>New York Times </i>(July 18, 2023) Linan Eirav and Amy Finkelstein ask a
very important question: ‘<a href="https://www.nytimes.com/2023/07/18/opinion/universal-health-care.html">We’re
Already Paying for Universal Health Care. Why Don’t We Have It?’</a> It is a
question that many people, including me, have asked many times over many years.
This article answers several important concerns. One, as indicated in the
title, is that the economic argument against it (“It will cost too much”) is
nonsense, as we (the US) already pays more from public funds (per capita and
overall) than other countries that have universal healthcare coverage. This has
been documented for decades by authors such as Woolhandler and Himmelstein;
when we consider Medicare, Medicaid, government employees and retirees at all
levels, military retirees and families, and (least obvious) the lost revenue from
the taxes not paid on employee health insurance contributions by employers (when
it would be if it were salary) it is not only more than other countries pay for
covering everyone, it is more than half US health expenditures. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The authors emphasize that while the emphasis is often on those
Americans who are uninsured (and despite decreases as a result of the ACA, it
is still far too many), there is also great suffering and uncertainty among
those who have health insurance. This is because 1) their health insurance may
be of poor quality, not covering all their health needs, and subject to the
whims of insurance company denials, and 2) because there is uncertainty about
whether they will continue to have it. The former is a real concern:</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>Many insured people still face
the risk of enormous medical bills for their “covered” care. A team of
researchers <a href="https://jamanetwork.com/journals/jama/fullarticle/2782187" target="_blank">estimated</a> that as of mid-2020, collections agencies held
$140 billion in unpaid medical bills, reflecting care delivered before the
Covid-19 pandemic. To put that number in perspective, that’s more than the
amount held by collection agencies for all other consumer debt from nonmedical
sources combined.<br /></i></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And the latter,
losing health insurance, can be because temporary government programs end or because
employer coverage (and amount of employee contribution) changes. Or because the
requirements for qualifying for many programs can leave people out because they
didn’t know they were eligible, because they weren’t aware of or able to fill
out the paperwork, or for many other reasons. The most simple, profound, and
perhaps important paragraph in the article is:</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>The risk of losing coverage is
an inevitable consequence of a lack of universal coverage. Whenever there are
varied pathways to eligibility, there will be many people who fail to find
their path</i>.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This is incredibly important. <i>The risk of losing coverage
is an inevitable consequence of a lack of universal coverage. <span style="mso-spacerun: yes;"> </span></i>The cobbling together of different
mechanisms for covering different groups of people (employer based insurance, various
government funded insurance, self-pay, etc.) <i>intrinsically </i>leaves the
opportunity for people to lose their insurance coverage. Only one solution
prevents this, one so subtle and elusive that <i>every other wealthy – and most
middle income – country in the world has done it: </i>cover everyone. Period. No
qualification, no sign-up, no criteria, and preferably in one program. Just
cover everybody. You are American, you are alive, you are covered. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">That would take care of <i>who </i>is covered – everyone –
but in itself is insufficient, as the coverage must be good coverage. It must
pay for all needed healthcare and none that is unneeded. Thus, if we were to accomplish
this by passing Medicare for ALL, that Medicare program would need to pay 100%
(not 80%) of what is covered and cover all health needs include mental health, eyeglasses,
hearing aids, and long-term care, without payments from users at the time of
service. Unlike Eirav and Finkelstein, I do not think that the best answer is
to provide basic coverage to everyone and allow wealthier people (or their
employers) to purchase “upgrades” <span style="mso-spacerun: yes;"> </span>as if
it were an airline. Indeed, the best way to ensure that poor, uneducated, or
unempowered people get the coverage and care that they need is to require the
wealthy, educated, privileged and empowered to be in the same program. They will
make sure that it works for them, and that will mean it works for everyone. The
“upgrades” (if you like that term) should only be to allow people to purchase
things they’d like but are not medically needed (most commonly cited is purely cosmetic
surgery). </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The money is there. It is currently going into the pockets
and profits of insurance companies and pharmaceutical manufacturers (see, for example,
<a href="https://www.nytimes.com/2023/07/22/business/gilead-hiv-drug-tenofovir.html">How
a Drug Maker Profited by Slow-Walking a Promising H.I.V. Therapy</a> in the Jul
22, 2023 <i>NY Times</i>). Their greed is without limits. As I have discussed (<a href="https://medicinesocialjustice.blogspot.com/2023/04/why-do-drugs-cost-so-much-and-what-can.html">Why
do drugs cost so much? And what can we do about it?</a>, Apr 18, 2023) Medicare
is the only drug purchaser in the US with sufficient clout to negotiate down
drug prices (other than the VA and TriCare, which already do). In response, the
administration has carried through with its promise to the American people to
let it do so, originally forbidden by the pharma-supported legislation creating
the Medicare drug program, “Part D” (<a href="https://medicinesocialjustice.blogspot.com/2023/03/fantastic-fantastical-hospital-charges.html">Fantastic
(& fantastical) hospital charges: The industry + insurers + Pharma making
money hand over fist!</a>, Mar 26, 2023). This is<span style="mso-spacerun: yes;"> </span>incredibly popular among Americans of all
political persuasions, but not, of course, among the drug companies, who the <i>NY
Times </i>reports are going all out to keep us paying the highest drug prices
in the world (<a href="https://www.nytimes.com/2023/07/23/us/politics/medicare-drug-price-negotiations-lawsuits.html">Drugmakers
Are ‘Throwing the Kitchen Sink’ to Halt Medicare Price Negotiations</a>, <i>NY Times,
</i>Jul 23, 2023).</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The money is also there and being pocketed by the owners of
hospitals, health systems and practice groups, whether for-profit (often owned
by private equity) or ostensibly non-profit but making and socking away money hand
over fist. It is outrageous, but these companies are able to limit people’s
access to healthcare and provide administrative or paperwork obstacles that
discourage access, as shockingly demonstrated in another recent article by
Chavi Karkowsky, (<i>NY Times </i>July
20, 2023), <a href="https://www.nytimes.com/2023/07/20/opinion/healthcare-bureaucracy-medical-delays.html">The
Overlooked Reason Our Health Care System Crushes Patients</a>. In discussing
how her patient almost died because of the bureaucracy, Karkowsky says</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">This is the story of our medical
system — quick, massive, powerful, able to assemble a team in under an hour and
willing to spend thousands of dollars when a patient is sick.</i></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">This is also the story of a
medical system that didn’t think my patient was worth a $12 medication to
prevent any of this from happening.</i></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>This patient’s story is a result
of the space between the care that providers want to give and the care that the
patient actually receives. That space is full of barriers — tasks, paperwork,
bureaucracy. Each is a point where someone can say no.</i> <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Why should we want to say no? In a rational system, everyone
would be eligible and get the same benefit. No obstacles are necessary. Then
the money we already spend would not only get us better healthcare, it would leave
enough left over to begin to ensure that people have sufficient housing, food,
and education.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">All that would suffer would be the already bloated wealth of
billionaires and huge corporations. And that should have zero weight.</span></p>
Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com5tag:blogger.com,1999:blog-1509187841033628660.post-53205731411611569302023-07-07T08:19:00.000-07:002023-07-07T08:19:00.849-07:00Consumer experiences with health insurers: Not always good<p><!--[if !mso]>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/>
<w:LsdException Locked="false" Priority="35" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope return"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
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</p><p class="MsoNormal"><span style="font-family: verdana;">I have often written about the particular burdens that
people with no health insurance have accessing adequate healthcare. However, these
problems affect Americans with health insurance as well. To look more into the
experience of insured Americans, the Kaiser Family Foundation (KFF) did an <a href="https://www.kff.org/private-insurance/poll-finding/kff-survey-of-consumer-experiences-with-health-insurance/">extensive
poll on consumer experiences with health care insurance</a> to understand</span></p>
<p class="MsoNormal" style="margin-left: .5in;"><i style="font-family: verdana;">how health insurance works
involves exploring how people feel about their health coverage, how affordable
that coverage is, how they interact with their insurance provider, the problems
they experience, and, critically, how insurance works for people when they get
sick.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">The findings often seem to be in conflict, but this is largely
because different people are experiencing different things. For example, 81% of
people surveyed (91% of those with Medicare) rated their insurance as “excellent”
or “good”, but for those who described their own health as fair or poor, that satisfaction
was down to 68% (still a large majority, but a lot lower). This is to be
expected; insurance in general is something you hope to not use, and when things
are going well and you don’t need it, it functions well (except for those
premiums). When you have not had a fire in your house, or a car wreck, or a
close relative die, your homeowner’s, automobile, or life insurance are working
just fine. What matters is how they function when you have a need. And health
insurance is different from other forms of insurance because, for a bunch of
bizarre historical reasons, it is the common, routine and accepted method of
paying for your health care, not something you buy hoping to never have to use like
other insurances. And, yet, when you get sick, and need hospitalization, surgery,
cancer treatment, etc., is when the rubber meets the road, and why sicker
people are less satisfied.</span></p>
<p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgenZU_UNZttvOA5kbXXh2Th49ceB_f4-QMj-RvfaS-Epcb7zX4-E2p1f2OtmRBfYj5wei8EY4hrlk32NbpbiNGZFr92DP27mmVx2qQmjp-WtoUmlu3wXGUbdMrOrThMW02IKcLJ6p8fhGD736DmByqBTnPgElfQj1egRi0xvzrSe3pYj5HIrQhhH1_SnlT/s1443/KFF%20Health%20status.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="794" data-original-width="1443" height="258" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgenZU_UNZttvOA5kbXXh2Th49ceB_f4-QMj-RvfaS-Epcb7zX4-E2p1f2OtmRBfYj5wei8EY4hrlk32NbpbiNGZFr92DP27mmVx2qQmjp-WtoUmlu3wXGUbdMrOrThMW02IKcLJ6p8fhGD736DmByqBTnPgElfQj1egRi0xvzrSe3pYj5HIrQhhH1_SnlT/w469-h258/KFF%20Health%20status.JPG" width="469" /></a></div><br /><p></p>
<p class="MsoNormal"><span style="font-family: verdana;">Let’s spend a little more time with this. It doesn’t matter much
if you are happy with your health insurance when you are well if it is not
going to serve you when you need it. <span style="mso-spacerun: yes;"> </span>While that could be never, it is unlikely; if
you are young and healthy, you will get old – or get sick sooner. If you are
middle-aged or older and are healthy, terrific – until you are not. You may ‘not
have been sick a day in your life’, and that is good, but then one day, you
find out you have cancer. Or are in a car wreck. Or a pretty-well-controlled
chronic condition gets out of control. Being concerned about the minority of
people and their health and insurance coverage is not just a matter of social
responsibility (although that is important) because there is a great likelihood
you will be too, one day. Maybe not soon. Or maybe soon.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"> Remember also that, although this poll (and others) are one-time
snapshots, the group of people who are sick is not static. Over time (say
looking at it each year), some people who used to be in that group leave it –
either through recovery or death. Others join it. This is how the magic of
consultants work – hire us and the 1000 most costly people you had last year
will cost you, as a group, less this year. Of course.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Going beyond this issue, the KFF poll found other seemingly
contradictory information. Despite expressing a high degree of satisfaction with
their health insurance, people also identified a lot of problems. </span></p>
<p class="MsoNormal" style="margin-left: .5in;"><span style="font-family: verdana;"><i>A majority of insured adults
(58%) say they have experienced a problem using their health insurance in the
past 12 months – such as denied claims, provider network problems, and
pre-authorization problems</i>. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Unsurprisingly, this rate was higher (about 2/3) among sick
people, but was still well over half of those in good health. And, furthermore,
only half of those who had problems with their insurance were able to resolve
those problems to their satisfaction; a significant number of folks simply did
not get the health care that they need. And these problems were even worse
among some groups of people, such as those with mental health problems.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"> </span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZIhN2R3lUcmVCSlK_Y5pskygdQ9vEw57RrmHkurCjGUMdtXal3ClV4iycFNXk0JYa9aVgoCrexaDuVBoIZhK8NiIpERPeG-PHdk990dky96vJPqO0vipF_za-fuU8ZJSmsKFTI15GafmrkCuD6TTf1JJOcceKujTqGrURr_3X4mcyNDzsRxB076kKQCPb/s1451/KFF%20Health%20insurance%20problems.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1276" data-original-width="1451" height="346" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZIhN2R3lUcmVCSlK_Y5pskygdQ9vEw57RrmHkurCjGUMdtXal3ClV4iycFNXk0JYa9aVgoCrexaDuVBoIZhK8NiIpERPeG-PHdk990dky96vJPqO0vipF_za-fuU8ZJSmsKFTI15GafmrkCuD6TTf1JJOcceKujTqGrURr_3X4mcyNDzsRxB076kKQCPb/w414-h346/KFF%20Health%20insurance%20problems.JPG" width="414" /></a></div><p></p>
<p class="MsoNormal"><span style="font-family: verdana;">Trying to understand these seemingly contradictory findings can
be hard, but clearly some horrible psychological factor is present which allows
the American people to think something is “good” when it is not because their
expectations have been so diminished. It is likely that some of this is “well,
it’s not as bad as I was afraid it might be” or “it’s not as bad as what
happened to my neighbor or cousin”. If you set the bar low enough, a lot of bad
can pass over it. Note that the cycle of bad that affects Medicaid recipients
even more than others – poverty makes illness greater, and makes it harder to
get treatment and to recover, and illness increases poverty. To be “satisfied”
with your health insurance should not require you to be without healthcare
needs!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Good healthcare is something quite different. It is getting
all the care you need (and none of the care you don’t need) promptly, efficiently,
courteously, and affordably. It should not require long waits to get into see a
clinician or to get into a hospital. There should be adequate staffing, both of
medical professionals such as doctors and nurses and other staff necessary.
There should be no out-of-pocket cost for medical services (or a very minimal
one which can be waived for the poor). It should be paid for proactively by “social
insurance” (such as traditional Medicare) and adequately funded for 100% of the
cost (unlike, currently, traditional Medicare). This does not mean the wealthy
should not pay more, but they should do so through higher taxes to support this
health system, not when they are ill. The randomness of “you pay today because
you got sick or injured, I don’t (until, maybe tomorrow, when I am)” should be
abandoned. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Standards for approved drugs and procedures should be
established by independent scientific panels whose members are forbidden from
taking corporate dollars. Such standards may be more or less restrictive, but
must be applied equitably to everyone regardless of where they live or their
ability to pay. Inequity has no place in healthcare.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">And, of course, all profit-making must be eliminated. This
means from both for-profit and ostensibly non-profit hospitals and other
healthcare facilities like long-term care, insurance companies, device and drug
manufacturers, and other parasitic leeches. Indeed, we could keep private insurance
companies, provided they are adequately regulated – i.e., they must provide all
the same benefits and must charge the same amount and not be permitted to make
a profit. This would require them to compete on the only legitimate factor,
customer service. Let the ones who don’t do a good job go out of business. This
is more or less the Swiss model. There are several potential models, but all
must include financial and service equity for all.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">They should not be about being happy with your insurance
because you didn’t get sick, or because they screwed you less than you feared
they might!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"><br /></span></p>
<p class="MsoNormal"><i style="font-family: verdana;">If you want a little laugh, <a href="https://www.newyorker.com/humor/daily-shouts/billing-the-hospital-billing-department">read
this by Kendra Allenby from the New Yorker.</a> But somehow, if you have ever
been in the hospital, I don’t think you’ll laugh too hard because it will be
too familiar.</i></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-46809092319261602102023-06-26T09:59:00.005-07:002023-06-26T15:51:01.447-07:00Doctors, patients, corporatization, and moral crisis<p><!--[if gte mso 9]><xml>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
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</p><p class="MsoNormal"><span style="font-family: verdana;">In the last few years a fair amount has been published,
especially in the medical media, about physician burnout. This term includes everything
from frustration, to saying they would not encourage their children to become doctors,
to leaving the profession or retiring early, to, in extreme but sadly not rare
cases, suicide. The emphasis has usually been on the amount of work that the
doctors have to do, the stress of new technologies such as the “electronic medical
record” that, rather than simplifying things or making them more efficient,
mainly create much more time-consuming work, and the ever-present threat of malpractice
suits and other litigation against them. Recently, the <i>NY Times Magazine, </i>in<i><a href="https://www.nytimes.com/2023/06/15/magazine/doctors-moral-crises.html"> <span style="font-style: normal;">“The Moral Crisis of American Doctors</span></a></i>”
by Eyal Press (June 15, 2023), presents more balanced and accurate coverage. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The article discusses the work of Wendy Dean, a psychiatrist
and administrator at the US Army research center. Dr. Dean was shocked to learn
that the rate of suicide in physicians was higher than that of the active-duty military.
</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">The doctors Dean surveyed were
deeply committed to the medical profession. But many of them were frustrated
and unhappy, she sensed, not because they were burned out from working too hard
but because the health care system made it so difficult to care for their
patients.</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">Dr. Dean thought about this issue in terms of “moral injury”,
generally thought to affect those who participated in or observed horrible
violations of their moral compass in war, such as the murder of civilians. </span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>Doctors on the front lines of
America’s profit-driven health care system were also susceptible to such
wounds, Dean and </i>[her co-worker] <i>Talbot submitted, as the demands of
administrators, hospital executives and insurers forced them to stray from the
ethical principles that were supposed to govern their profession. The pull of
these forces left many doctors anguished and distraught, caught between the
Hippocratic oath and “the realities of making a profit from peop</i>l<i>e at
their sickest and most vulnerable.”</i></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The article goes on at length, comparing the doctors to
assembly-line workers who fear for their jobs if they speak out, to non-compete
and non-disclosure agreements they are forced to sign, to the way that this
manifests in particular specialties, such as Emergency Medicine. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This piece gets to the heart of the matter more than almost
anything that has been published in the mainstream media. I would summarize the
lesson as: <i>The pursuit of profit is dangerous to your health.</i> The
transformation of medical care from control by doctors to control by
accountants and venture capitalists means that something other than what is
best for the health of people, as individuals and as a population, is the primary
consideration driving the structure and implementation of health care. It is not
a pretty picture. Yes, doctors make and have always made mistakes. Yes, doctor
have often been avaricious themselves. Yes, sometimes people have been hurt or
died from unnecessary procedures. But at least in theory most doctors believed
that what they were doing was for the best interests of their patients.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">We have moved beyond (or backward from) that. We have entered
an era in which an assembly-line mentality has been implemented in American
healthcare, when doctors and other healthcare workers are seen as replaceable
cogs, when the provision of healthcare is, like selling cars or liquor or
financial instruments, not mainly about the “product” but is just a vehicle
for generating money for its owners and managers. Tough luck, all you “burned
out” doctors, probably suffering from moral injury. Tough luck, sick people.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This has been a long time coming. The deprofessionalization
of medicine should have been predictable decades ago, and it was. In a recent blog
post (<a href="https://medicinesocialjustice.blogspot.com/2023/05/private-equity-private-profit-medicare.html">Private
equity, private profit, Medicare and your health: They are incompatible</a>,
May 11, 2023) I cite two books. “American Health Empire” (1971) by Barbara and
John Ehrenreich and other members of the HealthPAC collective, showed how even
then hospitals and health systems were being corporatized. Paul Starr’s 1982
book “The Social Transformation of American Medicine” focused on the impact of
this on the professional role of physicians. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Another huge warning signal was, or should have been, the
explosion of the space shuttle Challenger on January 28, 1986. As reported at
the time and in multiple more recent articles (e.g., <span class="bold"><a href="https://www.nasa.gov/centers/langley/news/researchernews/rn_Colloquium1012.html">Engineer
Who Opposed Challenger Launch Offers Personal Look at Tragedy</a>, and </span><a href="https://www.npr.org/sections/thetwo-way/2012/02/06/146490064/remembering-roger-boisjoly-he-tried-to-stop-shuttle-challenger-launch">Remembering
Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch</a>, both from 2012),
engineers for the Morton Thiokol corporation knew that there was a problem with
key pieces of the shuttle (the infamous “O-rings”), and had been ignored by their
bosses when they called attention to it. And never went public with it for fear
of losing their livelihoods. Until after the disaster. At the time, it was
noted often how this conflicted with the codes of ethics of the engineering profession.
But engineers were no longer self-employed independent professionals; they were
employees of huge profit-seeking corporations. Many of us who were doctors pointed
to this, saying this trend was not limited to engineering, but was happening to
other professions, including medicine. It had not yet progressed that far, but was fast moving down that track.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Independent physician practice, solo or group, single or
multi-specialty, had begun to disappear, as practices were acquired by larger
companies. Sometimes these were physician-owned, and seemed to continue to
carry the same “old” values. But then they were bought out by hospitals, health
systems and private investors. So were the hospitals. We got a lot of glitz -- fountains
and art work in our entry halls and fancy new machines, and investment in our
practices, particularly those “product lines” that had the greatest “return on
investment” measured, of course, in dollars and not human health. How could we,
as ethical medical professionals, buy into the casual use of such terms as “product
lines” and “return on investment” when talking about the health of our patients? <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Some of the explanation is greed, and some of it is
psychological, as doctor began to think that using corporate-speak meant that
they were cool, and allowed them to hobnob with the real power players in
control of the industry. Many doctors obtained MBAs.<span style="mso-spacerun: yes;"> </span>And now some of them are very rich. Some are
even CEOs. It’s not surprising that doctors can be smart enough to achieve
this, or that they can be as susceptible to the lure of power and money as
anyone else. It also does not mean that all doctors who get MBAs use it to
limit care in order for their company to make more money. But that does not make
it good for the people of the nation. And it can, and often does, create
another moral conflict, perhaps even moral crisis.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Another recent piece, by the Reverend William Barber and
Gregg Gonsalves in <i>The Guardian, </i>“<a href="https://www.theguardian.com/commentisfree/2023/jun/22/us-leading-cause-death-poverty-crisis">The
fourth leading cause of death in the US? Cumulative poverty”</a>, is scarcely
unrelated, although rather than focusing on physicians it focuses on patients
(the medical term for “people”). It clearly and thoroughly documents the impact
that poverty has upon health. And while the poor are the tip of the iceberg,
the most vulnerable, the cutbacks on care that come from megalomaniacal pursuit
of money affects much larger parts of the population. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Because we have a healthcare system that is designed to make
money for the corporate entities that control it, that system does not deliver
quality care to many (or most) people. As a result it creates unfulfilling,
stressful, and sometimes intolerable working conditions for its employees,
including physicians. Moreover, in the classic “divide and conquer” technique
long used by those in control, it leads to people being angry at their doctors
for the frustrations and denials that they experience, which they mistakenly
believe the doctors control. The denials of care are made by the insurance
companies that they have (and often choose, such as Medicare Advantage). The long
delays for getting appointments and the inadequate time physicians spend
listening is the result of the management of the health systems that employ
them, not only treating doctors as assembly-line workers but patients as
widgets to be produced. If it seems impersonal and uncaring, it is.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">So what is to be done? Doctors can start by demanding that
their professional organizations, beginning with the AMA, condemn and resist
this corporate transformation. They also must recognize that they are no longer
independent practitioners, but employees, just as the Morton Thiokol engineers
were, and that the greatest protection that they – and their patients – have is
unionization. You, doctors, may be well-paid workers, but you are workers! Unions
can educate people, their members and the public, about how the power is
actually distributed and who is calling the shots. Other people can respond by
contacting their political representatives and demanding that the power and
authority of private corporations over their health care be drastically curbed;
this includes insurance companies and health-care companies. A great first step
would be to repeatedly demand that every representative and senator, every
state legislator, sign on to support a universal health insurance system, such
as Medicare for All. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">There will still be plenty to do after that, but it would
provide a structure for making things better.</span></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-35800603868035402722023-06-18T07:27:00.003-07:002023-06-18T07:27:26.847-07:00We don't need billionaires, we need a healthy population: It is time to move forward<p></p><p><!--[if gte mso 9]><xml>
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</p><p class="MsoNormal"><span style="font-family: verdana;">I recently started reading Ricardo Nuila’s book “The People’s
Hospital”, about Ben Taub, the largest public hospital in Houston. This will not
be a book review (which can be found in many places, such as the <i><a href="https://www.nytimes.com/2023/03/18/books/review/the-peoples-hospital-ricardo-nuila.html">NY
Times,</a> <a href="https://www.washingtonpost.com/books/2023/04/06/peoples-hospital-ricardo-nuila-ben-taub/">Washington
Post,</a> </i>and elsewhere); I’ve just started it. What affected me was how,
even in the first few pages, Nuila’s description of Ben Taub was so like that
of Cook County Hospital (now John Stroger Hospital), the public hospital in Chicago
where I did my family medicine residency and later practiced and taught for
many years. That should not be surprising; the characteristics of large public
hospitals in major cities, and especially the circumstances of the people who
come to them for their health care (a major focus of the book, per the reviews)
are going to be, sadly, very similar. What was most striking, and depressing,
to me was the temporal aspect. Nuila is writing about recent years, including
the impact of the COVID pandemic, while my years at Cook County were in the
1970s, 80s, and 90s. And yet so little has changed, especially not for the
better.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Yes, medicine has changed. What we can (or, maybe more
important, <i>could</i>) do for people is more. When I was a resident at County,
CT scanners were uncommon, and didn’t exist at our hospital. If a patient
needed a CT scan, it could usually be scheduled for after midnight at the
private hospital across the street, if they were accompanied by the resident.
Who had been up the entire previous night doing admissions. CT scans, and other
imaging, are far easier to obtain now. We now have dozens, perhaps hundreds of
more antibiotics, and are able to effectively treat many more infections,
although bacterial resistance to them seems to grow faster than the antibiotics
themselves, both because of overuse and the special breeding capacity of bacteria
in hospitals where antibiotics are so pervasive. We can treat, even<span style="mso-spacerun: yes;"> </span>cure, cancers we could not touch in the past,
although the cost of chemotherapy drugs – a bonanza for not only the pharmaceutical
companies but the hospitals that get paid a huge markup from insurers for
administering them – makes them often unavailable to those who are poor and uninsured. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But there have been other things that have not changed.
Indeed, have often gotten worse. This is the main focus of Nuila’s book, the
social conditions that so many people, especially poor people, live in that
have such a major negative impact upon their health. Calling them the “social
determinants of health” is largely accurate, although the “socioeconomic
determinants of health” would be more so, but it tends to almost make it sound
trivial. It is not trivial. The socioeconomic conditions in which people live
have a far greater impact upon health than anything except, perhaps, genetics.
Certainly more than medical care, which accounts by most estimates for at best
10% of health, although it is where we as a society spend more than 90% of our
health-related money. It has far more impact than all those
diet/exercise/lifestyle factors, or vitamin/mineral/“natural supplements” that
are promoted by those who are true believers as well as those who see this as <i>their</i>
way to cash in.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">It is shocking and distressing to me that conditions for
poor people are not better than they were so long ago, and are in fact worse.
The same groups of people who have always been pushed into this category,
especially Black and Latino and Native peoples, and indeed poor white people, have
been supplemented by immigrants from all over the globe who our society treats
just as badly. And even more, supplemented by the NON-poor, working and middle
class Americans who often have trouble getting the health care that they need –
and deserve – because of limits imposed by insurance companies and health
systems, which all operate as if they were for profit. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">It is still surprising to me, because although I
intellectually know better, much of my instinctive reaction is deep-seated and
believes that history moves in a positive direction and things tend to get better.
Said so much more articulately by Dr. King, “The arc of the moral universe is
long, but it bends toward justice,” it resonates with me as much as I fear it
is not so. My own perspective is generational; grandparents who were immigrants
and low-income, parents raised in the Depression and in WWII, myself raised
after the war thinking we were now middle-class (we were working class); better
off than our parents were growing up. It was in that period that CEO salaries
relative to average workers were “only” about 30x as much (not the hundreds of
times as much as today), unions were stronger, the civil rights movement was
gaining ground. See, e.g., this from the <a href="https://www.epi.org/publication/ceo-compensation-2018/">Economic Policy
Institute from 2019 </a>showing CEO salaries gained <b>940% </b><span style="mso-spacerun: yes;"> </span>since 1978 while average worker salary was up
only 12%!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But now it is much worse. It is moving backwards, except for
the wealthiest – and by the wealthiest I mean the <i>really</i> wealthiest.
Midwifed by the Republican party (but abetted by the Democrats), especially
since the Reagan 1980s, we have become a society in which not just a
disproportionate share (which was always), not just most, but virtually <i>everything</i>
goes to the wealthiest. This <a href="https://www.oxfam.org/en/press-releases/richest-1-bag-nearly-twice-much-wealth-rest-world-put-together-over-past-two-years">Oxfam
report (January 2023)</a> shows that in the last 2 years, the top 1% has accumulated
nearly <i>twice as much </i>as <i>everyone else in the world put together!!</i>
This is what it is all about. Yes, there is racism, and sexism, and anti-LBGTQ+
ism, and they are terrible and they often make people’s individual lives
terrible, and should be fought against ceaselessly. But it is the gangster
capitalism (Noam Chomsky’s term) in which there is literally no limit to the
greed and the amount of money a few people have, hundreds of times more than
they or their descendants could ever spend. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This is the trend in our world and our nation while the
people who seek health care at Ben Taub Hospital in Houston or Stroger Hospital
in Chicago or their equivalents, not to mention those who live in places where
there are not public hospitals, not to mention those from all the parts of the
world to whom coming to Houston or Chicago seems like it would be Heaven, get
sick and sicker and die. In fact, contrary to the proclamations of right-wing
pundits, all of these problems can be solved with money. It should be the money
now being amassed by the richest individuals and corporations, including those
in health care (providers and insurers and pharmaceutical and device manufacturers)
could, and SHOULD, be used to provide medical care, but more important provide
the conditions necessary for health. For EVERY person to have adequate and
healthful food, to have adequate and warm housing, to have an opportunity for
an education as far as their drive will take them, to have a job to feed
themselves and their family. There is enough money to do this, and yet it is
being socked away in private pockets so deeply it will never be touched. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">In 1850, the Frenchman<a href="https://en.wikipedia.org/wiki/The_Law_(Bastiat_book)"> Frederic Bastiat
wrote in “La Loi”</a> that <span class="x193iq5w">"<i>When plunder becomes a
way of life for a group of men, they create for themselves, in the course of
time, a legal system that authorizes it, and a moral code that glorifies it.</i>"
</span>They get to do this because we enable them. Directly, our politicians
enable them; while Republicans and Democrats keep our attention focused on “culture
wars”, both parties (except for the most progressive Democrats) depend upon and
enable them. Indirectly, it is the rest of us, who do not demand that the
politicians we elect fight for the interests of the people. If the <a href="https://www.thenationalnews.com/business/money/2022/10/18/us-has-highest-number-of-super-wealthy-worth-100m-or-more/">10,000
or so Americans worth $100M</a> or more disappeared tomorrow, no one would miss
them except (presumably) their families and the politicians who have become
accustomed to being owned by them. If they averaged <i>just</i> $100M each,
that would be $1 TRILLION ($1,000,000,000,000), but of course that is an underestimate
since many are worth billions, or tens of billions. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">It is well past tim</span>e to take that, both in taxes and in
other changes in public policy, and use it for the people.</p><p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com3tag:blogger.com,1999:blog-1509187841033628660.post-91424760643931522092023-06-07T08:21:00.004-07:002023-06-07T16:18:04.667-07:00Outrageous behavior by hospitals harms Americans' health to make money<p><!--[if !mso]>
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</p><p class="MsoNormal"><span style="font-family: verdana;">The article in the <i>NY Times</i> (June 1, 2023) titled “<a href="https://www.nytimes.com/2023/06/01/business/allina-health-hospital-debt.html">This
Nonprofit Health System Cuts Off Patients With Medical Deb</a>t” carries the
subhead “Doctors at the Allina Health System, a wealthy nonprofit in the
Midwest, aren’t allowed to see poor patients or children with too many unpaid
medical bills”. That sounds bad. It is bad. It is disgusting. It is reprehensible.
But it is only one example of the extreme lengths many “non-profit” hospitals
go to in order to maximize their income (their “non” profit!) at the cost of
limiting care to people. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">I don’t know how many hospitals, hospital chains, or “health
systems” have gone as far as Allina in explicitly refusing to see patients, but
most of them go as far as they think they can – and maybe tiptoe over the line.
The article states that “Many hospitals in the United States use aggressive
tactics to collect medical debt. They <a href="https://www.nytimes.com/2019/11/08/us/hospitals-lawsuits-medical-debt.html">flood
local courts</a> with collections lawsuits. They <a href="https://www.nytimes.com/2021/01/05/nyregion/coronavirus-medical-debt-hospitals.html">garnish
patients’ wages</a>. They <a href="https://www.startribune.com/state-takes-minnesotans-tax-refunds-for-debts-owed-to-hospitals/573167371/" target="_blank">seize their tax refunds</a>.” This is, unsurprisingly, most prevalent
among those that can do it, those that are wealthy, those that are in urban or
suburban areas where they can make money taking care of insured people. (A
different calculus informs the often-marginal rural hospital.) </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">It is, in theory, possible to have two different worldviews regarding
this situation. One (mine) is that the main purpose of health care, hospitals,
doctors, etc., is to improve the health of the population, not to make money.
To the extent that the pursuit of money gets in the way of (or explicitly
blocks) caring for the health of people, it is wrong, unethical, and should be
condemned. Another possible view, however, is that the business of any business
(making widgets, providing income tax services, flogging corporate interests on
the internet) is to make money, and that healthcare is just another business,
and if some people can’t afford it this is no different from someone not being
able to afford a car. I do not believe this, and think it is a morally vacuous
position (and, more important, one that actually hurts people), but it is
popular in some circles. Folks cite the maxim attributed to economist Milton
Friedman that the only responsibility a corporation has is to make profit for
its shareholders.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But wait – these are NON-profits! They do not HAVE
shareholders! They do have Boards of Directors and (very) highly paid
management teams, but they don’t pay taxes. Because they are non-profits! The reason
that they don’t is because, under the law, they are expected to provide “community
benefit”. While such systems often try to claim that they are doing so by occasionally
sponsoring low-cost events such as health fairs where you can get your blood
pressure or blood sugar checked, that is not what the requirement actually
intended. The <i>Times</i> article correctly states “Nonprofit hospitals like
Allina get enormous tax breaks in exchange for providing care for the poorest
people in their communities.” That means taking care of people who have need,
and not pursuing ANY of the gross collection tactics, not to mention refusing
care. “But <a href="https://www.nytimes.com/series/profits-over-patients">a New
York Times investigation</a> last year found that over the past several
decades, nonprofits have <a href="https://www.nytimes.com/series/profits-over-patients">fallen short of
their charitable missions</a>, with few consequences.” Put simply, these
non-profit hospitals are given very large benefits (no taxes) because they are
supposed to care for those with need, for the poor, but then they do not. But
they keep the money.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">These non-profit hospitals (and systems), run by finance
people and accountants, operate as if they were for-profits, seeking to
maximize income just as much as the for-profits do. Not having to pay
shareholders, they can pay huge salaries to management, and accumulate enormous
bank balances. In fact, this is an incredible competitive advantage – if you
are a for-profit, you have to pay taxes! As a result, most for-profit hospitals
in large urban markets cannot, and do not seek to,<span style="mso-spacerun: yes;"> </span>compete with non-profits, and are found
primarily in niche markets, for example in subspecialty hospitals providing
particular kinds of procedural care to well-insured people.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Not that I am endorsing overtly for-profit health care. It
is also slimy and disgusting, meeting some needs of some people and openly
refusing care to others. The pursuit of profit and money is the root of the failure
of our health system to do what most of us think it is there for: to improve health.
However, non-profits operating in this sector get huge government (meaning
taxpayer!) subsidy for doing – things that they do not do, do not want to do,
and will take every legal (and often extra-legal) avenue to avoid doing.
Indeed, in addition to not paying taxes they get great financial payments from
other government programs, such as the 340B drug program, often worth tens of
millions (see <a href="https://medicinesocialjustice.blogspot.com/2022/10/non-profit-hospital-systems-behaving.html">"Non-profit"
hospital systems behaving worse than for-profits: No end to the scams</a>, October
1, 2022).</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If there is anyone left who is still taking evidence-free
issue with the idea that the US health non-system is a failure at providing
health, take a look at <a href="https://www.washingtonpost.com/opinions/2023/06/01/american-life-expectancy-decline-covid/">this
recent piece</a> from the <i>Washington Post </i>by Steven Woolf and Laudan
Aron. Yes, it is an “Opinion” piece, but it is full of facts (see graphic) and
backed up by the work of the National Academy of Medicine in its report “<a href="https://nap.nationalacademies.org/catalog/13497/us-health-in-international-perspective-shorter-lives-poorer-health">Shorter
Lives, Poorer Health</a>”. Since 1980, when the life expectancy of Americans was
in the lower half of wealthy countries, it has slowly dropped so that by the
early 2000s it was the lowest, and well before COVID arrived, had plateaued while
that of other countries continued to rise. Almost all countries took a “life-expectancy”
hit with COVID, but for most it was short-lived and has since rebounded. Except
the US, where it has just started to drop a little more slowly.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"> </span></p>
<p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUPqguAFSId8WyYbOca-V0V3yvaq2Y0xRdvCMsdozdhlYZ_f_ub5KNelLTVrfMqXtRiY_4B1JP3bjSNWEFIr-zvd5RyQfWULFmVGRHQReEUvw-sfE611RUEF6IpBA2jMoMLsMX4kcVnNq1_8XcrK_h6bleeo4Vh7gK146yZ6VKMfVE1wQyq1zHMR58rA/s1702/Woolf-Aron%20lie%20expectancy.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1041" data-original-width="1702" height="392" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUPqguAFSId8WyYbOca-V0V3yvaq2Y0xRdvCMsdozdhlYZ_f_ub5KNelLTVrfMqXtRiY_4B1JP3bjSNWEFIr-zvd5RyQfWULFmVGRHQReEUvw-sfE611RUEF6IpBA2jMoMLsMX4kcVnNq1_8XcrK_h6bleeo4Vh7gK146yZ6VKMfVE1wQyq1zHMR58rA/w640-h392/Woolf-Aron%20lie%20expectancy.JPG" width="640" /></a></div><br /><span style="font-family: verdana;"><br /></span><p></p>
<p class="MsoNormal"><span style="font-family: verdana;">Life expectancy is not the only measure of health system
function or success. However, there is no accepted measure (deaths of
middle-aged people, infant mortality, maternal mortality, years of productive
life lost, etc. etc.) in which the US does not lag its peers, and often poorer
countries. Unless you think the provision of boutique specialty care to wealthy
people (including foreigners) is somehow a measure of health system success.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Woolf and Aron cite the National Academy report which lists a
number of reasons why the US does poorly:</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">(1) unhealthy behaviors, such as
our diets and use of firearms;<b> </b></i></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">(2) inadequate health care and
public health systems; </i></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">(3) poor socioeconomic
conditions; </i></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">(4) unhealthy and unsafe
environments; and </i></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>(5) deficient public policies</i>.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">They note the last is most important, including failure to
address basic human needs for food, housing, education, and jobs. The continuing
effects of racism. The failure to have an adequately funded public health
infrastructure. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The National Academy did not look at the fact that our gangster-capitalist
system has taken over health care as a cash cow to have money extracted and
only incidentally (when convenient and profitable) provide health care, but
this too is a clear failure of public policy.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">If hospitals, non-profit or for-profit, are not providing
all the health needs of our people, rich and poor, they must be forced to do
so, by public policy. They should be provided with a negotiated, global, annual
budget for operations (and a separate one for capital, so they don’t milk
patients to make money to expand) by a national health system. And be held to
it.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Addressing the problem of greedy hospitals, the pursuit of money
rather than health, will not solve our health problems. Not only does it leave
the other parasites, insurance and pharmaceutic companies, it leaves all the
other societal inequities cited above, that also must be aggressively acted on.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">But it is a necessary step, and a good start.</span></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2tag:blogger.com,1999:blog-1509187841033628660.post-76696093154333579092023-05-11T09:37:00.001-07:002023-05-11T09:37:38.376-07:00Private equity, private profit, Medicare and your health: They are incompatible<p class="MsoNormal"><span style="font-family: verdana;">When recently scheduling a procedure with a physician, he
just shook his head and told me how lucky I was to have retired, and how
difficult the practice of medicine is now. Before the outpatient procedure, he
had wanted me to get a consultation from a physician in another specialty, but
it turned out that that group no longer saw outpatients but only did hospital
consultations because they no longer had the capacity. From his perspective, the
problem is lack of people, especially doctors and nurses. </span></p>
<p class="MsoNormal"><span style="font-family: verdana;"> But there are other big reasons, which I have discussed in
previous blog posts. There are different aspects to them, but they essentially
boil down to the transformation of American healthcare into another
profit-driven industry. My doctor, and the doctors he wanted to consult, and
the nurses and other staff with whom they work, are all interested in providing
high-quality and effective care to people. The corporations for which they work
(or are forced to work with, such as hospitals) are interested in making money.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This transformation, like most, is incomplete, but it seems
to have passed an inflection point from which, if something major is not done, there
is no turning back. The changes have been in process for a long time,
documented in books such as the Health Policy Advisory Center (HealthPAC)’s
1971 “The American Health Empire” (Barbara Ehrenreich and others), and Paul Starr’s
“The Social Transformation of American Medicine” published in 1982. They
document the change from a cottage industry of independent doctors to one dominated
by large institutional players. In the 1980s, <a href="pnhp.org">Physicians for
a National Health Program (PHNP</a>) was created with the goal of, if not reversing
this trend, at least harnessing the system to serve all of our people through
the creation of a centrally-financed single-payer health insurance system.
While every other wealthy (and many non-wealthy) countries in the world have
such coverage, the US is the outlier. PNHP has advocated for decades for a coverage
system more like that of Canada, where provincially-run financing plans cover
everyone under a set of rules set by the federal government. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">At that time, and today, a huge part of the problem was, and
is health insurance companies. They are the obvious predators, drawing profit
from ‘managing’, which often means restricting, your access to health care.
Insurance in general makes money when it takes in more than it pays out, and as
customers we “win” when we lose. That is, we collect when we have a car
accident, or our house catches fire, or we die. We bet against ourselves, and
hope we will not need the insurance. But health care is different, because we
want to receive it. To be paid by insurance may have made sense in the early
days, when it covered the hopefully-unneeded hospitalization or surgery (“major
medical”, it was called) and we paid doctors out of our pockets or in chickens.
But it makes no sense for routine and necessary health care.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The other big abuser back then was pharmaceutical companies,
which made even more than insurance companies, marking up prices to whatever
the market would bear, no matter how many people were left out and could not afford
them. Sadly, the news is not that the character, behavior or profit taking by
insurance or pharmaceutical companies has improved; now they are both even
worse! What is sad, and terrible, is that the actual health care providers have
become more predatory, and more often owned and controlled by companies whose
primary business is making money, and only incidentally providing health care. I
have written about this sort of abuse by hospitals and corporate-controlled
physician groups, and it has just scratched the surface. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Recently, the Kaiser Family Foundation Health News reported
on <a href="https://kffhealthnews.org/news/article/private-equity-takeover-health-care-cities-specialties/">‘Sick
Profit: Investigating Private Equity’s Stealthy Takeover of Health Care Across
Cities and Specialties’</a>, exposing once again the way in which for-profit
companies, and increasingly private equity, have bought up healthcare practices
and limited access or worse in the name of making money. The article leads with
the story of a 2-year old child in Yuma, AZ who died of complications of anesthesia
while receiving extensive dental work that, his parents say in a lawsuit, was
unnecessary (it almost certain was). They charge that the dentists were pressured
by the private equity firm that owns the practice to do the maximum number of
procedures on children with Medicaid to maximize revenue and profit. But that
is just the lede; the article documents the increasing frequency of practices owned
by for-profit companies abusing and sometimes killing people, either by over or
under treatment. Which one depends on which will make the most money, not on
whether folks need medical care or not.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Killing children in pursuit of profit is something most of
us would frown upon, but while all practices owned by private equity or other
profit-making entities may not behave so badly, it would be a mistake to call
those that do “bad actors” and excuse the others. It is the entire concept that
YOUR health should be a source of profit, and be attractive to the venture
capitalists investing in these practices because they can make so much money.
The money, whether paid by you directly, or indirectly through your insurance
premiums, or by the government through your taxes, should be going toward your
healthcare, not their private jets. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This practice complements the impending takeover of Medicare
by for-profit Medicare “Advantage"”plans, and private-equity controlled ACO/REACH
plans, just recently reported on in the <i>New York Times,</i> <a href="https://www.nytimes.com/2023/05/08/health/primary-care-doctors-consolidation.html">“Corporate
Giants Buy Up Primary Care Practices at Rapid Pace”</a>. The article begins by
noting the shortage of primary care doctors, and that it is getting worse (also
something I have written about often) because they get little respect and less
money (than other specialists). It would be nice to think that this evidence of
the impact of family doctors and other primary care clinicians on patients was
a sign of respect, but it is just a sign of greed, especially through the
programs that privatize your Medicare. This represents a huge potential profit
center for these companies. “That’s the big pot of money everyone is aiming at.”
Yup. It’s $400 billion!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">This is why most of us who are paying attention agree that
we now need to go much farther than simply national universal health insurance.
While that is important and good, it could end up being another vehicle for
profit-taking; remember the Yuma dentists were ripping off Medicaid, a
government funded program. Thus, only a truly non-profit (unlike the ostensibly
“not-for-profit” hospital sector than emulates for-profit competitors to maximize
revenue) is acceptable. Steffi Woolhandler and David Himmelstein, founders of
PNHP, <a href="https://jacobin.com/2023/05/physicians-for-a-national-health-program-interview-medicare-for-all-national-health-system">call
for such a national health service in a recent interview in Jacobin,</a> and it
makes sense.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The justification cited by these companies for their rapacity
is that they increase efficiency. This is of course, BS. Efficiency in generation
of more money for them, perhaps, by cutting back the number of doctors, nurses,
and other staff, overworking those who remain, and making them all, along with
their patients, miserable. That is not efficiency in production of healthcare,
and is certainly not efficacy. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Doctors and nurses are being “sped up” as if they were on an
assembly line, and are burning out and leaving in droves. The people who are
the “products” are getting 7 minute visits, don’t have time to even talk about
their problems not to mention get adequately treated. It is bad for everyone
but those few earning the profit.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">The <i>Times </i>article says “The companies say these new
arrangements will bring better, more coordinated care for patients, but some
experts warn the consolidation will lead to higher prices and systems driven by
the quest for profits, not patients’ welfare.” Yup. That’s what they say. Not
to put too fine a point on it, it is a self-serving lie. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">We need one system, well-funded, to handle all of our needs,
generously paid for without a cent going to private profit.</span></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com5tag:blogger.com,1999:blog-1509187841033628660.post-64350112806879687722023-04-18T08:37:00.004-07:002023-04-18T09:39:50.301-07:00Why do drugs cost so much? And what can we do about it?<p> <!--[if gte mso 9]><xml>
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</p><p class="MsoNormal">I have written before about the cost of drugs, and I recently
was asked to give (and gave) a talk on the topic to a group of neurologists
subspecializing in neuromuscular diseases (such as ALS, myasthenia gravis,
muscular dystrophy). </p>
<p class="MsoNormal">There is a lot to say, as the outrageous profiteering of
pharmaceutical companies seems to know no bounds, and the stories come out day.
The outline for the talk is:</p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>Drugs
cost a lot in the US</p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>Why
drugs cost a lot in the US</p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>Examples
of drugs illustrating different ways of charging a lot</p>
<p class="MsoNormal" style="margin-left: 1in; mso-list: l0 level2 lfo1; tab-stops: list 1.0in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>Neurological
and Neuromuscular Drugs</p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>Impact
on patients</p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>What
can doctors do?</p>
<p class="MsoNormal" style="margin-left: 0.5in; mso-list: l0 level1 lfo1; tab-stops: list .5in; text-indent: -0.25in;"><span style="font-family: "Wingdings 3"; mso-bidi-font-family: "Wingdings 3"; mso-fareast-font-family: "Wingdings 3";"><span style="mso-list: Ignore;">u<span style="font: 7pt "Times New Roman";"> </span></span></span>How
could the whole problem be fixed?</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Rather than reprise the content here, I thought I would just
post the slides from the talk to the blog (found on the right, under Links to
Documents in Google Docs) and encourage anyone interested to look them over. </p><p class="MsoNormal">Link: https://docs.google.com/presentation/d/1kDFFHpZpwK58WRhuTkKPMBflfkjwvXHe/edit?usp=sharing&ouid=108196900244678484854&rtpof=true&sd=true <br /></p><p class="MsoNormal"> </p><p class="MsoNormal"><img alt="" height="439" 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XMze6lV4UBVe1OMNEnEXDnPlYsXyXVuTb2BL9LD2+a3/s+MkXD8cIIvXeFqTKKs17q1SIxO+dK/xvIuEAuAnrkT9jUa0tinCQ3cbHFQQrxCs1J9SBFQBBQBReCvR+AZi28NucHLObBhM9/f8KVGhyG8MbIWzneUklZe+BeWsHHFLn4MdKHOgJHMmOBHPXHllG2wv0noiqWsFY/gPr1q2DSuT0ePKlRzr4uTCIz67rY43lEOWvFyBm1g75ZDLAu2wLRWPTo0ccROFIKBXRXs6zbGs4YNVe5uApKIk03UzjXb2XDNk2qdRzBjfBPqi2B8cJ8gm+Dwg5zbs5ONpzK4ZedNi66daNfEgwbVS4s3sf6niPgL2sf+Xec4ec0W5+6D6Pdca7xlg3XXEaYbV1HbOL5lA19uziBdNvfNmtpBmhgSCoywqm6PrXh6TS2rYlvZlYb1nXFzNJUNWiFcWcPm5dv5/rAl1fsOY9KMTjS9r+Bawc2ThBzZxpoDcdwwrkfTbl3FGFGHRjXFm3J3TBdSIOIj4vRW9u8J5licM7U69mVw/5Z4OejxmzMnlbhTmziyYTcbI52w8OnBsOf88Pawxb60wyf7BvEXT7B/4wq2n9eQ5T6W50Z0YXBLe2TPfc+Vf2Exh1d/x4KDRqQ4t8Cva0Mc7dyoUbmmCOLquNgalaqonEbyuZ0cWreGVecro990JFNkzLRyFQ97qbtqdL9/Yg1rNp1l/62a1OvUh/7dfWnsavzb7+fGEBW0nwPbd7P7mOQK1+pKxxEDeK5VVVwfy61+7/OUDjvX+EnO9+hmtHSqkO9WbpRO+rnVbP5lFytCK+PadyRjR3bEx/bOeMlBmyxGq3Wr2HgwkujqXWnWvTMDfcUIIZWvfhPA+WRGnib46FY2rQoi1MCbumPFu9fJg+Z2v3ZUcRKxJ9ax5ofVHNb3w3P0a0xqZYtnWRaSkkfMR5N0lt1ffc+2i3oU953DoF6N6Fr1SUJF7hPfIky6zHibMZ2q4JEezM1dP/CRzIUrdv2YNqMHveqLt6289VeTTn7wfJZtCGN1bCd6j+jBtK72Mh5C8H9vHj/vSCCk7UPEd56MlQt72LRc8u1vyTju0JmOvo3wq18V+9KPViRrytVAAo8eZN/RC0SatqBBz+EM7FSDOvePlxwRJHvfZdmqALZHNcGtqSPurloykitJVXsbHOwkwsPWCn1Hd5xr1aaZiw2WstAU50hbTm1m6/azHE1wwMGnAx3btsC3vhNO90QwiPEwTIT8qYNs2RlLcmU/2o8fTJeGjtT43a7wPFL8V7H+wzWsKG5BrfHTebt3FWo9cF9ZfzKvcmHPZjbvCCLC0Au39p3o3LYxDZ0l4qh0f+VEkRgawIn9O9l3KY/kKt3pLGkBA1pXx/7+fr11jNBdq/hsdSzXKjnQTCKijMVIWJClj0VVWQsrW4g33AlLa1e86gp7FynU91jv5qcovhEjQ+xRtn00n62XzTAY9jdG9G5MJ6c7MzGLpKDtbHtPjMZxxmQ3a0pLy1wqS2REsr6shXYSmWIhueaVbeUd1hRX12rUMNPVSLlE0IolrFpyhjTf8XScOpYezlDKPnP/KkrW9QPsfmc+P4fZkDd4Fn8b5E33mqUGsBiLC+MvcHCtrC8nEkl27kabnu3o28qDGjK2bq8Kukiam1w7o1tjt7L+yC1yG/ei66gBtHfMwbaSGVqHelStLGkdBmnkx51h9/K1bDuTSV79frTr1lKEubzj747VbPKjgzm3bx1bDgTjn1mH2rIPGD2wJT5SB8P6z1kq/7FGm/qwIqAIKAKKgCJQmsAzFN/ilc0L4diihazZdp3srjPpOawHA6qJ56a0i0xznfAdklv4/T4CHLrjN2U6k1pYU3aKbDSXVui8YrL5tfSjydixvDSgLu7lhNXCTW7uX8mPX27lWGETGo6dxcS+dWhcnvug+Cppx3/hnXkHOV2pJQNe/huDm1WmVmndVJBIfvg2fvlxm2y27HAZPJ0RQ0Rcle+SuM07Zjen1izm+zPOFHmPYPa4BjRzNP7NyHBzF/5bl4v4vs5lg7q06t2fHm38aOppT7m1urTigY6Q/OCVO5h/xJJqvYcwYZoItTviW5uJNvYwG35ay/rjGix6TmHwiPZ0c3zYJNCSGbpNCuOt5pCmIVW6j2NECydcdXG2xRkUxchGU8JRd180ocqo0fTrKx7Vh+nK1B0cWriaT7ca4dRrKNNndaWJVG0qbdDIv7iYQysXsPCQhAv7TWT8nH50d5aQ/XKbmYg2ZDUffrmZ7bFutJv5KqO6ieHj7hcKZSMqbXxnLmuuOcGYN3h1eB2alScqpQp/+O6NbI2rSn79vgxqWQ3P31F/ICt8p+R8f8fPF2zJayLGgYGN8a36kJjuSmKkyU8nNTyI8CB/jgQlk2LTFJ9ufens54yn9W9htZq0S0QdWs6P+1OJsO7C2NHd6VnX7CHRImnc2vRvFmwIZbfZaAYM782MDpXvGiq0WeHcOrSIuSvjOK3fhTEv9GZAM7uyPWzpZ4k8soovVuWQ6Nidqa90p42zyZNXey7t+daJ72lvMUK8mPUMJPciw5/tn/zMpuP5VBo0m4FDWtFDuvLBS0LDY0UAfLGYY4mVsR3zMn1E0DXUCZiiCxz/6FuWlSu+dUedxROxaRGb1hzjqGVfWgwbzfOdrcXf+7ArjaLLa1k0bxvbr1Wl7viZDOneqCQv/+6VE0f8vvdZtXovG6LqYy3VwXv2b0/Hhp6420pV7bJun3KGkH0Scr8slBtVu9J9xlQGeZtJWa+HXTJu9n/Fio1ygkR+HzoM6cakbtUQ093vuDKIP7qGjZ+uZ01xM1zGTOXNnuLpvm+NK5R0oivrvuXHg5mE1BjJ5PHdGVrf+BEREDeJ2rOCn+YeIsCuLc2mTWact6OEtJdq7q2TXNqzjK/WnOdkdi28u/WhR8e2+NWrjuudim+/4+lkIZNvl8r5fuKwc10jiihIP8PR979j2YkCbnafxpRhbRjueWcxEvF9fhfb3/+Z9cGS7uPbjc49O9PDtwF1XS3LjAS6077gVctYs+wsaS3G0mGyFCat/gjxfeMge9/7kaWXRXwPnMmcgU3oViqPqzjxGGHb5/Hp8jxuOg9j2tuD6OtaXtqCRC1E7WLdO4tYc8MZs9Eviyfdg5alx3jWeeIOLuWdH64SYtmN6e9OYYiHRDuV2TeJpF86zqa1V0kwrUvzIZ3xFuOvzWOHy/yujldfVgQUAUVAEVAE/ucEnp34Fut5+smFLFgVxeGibox+sT/DG5Xju8oO4OraeXy+tZCYWrIpeL4Lnd3KOmZJxPcvP7Jq0Wn2uQ2h4/hhvNnGHJNyX+DXubZ3DSslfPd85W40nTyb0T6mVCtPB2kipdDQWt6XkNfjheI1mP42w1o7UvfubkJLnngXApd/zbcB9mT4zuKN6U3wfZTwLunmLPFur+Pj9/dwNNmT3i/NoG9rJ5zvtP3mDo5tXMfcrSKofQczcc4Auoh3/KEenUeIb22qbOJ3fMy3W9MJtBrJhFk9GNrIqgJeIslJzZcwcrGf6HIuTY0lb6/EQ6FBmy+5p5KLWainC3mVc2/vGcISGi55rtmZkjsqoYcZOZKPnhpE4L4drDoaj0nrCYyYPJ7uLtwjbvIvLuKgRDT8eKiuVL8fz+x/+tHgHgvNffNEm4D28hY++XYFm2840Xzc24zuWY/md4dXEXm3zhC46EdW7IzkomNb2vbvKqKsDjXtbLGzlud5YOpJaHHJVlryU+X/f8+eMOvaXvyXzWPVyUQu6XtSs5p4Os3KdvEUS1iuvoTjWlaWo7WqiZe/eg2q1axFdfHwOZWRWKwtknxkXS6oVqIBzMyRFNp7L119AEl/yND1QbbkcuZIpEDgUvbsuMzJ5C50mDqUiSPqIvv4Xy/xXuaf5/A3P7BuVwJZXWfRe2hXBtaSHNR77pzCzT3L2bF0N6er9qX+iHGMayTpIxV16Je11D0gvt9kRLvq1CvRLRJG6/+dpFTsYVGURF9IVMecUXXQRdGW7hvtraNEHNrIZzssKXDvyQvPN6eJGE6kOoLc4iLHP32I+NakoY3cwcIfdrI22JamEyYxZlhjvCrkyJe8/NVfsGazRAI4jKLToAHMaWf3m3de5/ne9x4/Lw3mQGY/ur00hvE9y/Dy3uUignfHl2xYf4w12oG0Hzmat7tYVvAM7UCCV6/k48WxmLUewtiZ/Wkua0e5NslHvnbSiTu6lk13xfcU3ujhIkagUl+UMP+4Y5v44etNXDBpSZuZf2dwcwvk0IpHXsW3TnNxw6d8u9eA6BrjJbKhNT09LX6bk7eOE7JzJZ+vSiDBVULL/zZGRKJ4vR9554p+4GmKb42Ib4lSeF+Kh4qhKErE91QR3yPqlBLfgVvZ9uFyViTVxnbU87wx1JNG94f/3LeO6owDT1t8a2IOcHHjp3y2RiKMPCfx4ju96VatvMGuRRO3l01vzuWnMDs0Q17m5UGN6FY6jD33BqnBm1j40za2XbXEqdNw+nRsTlt3exyspdZJWe9ZnVNfagH8+kKpaIepzykCioAioAgoAn8ZAs9IfEtYdoR4HufJhuR0NnEeXeng40x9ifkuOTb1nktCZTWpFNw8x66Dl4gw8aHN5DlM6FGPZg9sUHTieyGrFvqzr+YA2o0bxj/b2T6k8FYk1/asYfl3ezlv0xmfic8zqrkVLuXtSiU/PeXUWqm+vI2TGikCN+NNhrZ0wPOuUpPQ9BObWf2JhHrHmKHn15YuXnZUk/s98rD0SnkUJYdxZvsBIqmL58R3GNlTPNx3XFQ3t4v43ijiuxhDvwFMfKkfLWUDXW4EsI5hOeJbF3ZuJDIyW0Tgobnfs+RqFfK7zZDNU0PaV6/A7riiwztHIgtCLxEemUhchuQN6knROiMp2FOpkKKCQsmXzSA7OZKIiwGcjyvAsfsMBo0dT8+aZYnvJSK+PbDtOo6Zr7emseltEVzmVRyPJmwzn367mq3R1fAd/yajetSl6T39qguJvczlsyc5vC+IgPBkkoukfTZ2OFSvQhVHO6zNrbCUf3dyccO1thtu4pH8PaL7Tlt/Czt3oLD5BF4Y4UPrag+LBZY5IEXSKsm5TY/3++JJux5O6OVIridmklEoQt5YCtLpSdm7IvFcFeRJEcAkkiNPcf5cDrfoSO8XBkuerBcSwVpaSZF76RdJD9nEd0G1ce44lDkTm+NxJ/1DChpqYzazYdUJmc/VaDG4L+OHeiEpqI/Z3vt686HiW7dJv8YNSQVZ8M0hLjt2pt0MKchW34SqJUNYN+OSCd/0Mzs3Hudqo5E0HzSEgWLYuW3n0BmCLnLiYeJbQrxvHZ3H/J8jOJLVnf4ScTG8k3MFjzcrJuv0l2xbvYWloW2o038Es6Y1oPadDrwrvkM4mDmAXi8OYnSvmuXcW8Zq3kWOfP2ThKkHE1zNh3riGe1UQ/L2H7mw6DrhFjFnjnDu5A2K/KbQfcoM8UAb4PB4sdilOqcC4jvlGBe3b+DDFQlk1+3B5JeH076G4QMpJWXO35xrJJ9azLwfxSCU25J+Lw9lUNvqVL3zYQk7D9m5WsS35CO79WDs3wbTuZZ4SSu6Lj3yc09TfOdTkHCCnR9+x+YQQ4pFpI7q6yOpGHdMV+L5viO+0+tgM2om/+xdG0kLf8h1u31PW3wjUVvZ10+zc91ejl7Vw0RShlp3kmKQdSS/+54acVIbJXQfp7bvZPGhdArqSWrRpOF0cReB/UA4ktQ9uXCUwGOHOHAxjtBbUpTNSJdWUV0MiA7Y2YthUQpk2tjXwMWtNm5uEmb/eIvcI3tTfUARUAQUAUVAEfgzEXg24jvlEEF7t/PlFhGAFi506eCEdbGE1ur2FGVeInr0pUha7AGCryRxVq8P3Qb0ZnqPKvfluP2vxXcsNw9vZPXnm2XTKBV/O3TAu7optvoV2iHLJtkQE1MDzByqYVu9LrWrSp7fHW/tXfEthcp8+zNBIgVaOVR6uLfnkeJ7j4jvH2zwe+kAACAASURBVPg5qiqFPWfxal8vWj9pfm5Jv8lz5scRde4ox05KPnGseMBNpSiPYxUqV9ZVihdRW6UqjuK1tbe3vF3cSyMe6FWLeGf5JfKbjGXMtEn/JfFdeqCJNzghiuuRUkgrQTb06eKdz5Lq9CnxxCYkkpAqHnpDByxdW9GidWu6tnCWnO8KuT/LHM33HjU2kZdGNRPuT6nCkFYqI0ef5vSRk/ifE8+g1hZTRyfhboutGBIqV5E+kE1vVfvK2Esuqb5EKxSc+DcrFu1n9dWutJg8nCmjpfjfAy2Xe53ews+fyNjWk6JI019gnOTaekj4dnHqeU4t+JzNYXqktJ/DsG4N6Fyux+wxlr9HiW/d8JGUgCvrv+L7fYVE1hwtReHal3hJDSSloih8BUvXh7DlWiNJaenOiC41SsTf7b19RcR3VIn4XvBzGIcyO9PnxYGMkMJnDw/zvvN8FRXfF0V8SwqJzujRu1ZJYboHL6lMlRXA3nlS/2JrOPH1W+HhU5cGluUumPfdwkCqn+tLETbJha7iQTU5L91NQhLEfvWEV0XEt3ind6wT8X2TNIk4GD9nLJ1dDZHSBI++RHwn/Sq+/R8qvpNJcu3OmFeG0EUioSp070f/esnYeGph5wURpBxfx+ffnSJIvyk9XppGv2YO1Lxr4ywlvtM8sRk5g3/0ccfb/mEK9EHx3XHKaLqKteuhOd+PCDu/jUaKYx5dxqath1h73Q4LWbt9qhtKccaCkogmPSNdsUZ9dDUG9aXGSHWvljRv5EnD6kaPrlKfl0j89WtERsWRIBXUs6QIZ4YY/+JvSfHBmBSJiJJ7OLjj0a4jrTv40kTu+fQMKhXqePUhRUARUAQUAUXgf07gGYjvZKI3fcPWbac5WHUMbQYP44XGFTR1F0vl8FUrmftzFPlN+zPkheF0FHfIb+GG/2vxXSD50Fs4tmARS1MbYtL/Fd4e6EStp9GNT1F838n51qRIEaRtEt65O58wx/EiXDoysJ55xUJZxdupqzCerzWUSsVSdE5PQ168eLA3LmLtfslLt2pL637d6dW6AR66SshlMpBNZNYJTq5dwkdrL0uu+zhGT/1viG85dkdchoUFUu1bdzxPuc5+OV4nW8R4dAgR/ptYuvEslyp5037CCwzr7EmDh4YdlN/pv7/aeTn31twg5tRu1i+SYkhxUjyw/SAGdPPBz0uMHeWlUhTJkXJHP2D10iNsiOwildOHM7lM8S2mlcxwCS3/mh82x3PGTMTi9L6MbRJP/LHVfPJNNAmV2zLh7/1oJaEjT4jm3gergPhGjA3F8YdZO3c5G89WwmnMS4wd04xGyXJE4TdfszXeCYOBUpvBrzpN7lEmFRDfJWHnO1n0w3bWBFvhPX6qhJ2L4aFCwSG/hp1LQb89TqPpNHAAL0kUzt3Mh7ue74qIb13ueQzXfvmSdTvCOOAxhf5S4GpGnaexsDzJPSogviXsPL4k7HwDQSZS8FAq1Q9rYUHNCnjbNYm/hp3vMyDGZQLTpuvCzs1LhZ3f8Xz/0cV3AalnJRVj2TrWpfhQresoXhgg1eCtSh999qTiW1dwbRmrlgVIetNYOunE90NzvqW4qdT32P+f7/n5khXZZeR8axJOc/mwnCpxAJIkkuS5oY3wsZYopSyJmskpkmMndUfqSXVyEwkZr+yEg6MlDy19IQZ1Ue1o9G/n+ZdbO61Y7p8UQ2zIESmsuY7tV2wo9p3ExDES9eBl9WhR/yRDWH1HEVAEFAFFQBH4gxJ4uuJbm4Emei/L58rRKhesaCRezuf6SGGZCjv98km/KMW+vl7AuqQ6WPSdxax+7jS5GxP3vxbf0ovZ10m+sIKFiwM4ltSINhPGiCfQlVqPfMZksi8fYPkvoVwr8qD9uF741ZVzb+8MjGcgvpH+0MaJ6Fq0nvUni7HqOZHBw9vTpWz3229D9NY5IvauZUOSC3kNh0rBtcp4mGeSdG4dq95Zyi7Jh3ed9SYvd5dq3I/yrqUd5OiyBXy09SbFcub12CkTn73nuzCC2LP+LN8ST1YVb3qP6kxzKalcvglINpFJW1n53kJWnjPBadxrjBjYgk5PWLXqmYnvpD2cWLuK91akYtBmDLNfH0gXEZwPN22lk7T7PZYuPMquhO60njacSaPK8nzrul/qDaQHsu+nn6QyvoT2dxpB08pJmAXt4qT1AFw6D2eWnwXWFRKnFVjxKiK+S26TQ9KBH9i28QirczvSuKkN7axD2XhUPOC1OvL8jFbUs5KQ+3t+sgLiuyR0PYGrm39i82oRBuZ9aDZ0NLO6lpqXZT5GKkWhq/nx6x3suO6M18QZDOnWkGalxf9jie/bP6KN2cHxnRtYsElCdxv0Z9SsgXSSohCPPH49O5BzOw+x8UABdi070mtoC2rLlyqgg8vppAqIb/lmYXKwnHT4LQsOZHChmhh1JkhNiQYmjzDu3eD6bl3BtSME2rfHV94RY70d7j1K7m7Y+X9RfE+Uc+AbGVa8hkFBJFH7NrJ+WxgnCrzwG9CL53p44ipz4975+CTiWzcuI7m0/mfWLDzGlXrDaT1lKmPrlTZE3991qaSd28CqL9eyIroGps/N4NXnGtOlVMG13CtbOL7qe749ZUt+o7G8MLkdnWubPeE40ZATcUAKBO7iSK4X5r6DeE6qsd0t8l7myIolfvk/mPvLdQ6bjWXUi2Lca+dYsVSFCiwn6iOKgCKgCCgCisCfgcBTFd+FCVKldt03fHsQrtUaxewpbeldx/IhlZjLQJQTQfLx+Xz5cyjH89syYPYYhraRfMCSnbUcNbZ0ASsWnGRvTSlKNHEEb7V/WM73Na7KkTXLvtlDsG0XKbj2AmNaWCFFVsu+iiSE0H81736zlROaZvSa9TbDWzlQ54FdbCoJZ6RA2uaD7A4Xq7+7Hx27tcLHywV3SbS8J30u/QY3z5/m7Cl/TkfIma9yLFmjDu3p4Sf5b1a6sOBfr6itHN2wgS82S9i55HxPevk52lQk7Dx8rRw1JueoH7Yq56gx8V7H+MtRYzvEYx3DdRMvmnbvRofGnjQWD+Y9j5YVQ2TAPo4eO8upaKk479uDHj3bII5VyaMVz0hiIBdW/8RP+xMIdegiR6Z1pW9bOeJKYn3vET7iUUwKDyPqchixSVGcDQziXHA8lp0m03fSRKR20z0hpPkXfmT/L4uZf9ATu24TmPVGG5o8NOc7Ds2lTXz09Uq23KyG30Q5oqqX1Ai40695caRcOcberXIEUqBUg3Zog1+HTnRr3ZAGUp37t1ICIjbTrhNx7jCn9h5kV0xljH2kMOAAX3ylEvFDayI9ZHZnXdnGsWXfsuiiE0W+k3lZjhprK7/7u69COXf5zEZWLl7P4RQ3qnabzKCukkrgZnWfJzqHotRorlyK4bKcvZsUfZRzAamEJLeUIoIDmTj6dr522VcxuRfWcXyjFEsMSuN0ZDXqV29O/+eH07O75IPL4K5gHMujH7coksxza2S+beJQVkO6zvwXo9qLmC3LkCUnJ1w/tpXv5/pz6NxlTH1qU2PAywzs3pH+Ne4vDqf7aZ341lU7/5ol2+Wc73bi1R7djZlNyuiH/CgSLh5g66qTnEywwrpNZ9rLUWMt61f77ehC3S0LUkiNCCTAXzyMp64QbdKcRl0k+qBDDdzvT1PIkYJke97hp58vSME1yfl+aShj+7qWE3Z+B5WkCKRcJHznJjbvjZCD0jyp17otbdo0plFtKRR4Dxc5w/5qEGGB/pw4FUJolj0WDTvRqUMT2ng5PuQ86Ed3i+64u9gjq9n40VpWFTfHZdw0/iX56nUeiHmWioxZVwk9sJ2te85zWeOOS2sRdO28aSjHf90TUixGy/jQcxzfJ3UorkgEkRxz1alPe3r7Vn0wD16K6F3cvpJPVyRxy60n414dRjcRiU837DyM86uWsmzRKa55SoTVlGmMafKwsO5CCtNEPF4LIzjkEpd1NSRyrKnSyJfmXZrTQGo6lL1eiPgO2MyW95bxS5rkfI9+njf7eeDz0LBzXR8VirjdT8C6ZSwKqCQF0voybHAnOjaSlJK7LxgZL3FXuHYhkPCUGK7ckDm//xzniryw6Ted13Xiu/RRY8VZ5F09yLZflrP1TCJpzs1w9ZB6F6ZyvneO/C2/CK2+pDBIuJCczl6SCqYvZ9tbyPGWNeRc+3p1nalhdWeuFZEbH8zVg1tYt/UcATlO1GzfnQ5tWtC8fk2cpVjk3WZK9E1axCmC/fexc89NYux88R4qR242lrPN5XhEdSkCioAioAgoAv+fCDw98V0oR8gc3cDyn3YTbCnnWI+exbCm1mWcDfsovHLMkC7/8dulbDycTnaXSfQd1JHBJZuIOC6vWsw6Ofv0YI0+tB41iFdb22BRridOvCz7N7D6R6nyat1BjiabylAfy5IzTcu8RAyknpXKyQt3ckrjTbfJrzGwhT3u5bmQJP85NiSYsLCrXEvKIC0rh6wcqdIsuXOaYn2MzWUDKmf52kgupkVlKeRUsy5eHjWoKRuYB65o8S5u3cp3O0V8N+vD6Jm98ZMN2iMLrl3bzE5dRejjFlTt/hxjJraj8X3nfN/+rRwyb4RyWQRxWFQSqalyrnVmjoQbSqE02UPrmVpIzqgtNjZy9nnNOrjVbYSHszlynGupS1dBOp64yxcJDLjElUR5Zvl+UZ4c91QozyyV0Y0tpXiPkxTbsXeiqp0x9o56UrznBOfEsxji2A6P0eMZ62NHaS2aH7qUI2uW8/PR2th0GsWUl/1o+FDxnYDmynbmLljPjpiqNJfzqYd28cT7/n4tTCApIpSg4DAiopK5lZFLdkE+RUW6TaYYHuSZbSwlV91CxpB9dWo2lEJ4tSVn+sldhiWssq/uxn/1Qn655EBR07HMHNqElg8tuPaoOVHq7xrJ+Y4L4dJ56YMrsdzKzJf0gEJycyV8tFjqJphaYmVfBSfn6jg4VEG6APtKoQQfOcW6E1qcRSyOHtOJxqKMyvWoauXc6MCNLPl4LVsSPKkhxwxN61eHNo5PeaNcdIMsqZb86QIpNpjjRceJrzGkdTXuFoq+B4uc83zrLGeXfM3SvZLa4jqEEZP6MkBCGsqeIzrxHcqpuQtYuVuqzrcaz7ChHZjUsDwjiHgb06XA25Uwgi7JupEsZ3rLeMnLyqWgUCaIsSlGIkSMzISvg4xvDy+aeLji7ljKgFa6vTmS53roE5avCJVibr3pMn0Aw3vUfPBM6zK7Po8cnagKPk9YdAJxUqMgKytP5qr0s6SHGxhK2L9Uk7axkX9kzppXdaeWuyderiKUHmMolf9Rqbx+YiPbvpIie8XeOI8Yz2tdxcBQ7qkOuZKbf42QcxcIvioCNTuHHDntID9Hiv5JNX+tkZmkrphjKWPTzNEVl/r18W6gE2jlGHKSdEeNrWfeOkkJqdWZES88R8daZk8xP1iXUx1O2LZNrPzxEIFZphjXrkVVMaAY32M5lVMfKsnLxUBO1LCyorKcze5oa4OZqRi77KpSy0MMqHJc5MOXi2ySgyUS7PPVrE33wHrIZF7p6UbjyhWZS/loMq5zxf8IJ/1DCEuS0HJpj4GI4kq6/zeTYmbW9jg6OODmUxPzXKnHsXiNRGNYk913CjP7NqRzSXVyScPRRBF58gTHDopR1MgBRy85otPeHGNdoUfJ986XgVWokdMspFklRf50/6Mna7sYnOLCLhAemkKMfmPqd5OTEHrXk0ioOwUxZUzGX+FqWBAXwkRYJ0otDVmLsosk7UcKQBrp+t3WGnML3ZiVKuiu9eUd6Iqnk8njGeWfyrhWN1EEFAFFQBFQBP73BJ6e+JbiX4W5ufLi1VDJyBQLedkaVmR/USYDKfKUKyIjt4BcfROMTE2xNNLdrLhE6OXJy71AhJ6RqTHmRg+rUK1BIxWf83QCUSpxG5iYYSKN0i+3XRqKC/PIFgFdKFsqY1PZdMn9HxVZXeJly0uX451EfOdJHrEuFU5aW0ny5wzlHuZWIvAeFTuqkd/Mz0d+WuJFjTE1k03dI72M8ivyvfw8EWAF4mkwlmPBTOU55fkeil6TSbZs6HWb+UKNbDDlNrq26stGycLGtqStj+46ec6cDDIyZKMt6l2XLqitJOJPX47xks22uZU1FqJzSvayWqkILJ/L0kgldOlLC2PZOJba5GqLRODk5cozyN+N5BnMjR4xdmTzLEduZedKITWNnJlc0k/C+mGNLsiQyt9y/Jacn1YoD6xrayVdW3XPbGmF1VNwTN8ZylpdX8pcyJW2YWAqm3Vpm1Qyf+qXeJRu92MBBdIB4quSfpRNscw/Y9mYW1kZ3xXY2rwM0mXeFBuYyRiRv4umKDdHk6skHt/FN/OjSK7mx8CXe9NcRGaFTtR7rIeUzX7h7X4s0Mq57mIMMZFBX+4pc1qZZ4VZ5MhYL9STeWUifV/+Q5Tkoxbm5JTULigSJqYmRpg+7Ai7u20XnpliWMrMLTEqFeuEiG5sG8qaY26NlUyQRx7jJW0tLpCj3mS8FWjFKCXz2cRY51F83EsMAOkyz7ILyCtpizRF1xYDI0wspFq/tWk59RYe93dKf17WX1k3deI5T9ZBPRPdnJVxVZEhXJxLTprMNVnI8mVt0aHT6tYWQxHgltZi6NJ/dI5vsRiS8sUAIf1WrC/PaSbc5ccfn93DGMiaVSDvl2x5TvmtgiLdWnj/qRW355QsFCXrmrGpPIOFRMQ8MsXoPpa64wHld/LEIKsn7yBzYVl6/atQTxWKsTRN1i+dsbSkvqfMdWmTziBkaSPG3ZKXlLzvsrLIlPmhlT4z19Xq0P334mwKLi1mxcI9LPZ3x2fKZGZP9MKtQj8sH0o/Ssia+fxncQa3PAYw/e1h9HAzL6P4m26dl7EqBqtcGatFouT1ZKzqy5puLBXPLQXcU1xmK9p69TlFQBFQBBQBReAPReDpie8/1GOpxigCisATEci5zMU9mzlwJppY1774tW1PL085vqwiwuuJflB9SRFQBJ4pAd2pGPHHOLxpPT9vukGyczvaDZYTRbxr4VFFjHHl/bhGjoqMu0zo8R0cOBzMmcxG1On0HKMGesmZ74aPNqI804dSN1cEFAFFQBFQBP6cBJT4/nP2m2q1IvD7CeRfIybkDJsPhxNxM1MiDswxMzNCz7I21dyb0s5XjlyzfSw33+9vk7qDIqAIPBMChRlRxF4OIvD8FSLiJYJM5LNWIxEAEnZeErlU8qsSXyBRYqYSvWShiziQRPYiPQmzt3GnTqM61HOT2gNPNwThmTyruqkioAgoAoqAIvBHJaDE9x+1Z1S7FIFnTUAjYdFpydxMSCc9u1BCgyWvWXL2HatITqi5cnU/a/zq/orA/4aApHtkSyX55NupFXlS00BStH+7JMxeXxfur0sDsbHDzl6E+P+moepXFQFFQBFQBBSBvxwBJb7/cl2qHkgRUAQUAUVAEVAEFAFFQBFQBBQBReCPRkCJ7z9aj6j2KAKKgCKgCCgCioAioAgoAoqAIqAI/OUIKPH9l+tS9UCKgCKgCCgCioAioAgoAoqAIqAIKAJ/NAJKfP/RekS1RxFQBBQBRUARUAQUAUVAEVAEFAFF4C9HQInvv1yXqgdSBBQBRUARUAQUAUVAEVAEFAFFQBH4oxFQ4vuP1iOqPYqAIqAIKAKKgCKgCCgCioAioAgoAn85Ak9XfOfFkRW4lAXLd7BgX7zAKqAgL5/cHDlLVIfOwByj6vVp4NOOLl060LZ9IxpUNsFc/y/H9YkeSJsRwtXdL/HD4mCWBliB50SGzBzDv4dXx4GrXFyygIXfHGGXUXt8J43n9aFy7qrFHwFePiScZOuyn/nXihByzTrScvw4Xh9WlzqWf4T2PVF3/MW+lIUm4TjbP53P/G0p3PAZxZip/Xi+g9PtY4RyQ7m88xfmfL6Bs+E5WDg+x9h3ZjByYF08nxmJDPKjjrDh86Us2X2em/I7PmPfYuSYUbSrAebP7Hf/yDeWuZQdyKEFy1k4fy8B0lTXzqMZMesNeterhHHAj2yb+x/m7yngglMLjEa8wsdDWzPK9X99Hru0O/Yga39ezKtfHyNH44hXh8lM/s9YetazpPIzQZ5LfkZmyXFZOflyfJYckVXJ2Bxzc2tsrQ0xLPc3iynOSSEpLYvsvGL5nhyrZWmDpa0FFVuuCilMjSchrRCNkTlWdg5YmuhhUNbpfMU55KSlk5mTR06BVs7S1kPf2AILm8rYyHF+anV8JgND3VQRUAQUAUVAEfjDEni64jv3BulHP+eduUv4YkeGPLQ91lVcqdvEHlvZmFTKu0VqbDiXb6STqueBY/OZvPLqYCb2dKaynvz9D4vpv9MwbU4U8UGL2L3/OgevmkK1zrTu24uxLc0x4SL+n77F82/sIsB8CB3+8zaLX6hNrf9O0x7xK7kQvZcln3/MhLln0FoOoM3fX+e7l3xoaPaHaKBqhI5A/Gq+ef5fvLUhjTS/1/nHR9P5oL2MM91VFEXMmcMs2uzP1bh8TKz96DiyB+38nKn2zOilkBu+jYWvfM6nW2+Lb98ZX/LCKy/RpzaI+en/56URA9ubn/Kvj7ZxRgjU6j6VWe98y+jmBthE7uHM1tXsCSriho0HBm37M7ZVPdpXMfgfsyqElIscP7CfJdtDyS+2oUaDLnQZ3hHvGqZYP63WFaeQHHaRsHMHOervj/+ZIPzPixAW7V9y2Xjh1tCXDm170LZHOzr5OOBy17qbSfqVM5zctonth/ay83AYV3WvKaR9ddrTvEN3+gztQ+9W7riacI8w1uYmcis6nCtXwgg5eZATh3az91wqpr7DmPz2N4xoY0utErUvB2bnxxMfcZETR45yyv8EQSdPE3A1k6Ti202sVLkRjVp3oH3HzvTq2hJvdwccjNX772kNEXUfRUARUAQUAUXgj0zgKYvvKDJOzOXDbxfx0UbZhDCcoa++xAef1EP20nKlUhiwgA9e+4G5IjBTcabn3z/j+TnD6OIEsv+AnOtEnvHn1InzBMdmkmVojYVLExp7t6C1rws1ZFMEsospjiby2BEObr9MiMYNj0bNaN9B9j03Ajh+OpVbFj60bN2Ijg1seKhPqDCR1MsnOXU6lNMhssEqtMTIuT5NW7ekTTMXXEoadfvSpEUSHRZAUNBlgiMTuJUj7ahkiZmjB3Wa+eDboh4edkbye/Ls0r7rx49yaMclQgudqOJSk/peGWTERhASkkq6kSP29drg16IZrWqbYaqzPOQnknxlG6fOxRKQINtV+6bUr5FI1byDnDkRzubdwewPSQIjN1yaNKZ1o6rUadkb3/ZdaOcMZjk3iAo5R2BQGMHX7m2fZ1PvkvZ5VjZ+OA9dMxKCCT+yhUPn0kmwcsC9cRPsNBnEXwzm6i0N+ZbueDb3pV0b8bzbGoovR3a+MftYPu8Lpn0fSLbVQLrPHsvbvSXY4VoIR49HElsknOr60aJNC9p6WGNdohUkHiInjvjw8wScu0Do5XhiJUqiEANMHWrj2lg2ps0lOqKa4W3vbHEqiWd2cvJgAAFp4NiqD74NXLG4doYLp68Rbe6OV/cW1Na7SuyBLZy8WoniOj4ydhpgHXeBiHOnOZ8uvSNcm3boQIfmDjjlRXDt5CH8AyMITZT+dGmIZ8tOtKvvgvsd16s2m8KECC6dDyIg8ArXojNk7ErXG9ng4NqYer4taVq/Oq73GxpSQokIPM6JwMucv5FPoUlNESS++LZpTJPaVliWXhnybxATcJqjx2TcR6WRpWeObU159latad6kZokY0F2FqZeJPLKJ42duEaIVedqwm/SDL/2q5kn0wQkOHznG9rO5MkPq4N6sK116SxszthGwZze79lxh23HhrFO5VRvSrGkdfH1kzLYdQK+Gdtgln2P38RCuJRRgbOGFT1c/Gtd3EBPa7bmbHh6I//EznA+NJj7XFOMq9anXui1+TWX+3XkYTQ5ZMSGEC6uzF68THp9BrkaPSoZVcHBvgE8rH5o2rE6VEpdfKvlXd/LT6/P4at0prsl/af3iN8x84Xl6unEvn9KsSobOLeLPn+Ls8XMEXEniltYQfYtauNSX5/JrTAN3eR7d5/J068kJVh8KFfHjhK1HLZqYpZAfd1U4Z5GuL1ElDVvi17IJvjXMsChtAZTxln7Zn3P+p2VtSCI23wx925oy15vj27IpXg56t9cs8kgLOUDgwQMcvyFj3ssX7yb1ZcwFcCXwDEG3ZLCbuFCveWtat/emtr3+r9+TrxbEc+vCUQ4fD+RsVCX0qrvh6ZZP6s4dbJ6/nVPyEdf+s5j2xhcMb2qIXfwZLh3fz+nwIuItXTD0bkdvn5o0yDlP2MHN7DmbQbK9C14i7ly1CcSfO8DZm3lkaipTrU4zWnZqSSOZf78ZNnIoigkm6PQ5jp+7SnhyHho9E0ycG+BRrwl+nkYYJl7lwrlkKtVuRONuzXGTcf7rcCzVK0WQcY0LAefYeeI6BcUWOHm0xLdTAxpZJ3H15AHpg3BStLWp5u1F22op5ESe59SZWOI15pi6+dKkTSva17PHsdSae3+3azWxJBz8mQ0rdrL4vBVmtTxp5l0FR3E7V8q7RkzwCfbtkTGebYmhZz9mfvBPZg7ywqMoiYyTn7L4sxV8uCWaRPuW+HTpTNf6pthlnuHU4d1sPJWLXs3hdB73Cm893xBfacht73kut46uYN+yBawNjMH/ag6pqanS6+DWbhgT3/6eUW1Lie/cKML3rmHFjyvYm+WIUZ22+Lqa42RcJOMukND92zh8LpMb2GIx/iNenDWKN33EwPr/3fp8f2erf1cEFAFFQBFQBP6CBJ6R+F4s4ls8IfSm1+QJvPyhLz6y/9Rtjm6dXMnnHy9l0alEiiq1ZMi77/LK3zrTzCiR+L2LWbd0BcuPxBKZnCNbHvEj6MsX9U0ws5VNW48ZTBoxgKltzTDRnuPQRx/x7j83ckC2snoWsrFsZUFlw1RupjqhrdGbSYzkkAAAIABJREFUCRN6MrG7y23hdv9VnI4mYgeblq3k6xWHCIzJJOOO90R8Hob2zajZaxovTu3DpJbWmORewn/zdjat2o1/0CXCUrPJ0EgQYXExhUUG6Fd2x6nnTMaNH8wrHWRzqw3gyCef8O7r69in++1KTlR3Ffd+TjIJ8QXIVlV26Q7UajuYEa+8xujutfDKCeLqhiG8/UkEyy/J9rbWy/Tun0Ffo/ms3F7I4dD7HkLPCJdRHzBj1hQmu94g7ugOVizdwcmAS1wq1b4CaZ+BXW1p3wzGjBvAnA5VsJOmlHdlXFzG7g9m8OHKbALlQ8ZONbE3LhbbQDRJeTqjilwO3rgPfIkZEwcxq7khRqkHWPHZPGZ+e5j0fHuq1nWhjnEqObeiuRiZTk7Jl5xw7TiO6f94keFdqlEtI4LI3avYvWMrOwKvEXw9h3QZNlqt8CmSkEyzOlTxHMqk10cwbpA71bU3Cf9+Fl99uIUfouVzju4iIOtjL+I4LTIf63rt6DpnMI0zNnPu/X/zlb84e/XNqezmhm1hMpnRsnEvAW+MZS0REo1q4Vgo0RjhwRKNkUqsbshig577WKa+Ook5UxrhUUlD5kXxNm5ewdajJzgoIuzGrUIK9LUUF8oXKokItZcIhT7jmP3PXrSvaYxZRjiR++azaOUWVongiE4Rg8avXi9kNFr5DKDdpBf5+0BvWjrFk+6/kRXfrZVxH8KVlAJyizRUkv4xNDbF0MpTBO5Ixrwykv4+dthe38aBDyby4Y+3OKyTQIM+Zsprs1ngLeaA4C9576OPeWu97kE64DPgfd7/zoOGCf9g1YeL+GCLOCd1iqHUpe8sbXj+M97p64jjua8Y9+Zizt2UxhoNZeaCt3llXD2qxh3k4PzvWLrsCPuibpEiDG+PAhGLliLAO4yTNoxiuJ8FxlcPsXPlNnZsP0JQZCw3cotkrEtIcIE41yuZYe7VDa/hs/nHMF/6uuaiubGdhX/7ii8qLL5F+JzawKFlP/Ljnsucjcsip1DCiPX10Teqik39jvQdPZrRA9uIeJIxlCEGsB/nMuSt9STpFhTLalS1KsIwN5nYFM3teWjsRg2fgUx9fSoj+nmIoTAfTdgmtq1ZyYJV/gQliNEsTww5IsX0Kknot0UVLGv3Z9iMYUwZKWJaL5fYDX9n8Xtf86lMmHRDKzHKuGInhr30GDEuybOXXNW6UG/C67w1vh0j3AvR6lI1vp7Pj4u3cSg2lyzdZ6yccHIQY1yO/GZcMunyn7z6z2bav79iWBM9TE58zIq3XufDA3DdvCHM/oSFL3RlUvoKtrw7nbdW5HBevmNW04tqJsI+7gpR4t0tGX6GbjgOeo1pz4/g760k3Sf7HP5LFvL14sMcTpE53qk3IztXx8NIRPjB/WzfdpMbBq5Uqd+YVl7OeHdqI8Y+H+qLoeXBlACBGyV9+cXnTJkrE0/GeY3W/+KN7yYxpfZV9s97l2FvbyW1UNZzMWC4V9FikBnPjejb67xu3jl4D2bKP19hVK+61BOBX74WzaEgJ5/kbHkv2IjX+m58eSq5J7/lrWnz+O7CLYqs2zHkgy94dWZTPBP2c+jlv/HRmiBOimHLa9YCXnt1JKOq6H77CldWf8HbLy9ngywC5h5jmPbFW0zs5iIsdH8vIjcpgYykRPK0kZxctpZFH63ikEyCGh1HMPmtbxl51/P9a18XF6DNSiJda0axhQ3WYmzSlzSs3LD17PrmIxasvkmgeOndR/2dSaO7M6q2GG2V+L53cVL/pggoAoqAIqAI/AUJPAPxPU8836tEfMeUj8vQFmv3djTr9zzPj2lH/7qJZJ4Qb/kH3/PJrkSKzbzx7tuT/l3dxDcez7U9y1i/5jKXxVPg1u99Pv5qAv1q3uD8t+/y/qub2JIvoe2dpzL73T50F6+OrbEJBiLajYwMMDQQr9sDLZHN1E0JW/zgdT7/KYA9GitqjHmfl58fxiCnKFL3LWTt5kCCTNrS5LmxDO3ZkLriKjKUTXlBWhJJN28SHRstm/dE0uIkHHzbTjYdjCOB5+j22it89mFjGuqFcWrep3z82ga25tfArcNUpr83iAHuZhjcWM/hH97iu1W3OIkrJsM/5INXhjC7ZigJuybz7henmH/aFurNFNE1jg8HiWBLPc6qz+fx0qJgcix60nHmdN4Z14AG9paYGBthrPP83Glf9E1iYqKJSbkl7bvAqe272HRAPEz0F3E6mw8+bE1TY93ny74yL61h/+cv8/nyGM7YNaDtpPeZPkI81tZp5AUs4qvvF/PlDnE904tur/6dj/4l/aX1Z/WHIgTnHSOzsD5Nxk7npckd6eKSz619S/nlHyLeYtLJr+nDkH8vZsbgRjTVWUW0GgpzEkiJiyI6OpGouDSSkkSE7lorojySUL1qdHj9a15/YyBtjBNI/OUV5n68nCURIgB6vcrE52czuLEFVYwNMTEUI4NxIYl7PmP9p+/y9REt8XX70G/aG4zr7Yp3wWkurfuI9xeKd+ymBFN3nsacycN4yU+Lccw2fvzyJz5Ze4lMmtN19mvM+c9g2ks3mMkmW1ucLXaTaBKE642YZOJSkogLEQ/kpo3suSJCwns00z6RKI4Olmj3zWX+rI/59qqkV1RrTf/X32X20Aa4xe7j2KKVbJNEXr32wxkwsRkeMVs5+K83+O5oPhE2EknQYzj9W9XA3eAGCadWi4AXT3uBKIQRn/HlvwYzzeooAXNf5NP5oWzWVoeB/2LO7Cl80VD6I+QHPp87j9d/ThO5IB7xoc/z1vedaWedR3H2DTL9N/CPTxayaL9EHPiJceHFIczpUQMbE1NMiy5xZetCpry7khOXsrFyHseML//GhFaxpKx9tWRM7owSd3SP2fz7FRFJDWXs+69h8cZAjuQ0xKfvSCZ096aFo8AqyiIrIZ64qBtEJ4r3NV08jeePs2PtAfZEVcaw1mze/GYsr/eWSRW9hSVzvuSzCovvG1z++i2+f2kZ3xa7YNt1GOMGN6OZkwXmxpZYOlWnVi1nnG2NbocNp53g2LLvmPDRViISPKg1dAZ/m96ZgXWNKLi2g11irFiwOYIAIwdcp3/B63N6M0R7lGMfiuHix9PieRZPbLsB9O7jRzPbQvQvSsjy2t1sjZV7N5/K2I8/4j9tTHA49D7z33sfGf4kNRjAczPeZEw3ZxrnnuCCbswtPs2hG3XEHvkan701hjmNQ4ne+gZvfLCdX4JsoK4YmF4Yx5yBNaiSH8Tpr35g/pdbxbAowRgivp9/+ytGeOthenoe6z98ja+25RNYtS2mU95mwdQOjM5Yz85P5/D+L7GcsvbCb9RbTBrTnk7W8WQf/ox581fxg79IZs+pjHzjFb4cZo5jzBK+f+3fzFwnhptGrzBQ0kbWdtGTSBYNufv+yRtDZMyleWLX4d98s6A3Az0s7kbNPLh2iFUneg/Lvv+OGZ8cJPv/2DsPwCiqtQ0/KZvee4Uk9BJ6kd6bCFLEAmJBsYIgqIiCighIUYooYrlWFFQQEEV6Db2EGhJCSe+9bnaz+3+zAS9yRfhRVOTMvSspM2fOPHNmct7zNWMAjeT5HDdLcguEn2P74pmMePMnzmWHED5wJM88cQcDG9rJ++RbvpXn+8NjSWS5h9L3tU8Z9aB4nshz9//TorIIc+RLvvtwAa98EkOidWcaDR/Li2O6MqSOieKjX7PomXdYICuYufZu9HjpQ0Y9djfd5NGylSWO7K1y7MOvM/98Jhk1mzLklc95fJB4avzPKsNBdr39DtOf/4x1sqJxRfF98dVadojDX70v+ROWcVxbBdE2vxpENO/PgP53MbRfcxoH20sf1KYIKAKKgCKgCCgCtwKBGyS+vxDxrTnmRhAe2ZAW7cXl1EasZFa2WHsEERDWmOYtmtKikW+Va2jadg4ve5YpHx5i1UmZiFZrQatW4hIrvrb2JpmC2dhhq7PBzlyOb522NO3Sm2b+8Rx9fxoznlvLKoO4jQ4eJ8d3p6cWXH7VTdzLd33HB0+9xcIjZynyDOLO15cw5pHOtLoQAvvrJsQknp/AiV1b2LplHwfOllAmiX18AxzQGXJJPLBXYvtySRFLf58nxzDlHbk2m1PsWzCDGc+LMK+4Tfr3AtM/7UIXTXAW7yL2m2G8tuA8S4+Iv3iL0Tw3ZTQvdjxD8frHmDlnN4v2CQdNfE94mrlinvEu3cq302bw8DsHLG7dfSY8x4Kn6olI03oqprX885yUWMQtW/Zz4ExxVf/8pX/GXJIOiIjYky0xtdK/kU8waYG4QYqP45WS/VSJ72eZ+VkqcTXaMmzqEkYNCZPEWyKsMlaycMYCRs/fbrm/tw2dxPPTBjHI7TDfzp7CI+8epMhlAD2fm8A7Y8TN3cYoeQAWs/SBCxPb2q1kYvsxTw1pSIPKc6TvF4vU+r3sis8h285TXPi9xeqXTmnMDg4eEJdhsaB1GLWYZ18cSkfnTDKXjGPujCV8IT7KEQ/PY/yLY+gfrkVtXtxKSVv7Jl/NFPG9TSbwPZ/gmWmLeLAFeOkPkbx8OmNnrGB5ZjN49A0+erw3j1STWXTJBr6bMJM3xXJ/mOZ0HTtR7slAOrqJFTlhLyd3rGd9VAzHc8Qk7eMvSZ1kcSf9GOclTnpfnAG72wYx4qV5jG5dQtKK13lm0iqish0kPGAUzy56luG3efxG0qkj7HlzPnMmfsJa6b51WD0i2/akQaDOEiNrZS1Jo+zFoiuLVYbAlnTt0pSW9lEcmjeWBR+eYrW1jJ27XmP8M48wJ7IITi5i3tx5PP9xXpX4HvIkk9/vRWcvK5ncS7jCga8Y8+p8Fvwk4rvjWF6d/CCTu3tWjYOyo5xc+RGPivjeHVOGR7X7eXL+U/QNjOLM20+xcBXsD+qK05NT+eSBttwtYSL/u+VTJCEE+zZtYtP+OM7k2eDg5YKvuFmUpMQJw4PiAi3i2/Nxxn54P88P9sBWxPcXIr5nX7P4LhdX8E0c/mEJ3/wkMcbHYjibbayyGhOIf5NmtOxwL70GdmdwW1/5yQGiPpgn4nstpwvb0fDpl1n0fFvaaxnASsXdeu7jzF+wl09L5E3UexJPPNKaF2w28MGsz5m56Sxm6zo06dRSQhcC8LGS8S/vMFtZ1LOzMWEMaYZvi07c3cAO562z+GDqdBZGySLd7c8wbvp8hjUWe27pPs6vmMEzs1bzw/G62PWbIOL7AR6tuZGTS+5n2vwMvk9vAAOnMGPsYF5sankhcnbedBY9u5DP5Ds3Ed/PiPgeejXxPWssr32aRnyNdgyd8jmj7omQ4IMsiJrDK7MWM/UneVnUepgHX3ySN4dXJ8AooTHrv+HbL5ez+KgN5cGNGdDCCz/HLFKPxnPkjC32jfvRbfhAHmoTjIRu/852FfG9aDojZm/gXFknmo6WxaZxrblNkFfELmPl8Fd4S8bLKb8wbp/8CU8P60y7axbfeZSclHfI11+xeOUudqT6EdppAIMfGMKgbpHUFyu9DTIuT63mkyfn8M7WYyTZudF50sc88+Rd9JGYCivEG2n9Z3w6cgbvJWZTFNGZe15fxGMD69L0V6Ek8p4w7mf73PeY+eLnrNfEd9ehPKa5nbeXBdzf9CaS+O/9O/li3WFSssX/R59N7un9HD6azGmH5jTr/wQPP9Sbe5t54vo73khX/ZOmdlAEFAFFQBFQBBSBm4LADRDfl8Z838OQ58bwxuwGv58xufAYyRtnMemtlXy2S4Skz+0Mem4cE8Z0oJUWXCjxjMnH49hdUhvvsIZ0CjdhYz5C1Pw5Ylleyw+G1rQaKGJiUVeJHb96TLMoLQpjf2Dly1OYv/wUh2w9qP7QLMY/+RAjG1aKC/Uetm/ayc/xDviJhaJbXT2OURPFMv8jn8RKh+o+wUOvPsuMe6sRkL+J1a9P5Y25hyU50u30fno8U+c3viC+ZzHjBc0yX5sGvZ9h/PxBDKzuiNXZZWxZMJ63v8hgW2U4toOnMv25exlTM4bMn0cy7e09vH9RfL/wBG/dJwl5ijbz5RuS0Oy9gxg9pE/jnmHm4y1pqs3Y8g+TuPolXp2+js/jJGCy9uM88No43ryvOoHSvx+mTuONtw+xj170enw0r8xrdw3iexxzvkzhcEAzeo0RsX1/C9o551B+YBEz5y9m+grxpaYHPcZO4I0pLWlltZdvpk2ziO9il350f/Y55o6KpKGTxEtu/ohvRkxjYUIWmXXbcc8r4vLZzx/rXeKWP34uHx8XF1xJInffrJeY+FQTIgv2cHjhi0x/exvrK5xp+fSHvDjxPtpfJr7DHpjDs+JpcIek4/5vQqcSUtfO5OsL4pvuI3l6iiSraqsjsFDiir+fyXOzV/J9VlOsHp7Cokfv4PGa4viau4mvX57D7Pd3cEQs392ee5WXX+lC+8rdkiF8Ms9PjxLnVB+q9ZSv3xrJg2K1s90zlyVvvMLsH8soaDmQka+9w6juDpSsmc2bYmX7OqUUQ7VuDJw8jafvbklb23RxYZfFoh0pxNjWoVWPangd+4FVL85gyXnIqSbne2ImL48Uy7sl0DqJ2E3HOJ3nSGDLVtSuLpmc07axf/FIZn94muU5YrbrOp7R4x9iSjNJXrb9Hea++xFvbxCXePqI+BY35Pd70EnEr86UgmH3V4x6baFUIhBn63ZP8cKEYTzfN1QWwMQ7pOwYMasviu9S3EOH8+S8cdzdMI7U/4xh5sdn2ZFXSxYznmHai0N4Rtxs7UtOcnDpJnacsUPftC1tfXdSvHoGE97LIEa8HzyHvcjsiUN4pEEZOdsXs+DFd5m7WxbhPEcx5qPhvDDI/TrE98X3ahmFCZKDQazrafn55JWK18SuNaz/ciPrcsMI6C73Zf5g7q+dwJ4P5LmZ/gOnMhpR88FneX2s3JPa4sciyd5WTnyV936UhTJbH4JHzmHi6B4MqVjP9zIWZvxwQuJyQ6n/2KuSBO4RHpZxZidx6lmxJ9kdXYlTtZoS+x0ksemlpK6ZyhcSBvOuiG/b3k8z5vWF3NtSAi3yZdx8P4txb6/hx5Oa+H6B2ZPu54k6Bzj9zRhefWsvy2P8oOnDjJrwCC8NCsK7ZD/bZIFr3iwtpEaiT0R8P3Utlu8L4vt0RBvunfwfnryvLpFy3/VRc3n9rQ+Z/rP4Z0sFhQflnfLmAyK+SSZu1af8tOJHdto0wb1GC5q6V2Bl44idCOHwiLo0qBNM4DWlnb9G8V0q3kRPTWD+2NvoKMO36NgyVo94nXkHJJmZX7iI7/9ck/g2F8aSuG8ta1fKQtr2JMt4q9PlDobc2ZWut9WmprwQrLXFQu3/sh5bKe/IQ/LOfWfxVr5Ktcbljik8M24UT7dxwq9wLWsWvSV/f3ZyrKgWoX2e4eU37uWuJt6WRKCWzSyZys16zPoDbJH335yXv2SjJr4738sjk7SEa16Eid+4tbZAY5Jwi+gj7N6TgcGvPo26tKbxxXTv5rMkfv4K0+ctYXG0tOs8nF4vjWbW+BZE/o430k0xm1CdVAQUAUVAEVAEFIGrEvhzxbckSyvYPpNX3nqfBZZA54F0fWgMUxd3pLVMTK5cVkViQouOs/Or9/j6Y3GfjBa3XqO1xMq54eigkwhdEdsO/ji1eph7HxzKMxKf6k8029+cwmsT17CF26jTfSIzP+9Jn0CHqyYUs8ylDCKEDi1h6UdLWbhShEehxHRaO+HmIPHbOumPg7iDt36A0U8P46GGqeRvmsKcd1bxRZTE+2pOgk5iIfJzxd3ZjD4liVQpO2OkHx0efIGZH7amjS6W/QvmMuvlpawtllhRLz+CqokbfHk+WSkZZBeZqLTyI6ytiM6JE3hA3H/rlmgx33fz2pzTfHlCOhkyloGvPMN7I8RboGQfqxe+w7g534tFUcSTxBo7+QbR8P5XuFdiJFslzeHbL37g/c3l4nx+Wf9SpX95Wv/uoP2wZ3jjA4lRdpLSOFcYHprle7O4HM//Lokd5a54BYfh7WjGmJdKTmYuEpaMlZ9Mdgc8z+OP3isx32JZzf6ZT6ZMZcTCAxJDO4BWEyfzwXOSKM+5lIx17/LlPZOYU2AkQxJ9DZ++hMl3BmAX9S6zp33MZ3uTKdKMig6eePn64e4g97sgntRMsyyTQJsx/+HFVx+mh4tkNf7kCWa8soqPMsTyfe8bTBSX7UH1tIjRi1uxeDK/xmevSQZtLWC91VDGzf6URzrqCC6IIn7Zazw5dSMbMyQF4BOzmPf0IMbUEYtUzs98+uwbTP3isCT+qkvrp2Yw9Y2edDHuZt2CBbw2dzUHtM7IaHSU0kKenh64mLIozchAwlZxlmzJj8z4kicHhFA7+yBxKxayYOnPfLNfYror7WVMSbyzrVhMrSXOOLQL9QePYuJwSVrnc0IWThbzzgeb+E6ST2WVSB4BBwfcnLSwCR2VZhGFkQO5Z9zjDJGqADVLJJncpqnMXvgt72worSrh5yRWyVAfIkQ4pSWL+7jmEk13mvYZw7TP+9BdEnzpTJJj4egqXpsp51p6EIsDrLhp+9YT0fzoZCZ0lzwF++bz0KRPJfGXjC+H+3j6g8mMGxaG1+lVfP/O+3zy9QEOyM03SZiDk5OEduhE3lT4Etx8GHfJ4lFf310krJCFpE/jkEvRlIWw8sTXzwl7o5SEik8TO6ysKtg+zQufP8qk+8QKnvgdHz8+ndd/PkWmHNH00TmMmzCe/jWvkO3ckEf2sc1s+2ElKzcd4WCaxAwLBBsb4VpeTnmJqKUa/Wh/30heHt6Qph6Sdfqjd3lk+gpOpdniFBBAde9KdPpc0lMlUZs8h2YbEVzC+NHXH+WBfrWoLsnc8td9yJdiTX1vw0l53qwwmF1xdpKSVFpWamtXyVjdkTtGjOCJJzrQzKmcnJUTeP+VBcw5Jpbvdg8xYfYnUqVAbPF524hZNoUnpm9huxbq0HkS018fxovtJR771I98NnsRC77ezTEtFl/adasWgL+7FcbkZJIl74UWvV+t6wieefNDHmgpbueyYPX1KxLqsQnOuohpffSbfCQLBo8UfC2LgCN54etyYuXZfGD6Mp59SMI/TEmUb53BRPH+mLdN2AQ9xZA3JrBguI8sHP7Ed2+J2/y7+0mqdMHGJxg3effZWBJGyvvJ7IKjfw3qtulMm9530Ltldep7yfvxN98bF2K+585l5Lxdsocb1TtM5qWFI3i0Rjyb5k0Wa/J68io6Ej76NT58sT3dBEdh9Od8d7csbJ7O4rR4eNwh/R4/Qlsw+i23cxHA+jiOLp7Pkg8+4/MT8m75pS/iJeXljY+2UFChR2+QvAleoTQcLu+k+/tzf7gBU+5Gtn+6lPkfrGNbmngvSSJAnYxhWykHVi5DXu9Yg0YSCnXPo/fzYCt3xAHlwlZC+sYFrFw0h493l3E8rcySbO2XzdEf14ZD6TVCQoHuq0btgh9Z/dmHcl9l4SxHypJpJdCMksfCJItiWrIEk5Qos7HHwa85LQaPZOg9EmIV6fzrZH9XeDerHysCioAioAgoAorAzU3gzxXfFdmUxYmb9fqtrNqnpfiRWMxe3RkwvDYREpN8da86EY7Jxzm2axe79h8kOiWPHLM7zoHNaNaqg5SPqU+DIEdLVlgr01lif5ZJzlfRHDTWpGar2xn8SAMiJfvO/yt+TkuOdXAbO6OiiTqaRmqFlu28Mbd160bPzuK2KG7sttpk1JDCub2b2L1xB/tjJalbuQiKcHETblWDwKyzpEXFimVUrrN7P4YMl/rWdifZ+45m+ZY+6pvSpEs/Hn5Sh1PKMQ5INvZsl3pUb9GZ7h2a076OZHTX4EipsbSD7/PjhrNsjJdZZHBPOvTtxH1agjSZhpcnH+bEZnF93y1tZIprucmPkF5D6NO/I528cymJ3siWtdvFDVpc4cukf5obc2vpX7b0b6fWv1qS8Kw3g4Y3pc7viu9lbJrzLLO+TCM2JFKS5o2nXUiFGNijOC6Zss1+TWjVVc7ZSZJt+diLHJWZa95RdkqG5o/Wn6Vc3Ckjb7+DByTZXah9BYWSCXrP+9+zLquQgsCatBn8BD3ahlBNkqDli8voFsnQvflIqlgwzdgFtqZmg3DqOUSTEStZlnMc8O84gn4DOkr8ZQElUV/y48odbBel5tvhfm7vfwfNAkV//vIcSqbo6NVErV7OOi1BXaTcxyEj6FDbBo+yeMmWvpovf9jPvsIwrDqLVbZLM7oHyGpCsbgwL1vDmg2nxNoZQcO+d3LHXS2pJ662uswjnNi7nnUa99PFsrjhi3eD9jQKM+CVv40jJ/Rke0m27IEj6NHUj3BLtuYKSdx/gKNRIhT3H+PQOalJbB8ubujCrWdb2jUNvJDxW9tXktmlRXNqv2RG33uMfbEZ5Bid8AxrSiPJZN+udSSNAmTsWB4gea4qJPHcbnHtXitW8LOSsduxDhGSGb5vc3vykg+y/MfTGEyStOq2Xgx6tCH1pRa8RTCZs8iO3sP+jdvZFn2O+FIDVr5icRswRDJpu+JybiP/WSH3OLEcR4+2dB/ely7tQqtKjZWdJzFa3Hq3S4bx6PMkS7Ir+wDJxt69N106ifusuKHrZIyWSab8Y5vWE7UrmiPpJgok0WBoG8kILz7LdgcPEqMl1XPpRJdHenBnG0/scg6w44sf+WGP3Bs5TZ0+wrBPT5qIMfi3vZxNVOSeJeGIXMeeQ+w9mcA5LUufJNZzCpXntWl7unRuRtNwqaWs9VsWXHZ++i4PzfyRM6WtqXXXYMZ1Fk+WdBmvRyQTu30tarXpSfvOkok/QhLxXRK1Yi6OJ+HwTvbujmaXlLNKLBQR5SlZy1vLgkWntrSoJQtwsqhoJSnDcg+uZOfqVayLla406UWfIQ9LFQPxyCiJJW3/D3zxo2ToTwmS393O0P4tub2uCHjtbqbs5dDOn/lpzymOJkveAsko3rBlBMEZ58nYvo9Tso9bi970vOtB2oVZYRf/M3tXLWHtIQPnPMSS3u0LhzxnAAAgAElEQVQuHutWn/Zle4leLUJ2Wx5pfrVpa3nGgqhmzsUQ+xMr1mzm+yMyCgKlxFX/ntzTShYrjm9mw4pVrNqZit43BE9/b0mKKSLaLGPMXEZFtlQAkGzy0fliRm77EqNffICp/QKuUDZMKzV2lB0b1vPx6hOUV4o3UdN+9B3Wng6+mcRsWMn7Pxwjs6IuYT3782CfWtSTFbOyxN0cXCwLrmfSSHP3o8mgJ+jVvj615fX3vwFEsiiqP83J/3zLhvVy7yUEwGBrg621vJ8rpUqCURY0JAnmhZSQ2LjJs9jzYfp0a0dXSY9QtWhQQnHiYQ5HbWXzjmiOplRg0MkYjWxL47Yd6NhSFhs8Lj9zudzf5USt+pYfYyTyxiR/YyQMSmvPbBKOcunGgM6SCb63JPiMIEwWDytlkbUg4RhHjh5m34FTnD2rVdKQfXV+eIXXoUGLtrRp0YimEbKoc/U/jDf3LEP1XhFQBBQBRUARUAR+IfDnim8F9gIBEaPGg+yUhGvTxq/hZ7HMN+47kRlfyKRcYhn/6VvRya9ZP3MU0z/PJaZaM4a98TVjh4nrvJok/tNvnerfrwiIDJNEhds/mcewaWtIzm9DjVGTeX+ihKdYslzfwluJlOZb9ylfrj7MmlQpuRfmQd1AOyRJt2yyUKoz4WhjIE0qFRTqwqjZ/XZ6ta1PC1lE+X8tbt7CiNWlKwKKgCKgCCgCioAicDkBJb5vyJjQAg1LKMoQS3pCPrkmcSn0CiIkwh0P3ZWzjN+QrlxHo5VShqkg9Typ2VIaR1yTvYOlTJm3o7LQXAdLdcjfTEDc3Yuy04lPkUz94lrt5BdEWKCEi9irlSTNO8NQlENWuiQFy8gip0hvcb+2yG9Jcung7o93iNROD5FkgVeOGfqbb7A6vSKgCCgCioAioAgoAjcPASW+b557pXqqCCgCioAioAgoAoqAIqAIKAKKgCJwkxJQ4vsmvXGq24qAIqAIKAKKgCKgCCgCioAioAgoAjcPASW+b557pXqqCCgCioAioAgoAoqAIqAIKAKKgCJwkxJQ4vsmvXGq24qAIqAIKAKKgCKgCCgCioAioAgoAjcPASW+b557pXqqCCgCioAioAgoAoqAIqAIKAKKgCJwkxJQ4vsmvXGq24qAIqAIKAKKgCKgCCgCioAioAgoAjcPASW+b557pXqqCCgCioAioAgoAoqAIqAIKAKKgCJwkxJQ4vsmvXGq24qAIqAIKAKKgCKgCCgCioAioAgoAjcPASW+b557pXqqCCgCioAioAgoAoqAIqAIKAKKgCJwkxJQ4vsmvXGq29dGwGw2g+Uj+1tVfak2RUARUAQUAUVAEVAEFAFFQBH45xCwknm6VdV//jmdugE9UeL7BkBVTf59BDSxrT24ZpOJooxcMg7FkHkknrLSUsy21lUiXG2KgCKgCCgCioAioAgoAorAn0jgWiXjb01Fr3Ts9Uxbr9aPK7V5vcddivC32rjaNWhzd2NpGR7Vg6nfv5P8G/gn3pV/XlNKfP/z7onq0R8gcFF8mypN5Cemk7RlP8k7j1BYUAg6m6oVNbUpAoqAIqAIKAKKgCKgCCgCfwKBqpml2eJdaZL/mA0VGPV6Kirla50OO3s7mYLaILNQixem5VP1H8umfWXx1LS08t+fWX53Yd56NQH73xar+vFb2wUnUItl+X9mw1q/Lx5k+UL+oxmzLu3PheMub/6/bVWd+/JruJolW7v2iqISfOuG0/KxwfjWCfsT7so/t4kbI77zjnJm/3q+2RpPQkE4ri17MKRHfVoFO/yXRGkiWUd/Zvn6Q0SXR1C72xB6twinvvv1wSo9v41ja5ey4WApp53Dod2dDOvQhJ6BlaCP4/B3P/HzzgwSgtvTrlc77mzpg9v1neoKRxnBkEDspm2sX7mPGNnLq25r2t9+Ly1rOOJtcw0nyz/LmUNR7DlwmOjzOWSVyAC2dcMruA5hkU1o1qweDcK88LS5+NDItWXsZd/Wn1mxP5fS6t3p0qsPXSLs8bC9hvP95i4lFMVGcfCzjWzKFULhPekzvBHNgxywv94m/8LjfhHfYvkuSMogccsBkqKiKSkWmCK+NYu42hQBRUARUAQUAUVAEVAEFIE/TsCMqbISo9FIub6ccvm6KKQGro0b0jjUCue4GBJ2xJJTWonJxQU7W1t08rG1tq4S3aZKDMaqj9FcSaXMUzXxai1C19bGFjs72d/aRr4X783f2cxaaKWlLSMVBiNGacco32uLAdqmtWcj57S1spHz6yx9kG8xacdc2N8gX2vnN1n6oHmSWmMjH62vttIHnc4OW+24C2sIF7tjNpuo1M4rH71cf6V8r202coydnEu7ZltZfLiidd8ivktFfIfR8pFBSnxf16BMXM7WT6fw2JxjnC6qi+2gySye1JcRTS9R1nl7iV3+Gk+99jObC+vT9MUPeP3BdtwRfF1npODIEra8N4WPfipgv0cjuPs5pg3vxaNh0l7FOr5+9Dle+CKO5IhxPDBzHIvu8sXp+k515aPMUWyeMpvJU1axS/bybDmAp6d9wojOHoTrrnCY2Yi57CTRKz9n+Wffs+ZwLonielFuMiPjV3sssbKxw2TrhU/j7rQbNpIxfZvTPtSuqsFz7/LltJd4/JNCSjtM4LkZb/JKG3C97msrpWjb2yzuN5WpRaHYN5jGnB/u4QFZz7gZNiW+b4a7pPqoCCgCioAioAgoAorAzU1Am3MaKgyUVVphCIjAu0kDajUKIaBmAK4+zlhUj0ks4Fk5lBblUHgmhvSDx0iNL6KgyBaztQh3UbLlOlesfIMJbFqPGo1D8HEUsVyeQO7xaI5vSyQvxYCzswM2Nr8twDWhXFmup9xgRZlbMG4N61GzRXWCqnviYq8J7krMxgpKs5LIjzlI0sEzpCYYMVSKEvLywyGsOoENwwiSfnt6OuFkL0Y+0SemChHx5UWUpJwl5+QJko+nk58tIl4WBXSyKKDZxU0mA0VFoltcfHBpfZuctw4RAfJ77dIzosnZt5WzJ4vJLfCoEuG/EQFaZflW4vuPPQ3JPxD19SyefTeK/Wmt8bvvOd4e34NhkZfYmvMPEv/DTJ6f9S0ri9rSecxcJt7Xip4BBijO4HT8ec5my2qNRxgR1V0JsskiIyGVxMxy9LaeuFarIT/3JuCCBq3ITyDz9HHOphnIdfCB4HDqueXjWniSs3t3sejTFSzdWYQpojd9h/TigR7hhIbWITTInxDnC5drzCL7zBkSUgvIrpD1GSdvPIIiCA/xxO9/zL6yqlOUwLn4BM7nSD/dvfD3TiN+yRI+evVL1suPgrsP59GX32FoO3eqX0l8F8WRsmkG097+jEU7ZER6DmbAy2N5ZUwbmmrWa3MqmScPs25zBoVO4TTv05IGfrJilZtC+vFTxB5+j+WrfuLbg2b0DYfR7657uLOeP3VrhhFW2w8vbZAXZ5GZnEhaTh45JdrKmqxG2bnj5l+NgOpBBMv125gL0WcmcOr8IfavXsmKxZvZmOOPX91B3PesWPAb18RHmDb0d8Hdci3yoOcmkHQ2iaScUkqtdNi6B+IfFEbNUEcu8XG4ALeAovMJxCdkkl0uK3FW9jh7+eMZEESgr1j35UH/MzYlvv8MiqoNRUARUAQUAUVAEVAEFIErEdA8KY0VZRTb+1BZpy31ejajRQt33M255JZZUWp2xUtEtF2xzH/T8ykzllKWdJKsPYdIPVdGTp7oCGcnfHv1pfbtnYkItP713Nl4hsyoTWz77hQZZ/R4uDmLtVo8OC/pUJW7uvTDqCfP4IbetyEN+rehRfdQfDXdYiqgLL+EbL0Xjh4OFlEPhZQc3kTcqh0cOOyEqWFXmj/YgYa1dXJ+A4bcLHIyRUzLgoBzoC+eTmKB1w4zZpC9fg3xa3dzPtOOMpyxEot5aYkN5UH18O/RgZa9alPb+5IOZuwkce3XHNldSLpoCkdxwdeJ9+4lDu6WnZX4/jOes+sR32PnMfH+lvT0yYGjy3j+lfnMWXUaWb4hop4HEcRzOjqNBL3WQWfsavdk0PDHePqRHjQLtKHy4AesmTGGt5aXczCoI9zzJJNqfk/wzm+YtBQ0ffzrzYlqoz5i0rj7GBGYRObe5fzw9fd8s243+87LKo5lZzlPnTa079WPgcPu5o7IAMIcNTf2RE79uJzvP/mMb3YdJzpXdrUSd/A6gQRUFlN8OoEM+VF1Ed8jRHzf93viu+Q06Ztm88bbS3l3m5zVvj51OrShU9tm1A0PITgsjBo1wqkd6nqJNTudxK/n8+nQN3lXzpP5P/esIe2fnMLzkzvROGc9x75Zwhcr97D+WA75v+xrj0O1ZjRuO5jhj9/HgHo5lK2bzLMzVrHm1G8MgloDCBg/leVD69K29BBHfv6SL7/bws9bj3O8+ML+ulACGrWn7T0Pcm//zvSrJeewTiF1/zY2L/2OFRt2svVYFnkXm/doSdNBjzBieD/uui0If1Hsf1SCK/H9ZzzAqg1FQBFQBBQBRUARUAQUgSsRMFUaKSsswBguxqnB99CsQ3XCbQswJ+9kbawVZ23q06OuCZ/t69gxby2nC8QdOygId2dnnCUG3FxpEK9WG5zrROAUXE+swgFUax5E9cbuWDRy0UlSd29lx6o4ss4Zrii+jRJfXl4q2iOiPi63D6Bd2+rU1dxfjWlkrf6e3cv3cqi0OqH976Dn3a0Ishjcsik+up2oT3cSE2eNY/2GhNZ0wLHkHIkHYzl1rIQy0T/1xAW8a8cwallchUso2bmSuNWbiD1vQ3aBWO4dfdDVaU/DQbfRpJU7LvmiJSQK1+zjhb24uZsSt5C0/luO7ysiM9cfByW+LcPpxsR8/0p834bf0OeYO747QxtebvmeJZbvb6os37+Ib1GyJ5Yz6Y1FTFt6HFwa0LTvnQzqE0l9t3QSxCq78tONREnng9qP4PEZCxnR3hHPIx+zZtZ43v6ugN2+rWHYi8weVJP7XGI4uz+K9z4Wy3eUqMTwXmL57imW7whCQusR4ZJA1ua5zHprGSuiXSlt0J8hg9vSt4Y15pTdrP/4a745Iw9M9RcZP3c0L/TTY7tP9p/8IbM3F2Ny7UTbe+/kvl7VCOEMp1b8ICJ+JwdE7IdesHz/rviWVSZK0ojZ+CXffP4F328/xZHsi4+6mK0dvPDw8yMoWB7Ihl1o1WMgAzqFUYdUi+X71IGFLF8tsfOHZU2gwVDuGHw3/esFUr+eXF+wE/ZFieRnpJOWqycnv5hSyfqtL8ogadcn/LzmJNtzXaj9+ALGjb6Hu7zOkpZ4kKiVK/j+w61syvHDr45Yvse2ol3j2viF+dKwOIot/5nPpPk7OFFWk4jb7+SufrLS5lhM2r5lrPlyJzsLwwgf+AYz3+hLH6+NrJsxkdEL4kmr1pnu9w2lbwNvqrlYYW3rgZtYyqtXCyLE2x7xjPnDmxLffxihakARUAQUAUVAEVAEFAFF4AoENEORFhdtKBPR6ymZuVt2p1G3xrSq7YgdEvtcUUmZeNA62puwzs+jMP4suWlnSIk5R9rxbErLxZrs6Ii1xHgbywtIT/Ok2LYdzR9rQ+cH/PD8RXxvuyC+K64ovvUVFRQW5uPUuCl1hw6lbmMvvBBDYXEcZz5Zx+ElO0gWa7P9HYNocNcQmtTQ4WZdLmmqjhL7gSwK7DpFlli5C/RBeEqceu3+dQnwESHu6oqjnxeu9uWYUsVQeGQfsVtOkXCigHIrOyqqN8CvU0fRJXUJ8yugdN8p9n1RhCEkjCZjGhIiKwim8xtJWPsV0VGFZOQH4+TkgIO9JMG6LCOcsnz/GY9a0ip2fPUmz763h4NpbfC/bwLzXuzOvfUu+nfLSYqPkvjTdMZPW8Z3+a3oMHYBLw1vTW8fEd/Hv2PSlHlMWyFfR47k6VfEoj3IRxJ+5ZH60TQWjnyLj6UJx54P8sSr7/FQWyc8LOJbRP7yfHZ5NoMHpzD/8Tt4JlxUcPJS3nhhOpOXSXtNn2bsq08yp5+nZB2E8j0z+Hb+S0xfA6cMgehqNaJNLV8inDV3khIK84oQzSoJDBrTY9TjDOheiGndwyycf4JPT4dCt8m88MIjzGyvKcd80j59k/cfmckH4k1iJ+L7cbF8D/s9y/eveJdSkXqG+LMnOXbqBKdjzhJ3/DRnY+I4mZQvV2+PrXdXubRJPP10W5pqxx4ZzbtvLmTqWijrIswnTeD55prNXtvk4StNIS1OrPOHozkal0pSliSEKM4WQb6PUyeTiC1xIvjuN3li9GjGSIOOpJHy41ymPfEJHyXXoEa7l3hjaX8Gh0hzxvOkr3ieqQtX8N4OoedaWxLB1aJpDbHKS2xIeWkBhblFIvD1+EX2pNeIUQwIS+PcjwuZsXgdu5LLpEcO6ORlY+usubTfRsPbOtK7Zzu6NKmGt8MF15Y/MAaV+P4D8NShioAioAgoAoqAIqAIKALXRMAs+Zn0FeWUakLcPwzPyIaE1w8hqFaARKO64S6u39YmK0l8piUrq8SqJJm8Y7s5tPooCccL0TnYSRioJAjO86HMRsJKhzfjtrt98bhEfO/ULN/ikevuqrmdi2HwQs8upl7WV+gpEPHtLOK7/v3DqBPpKeJdE9+iHz79r/jW3T6QeoOH0KyWDndrvYjvI8QuXkPczhgyJJy30BCGf5vmRA6NJFRieu1sdFjbSbJlR4kZN5VQLvokaeNajh7MINW7A2Hdu9C+sy8+1vnk7tnAwVWiXeLqENC1PV0flbh3ufbKtL2kRP1EzBFZYEh1wKqowpLx3Uos4FoCuIubEt/XNNyuslPmRg4um8fTszewN8kb58i7eeqNMTzVP5ywi4eeX8FPi6Yw5aOjHHbvwYDJ83j2nvq0cRKBfEzE9+ua+BYH5caP8dSEkUy/J0QSFyQT/64I71Hz+ETacej5ME++upAHLxffXqI+H3iVeY/0Y0wtaSNmOS9PfovpK8TpuvlTjHltFHP6elpiGAz73+abeROZtrKCGF1jnHqNYdb4e3islZMlWQA5p0lJl0QBzqH4BPjgX7JXDPNPMOPdaL6O8YdWYxkz6Snm9naT4ZTKufff5K2n3mGJFgYu4vuxaxLf5RSfP0N6Vhn6wDqEhLhWJWmwbGXihv8Zc8fOZc6WODmDG10mfMj4CXfT00NWzHY/wcK3PkJQo+8ynXGTJzKhhbCRB68ibg0rZ7zC3BVH2Wvyo9ljC3nh+SHcGZBF4Y+PMnPaahYfd8RlwByeHfsUT8uahTNxxCxbyJyxS/gsXeK3201k6jd3MSRIumJOoGD1RCbPX8E7W+ShCehL7ydGMXlcZ9paMrzlY5K48Zh8ZyqdA4iQ+HCXC1nXTdkniTt2iIPRZzmfIgsJOaeIO7KHLUfzMDUdQZ/xrzCpd3WaWN44178p8X397NSRioAioAgoAoqAIqAIKALXRsBUqZdkazrK7CSxWZA7rna5FKZJ5SOfJrh27cmQJuLAm5THyXhXQluK12oNia8sieXcojWc2iAWZ0d7JBKcnDQvSsTy3eJxzfLtL5Zr2QqPkrR9PeuXniQtyYyfvzeO4qZeKWJbX14mRkEtI7nMxbXE4uYKTA2a4HnnXbRpHSJu4iJCKpJJX/49u5btkqpSwYQMHCDepx2oJk7ItmRRdGQ3uz7cT0KyFa5NQnF3N6BPPU/KqSRSk8opCWxMYJ/b6XJHI1pGOGBxTk1aQ2KK5G9y7U9IjVBq/2+CpyuAE2+A6K0cW7Se8+clQbS3uyXz+kWHVyW+r228/f5eEuCff/wnlswWofzDQQ4XSKr98JbUrVeT2iKurCgg78wJjh89T5JHZ9rfM4aXR91O+xp2uEgcAtHLmPDa28xaLUK83uOStOwpZg2rJis5icTNn8nise9ZLN8OnYcxeuoH4nbuhOfhD1g1fQyzv5OYb8+G8PBU5jw+gPG1q8T3xFcW8OZ3xySJWk2qNapDiyZ1qN91GP1bOeNx8j8snvMFX2xOk/hpf0KbNKZBQ0lWZi6hOP44SUbJ/tdvAo8P78vdoekUH/qEBTM+YN6q8zJ8ffGPjKRJpB++VtmkHT7OoZPplrjmah3uYeRr73N/Bw/CrpBwzZh/inNblvH5h0v5dl86hT41CawuSeYsbtiyOmQqpEiyDMYdOc0ZncSTdB7Jk0/ex90dg/G31VO0/Sk+evc/sngAeS61qRXZigaB9el+VyS1HE6z8fm5LI2RpGjyqAU07Upk/QD8TXkUnJaH8UiOXJuOoOFzePqZZxhjsZjHcnLpYt4a+yFfZRiodK1PZHtJbte6F3V6dmVkaAqJK95l+qxl7EwRY7hnHWo0i6R2kIj4orNkpaRxyr0fbYY8Lgn0ahFpl0J81BZ2Rh3muGRrLJUXh/bAWRXEce7YXrYdM+J02yMMeP4FxnYLpO4lzhHXMxSV+L4eauoYRUARUAQUAUVAEVAEFIFrIVCV5VuMXqUigP1r4dWtO5GSyDnC00hlniREFt1TIWGjfm4ij/VSeqxM9I2XE84OBejj93BoyW7JYn4Oo5skHL6tBT71muDh4od/HQkzDZGyYpZOFEsi5FSSz6WQu+0IuTtPkVpWgVXjRgS3boG3+KbrzJIIK1u8WHef4NQZEbMRt9FqcHtadvLFXTMslyaLu3uBHOePixgQwyQftfj8oj++npj1Ir6TIiRDeU+6D5LM6FoC69I0STwtseKScK3MTpK0SchrYIg7Hpbk1iWUHvpJ3NQPESPJ00zyey8R+SbxZpWc7xgNzuiNtQhpXpfInrIQYVlAiCPn6C7Ons4jPV6SuJ3NluzwwsxBxPwltcaV+L6WUXdN+0iB+dyTnN63g41bdrN7TzT7RQSmFldiI1bRwPrtadqxGz36dKOLpNWPuCi6TCK4Y9Yy+52PeWdtgYjv+xj+1FAm9A8Sm69Ylj/7gKWT/8O30gf7jnczfOxUhrRwxO3kUjYueoOP1hZy0CMSBo/h1SFdeaSmjD59Aic3rGbN16vYuEfKeuWKe7dbYzGCT2LUQ70Z6FtGSYIkJNi8kfVbJb5ix3GOZkqtOp9ahLfoSe/ePenbrQlNgiWpmrbKI4I47+BaNqz8iqVbDxEVJ09gSKSI1PrUKJI0/Jt3ckJ282w/iHtGT2VAS1dCrlB326TPpygjlZSzJzgavY+9+w6yf/+pKuuwxtnRn+B6shrWqTNdurajTau61HG1qrLKy3KXMe+wuIys4atvN7Eh6iRnpARAuVN77ho/mkfuliQQsauIWvUd322L53hqMUVOdQmt15yOYeJCkrKfnZI0wbn7aB546CEebWKHq5WUKkg6zKE1S1i+YTNr96eRnm+NvvVDdB35FDPuiKChdbo8TJvY9PM2Nmzbzq64JBJKJc4lsCVNWnejd7+e9GxXi9oSM+JkTpY622tZs2wla7ZL/fIUWXgpFzccl+rUaNmTjr370a97c9rW9MRZLkolXLumh0vtpAgoAoqAIqAIKAKKgCLwNxIwGMTdXAoX23iLd26jmgQ3Cye4muRq8hYXcd3Fubq4gOdkUJAaT+KhEyTsPUNWlliWSw3YujgTesed1O1zG8FuFZjLpfyXvqrOt9QZxlrqatvbiehdt5W4j9ZxXOJgTT36imv4cBrV0kJFRX+k7GTLZ9s4svG81OB2wSq0Bp4tpORZy5qEhPuI67u4vFtL2TCDnpIMyQN1cj/ndkk/zojXrc5Tki/XEPFfm+Da1aVQlDfuHjrspaSZVmrMbJDY8OJ8ChPPkR1zjMRoqSyVWIpRL/nKzdaac7ultrjZXE5ZqRtF+qbU6N2KNk+E4C9zepMkn0vZ/D3H9xeRUSALAC5OEvMtdcIvu2dKfN+oQSxZ/QyVUrhdG1Fa0XYpuq7VevvfTXawpM3XCr3L1zL4bKQwu60kC9DKW5m14u3a7yzNSDtaTIK0YyUrLyYp7i5eGFVuGFKDzlYGj+Wwi5tWvF4rJG8Z1bJCJFZYa22fX3VC9tHq2lkq3Ntio5NzX5GJXI9Ruy6xUGsF6+VkltPppaaf1tsL/dPK8l27qJRC9dJH7dqrHj7pp1yjdOP3N3lIDAZhcIHvr4+R9iT5Q9U16QSNVvNPvjZVUGGQVSthbGuxSF+MILlwqgu/t/C03AeN92X7XLyvWgyHtG0rDf/2bRVWkhlSu65fxoDEfFj68SduyvL9J8JUTSkCioAioAgoAoqAIqAIXIGAlN2Vua1mzTVIEjGjzMVlJk5RWF08WjShRXUrXE4e58zm42QVS5y1vaNoClvsdCJAZc5tFE1jlHmwQdMnon1MmpC1TJK1+b9M2TW9pGkgTQ5JPXFNbxjCWuDfpRst2jninXeAsz/uID46j6JSyQsl83uTHG+olH6JeJEWLWW8tE3ktEUTWYsWs7ESfSM6ycZK638leolLr5Sa49r/qo6xiCnpo2gQTVJpX0u7NtZ22MqCgK2mFy6bv1dKuwbpv1FcArS2tKRq2vm0GG9ba9EQcs7Lj7kIVYlv9YApAjcxASW+b+Kbp7quCCgCioAioAgoAorATUagqt625oquGZiqDHNGg4RuahpWE88itnUWo6BI0UtEq0UYy0f712I7s+jk/9ZGtuhmzT1bC+2Wr42VUgu8uoTh1vLD2ZBKQXyCxIMbJWu6LU6Odpq9rqotzYB3QXT/utKy1pYYybQGq/5fVXPb0u+qPS/th9nS2aoOW9zELxx35dujnVtbRKjao2r//57vSscp8X2TDXjVXUXgUgJKfKvxoAgoAoqAIqAIKAKKgCLwdxC4qK1/LXr/WE8sIln+o81xjZJwzVguwl5syrZ2kpVc3Mo1K/olmv2PnexvOFqJ778BujqlIvBnEVDi+88iqdpRBBQBRUARUAQUAUVAEfgnEqiyWv87NiW+/x33UV3FLUrgf8T35v0k7oympLhE0kLaWNxh1KYIKAKKgCKgCCgCioAioAgoAn8/gV/Ed70wWj06GN86Ydpmle8AACAASURBVH9/p25gD6zkgv8tCyc3EJNq+mYhcLn4ThDxnbTzsBLfN8sNVP1UBBQBRUARUAQUAUVAEbhlCPzX8h1Oq5FKfN8yN15d6L+PgFFfQXl+EXr5aBnyLSkb1aYIKAKKgCKgCCgCioAioAgoAv8YAiYpV2XnZI9rkC86R62u8793U5bvf++9VVemCCgCioAioAgoAoqAIqAIKAKKgCLwDyGgxPc/5EaobigCioAioAgoAoqAIqAI3AIELkZ8Xqnw8S2AQF2iInCrElDi+1a987fQdVvSGmj1CeWaLyuheAtRUJeqCCgCioAioAgoAn8XAU1nV81B/jsn+bv6os6rCCgCfx8BJb7/PvbqzDeAwMWEa9q/BoNBPlIPsaKCCkMFJsl0bmVZZVax3zcAvWpSEVAEFAFFQBFQBK5AwGyumoPY6XTY6uzQ2dmjk3+tra0t9Zur5idqUwQUgX87ASW+/+13+Ba7vkuznZeUFFNaXERZaRHFJSUYjQb5I2ejpPctNibU5SoCioAioAjcRAR+U4Neqarx9QjWS4v8XO343yoIdKVjZN/fqR9UKQYAGxtrnBydcHJyxcnFFWf52NraWg67Wk9uojuouqoIKAK/Q0CJbzU8/lUELrV8l5aWkJ+bQ0FBLqWlpVRWSsZztSkCioAioAgoAorAP5rAL1ZgsQhrFmMz1pbwsUuLlmh/780iaDWvNk3YVlXO/W2xrLVnJYvvNvIRQ7PWlGV/k8wLTCb597Kqu9pCvWaRtr6sSorlOG1/U6XFe1zs1dJW1X7XYrjW2nR0cMDNzRMPL2+L+LaxsVGW73/0aFSdUwT+XAJ/gfjWU56VTlZ+KUUVJnnj2WHr4o23rxfejn/uxdz41uQFX15CaUEJBltHdG7uOOnA5safWJ3hGglcLr4L8nKV+L5Gdmo3RUARUAQUAUXg7yZgFmFbUaGnQsqFVlqLi7adfExlmCV8zGC2x0Zz17aVmZcmnq1EuGo240qDCGnjBREt32tiW1PHpqqfWdnYyjGVIr6t5Xtb+bHM5+TXRhH1WkYYayvN7VuzPlfKT8Q9XCBYSdvWIoyt5VhNsGsL+BV6IwZZxzfLz21FcNtaGWVf+VjJPrb22MrPr7RpywLa+avEtwfunkp8/91jTZ1fEfg7CNww8W025FEQt4fjR09xOKWE3OIy9CUSdysvq8pyE9bedajWsgsdmodQ388B27/j6v/f5ywmbe8K1r31LfGh3aj95Fh61oAA5Sv0/yZ5ow5Q4vtGkVXtKgKKgCKgCCgCN46AZk02VJSjr7TGaOUgYtkWDz8/fPy8cTNmUJabTkaBifJyEeEizvVmHToPfxGxPrjpZF55wfptsX9XinAXQVzp6Im3pzveulLK0w6RkJhEcpEzJXjg4V+NoJBAAlxEFJcWUFRsxGjrjLOHA87WpZSknic9JZNCOU+52VkEtgMOzvY4ujnj6u6Fu5c7LpXnKEk7wLlUE/l6HxwdtYWBqhjuyzclvm/c2FEtKwI3E4EbI76LYzl/cD2fLIkl3asZvUYMoWNtV3wsZPQYEraz6dsf+HFHES697qH3sN60cgPHf7yILSF973esnbmU2NDu1Bk1nj41lfj+Jw14Jb7/SXdD9UURUAQUAUVAEbg6Ac1qXaY3UWxwwDUgmGohHniZizCarSnXueJQViBehmJjdvbAkQJK0xM5n5xLYbm4f4tRxyhW6cpKcUE3i2XaYKQ434jZwQ/fyEjqVxcRX3SapDNpnE0SN3Mnf3zrN6B2LfHCrEgj/Uwc8fGpFJRZU+nggZufD94edtiVF6IvLkZvpZMFAWexgNvj5G6DsUxcHk1ehNQNwM8tnuKEXZxJhvyKAInl1hYNxEz+G5sS31cfB2oPReBWIHADxLeenO3vsmNrFD86D6Nx1zt5sqnE2VxOsyybwqRU8ux9sPMPwsfBjK1Yy/OTT3J0/xGiTyaRkifWcnEPsnYKIrhuU1p1akbj6uKqY20U/58zHP3pFPt2leDd3B1n30LORh0hUV7GJc7V8QprQ9vOTWndwBNXObeVoYDC9BiOHYjm8LEEknLLKJfVVSunAAJqNqZlp+Y0reGD14WOmkszyIzZy769Rzl4OodiO1c8G9fErSCJgh93Ula/D3WeeIZeEeCnz6Dw/FEOa/2OTSW12ESZ/MHQuYQRVLsFbTs0pHGYG04Wlya13UgCSnzfSLqqbUVAEVAEFAFF4M8nYKooI7/SgXz3GtSpGUikjcwPd+3kTLkTlXUa4Fsehz4tiQRDAHbOrnjYi3XbKMJbi7eW7OEXY8QrysspKROXdadgfEPDqOtrgMwzxMclkCVel7m2wei8atK0fiA1HBPIFg/NE+eKyCiXMEIne+ysJXbcKF6aWjUwnQP2Ds7Y29mKO7lMO416SsvKSU91BrsImrSrTu3gcyK+d4uoN5NX4a/E958/NFSLisC/jsANEN9JHP9kPts2niav+zha9etEDzF5X1V0msXdKGkTh0/EE5Vfj9CIenSp64ROXH/ydn3Oxh0H+EnXn+adBzK+kz325mNELfqar746S1Hr3rQf2ptuwTY4GXNJjlrDju93kV5/AE0eeJDe1azxSt/CkRMxbMuqhW/1+nRtKCup1hUUHfiKbVt3sNLUg7qd7uW5jg64mw+x45vNfLuuGOdGreh6R0tqe9jgYJdBwuYf2PjFVjLq3EmLUaPpHQZusas4Gn2MaNtW+NdsSfsw7UWdQ8qmZWxbv4vo0IFE9hnKsPp2eMiCqdpuHAElvm8cW9WyIqAIKAKKgCJwIwiYRPCWGKwoFndwTzHIRAQ4404pBjHdGCT5mV1xIkWZySRly34Sd20tLulW9powlvmgKGNJvSau6CUUl1ujtw4gtFZ1wv0qMJ4/QnJSJpkVThIfbkW+WyAE1aR1iAvVKospyCqkTEvaJm2YTDbonF1wspf8REVpZCcnkpknlVJ0TtiKCNcM2lrVlMxMR7G2h1CvZQgR/iK+z4v4Tlbi+0aMC9WmIvBvJHADxHc6cV/NZ+um4yS0eYZWfXvQX951VxXfl9I1ZJGdmMC582lk5eaTn7iHaHEX2lXeiTa9BjHhbn98rE6x6/2f+GFNEd5DBtLzwRY0utBGccz37Fn2IRvphGf30Qxr5kSI04VfVuaSlyRtn0slMydPvj7AibPn2VbUlqa9hjOuj46A2AV8sP4cP+oeYmifjjzY+KJiLiNz/yVu5089S69L3c71OWQlnpUV0BSysgrIPh3FyTOniXKTRYMew5jUzQ+/my7J3M017JX4vrnul+qtIqAIKAKKgCKgEdBczyv05ZQabai0cZZSXE74+PvhrcVWG0rE1G2F2dERW2MeRSnnSEnJp8Rki42ziGGJsS7OFYu1gzcBDeoS4VuBdWaMWLyzySm1wd7ZQcS1gQzxtjQH1qRVqAdhFVkUnZMwyYxMUosMkhTYHpNjMIE1alOvhgc+pjNknzvJ6UzxZjS54OIkidpEqGdlOkgiOMlXpMS3GriKgCJwHQRugPiupPzYErZv3MBniS0IbXsnYweHEXBZCIwp/SjnT+4lmtq41O5IG189dqfXErXnMFF5fuh8gqkbJDUQKROL+H6OxiayqagFzbr14/m7AkR8x/5XfN91J90faEWknEPzGs879h37vvucrTYd8ekzlvvkF/7nf2LPnv1szfQCr1Dqhbjiaq3HmHyIU3FnWZcbSb1u9/Bsbwf8zyziwx/jWW0eyr13dGZEM/FvsmylZO79ljWzv+F0aE8ajB1Dz2pl2B7+iYN7j3G8Ihhbv2DCvMVKbhbXp9gdxMQeZaN9Xxp0GcrL3Xzxv7gIcB03Sx1ydQJKfF+dkdpDEVAEFAFFQBH4JxHQ/nZr2cSNWtkwyWpeVlxIQX4+NgE1CakZQWDxCTKTi0hybE3dRhHUc0okP/YAyTkGcq1c5Tgr8ky+uAaG06yWE555MSTHnCC1whGDs7dUppEkbtJuVqkjJpfqNGgQRLgugdzju4hLKyXb7CoZz+0ozJN5p08NGrWtRoRXDoUJJzmVUCzCXIezo8R7Szx5epoTZtvqRMo+tQLPUHhmO6cTzeTqA3FxccbBXqzyv2FxUjHf/6QRp/qiCPx9BG6A+NaWLwvIO7OLTd+s5XCOrBa27kGjMF+qOYgrj7h6myTxxYnd8Rw/7UhAt650u6MZNezFGr14Fit/jiW2/j1Etm9O11p+eIqftn38SnZu2c7i+MbU7HwXrz0QJBnGY9g+byXLvy/Ed+gQeo8Uy/UF8Z0b/RW7vvqQDTY9CBw8jvvr51O54i2WLz/A0fBB1OnUhl51/PDwdMRJRPmBbRt4N6Yufm2H8NowcVWyOc4ecTv/Zn0OVjUbcFv3JtR010ksT7a4na9m3RfbyI4cStfnRtHXP5HETz9g+ep4Cpv1IbJHc1oH+eDhbY9Z68eG7/iopBfVOj3KjD4BBEqokNpuHAElvm8cW9WyIqAIKAKKgCJwIwho2cuN2GHtHoifr6fk35Hs5DlpFFhJojN3yWZenEx5aSUFbjUJ8tPhVnielFNnyS4zUWprh0Gml7aBUkWnVk1qOEiOn5hjxMWloneU8EUPdykJZmWxWpcUlVNR6YhrcDjVZV7qa5dHaUYiCcniuVjhgqN3uCR707wUizFkxJKcmEx2uWQ7F4FvKSNmXUlRvgs29uE0aOVPuE8yxUm7OZ1gJLvUDUc72cVGvCVFyNuIK/ulGlyJ7xsxclSbisDNR+DGiO+LHCozyY09TvSBExw7n0V6oR7sXXH0DSeiQVOaNq5DTT9xB7Lsb8KQHcO54wc4cDyZM6klVNj74RJUiwYh8kqWrJdHs4Lwr9GQfu088bBKI27jYQ4eKse1dXMadqxJNXnLaQb2ksS9xO/dxknr+rg1uR1ZnMS9LJ6EY/vZfzSR07J6Wq6TldCAWtQPtcLFOl/a9sctpB5924cSIC9PJIlaTlwUe3af5NDpYsod3fBqVBdfGwP2sWexqt6MoB69aORtwiVL3JKi93PgVBLxGWVS2iIAt9CG1PLKx9lwlmPm+nhUb8ugSE/cLxrRb76xclP0WInvm+I2qU4qAoqAIqAIKAK/EDBpNbSNZipMOuycXHFzdbJYqx3dxOXcXRLWVuZhKCkgX0rWluRnUlxYSJFRxLrU1tayoxnkWEdPyWLu64GzKZ/sTInzLtCjk5hwR4eqiZdW/cssrucVFUZKS6W2t4OblBvzwsNZjDxWWqZ0TTjLjhUFlrJmeSLUS02aiNZJsjUXSezmjleACHcHmWyKkJfWLny0muDW2GjZ2UtTyS+SBQGDxIjrJGHwJepbiW814BUBRUAjcGPFt2KsCPzFBJT4/ouBq9MpAoqAIqAIKAJ/CgGzxH1L8l2DQWp5l1s+Vk4euHi4ST3tbCoK8ykQN3IrnXgtSkkvOxG3NtZVNbU1l3WL9dwoJcbEDGMrGdDt7HSW32uZ0C+vu20ySU1vcSHX66VmuByjlSnTkrZpYtlGLNeaaNeO16zdmgt5pdQg19zWLfvLcZUSn65Z0i3lvEV4a/vp7OzQ6aREmeU4ycIu5750U+L7TxkkqhFF4KYnoMT3TX8L1QX86o+b/CW8+Ie2tLSEgrxcCgpyZZW71PLHWW2KgCKgCCgCioAi8M8kYDEUXwiY1gSzWRO9FkFtI1ZpEdua53fVTr8S1BdLjV1+VZeL7ou/v9L+l88nLv1e65Ymtq927JXOqcT3P3PMqV4pAn81ASW+/2ri6nw3lICyfN9QvKpxRUARUAQUAUXgLyNwqRjXTnolYfuXdegPnEiJ7z8ATx2qCPyLCCjx/S+6mepSqv4w/2L5LhPLd+6vLd8WFzFLnJbaFAFFQBFQBBQBRUAR+IsIiOlcc4N3dHDA1c1Dkv564+zq9ovr/NUs6n9RL9VpFAFF4AYTUOL7BgNWzf+1BC6Kby0WS3M1Ly2WxCmlRRSXlFhc1y6Pwfpre6fOpggoAoqAIqAIKAK3IoFKmZfYSEY3ZyeJWXd2lY8kknOpyqJe5c5+K1JR16wI3HoElPi+9e75LXHFmgg3VBjQl5dKZtNy9BVS4k7+8F3uwnZLwFAXqQgoAoqAIqAIKAJ/KwFtXmItAes6yZ5uby8J4xwcsbdzkHxtSnX/rTdGnVwR+IsJKPH9FwNXp1MEFAFFQBFQBBQBRUARUAQUAUVAEbj1CCjxfevdc3XFioAioAgoAoqAIqAIKAKKgCKgCCgCfzEBJb7/YuDqdIqAIqAIKAKKgCKgCCgCioAioAgoArceASW+b717fstcsRbjbTQYpL630RLvfbFEicp1fssMAXWhioAioAgoAorArwhcjLDWsotbkrDKv7a2tvLRXbWGt0KpCCgCisAfJaDE9x8lqI7/RxG4NNt5mWQ7LyrMk08+xcWS7byy0pLsRG2KgCKgCCgCioAi8OcT+P/+hb10Mfz3jv29RfPLj7uWBXaTyYydToeTZB63trG1lPzy8fbDVn52cR7x59NRLSoCioAiIOt98pK5lveUYqUI3BQELq3zXVJSTGFBnuVTIqXGKkV8qzqaN8VtVJ1UBBQBRUAR+AcRuNLfzkunkL+1zy/C+BKFfL2zzsunq7/39/xqU1vt9zoR2o6OjtiI1dvF1QNfX3+LBVyJ73/QwFNdUQT+hQSU+P4X3tRb+ZIuFd+lpSUU5OVSUJBrqfmtiW+1KQKKgCKgCCgCisD/h4CmnMVOcyGEqxJbKY9lLfWpq2pTa2Ja+9trMhsxSolPg0H+rTTJ95Zf/OpEF129raTetSZ+dXY6rK3kWKOx6jj5t+o4aVvOoVmlNXdwnc5GamSLi/glm+Wc0iftmEo5n1mKiWr729nZyr5an3/fDq+d38HBwWLtdnXzxMdHLN9KfP9/BobaVxFQBK6DwI0X35U55MWfIOZMGok55Ris7LFx8SEwvDa1alcjxPE6eq0OUQSuQECJbzU0FAFFQBFQBBSBP0ZAE8larpTKSgMVZWWU6Y2U2rvj4KLDh0wMxWUUlDuKeHYUAWsrYtkGg1G+d7DHxU2EsqmSSjneIr41ha6paXOliGX5mXxvYyPCubiIksJSSo1yvJMrDq7OONnbYCti3MYipUWI64sok4X0skoR/Do5lwhrTaxX6CvQ6ysxWtth5+iEs4MIaSu9iP8SSvVyLmsR4SKqf886rsT3Hxsj6mhFQBG4PgI3THxXlpwnefdadh9LI84QiLuHA142RiqsZHVSn0Z6UiF5FaFEdOhCu05NqOcB9td3DeooReAXAkp8q8GgCCgCioAioAhcPwHt72il0YBeLNHliKB2dMPbwwkHb3+cXezwJYOKohJy82ROVyYCuqSQgmKoMLvi6OqKq4cIaBHaFvGtJTsVIV5eLmIbF/zDIggNtkdXHM+ZI2c5l2H3f+y9B3xdd333/7l7S/dKutp7y/J27DgeGc5wJhmFQCBlt6wCpaW0r38f2v/DU57S0vaB8gAFCoWGkISQhEASx4ntOLHjFTveQ3tvXd291/M5V5YtByfEIbJk6XvgxrZ0fuf3+73PkX7n8/suWEoqUFZTiBwzE6QGXBgf8cGXtMDkzEeBQwN9aBDj3Z0YGQ8gpLEhqbbCwDHZcmywmPQwW+ywOaywYQyevtM41eWFP6pBFsW8lub5N3NBF/H9zp8RaSkEhMA7JzAj4js9sgsn97yI7+/g7mT5Rnzogzfg6hLG1pwbZxiBEy9gz7YXsT2yBLlr7sIDVxeizEKvJrosxUIJqA06aHRJRH1e+ML8uiELjmzuburOXiQ0AY/HC2+U34Mehiw7snMssF7MyyjhQ9Djg8vPX+xQQ2NywJbN613U6k6XKb+Hi0qAO61cN7S8ZrYdjiw9pro+j5s7r3RpdntDPJfuUFozFwMHsjnI3z33nd8kafn2CYj4fvus5EwhIASEgBAQAlMEJl3I03TjjsMfUCGacqCwtgLVRYDe34vuiBUBjRkVqj6oUgYEdcV8j6LIHhvEcP8IgjQ4x7VqVhnh1zJu57ScU8CHg3xH0tphLanH4moHnMlh9Ld2omc4CU1+NcobSpCv9SDc34YBVwBjoRRCESMiiSKUNjRg2XIrHJFTGOigYB/VIJrmu6DZgDTd0AMTKhhshahaWoZS2wR8PadwqtuLYEIPe5ZNxLc83kJACMw5AjMgvn0YePZb2LHjAPZU/gmu2nw3Pl7/+yJvpri4MbD/Vez4zj6MVNai5LYq5AyfQke3CkGK+Juvr0Wzug9jx1/B7iOdODEc4S9n/rJn7JDeXICcimVYf81KLGtwZES4KjqA4e5DeHXXaZzsdMHPRSCZptu7xoLs0no0XbcOq2tLUW5W+o8j2H8cnXt34pXTI2j3xunapKb41sDgqEFe9dXYsKYGqyqsFNYR+NsOouXAPhzocaGHuwMJuk2pdXoY7YtQ2XQNNlxTgmqnUUT4ZX7kRXxfZuDSnRAQAkJACMwLAhnxzSzgyUQU7ogFUWMJmppLUW8egvf063g9UoBITi6acAie3iGcGrbDZFWME0boM6W6+B6k0WRcvZVPIhamiE4gkM5Fbmk16soN0HtOY5AieiRkQpJC3qDn+UooN63jSt9QKZbqKAJU8mPBPBRUNeCqZVbkJtiusx1tI1oaUYwwGbk5EElibJTu5fZyLLqqAlUON7w9iuWbSVZFfM+LZ1ImIQTmI4EZEN89OPrjf8eubZ0I3PplXP2e9bjBoaBLUdweQcehvTjW68dQfFIE69XFqKjnzubGKorgOIb2/grPfeNJHLKvQvVnPo0/Wp2HKib1AGjiDhzG9oe34re7wsi54z7cec8arMxYrymcX3sE2558Crvtt6H2vg/ivtIw4s9+H0+/1IMzjR/GxjuuxXurz5rFh5/B/udfwneON6Bk7Xvw5feYke3bgacf3oWnjuZj0a134AP3LkatnpdOcHf2eC9e77LCWV+N1XVcIAa242cPHceesWrc+ODduH1tHmOglKMfJx96CNtfaEPopgex5q5N2MC56y+19sZ8fNIu05xEfF8m0NKNEBACQkAIzEMC6Yz1O0IPxHCUXnx2J/LLnCh00O1co4cqEYYuOQ6P1wvXRJACOIBIOI5Ikq7mNEDo6bWo5DpLMhGaz8evp63Iq2tATQkzirtPortrGH1exmebzcw0bsicq4SDK7o7laLnYTQKT4hek4Y85FTVoKnCjvz4CMY6jqJncAJhjQNaI98dGSYeZRz6+BjFd3YJ6peXodLumSa+dWL5nodPp0xJCMwHAjMgvifQ89S3sXPH6zi66HNYfduteKBSQZVG1NWF4Y4WdLti8CWGEWl7HQ89yV/y5TfhL/75dtxaasbwvv/G8998DO1Vt6Hpz76AW9jWqTRPjCJx7BH88JcH8LPXzSityEZzgRaxOBcKupKrGBMUoCt6S95tWLv5JnyqrgctP3kKj/22E9GljbDz2mYm52AEEndkfQiNxdDWV4ll9/wRHni/BflH/gU/edmHVwr/HJ+7bQXeU/Umt3fsMDqf+ya+t3sUuwKLsbTQhCJDim5QiqldhfhYC4Jxxjit+Tiuv/lO3FunhunCBJ3z4bmZs3MQ8T1nb40MTAgIASEgBK4IAipaoRkCGKOXXyiZec9SG0xQFdELMN+GGs0wXcv1Gbdzp5W5z92tGOruwnhYj7g+G/Q8Zyx4EH6VA8bCejRX0m082Im+kycxEqQ7epaTFm99JiN5WknqpsSXx6IIx9WI0D09q6AclaVOlFpjSI13or+7G4OML48ztM9Ed3Ml8zlbThPfxahbdl58n+720PKtiG8rjTwS831FPHIySCGwgAjMgPjm7mXv83ht53P4wSsW6Bbdik989DqszGFI9HSwnl049OTP8e2HkwhWvwef+Z834qZiI8X3zym+f4nWilvQ+LkvYnMNUJAR326ke7bip48cwhMncrDi9g2457oG/nLmbisldTLsRsDPWCHkwurMQZW2BYe//zBefNWD+Ob3Y/VNS7CabuBGZslMJwIIeINwTzAO3VmI0pIo0md+ioeeacOzEzfgrntvxcc2Os4ngIt4MDYYQsqaBbthAK7X/wvfe86Fw8lrcf+dV2Pj4lxkM3Mn0owBd4/BH4wikl0OR34BSizM6rmAHqjZnqqI79m+A9K/EBACQkAIXMkEUnQBj6fV9Clk2J06BVVwAhNeH4YcTcgpycby1AG6jifQk1qLldfUo8HeAV/7fnSN6uBJOsDXLPh9Khid5ahZXIFSwyAmOk/jTE8YMWb/ybJbMsJbyaQeoaU7FKOU1tthzytEYZ6N71PMWD7Wi5H+Pox6QsxobmJoIROwWSwU7cwHRHGfiEeY6C2GkWEdDDmVWLK2CrU5LrjajuJI6zjzATEre24OzCYjBfjFLSCScO1Kfkpl7ELgyiUwI+JbSYEWHWfczfYt2HdmHAOWSjjpsmRX0WWbO5dmsxLj48VoFzOhbwkgu3IVbvnabbimmJbv3T/GM197CKer7kTzX/417qwDis65bXvQ/9rLOPLSARyL2ZB2lqAsiy5O/GVuVId4zRhCBYtRWrcSq/MSsPTuxIED+7GtVYeYOQ8VrGtmTGthoKUaKT08UcZ705V87WpmylSNoXvnS9i15RBOc7fWUFHCMmisMWlk4hC/BuGwE41rl2LNmgLY4r048dud2LenGxP5xbAVM3kby1qodKwXGXJnYp6MzetQWVODehugE7fzy/YTIuL7sqGWjoSAEBACQmC+EaDLeTqVQDBpQMLkRHExLdB8j0kHmYg2ZUKC5bucaZYaY8K1qJ6GBz0F9WgnhnqG4OfXUnQ9j7EsmDtJIV1Zg+U1Gpgn9qO3vQ29ATvz6GQzXltNa3eKidhYzoyiO7u8DBUluSgwKoaWUWY270PvgJcu66wlbmY8Oa3kOg03BGhN91Fwx+J0NTcyXtxiRDKqZ4b1fJTVMfzPyJJo4z3oLV0EmQAAIABJREFUGqB3YzTCkD8adxgXnmQZNKX291RN8qlbJuJ7vj28Mh8hcGUQmCHxPW3y/h70njmFlt5xDDKJWVprhTmfonRpLWqLDIi3jiDgS8HcXAK7WYfoaDsGjnfBa+W/m5pRkoVpWdKV63JLNTaE/tNncKatHyMBuh6Bgt7J3dXaWjRW5iBves2ytB/e9uM408pfyOMRhFMU31nFXBTqWGe8FMU2Zj8/N1yK8lAfuk614HT7AMYjXCCMThTUNKChiTHpVvW0BGpRxF2daDnZhjbOzcPFQKV3IKesHlUU9HUFSs3JK+MhmE+jFPE9n+6mzEUICAEhIAQuN4E0s5THY3TzjjH5mtYALcWvUjNbnVuErBwTilX9iE54MDzOUmORECLMbh5jMluDkSJZcTlnpZiQUoWGVmeHPknLuZtx4azBrTWy/DbjvHlOikHe4bAWaRXrgmdTZKcZ752ggSZTA5x1wmmtZto2/o8lu2kl16j4/QhriwcmxbfBxHfJbApzivJUPJYZL/U8NFpawmkd16vjTPgWYjiikmhXxPflfoakPyEgBN6cwMyLb6EvBC4jARHflxG2dCUEhIAQEALzloCynqboGh6ja3im5reaFVwMWtbT9rMsLMPskvy33jjpCk7BrIjqtJL/hqGAqQRFLz8J2kuUDOZaHbOh8wTF+jx1pFkLXClrFotOCu+UUhf8DYeSNV2ttGNVG8VSrVMyqquVcmjK5gDLx7KNIuQn22Y6ywh3tUbJvk4Rzjbidj5vH1GZmBC4IgmI+L4ib5sM+s0IiPiWZ0MICAEhIASEwLtDQBG/5w6lHJiSlVxJcpsRxdOFtCJ8zx+ZVhcq7Yw0vpi4vpSRKmv81HHB2N7kItPPf+Mp4nZ+KeTlXCEgBN4tAiK+3y2Scp05QUDE95y4DTIIISAEhIAQEAJzmoCI7zl9e2RwQmDeEhDxPW9v7cKc2HTxHQwG4HVPwONxIRQK0gWOgWhyCAEhIASEgBAQAguegI7u8kajiS7xOmRl58DpLKCrOuPQaV1/O1b1BQ9QAAgBIfCOCIj4fkfYpNFcJTBdfEeYnMXv87IEHbOmRiKZ2LDJmDA5hIAQEAJCQAgIgYVLQJUR2pl64/zTwlKyDkfuubrgIr4X7pMhMxcCM01AxPdME5brzyoBRYxfGPMl4ntWb4h0LgSEgBAQAkJg1glMxrIr/82kaVPi0/mRIjWzfmNkAEJg3hMQ8T3vb7FMUAgIASEgBISAEBACQkAICAEhIARmm4CI79m+A9K/EBACQkAICAEhIASEgBAQAkJACMx7AiK+5/0tXsATVEqisI6oUv/zfHUScTtfwE+ETF0ICAEhIASuWALnncKn6n+r1crXxFn8ir2lMnAhsAAJiPhegDd9Pk/5XMK1VJpJ1sKIRsOIxyIIKwnXkgmGdGkuKD06n1nI3ISAEBACQkAIzBcCKa7rKkZoKxnKdTpmJWe9cYvFCpPZkpmiZCmfL3da5iEE5jcBEd/z+/4uuNldUGosEGC2cw+znXsQZKmxREIR3+oFx0QmLASEgBAQAguLQMYWfM4gPN0yfNb7i39M+YFd7NzpXzvvOZaRuGczlF3QwflN7WnXnTr3XD9vGM8F/Z5r97vjm7pzaXqxqdRqmM2mjADX6w3ItufCassS8b2wHm+ZrRC4ogmI+L6ib58M/o0Epotvpbb3+TrfIVq+pc63PDFCQAgIASEwvwlMlcnKyFilxGYyjkRKhZRaB60G0GRctc8fUxVBUvQOi8dj/CSQSCrhWkq9ayUJuJpluXTQsSyXUp5LrXwRKSQTccRi8cz5KUWhKx+eq9ZoMrWz9fxoNepzNbOV6yl9JNhHbFofGRnPdhoOTqvVZ6zaSruLre9qim+j0QiTyQyzxQK7Iy9j/c5sC0h97vn9YMvshMA8ITCz4js+irHO0zhxphu942EEYypojHZkFdWiur4WjeXZyNbOE5JvOg2ltvQERlv60NkahraiEmXNxchTFsDLPvUkgv0nMNjbhxFzAxxldajPAXTzKFzqYuLb651AKCTi+7I/btKhEBACQkAIXF4CXM9T3GiOx6KIBEMIQo+ELRd5pgBskRG4fWpEUhZYzEYYDKxxTZGriOhoOIpYWgeNJZvfM8DMdzOVSnHzTkGdjiMdjyIa4Tlxiu20GjwdSRhgtFlgtfBa6jQ0mfOTPJchX0Efw70otLWmjBDXpBOZtqGkHiqDBdkW9qFTBDbbKKKZ7VKJMBLhEGIJCnu1YVLoT9soUNb36eLbZDaL+L68T5f0JgSEwLtAYGbEd6wHIydex4tbTqHDr4ajvgRZFu5qxvlJ+hEZHYVHXwTjkuuwYUkFljr1f8BUFHE7gO59p3HktQAMixej+YZ6lCtXHN+Pk639eDHIr9U34OaKP6Cbd9xUGd8R7PvPLXjsZ0Ow3n0vbv/8jVhhAIzv+JrvtGESI9v+DS/8+hnsKfk4mm/9CD66FLBe/l2AdzqB39tOxPfvRSQnCAEhIASEwDwkoHh3JRTRndIgqbcjm8LYnpsNfXYecgxBmKPj8HgTCASYCyXsg88XRiBEQa3SIWnJR15JFSqLsmFX+RAYHsL4BAWz0QFHUS5yzTFE+9vR09aLwbAe6dwKlFZWoKzAAFNsHBMjYxgJ6KCyFaIw34psDcO9+jvQ3z0MdyyJgDYLCX0e8oorUFNqR542gKhrACMTIYQ0ucgqKEGulYp+/AyGB8cwHDJCTSu4XqfJWLSVQ8T3PHxoZUpCYAESmBHxHT38Xbzw3G/wnYHNWHTzx/BP9zq4PzrtSLgR9IThgQ1WqwU2VYg7tB7ENFZoLfbMjmvG4SgZQzI8gQhbp7kAGPn1jKE8zV3RoAvRJHdsjdkw6YPwdQ2gtycKXWkxnKVm6Cf6MbL7+3jyQBueTtyODavW4k835MKSmwt9NIq4y4UgF6qYWsOdVA10Bh1N0coOrRkOO3dlTVOKlDu+/nEMj3rhDSeQ1FphzMpFgZNjZ5PJgy5d0RgCnjS0Bg2MXKQCngm4ghqkuItckNWNzid34IlHhmG+9Q7c9CfXYin3GxQm6bgbE0MuuP0RRGkLV+mtsOXlIddhgnnq8inuHofdiPH7CfavjXBH2eOCK5RkGwuycpTxcFy/46UVQWh8BOOuAIJp7iIzTip89FEc270TR0seRMMN78cDiwCLiO8F+KMvUxYCQkAICIH5QEBxM0/xPSESTcLrpzU6twQ1DfkoUg3CNeFBp6qEYtiLkvQY3KlCvmflIDvN946uXnT2hBGylKF8eQMayvkOM3oSZ060o63Xj7hKsVKbYbJaaQ2n23kyikBMi4CpClUNtVhSEACG96CzrQddExaE00bEojYYeL3Gq2pRm08B3rEPx8+MYkRbi+JFq7Ck2gaLqwXthw6ja9gFn9qMtI4x3Ga+U9GCbtTR0q7cFG4IKJbvKRd6Ed/z4UmVOQgBIZD59cadxHe99lKibxsO7fotfvpSFD5LAzZsbEZ1fi7y8wtQkM/dVQd3M6fxj/W+hNadP8MjrmVILfkYPn2NHRWWNMI9O3HgZ9/DVn8ttLf+JT64Jg+NtgSi423Y99Nn0YciVDxwF5YXjqP7iS145ikXzLfdhNWb7NDvfxaHX3oeL3SF0auuRqEjB2tW16F240Y4aXmfePkVtDMbtttihjo8htHjp9CjakDeLZ/Ex+9bilsqGJvk6cHh3fvw2uF2jEVSiMYovhVXKEM2rM1Xo/nqVVhfbIFD34uRg/vwyLfOYIKL3tL3l8E03o7WfjNi1dfgjmUhqF95GY//YgT6W+7ArZ9Zj6YkxfPe3Xhtz2Gc8ifg4aKmuF6pKeJ9hioULNqA229sxpJSCwyhYYy8+A947vgIXjPejoYsHYqS3Wjr92NkYASJnGoUbLwPt1xTj2sKFbIReFt248ye3djdFURfUAVLlhP28kKYhw5gvLsTo00fw+pb3ov7GwGziG/5bSAEhIAQEAJC4IokoIRgpxjXHYml4YrlIru4EssbaEgYP4r27nG0mOtQaHOhwP06jnem4Io6kJNlyriJu3VOaIoasaY2BxXpbgy1n0C/R4WwNhdmGhO0GTdyuoKHgwjS19wdz0LMWoPG5mosKQwjNfga2ls60OXSIKwy0yXdBIM1HzXNTWgoo3gf7cArr/J9R12Eq6+tQFWWG2Pt7Tg1GKHFXQ+Hje9UKuZjSfDfdDkPcwMBjE3Xm2gMEfF9RT6PMmghIATemsCMiO/MDmVsFAOH9+Hw4ZM4ORqEP5WEmvE+6TCttZosmGuWYdHV67G2oQAVuiFEe3fhe/85gNboEjzwZ2uxvnwIoye24ZGXRrD3VQNqypfjnk9t4PkjGDm+H/+x1QpN8VX49PucyNO14eDPnsOTj47BcvsduO3z12GFsrOw9+t49KUDeFj3p7iNovezyy4Cw/s6Ovb+Fo/vVSFeeh1uv2cdap3cce18DmdeeAy/6KmDasWD+ORdlWg0Ke3HkWjZgv/7n+046GnGfZ/dhNvZme/gc/jFN/fgjLkZq//8Qdy6zIGSTHfK3sZxHPz5Nvz60VFYbrsTt356PRqTnMe+Dgz5jMhZuxJVearJDYnwbjz/Tw/j2VeiKPj453DnA6uwlCx9L34V33+xE9sMD+Keu+/ERzbSTUs5f/RJbHlsF761uwpX3XMn/voBJyxju/Hwv72Ara3ZWPGJB3HfLYyxz7gMuNDz2+/j2Wf34lT1h7Hyjvfj/U20fM+jBODidi6/8oSAEBACQmDhEUizokcSoQBdz9W0VBcUoLgkB7kWimwmW9OlvUhGJjDuYRy4n+F/PnfGK67fXAJd7WJsKMtCBX3pQm4/AmF+WJ4zHGfyM0cB8uhZZ0u44GfOmK6OQQz6bdDk16K8nhZzJ8V2xAWvawK+BN9idHoYjPxYc2E3JpjyZgA7Xg7BjTysvyUfpRYmdPO5mIclCn+AYptt0lalDxscajcCo53o6x/DWJhJ3mgRN/FaU4e4nS+8p1pmLATmI4EZEd9pJas0s12ez+MVp5s43avp6u0aZ7x376vYsbMHe/pqse4Dd+LB9zWhFCNo+9G38Worf0nf+CdYnGpHoecU2htvQ7rtNKydx+G99oMoUDFu+vhWHCu/E7krr8ddBYqL+lEcfIji9jGK79tux+bPXYslFL3pl/8nHn35dTym/zhu2XQbvrhmmvM7F6LYyW14csthvOQqRvNtm3HX2hpUZU7xoWfbw3jmW7/Aa8k8xJsWo1AbgUrJ/qlSko/EMNYWpWvXMqz/kz/CHevoanVwC375r4cxXLgS13/lfqwp0sKeeWK4+KRP4dDD2/DUoyMcH93O//RaLKfLuo4W6vhEN7paT6O1dQA9A26M+sbQf/R1BFLchX7wf+Cu96/ButgIAtv/Dt8/GMbuwi/iU5tX4q4ahS45B3bilUdexf95woSG996JL37EAMuhx/HNpyI4ZL4FX/7ECmwqnYouT2Fs939g95Yt2Jv/IdRt+gA+KG7n8/HnWuYkBISAEBACC5BAkhbkMC3UAXrrJZPc/LcXMByvGtVZQeTH+Q6WKIQhOz/zLuXvPIhD41q48q/G6rp81EY6MXaSBolRH0aTBsRSeoRpSXeU1mPZqlJUWofoqn4Mxzo8GPFpoTeaM5nHFbGdyZ2WoqB2pxmI50TZkjo0VcSQGDqD3XsYZqitxprrilFp6cN45zGcbvNhIsi3GGY5j6QMsFU005reiJoshsm1n6Y1fQAhHa3i2VmZ7OrKG4+I7wX4QMuUhcA8JDAD4jsJ/6Hf4sShI3jdvA4FK6/B5kU2RndPO6IvYef3t+Knz6hR/t678YFPX40GflvT/Su8vPcVfPdkDsLDhbhr8RJc976VqLUfR/eh5/CjY8CJvUasMBZQwN6EpVeXwZGpOXls0rL8RvG9/f/DQzsP45fmz+Oeu+7AZxafHYP/DAaO7MOWLWPwFV2DDQ9uwBrH9AHGMHHgEex95JfYmlqLrE0fwvuudqKGqdmVrJ+pEBemQQ9CCSPsVSUoctCN6rUdeITie6RgBa79q/uxtlQPJhK/UHwr47vjHtz5kXqU9W7D0/99ALsG89B89yZsWFmDage9A3xn8OpPfsbFygXt+/8KN39oHTZMie8DAezO/zN8YvNq3NugmLIpvr3bsfOxPfjW01Y03Xc7vvTxPNi7X8D3vnMUO8abcN8X7sX9VznOxo+HMLj1/2LLs6/gaPmDWHbrB/ABxfItbufz8EdbpiQEhIAQEAILhgBz4SQotqN0FFezZJcxzezkE0MYYmZzfxGTzjoG4Rw/iSM9lTBXrcO65SpY3btw/OgYOqLLUb18ERYVuhHpfg0dXaPopet5jC7k0XghnCV1WLqSMeSGfrqMn8CpXsaJw4osmxGqGMWy3wtfkIneklqksqvhrF6EFXU5KIy3of/kAZxk+Fswewkql9LjMZ9ZzYdO4sSpHgxNMP+OSst8P3rkVjWjobEOZUY3fBTfHR1jiNDyrc2il2OmtJmI7wXzLMtEhcA8JzAD4pu7nv2H0PLabmzb34e+uAV5pQWwmVVIJ5nYTB2ntdYDr5q7sdXrsH5FNVZXmCYTbNClu2/7w3jsO4/iVcdNaPrEX+NTa6yoYEI1/6nf4Nff+A887W5A1h//LT5zUwVWZ9StYlk+hn0/2YLHHxqF9T13444/34QVLHuhbnkY27a+gJ8eooO2rYIW6jJU1udieO9z2PbMHrQ7VqFq6Qqszk/Rqp3kbnEWrPYaLN3QhMUlQcR6D+K5nS043J9GboEddlqrVYbJXd5IwIRsBzO1b6hFfQHF+N6t+Nn/fg1Dhaux6asPYkM5F5Nz4vs4DvwXLeMPUXzf8z7c/UkuMAPb8eyvaHVv16K0sQgl2cwwWuxEviOAnl8/geMHXdA/8FVs/uhGXB/nDvXWr+Bbe/zYWfiX+Owd1+D+RWfFt+d5bHvoFXzjcRua33srvvyFVSijF0Hni89hz/YjOBJzQMskc9XMVmp16OA/thWtp9sxuvRT2HDnB/Fgs4jvef4zLtMTAkJACAiB+U4gzfJiiTRYUAwmuopXFtnpxh1EKByHj5nGLeoArOkAv+9gglm6hUcY2tfVgb4BJkXTZNO9vBIl5aUoyaNFmxbyiTEP3AkmW8spQH42k60F++Hq60QvPfR8SSvMZY0oqypHoTGChGcIYx6Kb10O7HlO5JhppHAxK3pPH4bGgogwn03caKV7uROFxeWoyON14x74xibgjhigdvDdJ1cPMw0Nrv5ODNDyHkyZOE4mYNPrJNv5fH92ZX5CYIERmAHxPY0gf5FOdHegrXsUw17GEqUYw2PmL+eSBtTV0YXpAnP4ZLuEfwi+ni4mHSuAtrQGDCfKZAVPKTFFne3wqqxQlTUhz6pmnu/MXig/Xrh7RjDQx3zhhUUoqGFyMW6UqrkHHBnrR09LGzq4wKSz7Cguz+cCRffrQRfj0kNMnM4YdP6bTuqsi8kFxVqGupVVqC1jxk7l8pFBjHe14nSXi25WdJ/XMat4bjHKa2mpLmWd8swYmK19Ygy9rR5EDHY4G8uQa1KfTSqnjM93dnwRjq8YRbV5bMe4rPEu9DHxSMeQHxMxLjxctPLKCpEd8ULtDwPFDcgpz4UzzcWNGUg7WPZj3FCLqsIclNgyTlhMtM5a6n3jaB3QwkbxXlOTc5ZLglnae9ByrBUdvW6ETQ5YnKVwWuKwMLt8zFaJrNxSlHNfQiN1vhfYj71MVwgIASEgBOYbAaXUWDzKOtysBJPW02WbNbKVut3agmIUWwLIDvVhZCQKj5/vMokYwjSIqDRMbsaXgGiEbdM0kLB2tsmkgyHzXkDDBA0cyrtSPMr3nAQrzDDprIYVYmheZ/kZupszxFDH9momb1Mr5zMsLxmLsIINa3azHrjWZOFpOqRiLFUWnUyyplR1MbN8DfO5ZdqoabVHIsQxhDP1w0FLuMGkh5bXnn6I2/l8e2JlPkJgYRKYWfG9MJnKrGeRgCRcm0X40rUQEAJCQAjMOoG04oIej7HsF13PafRIMnbaqInDkKTATbButsoAg8EAHWtoZ+Kp+VHaJJMsaxrnh4nbUinFKEFvP35PKceqZSI1Ld3ZNRT0GVmunJtIIM7zU2w7VTcnc76G1nP95PnKv8+aChS/8cl2TL4bZ9tUSjF7TO+DFnYd3ebPupm/EaSI71l/tGQAQkAIvAsERHy/CxDlEnOHgIjvuXMvZCRCQAgIASEwOwTO1cdWVDHFcSpNgc3kZop2ntK2b6w0O/n1N3eF+93z39pt7s0q2U6v3X0xgf1mxER8z86zJL0KASHw7hIQ8f3u8pSrzTIBEd+zfAOkeyEgBISAEBACM0BAxPcMQJVLCgEhcNkJiPi+7Milw5kkcIH4Dgbh8zI5jG8CwWCILnXMDi+HEBACQkAICAEhcMURmBLfJhMTsSllzkwm2O25sFgnEwhNrf9X3MRkwEJACCwoAiK+F9Ttnv+TnVp8lXi1cCiEUCiAaJilUELBTGyaJpPAZR5lmJv/t1RmKASEgBAQAkIgE4eurN5my2QmdJVKgywm0rWK+JanQwgIgSuIgIjvK+hmyVDfPgFFhCuW7kxiFyaeUf6eiT8T3f32IcqZQkAICAEhIATmCgFlCc8kgGPsOjfStVotE7TpuKmulF4Vy/dcuU0yDiEgBN6agIhveUKEgBAQAkJACAgBISAEhIAQEAJCQAjMMAER3zMMWC4vBISAEBACQkAICAEhIASEgBAQAkJAxLc8A0JACAgBISAEhIAQEAJCQAgIASEgBGaYgIjvGQYsl7+8BKZnO1fivSORED9hxn3HmayFAWNyCAEhIASEgBAQArNKQKkprsRtK/HbGrWGSdQsMJutmTFJ1vJZvTXSuRAQAjNMQMT3DAOWy19eAtOznYeY4dznnYDf54bfH0Aikcws9ErCFjmEgBAQAkJACAiBy08gzazlyla4wWiAngnTlKzluc585OcXifi+/LdDehQCQuAyExDxfZmBS3czS+CCOt8U3173BLwU4CGWHZM63zPLXq4uBISAEBAC7z6Bt9owzlTxeMMxeb7y9bez0czzMqe+nXMvfW4XG59yFWWMSqZy5aPlJzevAHl5+SK+Lx2xtBACQuAKIyDi+wq7YTLctyYg4lueECEgBISAEJhPBBRLcVKxFicT/DONNC3FGrWKJbZYcuusN5ciZpX1T/mkUknEYzHEYiy1mVDapBRf7nNlurQ6faZMF5tmrhmP83zlPJbkTCnnnYXHq2WEuZrXVgSy1mCAQc+27FsJ64oq148n2CaZOS/jSk4X8oyo1tOqrddNju8iN0PE93x6QmUuQkAIXAqBmRXfaT+CA6dx+vARHG3pQ/cI42/VRmitOSisWYLFy1ZhaU0unMZLGbKcKwTenICIb3k6hIAQEAJC4MonkMqESikCNxaOIKoxIpFTisLsKJyRLrjG45gIGem6rafIpSCm4FUEdiwSQSipRdqcA2euHXlWiua0IsApjimMNeo4koFReMfdGPMaoclyIr8kC2YNxb0i8M+KaOUvyr+h1kKj1NPWRhEb6MdY7zhcKivUzkI4C+ywm7XQZjYFlFNZgxtRxP1ueEZcCESSUJlMGdGuCPjph4jvK/8JlRkIASHwzgjMjPhORxDsfw17fv0bvNqjRbLxRqxZUoImhxop/mJOuE/hxK592H/Ej9jSO7D+7tuwucYIB39xyyEE/hACIr7/EHrSVggIASEgBGabgGKBjoYouFMUrfZCxkJnw5ltgMpgg1EThzXlQySmzli2E8ExuIYoiL1BRFRqBLT5sBVUor4iB8W6ACIjnRgYHMFwWA+NoxyFxU7kaMYRHO5E32gCvoQRRiNN4LSWJ6mgJ63scQRDvLbajuLGJWiqdMDmP4PuYyfR4TbAWLsS9Q0lyEu74OrtRH/3GHxJE5Ica0lVOaryaCEP9vLrXegaiyHNjQOLmeOfJsBFfM/2Uyb9CwEhMFsEZkB8pxE98xj279yO/+hcjuLVd+BL91aiRPuGKXpa0XdyD3aPOaEquQo3LHaiwMQFIHPEEB04g7bTZ9A+GoEnboA5vxwlTYvRWG5D7tRpoWF4J0ZwMpSb2VmtSXdjuIMLSqoQjrrlKNUMQRPmwmSshDbsQWLwFDpHoxiNZiG3tAYNy+pRnU3XrJ6TaG3tZV90nbKXomLpYtRXOZAzfcjpMAI9p9HR2oqO8Rh8XPh0WYXIK1+ExrpiVGSfPTkwCLd7DCejOVwkUygNd6C7exQtwylobFyYFjehsaEIhaoYwp2vo8/FBbNoFQq4g1yoP99hMuyG62gPAjoLjIuqkWPSQBwEfv+PiYjv389IzhACQkAICIG5R0ARpClakWN05XYFrTA4yrBokRPF8RYMdHXjsLYONksCTakWjAUcCOlLUGChaB4fwdCACz6VBdbaxairL0Fhegj9hw/i+Cm+R6gMgMlMd3G+t9BKrqdLuMGgxFvTqp1xC6fhQ+mbwjtOQR/2hxA25MFSVoemci0coR70nuxG15AbSWcF32OuQXOpDdrx0zjBPtr6xhBIWBCKO1DatAwr19ahwjiGsY7TON7lQ1KlR5bVLOJ77j1yMiIhIARmgcAMiO9RtD36f7BzxzF0rPkC1ty2GfeWTKX9UOKRJmd58QQiCQQHj6B921bs7wtjOLsK+TY9TCqWiQq6MTQYh6N+DdZs3oQ65uXIGn4ZZ155Al/ba0EwbxU+tc6O3MgwxlCMnMalyGv9Hg7vfAZP+W6Cs3oJrq9iPFMwgpG2Y+jtHcKwtRmVS5dhTYUZptg4hvj1nt4BHNduQMOG2/HRzWWoMqkQHz2K/gNPY0drDL2papTk0AVLHUFsog+9Z8aRrt+Ilffeh2srjMh3bcfxF3+Fr21XIZizCB/YWASHOogRXjc4PIjXRsqQf9Wt+Mh9pahzPY6tzxzE496cc8gAAAAgAElEQVTbsWbTRnz6hrxJgR05jb4T+/Gjx8PQlK7ABz66GhU2Ed9v5+dDxPfboSTnCAEhIASEwJwkwPhpRXxPhKzQ0xjQ2JiHEtUI3MMj6FIVwmIKIDdwGC1tHvS5TbBarTBZ9EwqakUyUYiaZVVoqKH7t6sb/WNBTCTNsBq1MGlZ1kuVoG3DD7+bQt0fQUJDd3WjmS7l2kxcdiIWRoiu4j51HvLLyrGomJnIR9rQ19mL0YQOcQr1REqDuCoX+eXlqC1TjBQuXm8cIz4VLe9O2O1GZGuH4e5tx+CoD1FtFvQU/oZMVvPz3o1i+Z6TT58MSggIgctAYAbEdy+O/eTfsXtHB3yb/wpr7lqHTXZlJkn4O3bj+Etb8GqrB91R7rbGVfBMlKLqqutx30eXYkVOCw4/8Vt899EJpBatxT0f3sSvGWDT0BLeewjHf/1tPDlahMDGr+LTN1VjnXYfOnf8Gv+404Bw5WZ86SPrsOqcuTqB8Mv/gMe27cUjsffh2s3348ubssD9X8D1Il5/+kl8fVcerCvuxFc+eTWazco3OhDY8yT+5tsuDOSuxxf+/iZsLDBBE/VxJ3gcPmRBbc6DQxdFKhaAv3MXDj75fTw8XIX4hr/BX2yuxBrtLpze+jS+scOEdMOt+NIn1mNFxioeAgZfxA///hUc8lThhq9+AHcsNcK37xn86nuvwk0Bf90X78fVNm5M7H0IB/cdxuu1H0DdmjXYXABoLsPDMB+6EPE9H+6izEEICAEhsHAJpNMM0AvTOy6uRtpoh6MwH4VOOyx6E0zc+NemgrQyU6RHgoh5hjE6PIqefiPCqEbDVVVoblRDG6Fr+Tg9/8a8cPui8KsdsBRWoKI4G7laiu/BDnT0shpIREPxbmI8OFiak+7u6SwU1NejtlQFk+skejpHMOClwcGsmAaSCMS0SBgKUFxehMp8WtGjfoSCMcS1Fhis2ci2ANroODzdLegbHIOb7uhqA8fNsmJK8rWpQ8T3wn2+ZeZCYKETmAHxHcT49u9ix7ZX8Xz2g1h5y3347EruuJJ0OkFrcTiMSIK7n4kzmDjwG/zjD3zoz9tMobsBtzj2YudPn8A/b+fCY8rG1XVGqGNMOpLm+VyMNHTjDuY2o2DZJvzR6ko0pvei/eXf4ht785Cuvglf+dAiNNjO+renuNi8/I94cvdh/NLwSdy66VZ8/iomJFGOvi147ZWd+NcjtGKvuhFfub8WBcoAk6cxsW8bvvadUQw5rsJn/v+bsaHATPHNWtFj3bSWc+eZrl1jrjHWjvbAPzLEWKvTeN24Bo6Nn8Xf3l6D1fpXcHrbFvzja8WwLroJf/2BJrpfKZ1OINa/D4/908s46irEii9/GDeszEWx7wzG9vw3fnjQgZHCjfjodUH4jw5j7+FcXPP+1Vi9NBeZfQE53hYBEd9vC5OcJASEgBAQAnOUQCZjeZLZxKO0RIfpBh5gslpDFuIVS1DnjKAyyvC6CSfSjiY0laVhdB/AqSN9aJ+oQtHSFVjRCOhch3CKruIdI5pMWF6cVu2ELht5TWuxhKFvznAvho6ewsBYALEsC+PLYxToudAVNmB5lQ3OQBd6GeM9EmYMeJadlnENfLS0a60lqFtejPJshth1vI4jLV6Mh/QwMoN6LMKs6Iw3L1u6CIv4UmXob0HvkXaMp1RI5jqg1WjOZT4X8T1HHz4ZlhAQAjNOYAbEN8fsO4G2/Vvw08fodpS9Cjd++I+waRGF5lntqwjR8aNbsPVXv8XjzxlgWfU+fPLvr8MNBaM4sYXtnhxFsnk97v34ZlxDS/ZkMybtGD2NFjfgNtehJt+MfN9utL5MAb8nD6mam/HXDy7GouyznSjie+fX8atXDuEx3cex+UbGnq89GzXd82wmJv1fDnOhWnUz/uaBRhQrmj1xEq69L+DvvzOG4dx1+ML/2oRr8+Lo3f5z/PoHz+OEYz0aP/jHuGtFMeqyuCEwvB/HnvomvnsmF8NL/wpfub0W640v49QLz+Dr+4pgXsRrf2gxasyKq5UL0Z49+MU3KL7dJbjqrx7EdaucKOO8EG7Hzh9vxQtP7UaokHlPrrsXNde8F/fVGlFmmvFnYF51IOJ7Xt1OmYwQEAJCYGERoKFBSXwWVFHommzIM6Wh8Q1hyB/DsL0RZQ4vygMn0DKQj2QeN+iXmJEdOITOE8fR6rYjVbSSruo1qDIHEOg7gxbmsxnzJRj3bYatmK7iDQ2oymEI3mgrutqHMOZnzLjOQLd1FYxOJktrrkG5eQKerjM40eFGHIzXtltYkiwNl4tu6tZiNK6kBT1nAuH+Y2hrG0Uvc+mE6Y6e1DBOvaQexfU1aHaqYOhrQc+xdrhSTLabY6cBZdIQoxwivhfWYy2zFQJC4DyBmRHfyvXjHnjaDuD40ZM43OODKxBGOBhF2mBHVmE5yuudjIVOYGTLAFTGIiz785vQXMTYoEA/Jo7uxKuvt+Bgv5LtM82FiDHZ9lzkFeSioLERVY2LmTmd2dF9tHzvfg7/eiAXqcpN+NL7mcxsuvje9U08/eoRPKH7MG66/hZ8bvVZ8d33PA7uegX/fqwChctvwJfeW4+ijPim5fvADvzvHzB+ybEan/ofN2B9Xhr+1kM49Px2HOp1Y1hDS7jOBEvREpTZfDAPb8FL3lJ4Gz+FL91ShzWG3TizYyu++VoBzA034C/uX8RFUBHfE4j27cfj//YqTriLsOLP78fG5UykMnUv2n6O7U88h3850YSaTXfjbz68NJOkTvK/X9qPq4jvS+MlZwsBISAEhMAcIqCIbyY+C8RYI9vMd54ixl9bWSKM2cijTMCq1yRggx+RlJ7vRsyH42f+mr4RjHsYw63VI6pi/W4LY7KLylCcQ3fvZAihABPLaiwwW5lDJzUB33A3Bpk8LZBirDeFN1I6+MM5yCmuQEM9Q/3iJzHY3YFelxEplhUzmybLmEVY8iycpIC25iO/uJjXN/L6QVrmAwgmWHPcYGFCOD10SQr/4V6MjIzBG2cfmQRveon5nkOPmQxFCAiB2SMwc+L73Jzi1OHjmPAxW3g0ibSaNSfpUm7PY31IPaVljLFCESYBsdDFXKM+H9scpXh3eeALJxiDxK/rLTBlOeDIonvT1NZpkmXLYrRwM/M4/apgM7HepHpKrjK5G2ORwkrmTjpuGwxGWJX+lCNJ9/doFAEuChouPFbWqZyMqU4wljsCf4CLH8dpyWINzanrMcYq6PHA7Q1zQ4CLD0t+mFg6w6pjzUwVd3zVTGrC7KF6FcfEaytjUnFMVjPnm+mWJTySjOHyswYm2+us3NUOD7AW5gB3tJOY4EbFWCCKsdp70byoEdczoZwcl05AxPelM5MWQkAICAEhMHcIKOtYkknX4qzzHacBIhHnewY3/VO0TBfZY8iPdGKc1maXX6nBTdFL0a28y+j493SC7up874nT1TvFBGfKK4yKgl6FNK3O/JN/VwK8VWqKZL2O2c7pEq7UB48rCXHTdA1nVly6oFNtM0ab19XyHFqsle8psehxjisaSyBBS7iKbSffqvh3fl+t5keltM98ieNirLhS43uau/kUZbF8z53nTUYiBITA5SVwGcT35Z3QldMb49rbX8Cx/Tuxq5uJ1/LXYsXatdjYaEfOOff8K2c2c2WkIr7nyp2QcQgBISAEhMAfSkARvErdb8UVPUkhruS/UZKGK+JVrVbEt1IubFIEZ4rJKN9UhDIt5Smen5oqMXN2IComPdOoGXutqPILvqe0SfH8zEX4fYr6i7jeKV9KcQzpzLX5pzKkaddRkqqpMuKe7X+nj/M0RHz/oU+GtBcCQuBKJSDi+0q9czLuixIQ8S0PhhAQAkJACMwnAudLdCnK+EJFPF34XmzObyzr+vvOv1Ru7/T6Ir4vlbScLwSEwHwhIOJ7vtxJmUeGgIhveRCEgBAQAkJACMxtAiK+5/b9kdEJASEwcwREfM8cW7nyLBCYLr6DwQDryLvg8bhYhzTIGLXkLIxIuhQCQkAICAEhIASmE1DEt54x5zqWKNPqdMhzFiI/n+Vepm2iCzEhIASEwHwkIOJ7Pt5VmVOGQIzJ/CJh1keNhPj3eCZZjBxCQAgIASEgBITAbBNg5XAlya5Sfozx4WaLDRaLdbYHJf0LASEgBGacgIjvGUcsHQgBISAEhIAQEAJCQAgIASEgBITAQicg4nuhPwEyfyEgBISAEBACQkAIzCKBqZCxWRyCdC0EhIAQuCwERHxfFszSiRAQAkJACAgBISAEhIAQEAJCQAgsZAIivhfy3Z+Hc5+ecC3FmqWJRBypRIL1UZV6pJkCpnIIASEgBISAEJj3BJRa3lrGVGu0OsZWazOx1cohVuZ5f+tlgkJACMxhAiK+5/DNkaFdOoGplwpFeIdCQUT4iUVDCPLPBEW4Wq3hRS+sk3rpvUgLISAEhIAQWNAEuIy82UqS2ead2us9e9JbrToXnD8F9S3andtGfpP9ZCW5qLIWGgwGmM0W/mmCicnMjEaTiO8F/dDK5IWAEJgLBER8z4W7IGN41whcrM63zztB8R1CUkqNvWuc5UJCQAgIgflAgBWvfs+GbJpCdnKmk6f+Xhl94fWUxhc0Of+PKW8spezWWVU81ck0tErnby7z38yhS2mhYwkvqzULdkcOsrId0FOMK4dYvufDkytzEAJC4EolIOL7Sr1zMu6LEriY+PZSfIdEfMsTIwSEgBAQAm8gkKaXlOIplaK1WNmgTaXS1NfqjIt2pgwWy2Gpz4pjZX1Jp5KI04sqGo0hHmdYUyakSdHHaZ6nhlarp8jlR083b/47xfOVspfKufGEcv2Ucir4LWjoiaVlnWudnh+d4hZOycyLKV5acZbHjMUTmb8rY+PL2rkxXdDmIpsBynAUB/OM+LbZYLfniviWJ18ICAEhMEcIzIz4jnVg5Pir+PmWUzjRHUBWlgE6ZVFRdlyVxS0Zg6l8BWrW3YnrlxSixjZHaMgwrngCIr6v+FsoExACQkAIzDiBjIimII7GkwiHo1AbzMgqKkWuKQqtuxtjnjh8cQNFtC5jMVZTMScohoMhinFjNnKKnMjNNsAAiuMERTmFtE6TBGJeeMfG4XIFEeYsorosqE05KMizIc+ihSZFQZ06W+M64UNwfAgTbh8CKR3SGh1fktSIJw0wUTDnFmTDZlBBTQGe5tc1Om4MRCbgd41g3BNBJM3zTEYKeO0FvER8z/jjIx0IASEgBN4xgZkR35F9aHluC776fS9iNVfhU3+xHk1G7iBPyu+My5Nab4bR5oDNpAO/JYcQeFcIiPh+VzDKRYSAEBAC85QARXSSOUGCUSTUZlgKS1CQY4XDRPFssmbEsS4WQEylpdgOIe7ux/CIGwPjtFyrrLCV1aKypggl5hBiYz3o6xzCqIdvNtmFyC/Nh9NCq/hwD/r7fRjXFSKvqgZ1JSZYI+NwD3RgYMyF4bARmrwalFWWosqeRHqkHV2nu9DvSkNTUIPi+mpU5HE8wX6MDw2je8AHT8IGg7MK1TWF7NuHWP8J9PWPwJWyQaVnXLfu/IuUiO95+ujKtISAEJgXBGZIfO9Hy9ad+PqPU7BcfSO+8rdrUPUWuJLePngHTqJfUwJYC+D0taKndQQDqSKUr1qCReU2WELDGDlzFCfbe9HjTSOa1sPExau0dhEW1+eiwKh0wF1nVys6JsJojTtRonUj292GI+0eDLh1sJVWo3J5M5rKHOC6Nu2IINp7Eq2nWnFqKABPTAVjfjVKGpahuToXRZlrnz0Cfeg9cQSnOgbRH9Qgree16pegflE9GuzAhfvP8+IZuaImIeL7irpdMlghIASEwGUjoMRWpxKxjLV7TOWEpbgSK8r1yOo7gt42Ct3iZlgtQPZ4K8aRi5StADlqPwIjQ+jw6hFxNmJpczkWG4fga9mNIy1D6AqYaHmmBZziV0noqdPTWq78XWfk+0EOHHYL7PoIgmNj8PqYe4Su7LF4BGNqO2KFDVjTWIol6n64Tx1Ea38EfmsFHIWM0U65EaaF2xNVIUof9Qgt7m6XHfk1DVi+1gGnqg3DHe1oH+Sbj4ri3mKgu/xZD0MSFbfzy/ZYSUdCQAgIgUsiMEPi+zC6dj6Df/jxKZz2GrBsZRFytSrEwlwgcmqx5OYNWL26DCVns4XGu7bi1G/+Cb/oqIG35oO4Y4UOOWEfvKl8lCytRWFgH3pe24HdI/mIWipQn6viYuOB69Qp9AwmYFx3D9Zv3oRr8+IwtP03fvnrnfjuUbqzL2nGvWvyAb8PE4NnMNDjxhF3E1bcfAM+cn8DiokqPbAfpw7uwFP7wxhX56OpKQeWNMfq7oRvPADNss1YdsP1WGkbg3/Xb7Fv32mcNlTAnF+ICiYOTcOHkbZB+BN5qL3xVs61ElXMaTJp5ZfjchMQ8X25iUt/QkAICIErg8Ck+FZczRNwqXK4yV6BpWVW5Pn7MTEyDq+9BEatH5qB19E+EMBI2Ey3cz0nx3jwnFLYapZgabEJecERDPfS/Zvu4/osCzQqlvPihr46HkDEq7iEBxGMaynEdYwB1zBmWwXV2djxRDQKnzeAuLkQOXU0LlRYYfe2Y/j4CQz4YoiYs6FmaTAl7jzzYd/xSBDeqAYBYxmqauuxvISZzN2H0d3VjT6/he7qFpiNShsR31fGkyijFAJCYCETmCHxfRDt216g+HYhUNiI939sJWr1tBInmVzEYIOjKB+5uWaYz5JP9ezAiee/je+21CC4+LP4yr21WOo4f1vSYTdCMcY3qbNYs1IHQ4oLXMiL4X0P46XtL+Jp3XvQfMfn8LdrVMgZ+xWefGIvftK+CFdtvhWfv6ea+9fKQdexl5/Ff3zzDPxN1+Luv78Ta6zD6PjJT/Dsrzvh3fRhbPjjG3Hb5Mk8WKJqZBgTYJ/WKIzdL+CHPzqEnUPF2PDATbhhaRmKjYy/SvoxsuMH2LGX3yv+BDZsfi++eJVFXOln6adKxPcsgZduhYAQEAJXCAElsVo0Qgs446zV1jzk5OXASddzq8UEQ5Lx3zG6mzPJWTzK+O3hXorcQXj0xchvXoOmUiuykwH4RkYx4RqEOxChS3gWDDmVKCtzosgWQWLkFIYojF1xIxJGO/TMeROPRxEMhhGFni7nFaioqES1g7Hf3hb0d3XSrR2I0w3ebKNLOpV8mu7vUQr1YCSJYDqLnn5lqK4rQlVWDMnhDnR1dGPYG4OWYl1vZJuzeXWUWyBu51fIgyjDFAJCYEESmCHxfQCtL+yg23kChpXX4S/+fiMa3wJvqns7Tmz9Dv69txmxJZ/FVzeXoO6c+E7QCt2Hsf4OtPfTfXzMC7+fYtznh7//FPomJnAs/z6su+Nj+Lv1ajhGf4UnnjmKnw6sxg20sH/uxmImRFGOLvS+/BIe/c5J+Oquxc1/cwtWZ7Xj4L/+Es8+H0HZn34Et9y/GPUXG2ekBZ5dD+Prj3dix4AdKxpsKOPOAddEHkyCgjiSVifSleuwftUy3NpghU5KSc/KD5SI71nBLp0KASEgBK4YAso6kVTcz8NhitsY3ykCgCkL+Y3LUGGJQDvShcEUPdzKGlDv8CLetgcnh+NwlV6Dphonyn0t6D14CN0McQta7LRsqzERyqNAbsKaq4tQm9WCia59aOvTwBVkwjVasBNqZkDPKUZheTnKc/WwRIfhGuhF34Ar41quZ7y5gcnTVCla5iPKuFKIabNhdJSgrJwheA7GgweGMNbTxRh0DwKKiDcpsd66jPCeXvJbxPcV8yjKQIWAEFiABGZIfDPm+/lt+NqPmDV02UZ86e82Yem5hGu/SznV9SKOb/k2vtXTjOjSz+HvbitHY45yXpwKtwWv/ud/4ZlnOuFf/0Gsu+9m3MbgageDqyOHf4wXf/Mofui/GaWb/gz/61o18kZ/icefPoyf9F+F62+5Fp/fXHbWwt6B7h078PC3T8HfsB63/O19uDo7iNDz/4UXn3oVux2bUX/nXfjQeidjqdg13cBGelpxPFYMfUE+FkWP4vlH9mPXYC5Wfuge3L6uDGVTvuUhZkYdHEJrsgRZuSVoyqWFX8T3rPw4ifieFezSqRAQAkJgzhNQ3LKTSZbxott5Sp8Fc1Y2snQs6TXOmOtQAihthFMbgHaoBR3RKpirl2JFSQSqrtdw9ATz0BjrULG4GUtKWSps/DT6OjrQMRSFF9nQMqSuvKoaDcVaGFwn0HPyBLrdagTNJcyMXobCknzkm8JIe7rR393DkDkPghTdGqMFFtukiM64mFPIJ/R2ZOWVoDQ/G3nGMMIjPehup+ge9zKDOuPKLbSEG838MBM73eK1Wu05l3PlJoj4nvOPogxQCAiBBUxghsT3IbS/9Ar+9aEYNM1r8em/3IBFbyW+e1/G6e0/xA/6GhBb9An85Y1Tlm+alhNeDB7chYM79+DYRAzjSRUM5iJklTehSn0akZGD2Ja+HuVrH8RX1jJWfPw3+M3zx/CLgeVYf8M6fPKGYjA0mwdjo3bvwq9+0IJA7Wps/LO7sZIu5lmxCfgGX8eu7Ydw+NQQF1GWBompuduch/yqelQsX4UlteWosrDO5tDraD2wBy+dGEaXK8Ks7VoklYQqTiZ3q2N20ubFaKRLfZlVqQu6gJ+qWZy6iO9ZhC9dCwEhIATmMIFMzDfFd4wJ16Lcljdm56PAmQ2HgRVYFMlqtkHHxK1KtvOoWsta28wqPtaH4SEvS4+xRJiaAtmci2xmSC8uykK2lvW7M67kBhjNJhiZAyY81o2hniEMhEwI55ahqLwCjfk22DJlwrwI+DxwBzkGvj8oidl0FM6atA9RHzOkD6gQVFehqL4YFQUWWDUJJNnGy1JkPrZJa7TQKnHkjC/XpCMIeNwcV5AjV2dKok0dIr7n8EMoQxMCQmDBE5gZ8Z3mgsH6meEolwDGaBtZTuwtLcF0s0oypjucUlYUI0x6unJfIF55nWQQASYpCYR5bRXdrAxMMGLggqNNssomF0SNAWZaw1XpGGIxxkqluEhxJ9moUxKWKAfri3O3OxpRFjAddEbuFtNyfa6bFBdQH5O8hbgLziQqal7fZLUjm8r9wuRp3DX3e+ELhOl2TlcvliPRmmyw2sywnl/7FvyDNVsARHzPFnnpVwgIASFwZRBQ1olEgu8O/MT5iTG2WmUwIau4HE4TjQZMuKrU+fZG+a7AGto61vnWUCRzx52CnO8AbJPia4ki5hVrNV+kOPEUPxTY/K+KIlnFpGkpJmJLJ+NI8foxvhMlmXhNzXhuDZOvac6+fWjUar6r8Ot8R0kkafVOsq06mXGLj3OTgE0yWdQ1mZcinsc+1Uob/ltpq8p8jwKe1xTxfWU8fzJKISAEFjaBmRHfC5upzH4WCYj4nkX40rUQEAJC4AohoEjZjGROUUinUrSIM6M5/5xaQxTBOyWUlZjtyUTik5HVyjnK+cqf02OtM2Kc56rp+qacn6ZCV649dZ7y5xuPyTaT7ab6mGwz2c/Fzp/8GtuwH0WMT2U5F/F9hTx8MkwhIAQWNAER3wv69s+/yYv4nn/3VGYkBISAEJhJAm8Ur+f7orj+Xf37joby5n38PpH9u91dTJRPP0vczt/RLZJGQkAICIHLQkDE92XBLJ1cLgIXE98ejwuhUIiJdjLp6eUQAkJACAgBITBvCWTENy3vOrq+W20s78ocNlnZDujpPq8cU+vkvAUgExMCQkAIzGECIr7n8M2RoV06geniOxhkngAmtwkEvKyvGsjE9ykuemd9+y794tJCCAgBISAEhMAcJ5CiuV4pPmZgJnSr1QYL89fYsuwwGEV8z/FbJ8MTAkJgARAQ8b0AbvJCnKISMxeNRBEJB/lnEGHWTVXEt0pJULMQgcichYAQEAJCYEEQmHJL1zHprMlkpuhmWTKzmRnRJ8W3HEJACAgBITB7BER8zx576XmGCWSS4iiJdJhQJ5Pw5lzs3rsUxDfD45fLCwEhIASEgBC4dAKTCd+UQ0nkpmGG9anEbpd+LWkhBISAEBAC7yYBEd/vJk25lhAQAkJACAgBISAEhIAQEAJCQAgIgYsQEPEtj4UQEAJCQAgIASEgBISAEBACQkAICIEZJiDie4YBy+Vnn4DiZD4V5/37SrTM/mhlBEJACAgBISAEfpdAZh07u5hNhVG9VQkzYSgEhIAQEAJzj4CI77l3T2REfwCB6dnOI5FIJtN5KOBHOBxmqbEUE64xFu4PuL40FQJCQAgIASFwuQkom8jK+qbTaqHT6zKx3BZrFnJy8jIx3VI+7HLfEelPCAgBIfDOCIj4fmfcpNUcJTD1AqIkWguFgvB53PD7+AkEKL4TUDPb+Xk7+BydhAxLCAgBISAEZoXAZKKyN9miVRJ3vmFUFz9/8qzzST7PNzp/+Yv1wXaT/7/IoSQQTTNjuQ4GgzGTQC3bnoOCgmJoKMhFfM/K4yKdCgEhIAQumYCI70tGJg3mMoHplm9FfHvdE/B6JyjEQxTfybk8dBmbEBACQkAIvMsEFHE8Ve1C8XtSvJ/eNPxoqkJGRjVPl8CKUFZlNm+V651z9VbOTysVNVLTRp05AWpaptXs64IjI975P4popRb3G/uYzEh+kXbTLqKUD9Ozfrea1m6HIxfO/EJavkV8v8uPjVxOCAgBITBjBGZGfKcTSCWiCNLVNxSKIh5LYnJpUhYbLl4aAwy2bNiyDDC946mlkKBbcSwaR1pnhNZogJ5GTXEpfsdA50VDEd/z4jbKJISAEBAC75wABbHi6RSLKZ9JsaxjiWvla8kEXbcpYHUUsFqthm8kyJSjjCfiiMb4XsHXFMrzs7qYoUoUyWpVOnMNxb1bo9VBQ1GdTPDaPDmRVs7mOYqYVqWg4duOWmnP89NqPfviu4mOvbCPSCyOSDw1aaU++06ktFY+ShvqbopqLbQ6jo1/Xiyee7r4tttzkV8g4vudPyjSUggIASFw+QnMjPiOHEPP7i345/8+gROjQN/i2B8AACAASURBVF1DLrK4yFGRc0Hi4sWFJW0uRX7VUqxfuwRLax2wKIvOJc1/FKd/9TO89OgBTFz7Eaz84J24IQ9vX8wnI0h6etExEsFoyomK0lyU2fWXNAI5ee4REPE99+6JjEgICAEhcHkIUAwnUszxEUNcEc06E4VtPpy5DpQUJRmCNIKhgTGkKcJpm6YIVgSyCuFoCjGVCYacYpSUOFFsoxAOBxCK0HCgs8FkM0IfG0NgqAODY34MBTWIqU2wOUtQUlyAfAvPp6dVKKaFxmqGWRNExNWLwYFhuIMU2xoTxb0KCW0WjHnFKC92IN/Er4dDCCibA0YbrCYVtNEhuEf6MeCKIZrUw2TUZwT4dEu9iO/L8yRJL0JACAiBmSIwQ+J7H1qe34Gv/SgOw6rr8eWvXYdFF8xgBG1P/RRbfvEKBpY/gJUPPohby4DsS1Lfwzjxix9i68/2wLXpT7HmY/fhlnzA/HZJpRgDPHgU+9uD6ExWYllzKZYUvu3Wb7cXOe8yExDxfZmBS3dCQAgIgTlAQImHjsdCGcty0lSE/KISlOXS3B2gWzi/Zs1V/qpCNKFBtpHWaU83Brvb0OeOw2OsQl5FExZVZCE3Oojx9lPoGRzBcITu3OZ85NC6nGel/15gEKOjHkyoCmAtW4JF1bkoSA5gtP0k2juGMRqzADklqGxsREOhCWZ/C7paTuHkkAp+cxWqGpuwuMwAW6ALwx0taB8Osg899FncIMjLQa45jlTEA68/gURKk4nvVlzXRXzPgQdMhiAEhIAQeJcIzJD4PoDWF3fg6z8OAo1X49Nf3oBFhkn3LiAOeM/g8LaXsXO3G4YNt2HjfTdghZVW68wJtEiPnMKpw4ew/2jn/2PvPQDsuuo7/8/rbcqb3pukKepdtmRJlotccA24gGOHgGH/BAgQkmwKsISFbDbZ/LOQELrBwcFgWrBxQy5YLrJ67zOj6b2+mdfr/u4bjZFsGWyskTQzvxteJM27955zPud6zv2eX6NlOEqATPIrFlC/ZgOrFpZQI+sb9HHkR9/hmYdeZeiqD7H6A7ezWRZXZ3yAocaD7N6zh0ONffT5HbKrnEd5TRnF2eJC5h8iVbaSsroF1MUOcLRxgEOx+Vy2ci5ryuNEeg/z4k+P0Zkspv7dVzK/3E2O4UKWaOfQj3/J0eYYlmvvYullZdRGB4m3vshjLUmOBfNZae7E1NfM9uYAIxEnOQ2rmH/5MlbmB0g072PnzmMc6xghUbqIynXXsWnZHBZkn6eZ1NukCaj41gdBCSgBJTDbCBjJyAzLdlws3pkUz19IXZVYvnsPsePFOGOJXBatgf7hHppa/BTm55CfmSAwMs6wTyzY1fOZv1jeEcy9tB86wL5jPYRNDtyZbnEjT4jruVipxQIdT9oIBZxkF9XQsHwuldnDjLYc4kijJPWMG4nQLISCYVJ5c6iYv4iG3DiBA69y7Eg3yfrLqF3ZQGGwjfY9uznR0kfIk41FQuasqYTEgYu4N0smc4eIdrdrQnhPZHM761DL92x7tnW8SkAJzDQCUyS+99Hywi/50gOHODRgZv7CIrwS82SSWKikuIQl/CGSrhrKVm7mmmsWsLwmE2dal7fSvP0VHv+vk4wWzWfZTRtZkG8igwEGDh5g2+OnCFcsY/X9N7IsN0TXI1/l6e9vZ+CqD7PuY7ey3tRO3w//f57YMUD70j9m7brFXFEUxTS2h+e//jAvHojiuf0jXHXnOq7whHEffpAvP9nD09Hr+OD7NnDfclkom57jwf/xAkcTtVzxuQ+waVE2pUbEeuwgz3z2n3h+Vxj7n3yJ69+zgHXRLqK7H+B///AwTw4u5LqbNnHrFWV4o2NEm5/isS1HeKZDRPr6DdyyeQm17hAMb2PHU4d5dG8h82+9nj/8wArmyaaDdaY9WRdpPCq+LxJ4bVYJKAElcFEJpNLCNyyWbUdBFWUV4g7uEDE+GpXkZiacmRH6O1rpbOkUF3N5GxGLcsDvJhypoGrRHBYtEdEbGpAKGX7GUg4R3SmJ8bZjMcSwNURspI2Olh6OtnpxFC9izRW5lDr30XtyP6f6MomY8nHbUkQkF02PqxhXTS2Xl9nxHmima+8QpuV15C/OxRHoxxdI4I9ZcJolWlxy4NhdDnkHChIakHeYnn5GY+ISLy7zTiOx2uuStqn4vqgPmTauBJSAEnjHBKZIfIvle4th+Q5hXrSOj//VRhY6Jy3fImRDPZza+iRbn9nB4dLNLLz9fdw9VzJ3Nn2HR3/xFN84WoG3cgE3LM3Fna7LnCTcf4SWF5+gMXMd5ff+De/f4Mb56Nf45fe20Xflh7n8I7dylWOQsa0P8tyLJ9jBckrKCmXnWQQ/QzRtbxKXsxIW3nUva9cWUxXrI7nvB3xlSz/Px67m3ves5e4lcYKntvLwP7zCicQcLvvLP2T9/CyKDfEdP8qvv/QVXtobxvbBz3LNrfWsicoivvcH/PPTo+wwX80H37uO2xoMs7zEto88wc++sYNvby3gyg/dyP13yI53erqaOPHo0/zwmy2kNlzLtZ+4kZVyiTq8v+NnOX0DFd/nh6PeRQkoASUwnQgYsdHpxGmSYS0YTEh8tYhXbz6ZLinHle0mL9ckwtwsSdJkQ98WID7STPPxfhq7S8mvr2PVGjeZ8S5GO1tobx9haDTMeNKNOaec8nm1NJRbsfs62PtigMF4MYs3SWx41jEGTh6gqcdBOJWDy4aI7xCDnlIy58g9S62495+iY98olmW1FC/PxSnvP/2dbXS296ct9X5TBtaSGkrmzKG+0IyjX84/2EhfQLwEc3OwGBbwMyZCxfd0eiq1r0pACSiBNxKYYvEdx7HiSj79+Q00vL7tnmc48MSX+YfmlVhW/gX/61oXVd3f4JGfP84DpxrIL53P9fWetNtVOpeoxHOZJMuoo3ge5XUSm1UWpO+n3+Hp/3iVgU0fYu1HbuNKRx/Dz/6AV15p4oBjARleB8WSAj3pyCd3nriALZzL/JzTid0ivYT3P8zXnzlTfMcINr/AQ3+/jZOpWtZ/5v1cOc9JrtH3xGFe+OJXePFc4nvLGDssV/OhO1dzS0OWnCzu9n2/4scP7OU/thVz1Yeu449vl13vNIOjHP75c/z0wQ7M66/hmo9dz3IV3+ftv00V3+cNpd5ICSgBJTBtCBi/+42477hkLU8kYlIJxc+4P8HQUAklpWUsXhKjtb1FrNR2GlatYlWNlUDLEV7ePUQibx6rVldSkmqk7ehhDraKtdzqFnfzCOGEiay5q1i4qJYy8cLrevko3cMOctctpbo0TqjtMIeOdTEcTGIVS3VYkq55ymqZu2Aeczxj9O/fy6ETI9jqV7JgSTnZ44007TtKc3cAc6ZHkqCH8dtzsc5dwYr5JdQGOhjaeYD20SCBgjwR3+KWfob3uYrvafNIakeVgBJQAuckMDXiO2QkXHuKz31tlMiclXz4z65ggVi+jZId8v8ki2gnjS89y7ZtJ+mpu5XVt93NexrMeBNHOLL1ZX7+6CDJqqVcefvl1OZbJYO5ZEqXRCcjzYfpsRRja1hDbcEYff/5FR7/ziv0b/4YG//0PWwS8T3y9Pd56vn9HE2VYHK5yXaLu7vEUxllyZKOAjxz1nL5FWu4omQY85GH+L+PdfGr2GaxWm/k3uVmwu0v8bP/8zNe7haL9933sH5FIXU2qRXdso2nvvlD9g8WUfkn/4vbRUxfFmknuut7fOnJMbaZN/Mn96zlPeKmLp2F3if4wdd28e2Xirn2T27iv901/7Tl+xAHHvkVP/xWG+ZNN3D9n93EKol3T4ex6/GOCaj4fscI9QZKQAkogWlGQDboJS47HJZCX6kMvKUFFMquuWl8hJ4OeQdwuCmpTtI95KN/3MmcuZVUZfgkXvsgB5sGGbRK1vLaxWLd9uKN9zPQKtbnbh/DZOEpLqemupgSl59AzwkaT7bR6s/CWrqA+bWVkoMmQKi/mfbmbvqCEiNeNIfqeWItd/qJSsz5qVMttPrchFwSIz5vHnXiip4VknNPNdPWH2TMnIu3Yi4VFVI2zDbKWFcTp1qGGBfXc3eWWMWtZwelqfieZo+mdlcJKAEl8DoCUyO+o830HdrGw08f5VDrOJkZUuvSIjFM4hImRSwlwUimLGgN1MxfxeVLqkRISz3LyY7Fxwm17mPv7v1sP9ZJ33iUENlkF8qCtnAhS5fUs6A8A6dljK4XnmDPcyfwLbuJpddUU9nxPN/77ikOxeu58+Ob2DDPS4ZxYyNZim8nu36xhQceGsS+7hbu+cRqFo5v46Wd/eyOLeHqDfPZNEdUcGqcseMvsGPbDrYeDTIYyaR0cS1VdQW4D+0jPCxxWjfcwxJJuFYfk4RrEiP+kz1BjpuWcsPGBtZWGg7kYXE7383Wp5t45qiXpTes4rorZMc7PUZZuF/ex0tbBjAtWs7yW1chxnUkJ6se54GAiu/zAFFvoQSUgBKYZgSM3/3xmFi8Jeor5ZS1P9tLjkfqeUvWGI+xEZ+TkvhuEbs+H8mQD//QEL4RPxGppx01cqqaJNlZdjG5eXnkSfZXi5QjMyp2WyySuC06wtigiPIRKSGWkmhws5m4vM6Y3HlkF0hseaZdYralhrhkU7dYjfNHGR+WhK/Dkn09Ie7qYhFPyAVhKWdmy5KNgbwscp3yciJtGBW+rVZJuCZ98vX1MywW75jUBrcZSdekrriWGptmD6J2VwkoASXwOwhMjfi+GNhTw0Q7D/P0oy+x7dggFikz4s2RJCbiMmYIfrt5DH/QzFhsLgtWL+PKTXMolA3lt1Xd7GKMS9t8WwRUfL8tXHqyElACSmBGEUhK1nDD9TwSCYklPEkw5BEDQBZFxUkCgSEGB/wihh24RNw6DJduq3jWGcJdhHAsGiMmAj4mQjlhZB83pLGEvlkk5M0Q0HabLW2JNvb0E2JMMMR+LBYlGhPhnZBN/tPnG+fYbGJ0kI/VJrW/jXh0MQIY/UrfP/0RwS0/Mw4jqdrEuRNtWMRYYYjucx1q+Z5Rj6sORgkogVlIYOaI78nJSwyLh7pkTW8doNcXISI70RIsjs0ju9kVlVSL+1ihJEXRY2YSUPE9M+dVR6UElIASePsEDHd0EdIJEcpiqbbIRrwhtl8TtobANcLh5Jj82WRN7d+IX/neOOW0GD77+/QXryX6nOzfxC0lxE6uObNGd7qd9DeTt5sQ2JPr1m+un+jTuQ4V32//KdArlIASUAKXEoGZJ74vJbralwtOQMX3BUeuDSoBJaAELlkC57Igv14QX7KdP0fHVHxPp9nSvioBJaAE3khAxbc+FTOKwDnF9+iwlJ6R0jJi/dBDCSgBJaAElMB0JWCIb4fDIdF0FrxeSdJWVCxu6tY3WM+n6/i030pACSiBmU5AxfdMn+FZNr43im9JqjM68pr4PncU3SyDpMNVAkpACSiBaUfAcEafFN8mSfpmiO+i4hIV39NuJrXDSkAJzGYCKr5n8+zP8LGn4/yMmq/x+GtWb6NmvB5KQAkoASWgBKYbAYkiTyeAM0mCNsOd3iqJ4IxEbW+WnG26jU/7qwSUgBKYDQRUfM+GWdYxKgEloASUgBJQAkpACSgBJaAElMBFJaDi+6Li18aVgBJQAkpACSgBJfD2CRhZ1d+kItnbv5leoQSUgBJQAheEgIrvC4JZG7mYBM4s46JO5xdzJrRtJaAElMDMJDCZT0QF8cycXx2VElACSuB8EVDxfb5I6n0uCQK/SbgGsWiUWCxCPBYlKp9EMpmOjdOka5fEVGknlIASUAIzhoBUFJe1xSTJzyzY7U4cTpf8aZ8x49OBKAEloASUwPkhoOL7/HDUu1wiBCbFd1KEdiDgJ+QfJxT045dPLBbHLBliNTnNJTJZ2g0loASUwAwhkK4dLju7dkmAlpXtJVsykbtc7vSao4cSUAJKQAkogUkCKr71WZhRBF5famx0WEqN+Yw630GM7Od6KAEloASUwKVDIO2JJB5JafH6JsfUbpiKzfq12Ok394v6bf177YVKLjcykOfmFUj97ZK0+J7avl8686g9UQJKQAkogbdGQMX3W+OkZ00TAm+s8z2s4nuazJ12UwkogdlDwBClqWSCpGyKJrFI+SwLFjESm0yihFNGUciJ/zO+N0KIEokkSVHJhlfT5DFRdsss1mW51mbFYmhno8SkcY2cn0oZnzcytUhDZrOcb7Vik49Z2kwk4mnvKCM8yVhHJgS5lPYy7m2cJ/c32vtth/Gt1WaI73wKClV8z56nWUeqBJSAEnjrBKZGfCdH8PcP0tguMbZZecypzSNTVsXzFmsbDxEZOEmbL8GIo4aqAi/FGeft7m+dnp55yRFQ8X3JTYl2SAkoASWQFrLG7+dEPEY0HCYYDpGyuXFmZuBK+EgEx/HHnZhtLrEYO0SIm0jEYsRFa5vtrrQAlqAhEdhGbLUhwCdqXlus8mciRnhcwosSZhIZ2WTYrThTEyJ8MhbbeAExpeJpMZ9KmeU6UdeJsIQnRQhELSRPt+uWa22yCWA2YrhTMZKxMBHxnIrLhoDJ4U7X1Tb6dq5Dxbc+6EpACSgBJfC7CEyN+A6/yvEntvC5r4exLt/EX37xOpY5ZYFEXH9Hu9j/6wH81jzqNtdS4vw94qHG2ul96jP8+64gLxf/OR+9+XLubPg97vO76Oj3046Aiu9pN2XaYSWgBGYBgUQ8TjQiG+c4MLuy8Tid5BTkkZPrJTM5TNQ3yOB4jND4OOFwgPEw+MYseHLLmbO0jrKsEWL9rfQMp/BHHVjFem2RTX2rIb7jIqKHRhiOi/j2FpDrcZIhAt2wkoutnJRh1RYVHyKXzIJSasrk+1AT3SdPcGTQTiSziuqKIsqzzdgig4yMjDESc+HMLqQwy4w10EN/eztdQ0FiZjvODNkMEIv46w8V37PgQdYhKgEloATeIYEpEt87Obnlef7+gQjWJRv4xGc3scgSJuo/QuerW/nyv3YxmL2Q931uMyvL8slyuslMi3M54kEC/iChqCycJkt6F9yT6cZ15jo33knfM/+T7+wN8Wrhx/jQ1Qt5V62NqEUyjFrBdhYUw+csJAuvWXauHdhloU67pukxIwmo+J6R06qDUgJKYBoTSMajBGMwnsgmp7yC2lIHnrFuxqMQ8BTiDg5hExf0SGaxWK2jJIdaOdU8SGu3G3dJLQvX5FEQP0DXge0c7bEwHPPgtBmZxU3YJLu4TbKLOzM8OCS7uFnuY7iPG27nRp6PZDJGMGC0L4K7bAFza4uosHfha2/kRHeKUEat/KyS6swg4x0t9HR1MRSJMhYVc4GI8uy581k9x0uZ/xTdhw/S408Q8uSLBdyGVSzgZ8aCq/iexg+pdl0JKAElcIEITK34/m4U2/Jr+NRfLqHOt5Mdzz7Ffz13ku3Hw5idHioXzsFddxVrrljLHXNk57ppDzte3ENjv4/BoIh1iQOTLXLc1Zex8PJNbFqWQ6Vb1HWgk/5ffZHvHEyyK/cePrRwlMz+Fn58rJrVV13Ge68qk71140gR6ThA87OPsNvSgPXy93FVpV2s7ReIrjZzwQmo+L7gyLVBJaAElMCbEkiHYYvF2yeb3yOZNcybV84y+wC+ndtoCdiJz5tPQewkwfaTNI3nkHLmkOMxk4zD6FgenoJKFq8W8e2OEuofJRxJyLuBDZvLQ4ZTrNpjspnf3UbfiLiem9w43GIVt8q7gzScjCcIjgUIWrJxlM6hodpFXriDzkMipEciRMVF3SaC3WZs7otoT8j5Ruy5ESseGh9j0JKLtXIRq+oKmBNpYfDIHjok3M3vKpTrVHzrY68ElIASUAJvn8DUiu+05Xs9n/jcNSyWcpfm+BEGX32GL/z7EP15q/nY5zezttAly6if5GArr+7opSeSx6KNS2jIN1bDUVInf8nX/20vz7bXcMOnbuc9V1WSF+pm8Km/45t7I+ws/zgfuWkul7X+ki0P/Yqj829m4fvu4ZYicCeOcnzbfn74WIziZcu5/X1LKJDbinzXY4YSUPE9QydWh6UElMC0JZAUt++weLMZMd0ubxFlpflpd26bqF6jCIU12EdwtJ/+0ZDEYAeISIK1YNJK1JSJJyuH/Fw3GZYg4aE+BvpGGQ7IQp5bRvacWuoqcyhO9DN67BAdvcMEXDlYjBJfSRHr4Tgj0UyyS2pYOC+LzLFGepuO0xV0ELPLvZ12cV83rNfGVr3o72SKWES870LSPplipa+lfm4pRcZmQctRWhqHGU+J6M7OfC0Bm1q+p+1jqR1XAkpACVwUAhdWfIsYHhLx/XdfFfGdv5qPf/5a1hVI7NRrQxcXsaFmGo8d52RbJ12DEns10MeRnUMEHfVs+vgfcev1c6kOdjP8q7/j63tCbC/9FB+6cSW3FR9mdPej/MuTdkbKb+ZDd5dT1v0jDuxuZl/1H7NicQNXF1wUxtroBSSg4vsCwtamlIASUAJvkYCR2TwmFvBAJElYhLXZYiOnRIRtaRE5Mdloj6WIZxZOuJ0PnqKzuYNBcRePWh2S/FxSraWzk4vwtUoqtEiA4Qj0u2qYU1fLuuIItp5dtLV20RvPJ2l1kQyLu3nMiquinpo5eRQl2ug5cYq2rhDmDEnyJuFsRsI2Y80wkrBFoxGJNY8QMYure0EFZVWVlHvFrd3XTk9rI539fiLWLGwOl4S3SXb2c4Svqdv5W3wY9DQloASUwCwmcGHFd/wgAy//is/+m7iVl27kr/7xOta4hX68lbF9v+S7j7dxwFfDmo0rWLZAFmXHIJHe/Tz3g/0c6ChkyUfey7tulPisM8T3q0V/yoeuX83tdXKfaDO7v/Ftdp3sYGjlJkY6Myi2eLnu3vXMr8xCjO96zHACKr5n+ATr8JSAEph2BJKGS3dCMp0beVwkAVo8KNbrwQGSedUUz51HaeAwA+3DnLKtpWF5HUuyJSb76HZaByIM2wuxG8nVxJIdFYt4LJYQ1/MYEVs2lNTRUFvBfNcIweb9tHUMMGr1ptsZjzqJOEppmF9ObZZYxJt30tIrop18nA7JDyNW97gkgYuFxUIuruxxm0eSuxVSVJJHvksC1H3d9HWI8B7wE0hIBnRXJm6PB5fDlo41P9eh4nvaPZraYSWgBJTABScwNeI7tI1jTzzNZ74qbucrNvFX/3AjyyUI25xoZ+zQc3zta9vZ3Wtnwe0bqa1fSEO2j6zGR/jhq+PsDS9k4/JKagryyS8wkxU5zq8f2sXuxhyWf/ID3P4H86mVmO+hx/+Sf9ke4sWSv+DjN6/l7gWn7ec9j/PiIz/ggcdGGVhyNzfd/z7e2+Ag7+wsbBcctDZ4YQio+L4wnLUVJaAElMBbJRCPSXx10oYps4TC4kKKPXGJ1R5iXH6W8HjxBAelpFdSEpyVkCOx3fQ20nZCPNxsxXjnNVCR78ST9DEugn1oJECALIkFL6OoQJK1xgfxdbbS3jPCWFyynzvsErstbuOuAlxVC1hc4SF/qIm2XUfoDcWJ5+ela3EjJc8C0ZTEg2fhLZCM6lUl0i+wxETAdzRxqsfHcMiMw+HA6ZRkrZY4psSYJIOVS5MuscBb32D9VvH9Vp8IPU8JKAElMHsJTI34jvcw0trOq4cSmGWBXHl5JfmSZTy9VxwbZrhxP8cPHeXoqI2xsmUsWTyfdXmyo911nH0HT9A6FJYo8GwJ6SqlqkoWyiFx9xqFnCXzKZ+bKy5qfsKt29jfF6PbvYLF1SXU5p6exLAkdtuyj59scTFv02XccUc9OfLVG4uCzN5Jn8kjV/E9k2dXx6YElMB0JGAkMIuJuI5IEjUsImaljrdhzfbkSqmx/FyykkOyxvcz4BNBPDYmlu2QxHxLBZOkkTzNiVtKe7kkPjtdf1v8vcVZXP6Umt0RsUr7xiWbeQyTlC6zuV3p94y4uJDHzQ4cmV6yjOyrQRHuI+MkJJma1eXCbDYSuklZs6SZiDNLErfZ8RKTqihyT6nnbZYM6hY5J92W3NA435IKkYhKmdSQJHJNGOLbJt+fPRsqvqfj06l9VgJKQAlcWAJTI74v7BhkYd3HwZdf4qdbO+kJZFG19HIWr1vDZRVZFBtu7XrMGgIqvmfNVOtAlYASmGYEDBGeENEbkdjqcCRCSkqJ2kUwu5KSdFVqewcTUgPcbghtBzYjrtqo1Z2OxxZhHIsRl78bydGMw2QIYosVu5GtXCzZFlHCptOB2MY6YLQTl2sSkkRN1LTEi0tJMrFWG4J68khJHfBEbMKdPSLC27h/OvOacf/0aRPnGuLbENtWm/RL3NWNGuOTbZ05BSq+p9kDqd1VAkpACVwEAjNAfMtKmQgRkgypo35ZoE0esiQTqdedrhquxywjoOJ7lk24DlcJKIFpR+A1kSzi14gHFzt2usSXYUk2mVKvCewJEXzu+OrXD/rMrOOT35157bm+fzv3n7znm91nUqobLu25efkUFJbgkqzrb7X/024StcNKQAkoASXwexGYAeL79xq3XjRDCZxLfI+OSrb8YFBe8qQm7KTZZIaOX4elBJSAEpgOBN5MlF7M39FvpvPf6rJhXG9YyHPzCigsUvE9HZ5D7aMSUAJK4EITUPF9oYlre1NKYFJ8G0I7KN4QwYAkyAn68Qf84rYYT7sPqiViSqdAb64ElIASmHUEJtYesNvsZGbnkO3NTVu+jTVHDyWgBJSAElACkwRUfOuzMCMJGC9CRhxfVBL3RCNhokbsXyJ5ztqsMxKADkoJKAEloAQuKAFjY9csNcldbrcIbw82u0PXnAs6A9qYElACSuDSJ6Di+9KfI+2hElACSkAJKAEloASUgBJQAkpACUxzAiq+p/kEaveVgBJQAkpACSgBJaAElIASUAJK4NInoOL70p8j7aESUAJKQAkoASWgBJSAElACSkAJTHMCKr6n+QRq99+cgJF0LS61XhOJuGQ6N8rXnC7gqtCUgBJQAkpACZxBYLKst9ViS9cNN1ssykcJKPURlwAAIABJREFUKAEloASUwHknoOL7vCPVG15MAmeWGgtJebEx3zDjYyOS7TxAPJFIJ8ORyrEXs4vathJQAkpACVxCBNLrhvTHarPizckjv6AIt9ujlTEuoTnSrigBJaAEZgoBFd8zZSZ1HGkCr6/zPTY6gk8EeEBKjSVEfJvS4lsPJaAElIAS+H0ITNTCPtcGpuFd9Js7vv68c9XQfr0z0uu9k968rfRv+9ONnd2XyXbe6Oh0dv/OHvvEvYwa3Tm5eRQUFOP2ZKj4/n0eEL1GCSgBJaAEfisBFd/6gMwoAq8X376R4bT4DooV3BDfeigBJaAElMA7JZAkKb9PEwkRreKebZHPpE/RpCQ2fhcbIT8xKfkYjydIyr+Nn00K7HRZLqmBbbh3W8XN22a1yr9NIuvPFtMpI3woFhHPJWlTWjGbreIWbsVqmTgvlZR+xOOvlZM02jEO494WcSE3rNlW496/w+HJ+Noi5xniu7CwRMX3O31E9HoloASUgBI4J4GpF99JH4G+Uxw43oPPWkzV/MVU59lwq+evPpJTQEDF9xRA1VsqASWgBFJJYrEooVBUPIlM2N0usr1W8I8SGpPNTacLm8uF3YiXlvXdOFc0N1ZXRlpci/yVnydFWieFpUhsEd8WEdCWVIxoICTiOQ52+0SstXyXFEEdi4SIiMBPOrLwuB24iZAK+4jKz+I4JJdHgnDCRNzswuW043ZYMSK1LdKOOSXty/XhYJi4NGlxuLAa9z+XCT7dIxXf+pArASWgBJTA1BOYcvEdPPEkhx79Fg/v6OQF29XUXHkfn7i5nqsr7FM/OqOFQCfDx7ZwKFRGvOJaVlVYyH4reVQGDtF+bBtbfZWYK67gxvoscl0Xpsvayu9PQMX3789Or1QCSkAJvJ5ASkR3NBonHBKLss2FOycHtyubfG8WeTlWUuMjjA8PEkyECIyPiZdRiFDCypjfiiOjmDlL6yn3jhLra6RrIIEv4hRLtFks12KZNv4U8R3xB4hEYqROi+9kIkY4HGUwbMWeW0Z9wzzm5Ih1PDlE8NQ2TnX00+bPI2zOJbuonPKKQsqyU1j9/QwO+PCRhTu/iPyMFBZfJ70dHXQPR4mZRaB7nGmr+OsPFd/67CsBJaAElMCFIDCF4jsm/e9gx0Pb2flsK9XX59EzGmTnC3FW3HUjt9yxiDI5Y2IJlEU9KQtwKCY75bIguxyyey675OnvEsRDYVn8ZQs9vXNtwz65bsqiHRsTt+JAhGBcdrztbjK8mWQ5LbKLLfcbHaP/wJPse/zbPBtdgvnyj/LuZXnML8kiI8Mh++ZRokmznGnFRZhEcIyxsCRecXtxJoYJ9R3nZCgfcmpZWib3tp2eEtl5Hxv3y7lJcaGTfjozycjKItt5IaZM2/htBFR86/OhBJSAEjg/BIzfp9FwUMS0haS3ioryEircEXwdA/IzyCzOJjwSEgs1ZJVm40wN4etpoX0gRldfNp6cKhasKaTQdJS+g9sRBzgGYxk4rSZEd6fdzG0iuJ0SX+2SBGd2EeSG8Pb7xcIed5NdMZeS0gKyE0E8Hru4po/hb9lGc2MHHakqbBUrWdBQQZWpH9+BfTQ3d9IvcdshEdkRTxnOsnpW1HopD7fRc+gIveNiZc/MS7dpkbbPjDFX8X1+nhm9ixJQAkpACfx2AlMnviM9RI//J9/fZWan49184LoclrX/mOd/+iQvld7FnBvu4p5aKxlpIT1KvG8Pv/jXl9nXlcPCj97JhjWyyKf73sreb32Hrc+0Ebnt46x7z2Wst4mLmpx/dO8edhzppXMojD8mbnCOXFylK1m9YRlr66OM/Xorz//Xk+xob6HVlovVO5/KvCpWbL6W9WvzKe96jEe2D/Lr0CJuqTczN3CEQ61RWPYHLC4cxbz/QX4ysJDUwvfzqQ1e2Sw4ReuxHbywvZWm9lFxkxPxLvsG8agVT2kdDddcw7rFNdTJoN7Es02fxykmoOJ7igHr7ZWAEpg1BIzfp0GxZkdFzGbNWUZtVS6Zvjb27+iSVdvN3AXZxFtP0HmiDX92LvYcL27ZpBZjOSNjsh57K1i4Mo/irASRgVGxikeIpMQF3SWb5B5ZJ4PdDHe30jMgVvOkHZPVIm7tEsPtzie3uob6XHEZ9w1xsCcDb3Epi4vHiba9yokTrbSnqnHOWcPChlIq490M7NvDyeZuhqxOYla79LkQa/Y8Fi8qpza3l1D7K7R0BRiKlWIXF3mHbPCr+J41j7IOVAkoASVwyRCYIvEtYrjtADu/9SOaPbWUffijXFEA2akjDLz8GF/8uRV/4QY+9ZHVLMiRZCuMkOjZzo/+8dfs6shj6Z/fy1XryqhOY2pm51e+yjNPniJ6119x9QfWcfnYCTp+9Lc8eCDGqWV/wz03ruXmSjk12snxfT5G4tnMW15CgdsiLmpb2P2jr/NsbBWea/+Me1a7SXu8R/oI73uIrz1xkqd8q7n19uu5b2MlRgibcaQaH2XXU9/gK91rsK3+U/7umlyqE3s43tzL0dgCqubNZWXRxLmJA9/g0Se28J2ha5m/8d185l1F5No0qP1iPOUqvi8GdW1TCSiBmUjA+H1qJDsLiyNbxJZNdkEJ5YXZ5DpSYqWWuGxZ5kJD/fiHBhiPhAmI+3g4HCFmsctHYr1dEq7lFa8xi2yYj0y4hA/7TSQyi/HU1FFXU0iVZRj/yf00iqDuTWaRyJlP1dxK5hSIK3r7Xg40+WjzLKV+4XzW5AwSF/Hd1NpDS6iIkLOEkvJqastzKHRJfLi0MTAYFnd0JzZnhsSAu8nKzRJLex+h3hdp7QjQHyjFIV50DvvZ8Wdq+Z6JT7COSQkoASVw6RGYGvEdPUTbK0/w1X87yuFhC9Wri8gSUWsyScbSwT5OHujDVL+Rqz75CW5blkONZRT6dvDDf9rKns48lvzZPWy6vARDT0Mbe7/27zz7RDPhO/6c9XevY5PdsHzv4OD2Xbx8oJ/ukRhJa4bsuldQtng5K1csYEl5Bh5ZW/2NT7P7kW/wfFzE9zWf5L0rM6l2G+K7l/D+h/n6M2L5jm/ij+5Ywx2LvK/NUKLxl+zd8i2+2r0a6/IP87nrSqjOMr6OEu5v5NSJkxxv6qKvf4SR/mM0D4Q5atrIxhtv4hPvkQ2HSRf1S2/OZ3SPVHzP6OnVwSkBJXARCMRjRliYJC+LSdI1SW6GKS/tDl5Z5iLhk5+L91dmWSYehhlrFw+xrlHGo0kJBRN39ZSRYk1iu23iNm6zkIoGGJWQrR57JRW1Dawvi+PufomjjQO02ZZSPb+OeS4JJzu4m6NN7ZykmETZElYuqWV51iDR1ldoahugJ5wjCdfEei5CHxHaLpdTxLaRdV0yqxttxMT1PLOK+nmVzHX0EBR39ZbeIMOporT4tht9OaMemYrvi/BgaZNKQAkogVlIYArEd5yhX3+LPS+/wvayWylauIors+Pp7KcpI4o7GSDR9EOe3u/nZct7uePmy7hnSRgxifPQF55he1cJq/72v3Hzai9iLBeRfIAXv/J1trwwgOmuv+DqO9aywSUi3ie74hIHnkov7kY5kz5JrLaNxx94keZ4Has/9VGuX1tATuPj7PzB13kquY7cm/+G+9eYJ+4b7SWy7wd87ZkBno9eyb3izn730txziO/LcK79CH9zhVy390F+sWUvL9nXU71yNdcvLabAIXHqJ57m1Vf38HDXYurWX8+n76gT8a2W74vx35OK74tBXdtUAkpgJhKYKBcm2cbFxG0SS7cpJcnUJLN5X6+d7NJSaus9hI8dob03ifXyDSydn0P+4Ema9p2gJyjJzvJyEY0rqc+NvC0RohFJ3CafiC0LU0k99fWV1DslYduRV+kYjJOsXkNBvoeMuAj60xnQY5LkLeXykpOdSY4tIq8QYmX3++UTYqRjhEBYXNMdJrl3kKA/KP9OEknacJXNo3rhYuaXWXD2Hqf1YDMDkjQu5fVic0jMt8SGqfieiU+tjkkJKAElcGkTOL/iW8qKpYZ38PA3dvHSUS8bPnY7N15Rxm8k7WkYiUNsf/Axvv+f3eTcfid3/X/rqU80cfih/+CxrS10V6yhvK6CRcVWnKZujvzsUY6ehNw//jtu/aN1rIv2MPjiM+xt6qMzp0wStUjCtKQsyqP9nDrsx1K4iDXv28zyOVKepOdVjv/yWzxyIEKzawMr6+awYvViFtRAxrGH+PfHO3kqci33v289fySxaZNH4vjP2PnEv/J/OtbjvvJjfGGjFDZ54Xs89vg+DuevJb+mggXFeWTkycvGyIsc2b+X/2yVmLgNt/CZ+xqosqv4vhiPvorvi0Fd21QCSmDmEZioyR0VMZswiyeZxFwXF2ZJHnFxLx+WTXSzRTKfuyXhWkDyn5jIKhL37sQgg60ivnsCBB1llFTVUlHkIpNxAiODDA/5Cci/nHklFOWLO3p8kNHOVlo75bqgbNJLTW6jSrdR01skv1iwpS1LNpGCBSxdOJcV3iEip17iRFMnLYFi4rYKKubOYV5NJu64WMu7BxgKiNr3FlEoyeC8Fsm+3tdER0cPAwFxv7NKtnaXlELTbOcz73HVESkBJaAEpgmB8yy+/aRGTrG3MyGxW6UsmZNLRfa5/K/jjHceo+twC6N59eQuqqdaPNnsRkbSk0fYf6yfDnFXd5eVU1pfTt7YIKaBMVLzlpFXU0S5cUspOTLc1sjRY82090vm8ahbkruUU7NkEfPrCih4LSN6hMSoLO7Hj3P4xAhDcXGXW7KcxQtyyQ8bidPG6EjIDv6cIublOV6btpSvlYEOcZsPFGIuXMzKcgeZ1mFG2k5w/GgbrT1+glZJLpNfwZxSGx5bjM6xLDLzilkyL4fMt1LObJo8JNOpmyq+p9NsaV+VgBK41AkkE3GiUrA7mrRiskmVELuUCjNlkJObQ1GhLMajg/j6exlPSK4Xw1otlu2k1UE8ZZeYcCk35nZKDW4pEyaZzA0POElzlq5GkoyKFX18PJ1gzST3tMt5xpa1Uf/bSFhqeIQbbYclq3rY7CbT48JrWL6DUm5MEreFU+LybhILtvTJ7pSPJGuzmsS/Lr3vLfXExdoeD48zHpCqKCmLFEuRNqRaypsd6nZ+qT+J2j8loASUwMwgcH7F98xgoqOYxgRUfE/jydOuKwElcIkSEDt0Qsp+xqVUl9T8lvBviee2Sc1s2eUOBcWrXKqEOESUOyXRmU2ymacV8NnXJJISJmaYtU8LbLPFmi75ZRNrt+ECnv55+qrTx2TJkKRY3uNRaTtOQkp7muQ6q1WuFTd4Q2THY3H5iMA2vk++drVYt0WMp+PMjfON8qO//VDxfYk+etotJaAElMAMI6Die4ZN6Gwfjorv2f4E6PiVgBKYKgKGVXriEJd0QxSL2DWJC7fxec3Z7MwkZm+x5uaZsddv1vfftG1YxX8jss/8+bmvNdznfzcRFd+/m5GeoQSUgBJQAu+cgIrvd85Q73AJEVDxfQlNhnZFCSgBJTBNCKj4niYTpd1UAkpACUxzAiq+p/kEavfPJnC2+PbjGxlmVD7BYECS+MTl5N/lfKhElYASUAJKYHYRMOLQTWl39pzcfIqKSnBnZKbjz/VQAkpACSgBJXA+Caj4Pp809V4XncCZ4jscDuEf80lJGh/hUFhcJJPSv7fgf3jRR6EdUAJKQAkogQtGQJYFQ2cbcejZWV5y8/Jxutwqvi/YBGhDSkAJKIHZQ0DF9+yZ61k5UkOMnxVP+FaC/2YlKR20ElACSmB2EjgzyZs5nW1dLd6z80nQUSsBJaAEpp6Aiu+pZ6wtKAEloASUgBJQAkpACSgBJaAElMAsJ6Die5Y/ADp8JaAElIASUAJKQAkoASWgBJSAEph6Aiq+p56xtnCRCKRdziXOO5lKnlFqRhwMNez7Is2INqsElIASmGICk8XCDfdxaSpdBs0oh6au5FMMXm+vBJSAElACb4WAiu+3QknPmTYEJhOuJUV0R8JhopEQ0WhYEq6FJNt5YqImrWY8nzbzqR1VAkpACbwdArLlSjKZwG6z4XS60pnUrFYHmZlZWCSb+eQa8XbuqecqASWgBJSAEjhfBFR8ny+Sep9LgsCZ2c4Dfj/jY6MExn0EpNRYLB5PWz/UAHJJTJV2QgkogWlH4O0mIjPcjN7qNZMuSW/3/LMhGjk1jXXAbrfhdrux2ey4PVlSQixPRLhNxfe0e+a0w0pACSiBmUVAxffMms9ZP5qz63wHJup8jw5Jne8gCbF866EElIASUAJnE3gzl+wzK0WcL7ftyc3PcxWeSP/+nuza6RN/1/lvNpc2mxWXlAszSoZlZmXj9RriWy3f+uwrASWgBJTAxSWg4vvi8tfWzzOBc4lvn29Yxfd55qy3UwJKYOYQMMJ0Uok4yUSSBJZ0eI7NajorVto4Jx6LToTzxOLiSZQ4XcZxwmJtXGMxW7CKu7fd4RCLsxWLKOmEeBxFo1G5JiYboEYOjgmBbYh5wxJtWKZtYqW2WaVd+SKePj8in9PnS7sThwmLxSz3d+Cw2+VPub95oizYWeUkT589Kb4d4nqu4nvmPKs6EiWgBJTAdCcwheJbFvGBEzQd28eeI620DgQZj8iC7somq6SO2kVLWDq/nLJMCzaTRGnFuzjxxLOcbItj3XAzDYuKmWO7yHhTMejZyZ6jnbwyXEXdwnquXpiD/ZzdMnzdZMzynmC8WhgJXuS9QI8LTEDF9wUGrs0pASUwLQmkUom0wI2EI4SjccKZxXhy3VTQQXRkhL4xJ2arU6zHDlnPTMREQCftHpzeYrxuiac2GYksDeE94Vqero9tlr9Hxwn1DOILhgjYXSSd2WRkZOL1OLBb5MzTJm+LWRbLqI/g2DCDvgjBKBKTLW7h9kycGdlkZzjxyAUm6Wf6/mYwxwNE/UMM+SSkKGIR13KHxHXbz5lMTcX3tHwstdNKQAkogRlPYErEd2psP6d2vsRPnuxn0FnByk0LKM+T3eqELKDRQcZaTtAa9BCeu4G1i+eyvEhW5NgBtnzmH3l+VwTHR7/EdTcv4ArJlXJRj2QIjjzEj57eyzdaL+Oam67h0++qxHOuTsV8RNu38fzhMY7GGli3Zi6XV2Zc1O7PxsZVfM/GWdcxKwEl8FYJGBZsQ0hHo0mijlwy8/IpzhWRLYLXarfiZYRkJIY/lCIRHmV8aIDePh/D/jCe8vnUzJf13NHKwKnDHDwVwR+24nbZ0i7ddrFIyy1kPRfrdUREcWYBueXFcn+xhoeG8Q1209svwjmZjS23iqrqQko9PsLd+2lu6qM/Uk5GeQ2VlVlkpvyEhuX83hFGQiLKMyspriijujCFZfQ43a2N9PntxKxenGI5NzYIzrSAq/h+q0+EnqcElIASUAIXksCUiO/I7i/z5BOP8dWh21l6/Qf5p5syMNbj3xyyO56QHfekuKlZrFhlBzwZOczWf/g3XtoXwf7Bz3DVdfVcNim+o7Joy0J7on2QnvEYJocXT1ENc+dUUJ0j2+HECfR2MNg+CgVleKsKyTR2ydMNGrvmQfpbxvGNmcmpySM/S0zqcfl323Fa2nroHE8RE3u2M6eC4qo5zC13kyX7AaQicPRH/Pz5gzzYsZKNmzfysc3lpLs11sFofy9tpjIyC0upcYcw+Vo51hmiJ1HInKoCqnMdE0OODTLa0ULjKXm5GI/Ky4JhPSilsraGquKMc4v5C/kUzKC2VHzPoMnUoSgBJXDeCBgu3cbvx0Q8ymjARsRcQFV9FbV5fuKdBzkYyGHUk89CcyPmSIJ+qsnLEmv1eB+9Lf10++x4auZTv1AEdfIYAx2naB1ySxUJB6K9xUItbuKRIFHDtdzqFrdwp6zthiBOkJCKEzH5RCJRAmJpD8VdpKziAbdwMcsXmckY30H7yZOcGvESNXnEQh5PXxOJhAnINaGoWd4XjPV5CatW51FqO8Fg425aB234UwVi/Z5wQVfxfd4eF72RElACSkAJTBGBKRHfyaF9HN/9ND9+rIkmfxaVSxqoLC6hvLyUipIyikpKyM/kDEH+evH9Wa6+qY41SUmUdeoFnt16nG1N4Mx14XUYrm0xwkNiQc+pp/Cy67lBXNRL237Ozl88yrOZmynZ/D7ua3CQYyj+SKdYpLfwH88kOJlYy523VbOSXRze8Ry/brYxnMqjOEPEt8nPWHsfo8Esije9i43XXM6K7Bi2xof5+ZZDPNi5mqvedT2f2CiSvmcfLz2/lz19meQs28iKZXUs8fSSPPB9vvxkL1ui1/DHd6/nnmXywtB3nBcf28H+xkFMRTk4rIaL/Sjh4SFawnUULb6Gd98yhwV58qIyRZM8m26r4ns2zbaOVQkogbdHYEJ8+0IOwlYJ7aovpy5XKkF0nuRkMJtgZgbVyYMMt7dypN2BxZFJVrax3ewgEvKSU1bJ3IWF5NqjxIf78Y378UXF6p1dSFF+BhlJ2SjvbKa7fUB+Lmu1x52OBQ+b5B7OTHLdsslt7IqLO3pmbi5eS5BIfzOdrZ0M+ZNYJCu51WGTzXAHMZu0La7nWTYR1SYbLm8uuR65p6+dvtZTdEsoW9KZgUNc2q0WI15cxffbexb0bCWgBJSAErgYBKZEfE8MJE6o8yhNJ06INXiAQb+UexoeZqzfx1AgQax0MXPX3sB1a+pYXiBb8rHDvPD3/yqWb1l2P/S33CiCtOLwL9n6bz/l5eQiyj7wp7xnXQaV6XtLLHbX4/zouzt49GApl913K390i+y0n9rCd7/dSktyCe/9xLWsEQt2sPFV9v/4cY4XLaXwtrvYkAe5/jYGR8fwOSrJzs0m34gtT/no2/pdtjz2C35quZn6Wz7B36yCnL6f8IunDvG9FnElX53DWlc725/rJyAu8xveez1XFkA6ND3cS3j/w3zj2X6ei1zJvXdczt1LPSQCPrq6I/IikSG79mKxN+LAo22M7PsV//6VvewL1HLL397DjZeVUHQxnoAZ1qaK7xk2oTocJaAEzjOBFNGwbGCHZdNZBG5mYRElxSKEPWJxNmRvakxiwMVCHRRr9bjEbsu6PTRqeKpJYjQp3eWUeG8rURLBcfz+AOPivh40FeLIrWXRwirm5QwQbt1Ga/coQ/FCzGIBx2InYZY4cdlhNkl8eTzlxJFXQEG+eJmlRgj2NdE3KC7uiQw53yWx5naxgBsu7CZsUrM7HpMcKhl55MoGdp4zTHL4FH09XYyE7SRt2bgcdnU7P89Pid5OCSgBJaAEpobAFIjvFPHAuCQek8ykmbIjPdlvceGOSrmnYHBMdrpfZstPd/Hoq5ksuPPdvP/+5VSIG9vOL/4Lz+9L4Lz/r7npphIyX/oRj/zTPsYWXMUNn7+TFRJCPeGJbmQ/PcnObz7Bz3/ch/e9f8BNH15LQ7yfzof/mS2NMbo2fIRbF4bxtu7hkW2FVCxZyl3XV+CUaxNhYyOgkw5xOW9p76S7r09eMHz4uk7QNebjcNG7WX/zB/gf623kDP6CJ3/+JF/bYSZVMpc1+WHcnU0MF11F2XX3cftKF+VGBrbIafH9jCG+N4r4XiviO0uEtp+hzjbam1to7+mhd1Ti18aGGB0YomlfCFvpKjZ/+l42rymWRDd6vFMCKr7fKUG9XgkogZlOIJmUbOXi0h0MRWVNls1hCdIKlzRI1FYuCy3NhH0mBsz11JRnkZ9sYqD5IG0DcUZjHkmKZhWhK+FiRsZxq5ixEyEGhiwihMupX1HPioYxzP0vSgx3P+0j+ZgtLokFl/PE5d1IRppIxgj6E4z43BRUN7BsjSRedXTRe/IIh1vGCCVsZLhFsJ+uMZYQ8R2VGPThQYkp91ax6PIG6osDhDuPcLRZkq+FrGIhl813yZZ+5qEx3zP9KdbxKQEloASmJ4EpEN8Jxnf8mF1bX+b5+Ery11zNH2yopup0+LOoUeh+nMf+Yxs/2ZHPgvfcwn33LaQoeYTtXxDxvVeirz/8WW68dR5zG7ew81s/4OnROXhu/wh3X1vC/PR9RMAf+y/+84eHeKqtjqvfu5k7b6xBjNAw+CyvbN3PN3+VwB1uY/maMlzr38/yueUszoxL843sfPA/ePLJJoZW3Mllt1/HjQ2ym26XuPE93+f5J37Mt8evoeLqj/GFDRbyB3/Kz3/6Cg8cb2Dlzbfx6dvyyB7YzX9970meaXHTcPcf8q51tdSa+kju/0++/HQfzyU28/671nNHxV4af/Ug//iUicH867n/3qtYtyCXAms/oZPP8dCXt7Grv4LL/kzE9xWlVE3PZ+iS6rWK70tqOrQzSkAJXGIEklJSLCLb4jGJy86WYG2X5FQZlTCudncN7gIvi017GWqL0pZczaIVc6nNaGSkeS9No1lEneXkuSTLeWiMMcmIPjYmAj5hJ+UtJ6tiHgtqcimMtdF/fA9tQykikiQtR+LGHamAZDUfmbCUh+MEUxkkzSVUzK1lQZ0Hb/gYHS3t0kYmdneGWLclYVvQh39sjPFQjIC0EUnmkycb4AsWllLu7mGs7TAnO4P4Yi4yPK50GTIV35fYw6bdUQJKQAkogTcQmALxnSI50krXif3s3HmYxh4pOyIuZAlJuhKJW3A4JTmLlCvxlNVRtngVK2skOVmOxGrFDvHCl/6VF42Ea/d/jqvfVcdl5gDxgb3sePkAr+yReGyj5IiU80IymxK34qldRt0V67miPFcypk7W9ZIsrYce5+XvfZfvtlRh3fRB/vKeJSwrsBp77uKxPsCpF55l2/M7ORF1EJQyKlmeYjLlxaE8speR1ld4PHk1NRv+G58Xy3fewE/52eP7JeZ7FZuu28ifXlOaLjUW63qKA1te5pGdpeRvvJ73vstDQctPeODxLrbEruG+O6/gjmrJ1LrvCX76UieH+ywUZMkLgkOSxVTnUOQc5fDjJ+kJiNv8J+9j0/oyFd/n4T9QFd/nAaLeQgkogRlLICVW72DMQtSSTV5xEWV5blzJMCGTQ5KgWclmVCwqwWKUAAAgAElEQVTUFhHoYtkWYT7S0Uxbl5+AtYicSgkHK8mSOGxJouYfIxiIyHkuiceW0mAusaAPddLT2k7XkIhys5esokqKKosplAymdilBFhbvt/Gw5HixeXBJfLlHYscTvi562iROfDBBMqOagopqyorckog0REy86PwiviPis2YXT7pMl3jUhQcY6m6VrOmjRMV93eqQhK5S8/v1lT3V8j1jH2EdmBJQAkpgWhOYAvF9Jg+JGRuWTKkDPklkJjvZKSk1ZpcFN1fim4syyD7TS0wW/8CQxH7Jwmzy5uORmqCu1zay5T4DPXQNjknJERHQ6WzhxZQUZUsCtnPwFze4RGiQwZibhD2PQvFVN7zjfnNIVtbAIP19Rr1QyT5uuMV5JOYtw4zbKi8NuEUkeylwSzb2hOy8j4fF3c6JW1zbcjxS0uT0jVKS2XWwe4y4w0NWocSwJaSEimRj96ckji3TRbbTGKDEt49IybVBeWGQWPeoSWqXZsuLSpa4yYkrHVJ+zS5x5y6Jo7vYZc2n9ZM8OSfi2jiZeCcYDOAbkQRAvmFxrQySSBiZ7/VQAkpACcxeAsYGZVJ+F8Yk9jome9kJo0y3SNd4XjnZ+R4qzW1EBwdlvbWIi7h8JQnTkmIpN6XM6d+tCckqPlHX2/jKcCRPYTY2xkXUJ+OJtHA3yQa5nCG/cyUMTf40rjOb5Ly0K7n8mf7IzY0M6dJIQu5vXGesrUmTfCMfi5xqnG7cP92G1BU3GW3IxzjfZJFM7CK6ra+zeE/OrIrv2fuM68iVgBJQApcygSkW35fy0LVvM5GAWr5n4qzqmJSAEpgKAimp+Z0QN/S4iGYJykofIrnT8dmS+UyErZTwklhqo4a2IZuNGuFJo5SY8adxzhmHyRDMknXcnM48PiGa00I/fY1YtZNGzPfZh1mEvclskTJhklAtLeqNjQGjT3K+eLm9rom0iE+fL4LbEPITV5z7UPE9FU+M3lMJKAEloATeKQEV3++UoF5/SRFQ8X1JTYd2RgkogWlCYNJte0LM/jZZOz0GpOJ7esyT9lIJKAElMNsIqPiebTM+w8d7pvgOBCUMQLLLj/lGpGyOup3P8KnX4SkBJaAEXiNgiG+3lEazO5xkZEiIWk6eZEQX9/bToUmKSgkoASWgBJTAxSCg4vtiUNc2p4zA5IuV4epoxHyHRYBHQgH88veYuFYa7o0Tzop6KAEloASUwEwjYDi3J+T3v0Pizt1uj7iqm9MC3JuTr+J7pk22jkcJKAElMA0JqPiehpOmXf7dBF5LKhSLieiWjLoSQ2j8TA8loASUgBKY+QTMIrrNEhtukbh1q1USmtokCZzEiavle+bPvY5QCSgBJXApE1DxfSnPjvZNCSgBJaAElIASUAJKQAkoASWgBGYEARXfM2IadRBKQAkoASWgBJSAElACSkAJKAElcCkTUPF9Kc+O9k0JKAEloASUgBJQAkpACSgBJaAEZgQBFd8zYhp1EJMEzsx2HotGCYdDRKPykdjvlNSZ1UMJKAEloARmJgGjVrgR2+1wuHE6XVg1zntmTrSOSgkoASUwjQmo+J7Gk6ddfyOBs0qNBSZKjfnGhhkf9xOPxyeynUvSHT2UgBJQAkpgZhAwfu8bGc5tUkosMzOTrOxcsr05uNLZzjXJ2syYZR2FElACSmBmEFDxPTPmUUdxmsCZ4tsoNeYbGcbnG5ayY1rnWx8SJaAElMDbJZDeqvydG5biVTTxv/Tx2vbmua47XXXiLZ17rs7K9W/mw2S1WNK1vbO9eWTn5OJyuVV8v90J1/OVgBJQAkpgSgmo+J5SvHrzC01AxfeFJq7tKQElMO0IiChOC+TXhKz8a+J/byjJmC7RaHzky9dXazS09eTPTIZX0WmdblyT/vnp6yb5pP9pXGS0n+6Dcd7EuROlII3PGz2TJq3XxncTl5/be0nF97R7ErXDSkAJKIFZR2CKxPfEYj0RYiuLpcRhvXGpPOOc1xbiWcdfB3yeCaj4Ps9A9XZKQAnMKAIpcc+Ox2MkEkkSp6WuKSV/S8k6LTWxLeK6bYhYQwgb5xm5MyKxRPr8ZHpRn/iYZd02i+C2yLk2qyX9p0Xqaidl7Y/GE3JtQs5PpnNtGCLb+MirgNTeNs6TdiQe23g/mLivcb7RJ+OaCUE+8c5w+u/GO4LZaMcqMd1W7HKt0c/Xi3AV3zPqUdXBKAEloARmJIGpEd+RA7S89Cpf+0kUS8Mq3v/Ry6h3WDCfiXDkEJ17t/Ct3W78xev50C31LMi1z0jIOqgLR0DF94VjrS0pASUwfQikknFikngyEkfEdFJEsMRHl1RQmOPEE2hleHCEwaBVhK9JhK2ZWMJENAwZBWWUVJXjdYRJRsJyrXnCoG2I77QAl/tKXo3hngFGQlFC9mxMGQUUF+RQkm3BmogQjgknqwO3JUbc18NgbzcD41H8US82VyGF5V5yss2YDbF+2gJu/JGUfposdpyZGbidMZKjPfS09DAalEFkeNJC/syNfRXf0+d51J4qASWgBGYrgakR3+HtHH/qGb7wzQjWZVfy51+4hqWOCZe0147BXbS+8hP+fmsGo+U38Nf3LmFloXO2zoOO+zwRUPF9nkDqbZSAEpgxBBKJOKFQnHDSSUaxiOnibPKsCUx2J0msOCNjJCw2kmLBNvtFGHd10NwRYcQvAnr+QhoWWHH1P0/jwSMc6s0glHDgcooF2i5/ulzpv5vNNsK2IrKKq2moysIbH2SorYnuvl66xsUa7qkgt6ae+ZXZ5Ee76T96hLaeEQL2TFJ2sWKL9Tsh1nIjcVoiHiYquwTj8Sxyy+pYtqSSAnoYaDlG10iCiNmN2+WUNs/2qVPxPWMeWR2IElACSmDGEpgi8b2Tk1ue5+8fEPG9ZAOf/OwmFr9efA/toe3Vn/OPL2UwVraZv7hnKcvyxQ3N10L/sefZOpCDv2gjm+fnU54p/ONjxDp38/IJPycTdaxeVsOK0hjRwTZ2PTtMIGWhZGmKwdZGju1uYiTlwVq6nPnLVrJmcT7FzslFOsBY61GO7z7AgVN9dPkT2L2FFM2tp9QVwRGU7NjehRTVyWZAURzH6ElO7N/HviPttA0HCVs8OHIqmbt8NUuX1lKTATYiBAc6OParJkIZXrzLc0m27edkS4wuSwlzzE2S/CWTQM2N8uLhpdo9+TzF8He3cuqFZsLF5RSuX0SJGP8dM/Zxm/qBqfieesbaghJQAtODQDpWWkRtTCzWwyYv0bw5LJ+XQ4XvOF0799KVWYO1soT8oUNSFSLOsLOSHI8Ze9RHf2+cwbEiShqqWLjUjn2sB1+fD79JNslNYtEWz3RTzE9opJ8xv58ALhLWHDwZLrKc4truH8M/JokuDVEfDzEatzDonce8+nmsyw1hadlFW0cvA6Y8knZZVy3pCHCSiRjjftksSHjw1syjpspFzlgjvac6aR8Wq7wkVHN6RHgbIW0yDWcmX1PxPT2eS+2lElACSmA2E5gi8b2Plhd+yZceOMzhQQsLFhXitZ3tHkaon3Gfj6OplTRsvJVP37OchdmylHa+yNHHvsg/nZhD38I/53/eIkK7RKYo3EVo1/f4v0/18avY9dz/vo380YoEwaanefDzj/Nidxblf3gbly0qojoyRDjYwt7HXqEjVETlfR9l89VVNIwcpXPrt/nJ/jiNWddxxZJy5ueIy9zgfg488RT7RjKwbriHjVcsZ22Vg0LfMZ578hCHe0xUrKqnIt+BI97LeNNuntoGQ94ruPP+y7m+TjYQmp7hib9+hFdDBeTd/x6urHNRnDAzbrKTM/IkO3Z18Gj3FVx3yxW8/6riCYE9+Bx7d+7nu6+WMXflau67ZS5eeaGxzuYn8h2OXcX3OwSolysBJTBjCEyIbxHCsQijCRdRdylzq4qocYWJD/cxbs1O7/Y6hg/T3dFD+6i4nYsF2+4SwWz2EDcXUlBWTE2FC7dsgI9199A/HMKfyiKjrJKysizyzGMEOpppb+7GFxMpLO7gJrlH2iXcJHHjEjM+JiI8Km3lzllM3dxcsXx3Mnj4CJ29PsKZOVjEem6T+PG4uMUHpCxkWER8ZkU99WV2MvynaD7ZwoBfSoll5OCwS7y3nDvhnn72oeJ7xjy6OhAloASUwIwlMEXiexeNzzwrlu9x4nNXcv8n1zJfYr7PchAbPkCHxHx/bU8usZrr+Is/XM7SXFGe3a9y4ul/5t+aqhho+Bh/ff1clhcJ/0gP4X0P8/VnB3g+djX3vmctdy+JE2j+NT/8hxc5Eqth5af/mGuWZmNodRim5Yf/k6e3tXFyxX9n87vWcoPjBF3bv8+PX/JzzLyW9avKaSg0ERs6xslnX6TV1UDeH3yEm5fmMu+0+TlluMFFg4QCo/ICMcqIr5exU/t49EfHaAzXcu2f38tdV1ViO/Ukz33xW+xMNlD68c9yy+oMal57bIZpfeYxtjz8Er3Lb2HNB2/jSk+I8Z8/wPajg/g2f5AlS6tY6pqxz9kFG5iK7wuGWhtSAkpgmhAwfi8aIjgcTRC1ZOLMyiE/N5OcPC8ZNsPSHSBpEkGLJFgb7aKvu5feoSgxsVpbHXYs6czkkgxN3Ndjco+I3GvElgcl9aysK6HB3MXoyZ20D0bw2QolIZqdlAj+QChMOGXDlidCvaqaOXkWHOPNdLWcpGNA3ODJxOVxpBO2JRNRguE4oxIH7i2pZkFtBlljx+htPEFnyEVMYskznLY3zXRuTIWK72nyQGo3lYASUAKzmMAUie9Jt/MotmUb+bP/sYmFRvLUM4/R/XRu+xn/+0U3o6Xidi7ie5kszHRtk3jx/8O/nprD0MJP8Jnrq1iSLxcmBkjs+wH/vqWPZyJXnRbfskvevJWH/+FVGlNzuPy/38MV9VkYWp1EH40/+See391B4+JPcfV167g+o42hI0/w/CtdHBjIJSfXKklc5FxXEQXVK1i8tE7EuGRjNa5P+oj2N7N3dyPHW33Ejd12hzjFRQcZH+rlyEsDBJ2L2PDJP+S2jeW40uL7m+wxL6LiTz/LDYtdVJ855vGD9O7+f+ydB4BdVZ3/P/P6m957zSSTSZn0TkihhECCAiLSbLiruLqgrruirn9EV3fVFXVVwIqKIiBILyEhEEJ6b5NJJmUyvffX2/9332QwwWAoM0km+V18Bmbuueecz715537Prz3Dz15Jxp1cyA0LezhUaeNoZznX3VhOeY6dtyK6gJ/L9zx1Fd/vGZ02VAJK4DwlYHwvGnHfAb8kP/P66OvtxSPJzBLHTKY4R+Kz2yUBalcCnozpVIyJI9VVSUPlXur6EO8t8QiLZjMfyIQu+czxu/toE+t3KLOcaWPzGGcR8V29mZoWF22hZILi9RWWRGn2lGwyCwopTLPi9DTT2VhHXWMnPT5xH3dI3HasUwSziH5xjXf1u3H7ZSMgbyyjRmWTJzHeLQcOSux5jyRwkw2DhLjoJsA/OlR8n6cPsE5LCSgBJXAeERgm8S0J115YyTd/4f1bwjXHW7Kdt23mqCRc+681CfRKwrWvfnwa09LF4bpFhPuK/+X/NsdxLO/j3H7NJC4usBJq3MLel/7IbzeFOJb/ET7z0QV8ZKLsrFev5vffeoMD4VLmfu1jLJyQPGD5DjVR9fB3Wbm5lkNT/oMlyy8Sy/dBWl77PU+sO8YOTxEpKXGkS3ybZHeJljjBmU/2mJnMmDeRspj1HFt5P99/2URd2nI+fePFXDQul9z4NgJHXuWhH73G64dzmP6FW7l+SQnOQ8+y8v/9nC0xFRR86R6WT4ll1ElqWrKzivvc+t88ygtPvcrR1CySPvBxLlu6lCUZ4ql3Uir48+gJO8NTUfF9hoFrd0pACZyzBAy3c6Pcl2H1DlpisSVlkp4k8duuVrrb26MbwfEJEqPdUUWL2xDfExlfIAnYmvdQV11Hd0IRcZKgLdXikbQrbbS3ttLZGzruFl5Kgbiw58d6CDQeorrqGI09ISKJOSRJFvW8gmyyYgOYuo9Qd/Qwhxt66BPRbbWL6Ja4cIckWTNKhxlZ1yNS6qyn38iekkXpxNGU5fUTatjEoZoOmtxJskkucd52ozTZPz5UfJ+OkP5eCSgBJaAEzjaB4RHfvj3UrN/EL57wYxk7jVs/PZMxf1dqbB8Nu1bx2+1SaixzHp9YVibx17K4hlwEWnaycc1aXt10iGa/+H+nTqI4P4UxCTUcbLNwzDqHa5dM4fIxATx1W3j+VzupCecz6bZlTBuVgGEoJ9ROzYrfsmlfG/Vjb+GiebkUH13Ly7+URG+po5nw0SuYKG7uiYZAlhIsYf9+tv3pSV5d2YLlmtu56pZ5TOzZxF5JSvPG7kZ6fRF85jTyRhcySuLQOrfV0dGZxNgbl3Px3FwcEqu+8f6/UBkzmqxbPsP8Mgf5pzJlV/6cp57bxq9aL2Xx0sXccVkuWmBt6P4aqPgeOpZ6JSWgBEY2gWjMd8SI+Q7gDYrItSWKq3kqqQlSvkvWJ2tcIjYRtXZft9TmDuL2SVLRzgbamttp7bcRcmSQmpVJdnoc8bJQGa7kEolFxGwX13Kpxe3toNuIA2/tok9Sj7qTc0nKkhwmqfEky/kxIS8BjwuXuJMHJCnqQE1wKSkWIxfxHJMkbz2SUd1BIBiD1xRPIC6HElnrcy2tuOv309Il5cjMKVLb2zZgIT9FnPeJd0jF98h+XnX0SkAJKIELgcDwiO+hIhcJEgxK2ZGILNayOy45297H0SEu5xt55eEV7Op2YJ8wXRKomYmTKDeTvAyYw+00VrXR2ZnM6CsuZeal4xglhvgBF3SpTRoUtz2JejNJohcjkYwkZn1nh1HjtF5i4A8cQC5PV3sL5vR8UqYvZ1KRxJZrnPc74/gOz1Lx/Q5B6WlKQAlcMASM78Vo3LcIbKPWt9crCddCEezpuaQmG3W+RQh39dHlj8VsteNwSJy3rHPRZG1GG/kYZcDCIuRFUss/UidchL1xjtkiceGGBVvWxrD0EQj4pUyYT1zcA1I2TJKiGWumxJPLH9HU5MZ5hhu78bFaJZxL1nbjZyFxPTf6CoWkD7lOjPzMsIwPXvud3CwV3++Ekp6jBJSAElACZ5PAuS2+h5yMrPxecY07JHHcB5po6PHjEVFtskjCl4QMskvLKSsrpjBeXiqGqm/Z+fcc20CV1DTdJ8I+kjeDiknlVIir+ZD1MVRjPQ+uo+L7PLiJOgUloASGhYARMm0Yj6Ni3KinHQ25ChOR0mFmQxBL3WxDCBuHYTU31PKgsflUVueBcwbPHbiucZzaQj2YnXxw51pE/N9tYhuDM/53qt+dHomK79Mz0jOUgBJQAkrg7BK4wMT32YWtvQ8/ARXfw89Ye1ACSmBkExgUzaeaxelcu9/pzM9EH28di4rvd3p39DwloASUgBI4WwRUfJ8t8trvsBA4WXz3090pMYldHbhcLnGzDP7DMjXDMiC9qBJQAkpACQw7AeO733BRj4+LIyklXRKqpuOMjY1+5w+uC8M+CO1ACSgBJaAElMBpCKj41kfkvCJwoviOxjZ6JIGQ14XP55esv+LM+E5j9c8rKjoZJaAElMD5TcDweDeJ27xd6pI7HXE4nLFYJKZcxff5fd91dkpACSiBkUZAxfdIu2M6XiWgBJSAElACSkAJKAEloASUgBIYcQRUfI+4W6YDfm8E3prs571dRVspASWgBJSAElACSkAJKAEloATeCwEV3++FmrZRAkpACSgBJaAElIASUAJKQAkoASXwLgio+H4XsPTUc5/AmzHfUqwmbJTSCRi14o16s1JOZ7Bmzrk/DR2hElACSuCCJmCk5zDKnhn1vo24bSN+2yo1xfVQAkpACSgBJTCSCaj4Hsl3T8f+dwQGxbchvN1uNz53vyRbc0f/3R8MYjZq2GrWNX1ylIASUALnLAGjBrlxOJ1OrFaLVKqIkJCYLBnM06I/1+zl5+yt04EpASWgBJTAaQio+NZH5LwicFKpMVc/Pd1d9PZ0ifg2So2FonPVhOfn1S3XySgBJfCPvtQG0128+eX3br4BpfFJ6TJO1faEc956J6Knv8s20iIsXkqG1dtht2OT7OUWq53U1AxSUlV868OuBJSAElACI5uAiu+Rff909G8hcHKdbxc9XZ309HRGLd+h4+JboSkBJaAEzjcCAxI3Iv8Y/zYoeE9U3oMzlnNE3Eak9KLx2+h3ZrTlwGG4eBsfw0PI9HdeQgNtjZOjraL/M85/e5oD4T5GuwEhPnD9f0zfaGOIb6NsmF0EuNXmiIrv5JTUgVkaYz7dRc63G6zzUQJKQAkogfOCwPCL74gPr8uD1y/xt7L4xpgsmO1OcSezYjtpAQ4TlvjckOFtJnFdZrMs/OcFYp3EmSSg4vtM0ta+lIASOHsEBiRzJBwiYOS2kM3FoKyappgQlkhIrMcick3WaKy0xWKODjMs5/j9AQISghMMGucMuHcfV8ZRsW02myW22vhTrmU21mKjbYRgQNrKJ3RcTJtjDIFsnGeR6w+cN1hTOyLXDUkfgUCYoIxvUOBH47jluhaL0UbeBaTNqXJxqPg+e0+V9qwElIASUALDS2CYxHeAYF87DTs3s7tyL5UtXbT1+nB7TdEdbGdCFjljpzB+xjQmFySS6YwhEqhiw//9lk17fVhvvJOLFpUy1T68kx+Oq4f7GunubKYumIEjKZvSVHnx0V2E4UB9ymuq+D5jqLUjJaAEzhqBAdFt5LHw+EVUB8PExCVgyiwkN8lLmvcobS1eOnrNkudCNr1FIBtx1P6IiU57FsmZOUzIsBLr9+D2+AhGjeUDic0MQR3ja8Xd20hHfwwuX5z83IZZRLw9LpY4sT6npqQQH9OEv30n9c0+urxp2B0OLLJpHpSxhEKypseIwLYb630iieIunhwrlmxfA80NDdS2+2VMduIctlPm4FDxfdYeLO1YCSgBJaAEhpnAsIjvUP1zbF31Ir9cl4Zz7GV86uaZlOU6iDXczjzNdFbtFEHupyW5gnGjC+UlQHa/A3tYfc+9rNnmw/bPd3PpVeXMdQzz7Ifh8qHGLRyp3sV67zhSiqZy+ehYnJZh6EgvqeJbnwEloAQuQAKRqKXb0yeb3OZE4vMKyM92kmQP44rEYRVvs0Qk0SRxRrpwTO4W2o810tjUTo/ZRl/OOIqL85lkaeXo1q1s3HWUgJFJPNaJTazRhoiOjY0l1unAZpNkZ4FYEcoJJKaLAEcWM388GcXZpCfV4alby+FaL+3enGhyNJvVJGNDxLcde0IczlgR1x4TsWmZZOQ5iJdNgdpDhznY6MNiiyUhPvZtv8fV7fwCfLR1ykpACSiBC4DAsIhv3477WfHS09zfsIjS+Tfw1WtHkfcPrdjicu7by5r//ilrd4j4vu3rLL5iLLOj4tuLp76Sqs3b2HaoiWM9smPuTCMxbxwV06cyfVIW6QTo2reeAxsO0lsyg/x5UxntBFn2DbUPwQa2vd5OXUsC5QtHMTbXSUyknY7KLWzdtpddNb30+C3YUkopKJ/G7NmjGScvGiZx4qN+I9trO1jXn0dpbA95vfvZuLeDIy0QX1BG8ey5zK4opix+4Gk5WXxPZ0mZA0eMl/6mKg7u2MGO/fXUdXjlpUmyuKaWMrpiqvRXSkmiuO1dAA/ccE9RLd/DTVivrwSUwNkiEHXrDgXwift3myeF2MwipoxLIrNnB4cOHGGrYyKpyX7G+3ZT1+6km3yyk8W92+OO5r9wiTXaVjCR4sICCsy9dHV109zrxy7uWXabrEExYgV3ddDV0U2vO4JZPNWsDqtYzf14PR6am50EIsVMmlfK+FGN+OrXcfSYlzZv9nHxPeCiHgqJy7lY1bu7QnR2J5BTNpYp09NIC9VQW32I6ia/iu+z9RBpv0pACSgBJXBWCQyL+I7422g/vIFXn36VDfta6U7MIik9k7zsLPLSs0nNLiSnKJeCnBSSpWynCanBLOL7tUHx/alvcNnVY5jWc4DGNY/yl019VNmnM3tWIRVpVmJCcv09a3mj1kZH4VVcd9kU5ltep2rVYzzUNAXH1A/zucXSnwhwug/SveMJ/rg/mYaca7jl4nTKuleyde0anmsswlE8hcumppEqvnn+hg0cqaxkQ8x0CmYs45ZJJlIaHuHxR1fw060ZFM+az61LJ5Bh8uLr2En1lgM8tz2NUYsu4bbPzKRU3PvC23/Bqhce4t6eayld/C98d1GE5LYVvLL5CG+0j6aopIiZ+TZJO9NF67onWFfdzf7im1i6cD43Vzg1zv19/nVQ8f0+AWpzJaAEznEC4ajlu7vfjjkuk6Ix2eTH+whJRYf2UCIOcxeO/ioOH+2isZNowjKLQxZDw/NMLOHOjBIys3PIsHqI9DfT0tpJq7inhxLyyC3KoyDNjK3vMC21B6ntiOCLiSfWEOASR97eZsMXzGXsjCLGFLyd+B7AF4kEcfWH6eqJJb1oFOMmSqmw0DHqDon4Vsv3Of6M6fCUgBJQAkpguAgMi/j+22AlsUtXEw1NjbS0yyJfV0tjTT31tTUcDmRjKbuKa66ax1WT5IUhJJbvb/+E13cEsf/TV1m2vJD0LX/h2f9dzeGsucz4t09zaTGkRC8uSWK8G1l5/ys88XKEUbdey423lJLRtpmn713B7u5c5n3hFhaPTcK1ew2rH96Cq2wWcz6xmFExR9j3i1/x9ON7aZm4kNHzJ1KRZMEqMW8RTxVte3bx+1UJOKZfx5e/PIF5oZU89/gGfnt0MnOvuIzPL81nwMhdT/MbL/Pg/+6me8w8lnz9BmYnizV89+9YvfIx7utdRtGcm/nGpbLBEDXBizXA10NvZwedbR1093aJ+/3zvLa7idf9S1ly9ZXcuSxX3AX1eD8EVHy/H3raVgkogRFBQJKeBfx+3P6QuJc7iZUa2GkZEuaVlEqKLSDx2B4RzfaolTwisdvt9fLpkp9ZHEQkiZpJkqUZSdHEpB1NthaQOO2ubg2tb+IAACAASURBVC+W2AxGTZ7G+DwbkfYqdh2ok7jvMEmJ8aLbI7S12vGH3rn47u87Lr6LRzFexfeIeLR0kEpACSgBJTC8BIZBfIfx1h+ks6uH/qwJpGbGi1v4W47wRt544Dl+84ibrA99iI/eeRGl4f1s+/a9vLIjhONTd4n4ziN5/aM88YMNtJQsYOHXPsrcDEgYFN/h3ay9bwV/fbqH7JuuYfltsyjHhWv1j3h+dzevpl7PFcWNlPqO8ELzAsomTuT6qRKvFt7J6nsf49knDuGqmEje1HwyDDFvWAWi2ded4v6dTdH4CUyckUpO89M88+IOflc3nQWXL+BfLsuTM4xDYtdef41H/m8vPWPmculXrmfWW8R3yfxP8PWLYkho3sCWXVVsbbERtki90jjJCuvuxdO0i911HnZbFnLl8sv47JWFKr7f5/Ou4vt9AtTmSkAJnPMEjO+5YFA2twN+/D4frm5xE7ck4CmaQnlmHyV9+6iqzySSOZOZEx0kubZSV13N0a4EfBGHuJmL+7oseGaJ8TYSrIXEkt7R7gJHOqVTpjKuQNaqtgPsOSjiuy9CYoKx6omre6tDxHc+42ZKqFVRA16J+T5S46XVkxONE3fYxTMtKuwjhMMB+noN8R1HRkkpEyrE8h003M6rOdAgQl9ivhMTDFH/93XHNOHaOf8I6gCVgBJQAkrgPRIYBvEdwrXtcTasWMFTtWLdHj+fqy6ZRHm2ZD01So35Wug+8Aqr1zSwqWcSc5cv5COX5xMrYvr1r/+AVZJwzX77t7nyWokRa91G9VN/4C/7rLSM/gDLLillVpaYkf2NtG59jmc29bDHtoBrls/h6hnpA6LYv5/K1av5za93UN3cT9nSBcy/8UZmjxIhLTv3SCKallceY9Nr29gSv4DCixdy1ZQMssT9PSbSjaulkd1Vkq01MZ+J8tKS1vAXHnt2G7+qncnipZdw55UFRhobOQ5Rs/oVHvrhHnrGzmfJN25krpjlE3b+ipdf/DM/6fkg5Vd+nK+U19Dx0A946NUO6ufezuLLp7FkXC6pDqk7veMPPPXSZh5smsfcpUv58jXFiH7X430QUPH9PuBpUyWgBM59AmKtDkpNzn5TArbENAokdsvpFs+yXi8tseIxFttLjvcwdV3ZxKSPozw/hKl5B0ckUUkzRSTl5JGXKqLb3Ul/RxOtnb10h2KxJJaQX1BAYZYFZ98hWo9Uc6w7RF8kPlp6LBLx09keRyimhIp5JYwrbMRTu5qqw26a+jIkQZtNxLdYzI1AMtnPDon4dome7+uTmO8xY5k0VbKkB49KaNd+9h1zYbLYRHzHiviWWHMphWYkWBs8VHyf+4+hjlAJKAEloATeG4FhEN8ykKDU9e4Rd/P9O9hfeYCDDV009/noD0om1XhJupJfztgpU5g8sYjCeAsOEcWRwGG2/e5Rdh4IYP3AJ5k+p4iJNhHLIXlh2LeTbW/sZE9dmyzyknAtNpW4dEmKNmsGM2eVMcopdUlP2DwP1m3gwKrH+UtTMaGJ1/GphbkUJ51wgmSD9XVVsfeNTWzdcYijPVIGzReDPTmX3NIJlI6bxIRxWRSKmd3asIpXN1bzXEs5U2dN5frZmQwkYZeSKdu38fJjR3AVTGLmxy5hgpzvPCSZ3jet4nHXfLGqL+cTE4NYmzexbcMWNlf30NjlIxKXT2pBiWR5lwQ4fb1s7iynYsYUrl+QQ9J7u4/a6jgBFd/6KCgBJXB+E5AQJqnR7ZE1K2yJI1HczVPjJbu4ZCwnPol4w+081C0lxMJ4RP16eltoaeuTGPEwJnss9qRMkqT0V0qsGbspGL1WMCJrqFitreF+PJ31tLV10uMVDy0RyOFwovwpbu05cSTFWWSTWup02yTvuTkk67MkaJM/IiHZTHbXipXbL5byOKkfHi/Z0VNISY/DWMajtcMlE7qRxNSo/x0SdW4KSBhWbzftPZLY1CRx5ta/lQVR8X1+P8E6OyWgBJTAhUxgeMT32xB907P7/RAfkoucYgDDdd33M1dt+64JqPh+18i0gRJQAiOQQDgUkqziUuvbH5BM5G68JjvBlBwy472k+8VdvCNIr09KXUZLhklyNsloLgu+uKsH8Us9sIAhgsWCHv3OlPkbhmfD+myxiAi32rCImDc8wsMilI1zA9LGcHUPiqu70W84LPXARTRbxGptFeFsM8qVycfIyG60CYoqD8j5htg2/gxH+xIhLq7uhtAe6Mcqfxr/LkJf2g0eKr5H4AOpQ1YCSkAJKIF3ROCMiu93NCI9SQm8DwIqvt8HPG2qBJTAiCIwIFglvtpQtSJ4IyJ0JXcaYSkpZjbHiHVaBLKc81Zh+14naXy/GkdUJht9G/99gmge+LHhom6cN3Du8bNPee7J5/9tVCq+3+sd0nZKQAkoASVwrhNQ8X2u3yEd37sicCrx3d3dgdstbpFirdFDCSgBJXD+ETAE9qlnNSiYh2bOf9/PgB4fFNpv18vf2r2T898qvm12J6mpGSSnpEY7GPyeH5o56VWUgBJQAkpACZw5Aiq+zxxr7ekMEDhRfLv6++nv66a/v0cS/7iibpADVqAzMBDtQgkoASWgBN4TgXBYXOHli9rptEdd5okxk5KSTmraQO0UFd/vCas2UgJKQAkogXOAgIrvc+Am6BCGnoARc+j1Sl1biYX0+9ySfMgriYEk668EMRr/6KEElIASUALnJoGoG70cRvZ0IzY8JP8ZH59IUtJAPRAV3+fmfdNRKQEloASUwOkJqPg+PSM9Y4QSGKg1K4mBjEQ/hlvkwP+MV7cROiMdthJQAkrgQiDwNw+lAW8lk8SwS8I4+VMPJaAElIASUAIjmYCK75F893TsSkAJKAEloASUgBJQAkpACSgBJTAiCKj4HhG3SQepBJSAElACSkAJKAEloASUgBJQAiOZgIrvkXz3dOz/kMCbWX7Vy1yfFCWgBJTAiCIw4GGu+TlG1E3TwSoBJaAElMBpCaj4Pi0iPWEkEXgz27kkXOtv6aR5+35ad1XjdrmJWCRmcCRNRseqBJSAErhACAzm47CEY0jKSiN98hgyJpYSm5IUJRAxMqBLwkw9lIASUAJKQAmMZAIqvkfy3dOx/x2BQfFtJFnrrm2i7tWt1K3dSW9PLxGrkbBHc53rY6MElIASONcIhCNhI405trCJtKJccuZPIX9eBQlZx8uLqfg+126ZjkcJKAEloATeAwEV3+8BmjY5dwm8Kb7F8t1T10KtIb7X7cTV7wKrWawn8oKnhxJQAkpgBBGIbhkaRl8RqBH5hKX2ViQim4kmIwv44O+MOg4D9uMB+/Dxn59untEqEH+LzTlt27ecP3j5aDvZ3HzbI9rFiT2dfGZEmpqR+cjcUgqyyBPxnTe7gvjM1OiJavk+3Y3U3ysBJaAElMBIIHBmxHckiN/lwR0IEjFKhsTG4bRZsI4EQjrGEUVAxfeIul06WCWgBE5DICZGSiaGQgR8Aby+CCGLBVucFYvZS8TrJug3izK1YbVascq6ahLX7LBsMgYDfkIBKbUo1uRo/ovjtbMHdLlRvks+JrmO1NG22gwhL+rXOCcUJBgMEghKW7E2D8pyYwPAZLZglv4tEsJjPu4CLs7gxMiGQCgYiLYLRjcGTmgX7css45WPMT5js+AUeTgM8W0EBllCqPjWvxVKQAkoASVw3hIYfvHtq6LulT/w/e89wV92teCxJZG+7D+45RMf54vz40mR9wY9lMBQEVDxPVQk9TpKQAmcTQKGETko4tnnEiFsEZtwepKEzuSSPnYS5UtGkZuyh64da9m/NUBniwlbyEeo14/P7SNsN2NOTceS4BRBGxoQw/IZtEsbQtssG+GWYC8h8Qry94lgD4qwl3PcQSsx8fHEpjmw22Oilvao8DYUs6eHQGc3fq+ZGHMsNhHSMSEPnlAMXmsCtuR4nPHSt0k2DIx2hjVbmpkCsknQ14e7W5R1yILdYYh4yah2gghX8X02nzbtWwkoASWgBM4UgWEW32HcW3/Js7/6Ft9a1UzlMTN22VX3ORYz89bP8+17rmZRrhX7mZqt9nPeE1Dxfd7fYp2gErggCAT8LrwiToMZ48iePY/xC0spKBZRfKrZR2rp3rCGHY/vZd/GLkxFZYy97TomXz6KgYjptzlcK2hY+TTrnw9SXxWLPbuApHkzGb2onDHlmaQ6T24X7DpC555NVK/aTm1lB/2hODyWTOyjyylYPJXyiYXk59qwvbU7TwvdR/ZR8+paju5spKcvTsS8FZvk4Rg8VHxfEI+1TlIJKAElcMETGEbxHQTvHtbe+x3u/fVrvD7+A1QUxjB96x9YtTvCodEf4oP/+R3+7arRTE807oO8ZTSsZt2Kv/KH11ppi5tPyZXXcvuiQsZEfy875t4qtj7yOCteqycw9yYuvuYSFmcZrmrddFe9wYYVK3l9YzV7ekyEU0ZROF1+v/AiFk3JICtqYZe434atPPXUc/zpjS7Ims+Cy8ayIPUIRzZv5ZmWdALTP8g/LShlgaNGfibjfmMXm6uaqReLQlh2+h254xhbMZeLF85k9sQM0gZNCb5WmnetZeP6dazfX0ddl4wBJ4l5YymdPZdJBQHiW/ey7nAykbw5fPiqsYxJkhePUDvtu19j/auv8OrmYxzutRFMKKFs5jwWXX4JcyemHR/7Bf+sviMAKr7fESY9SQkogXOWgFiNwwF6u2IJJJQx5uOLmLmsgDT6aFu1j/ZmC7Hzy0hJqaRn+2oqt0N3pxVnoJu+5j6aa8TinTuLqZ+dzfSFKcQFWuh4ag1Vm6o4LHkvvFYbTrNYysXybfU04WtpoqfHQWvyDLIWXcKS5WMoSRE4wXb6d21k934vjY6JjJtVwoRCY6s8QKha+n36JdZu8VJTvISJH7qSa2Y5SJR12t+wm+pXN1BZJRb13MmMWTyb8nFJ8jvJt9Gygn3PrmfzK70E3Wbi421R9/foEQ1RV7fzc/ax1IEpASWgBJTAkBAYPvHtlwV93Q/53rd+zn27ixj7r//H165LouCNr/Od+1bz14OlOC79d75717V8dmEGDmM6nt3sfvzHfPffHuTRtkySpnyJb9/3KT46N53kYAP9a37A1+55id/un8EH7/4S//nPFRR3vcaaX/+Ehx7ewsutEkce5yTJKYm18NPf5SWYPoHJN36V229ZxDWj+ompfoJ7vvFDvvlopXSYR/r0SczONZEU8XIkfTYJM6/iP+ZYGNW1nj8/+wbrNx2ipctHr7w3mEI99PX20tJvJWn+bVzz+X/jrkuzKG59hhW/+R4//PNe9sTO4aKb/5Wb5+dS0reFqhf/xP0vVbPPJJsBi67mkorpXD59PLOmp5FY8xKvPPRbfvbYVrb3mLHGJxErlgCLrx+PJ4DbNp/5n/wod/zrlcxOk5crrbJy2odexfdpEekJSkAJnNMEJKFa2E9XRxahRBHRn5nF7MvixZrspuuVTbS1iCv33MkkxW2m+/VH2LTKT9MRBw5LROKpbfT6xxNbupCLbp/AtEniQo6XQFMf/b2yHtrCBEIBwr4u3I11NK+v5KhsWLdKhnH7kuVUXPdBZpRYSDDa1Oyg8v4nWL9iH20lFZR//BbmLplMQdT03kzbSytZ/9AWdidNIPe65Vw1J5vMeNk46DxAzZoN7HjxIB3mEkZ95GomX5RCcnc93dtXUvl6FccOW4gEZE1ziPu6iu9z+mnUwSkBJaAElMDQEhgm8e3Hc/QlXvqvu/ifPzVztOI/+NKPv8hdF8mued0j/OTz/833n9lLE1NY9q1vcecdy1gopTyNBGyh1vXs/f2/842fruc57wym3/F9vnvHHOY3P8PKb/87P9xfgO/mB/jGRytYxgtsevAbfPW+7bx6TC4wZjFLl87iytFypY5drH34CZ485JG9+GVcdc/d3PuVcZS1vsiP7/4fvvT7o5B/PTd8+TN847bJlMtLgMVIBHPiEe6mp/YQRw4e4nBTO6118jKyYTWPvFpDh+1Kyv7lP/m/z09kbuN9PPjVr4prvewfzP8sd/3oPr4yA3Gnr6H/ybu48UuP8nxLOclf/gW/uH0BN+T6oXM1T37z+/z4p6/yumEhn7SUxUsXMisP4o+tYcPzT/LYAQgXXcbMr/+IH143gYvfNLMP7UNwPl1Nxff5dDd1LkrgQiQwEJ/tcYfxW5NJmDaVUZfOYMyETNJP5XPubqP3SBWNO7dzeP1hjrQnQPksyi+ZzuQK2eS1ufC1t9HRLvHgznRS87PJSDbyisvhO0bd6pdY9/A2IuWLmPLPNzMq01i7xGp9eCeV973A7tUSW15SRPwHb2LKFfOYkm1kJe+iZ81qdtz3CtsqZWd6/mKmfeoypsxIwzCav/WI9B6jrXILB2Xz4Mi+DjyBBOwmG3aJZVfxfSE+4zpnJaAElMCFS2B4xLd7B9XPPcBd/+8x/nogBmvxTObNKmRCqoWQr56aVzazu1bctGVPPm7p17n+9i9wz9I0oh5tEanHXPscv/nGf/O9h9o5VPIJPvu5EhbEv8Fvfy5itvQ67vz5F1ieKy8Am/+XJ3/473z/edhpKsEy7TKunTGKGZnyWiFZXK0Ou1gDRIgHUymcOp0p01LJqX+OH333B3z5T/Uw+uN88q7P8p2PlpLzpu4W9/YuscCvfYknntvM9qMh3JmlTBQ/vCJ7J0d3vMFfXq2khQWUf/I/+NEXFrA0q5ljm/7MYw/cz7P7TbhFMI/NcZLul9i2NvldpJi8eVdyw/UfYH5pLKmmFsI7H+Gee37Jd5+qJMgoJly8UN5fJG4uzqiIJZlrbTJ2GXokpQDL6KlcWpZDacLf4uMu3Ef2H89cxbc+GUpACYx0AtEEaeJ67pWM5b2uCMH4ROKKcnAkFZAj8dXlC4tJdzbi72jHnVxOQnoiScEWXOsfZOsz69hRmYTbKucUi8XZ3oO3oZ66w530JRdReN31zL3mYkTLR2OzfZWvU/PDx2nImkTc7bcxrtAkLuJuEd/b2fvTZ9i2cifdpaPJvfkTzLhyFmWyzx1DJ20rXmL779dTL5bvrA8tZ8rULLIdR+nYJ+vnji6aexNIKxvL6OljKciXCidG6Fjfbo48t5a9T1fT7ZKkb4kS+z1YEU3dzkf6Y6vjVwJKQAkogXdAYBjEt7wsrLuXp+/7b771nJvDHgtOu2RR9cquu2RTNUSxPU7KjUhJEq9HapbaZzH+yk9xz/duZGlZHPHRQffT9uzd/On/HuCHa+LpdPpILUzEVX4nt9x8C9+6Nju6ux48/DRr//gN7vnlHtY0Si3Qio9xx1c+zR03jqPY1EXHuhfZvL+DpqJLmDR9grhu90D1M3zvO/dyV1R8f5SPf+V2/uvWMvItA7Qi3sPUPPJlfva9p7i3Sn5QfBOzvnQX939IBHhwNS/98ofc+atN1LhFfH/mq/zkzjlcmriVbY8/zq9+dZjmpDFMvW4K+bYQVpOTuPRCcoqLKRJrQ47EeA+UV3MRaVnLE/f8gP+9fzWbJIVOyuWf57Yv3MGnF+ZSFltH7a5drFrjIiZ3AouvqoiKck0Mf/onWsX36RnpGUpACZzbBMLhEF5/jIjuNFLniKv3+CScncc4uq6V/vgxjP3wLAqcVXhqq+nKuYT0MQUUiCAO7nuADevaONC7iKKxRZSm9dJ/uJK6SvHgqgvhkfWp9KpLmH5ZOUUS6xUja5Fn22p23r+KLZHRxN14A0sXSI1tYyO89wjNK57jjQ0d1CbPYvrVc5g7NW0gmVrbBnb/5RnWr+0i4fKPMO8Tiykx9ob7d1H76ku8Kp5tO4+KR9e0RVx0wxJmzBCLexR5Bx0vvcKeB9fS1BcimJKERcX3uf0w6uiUgBJQAkpgSAkMrfiOSEKzdnHL/vrd3POrHVSZl7H4K3fwzTtmM1EClgf0rbioBavZ++gv+elXf80joodJmcTMr4kr+c0zuTr3uAp2baHyyZ/w1a/8iWca5ZzUJXzsB//DFz4ylakiRAcOKV1ybB0v/u53/OXRNayraabRE+1B3irsmBNSyS6TxGg3fZ5PXns5y0ukswOP882vfZt7/loLmf/Edfd8kR/90zgKj3eLr4G6Ff/NI79+lJ+saqdBrhc9LClk5jmJ9XfR1OTBx0XkfOZu7v/aXK4IPcnLP/gvvvO7erZ4PFicNinjIm8UUiPVqLcakfJq8fkVVEybz7KbrueqhRWMTQgQ2f00rzz1O3721Aa2HOiizT04L8kWm5RJSv5iLpfNhts+Lq7neZKcZkhv/fl5MRXf5+d91VkpgQuGgJToCkvN7H5rGuHSSZReNo1JM/PIiiZGeZsj0EFP5Q6OvLiJhv5UHBctYdQsyTMioUqDS9vJLWUj3N1CV+V6Dr++mb1bu2lqlHVqdAVjPjiH8vlF5KdIDfC/686Nr3YPtS+uZN9re6nziHievIiyyxcyfpK4sydKzpJTDjFIuF/ywOzbSuWruzi4o5NwQBLHyVqpbucXzJOtE1UCSkAJKAFDoopYOaHS5vtkEu4j0riVFavX8/JBWfTHLOTyhbO4vHjA3nviEWyRRfgV2VXf66bGmk1w3GKWzxvPJVHfc+MQl7vmnex5fjVrqm0Exl/CZUvLmZ5pH4hVO+nox1u/j93bdrJzl2Qu7w7iT5CXlbEzmTVtMjPKEhnw2BYl3bqf115by0s7RYinTWPaojlcMTUdI/H4m4e4vncf3s3WzeJ2XtVEu9tOMKmQaTMKKbB1Ub+lmsruLFJmzGfpLCvmA8+y8olXefFwKraCAqaNERt1QOLXxdIfCUm8Xe1G1r+2gXVibE/90Hf44l1f4bPTzKRF+zQsE+Let2MPW/e3UNsVJujMomjCJKbOmUZFSRIpmmjtHT+YKr7fMSo9UQkogXOUgLEohwI+fLJ560tIx1mQK5u/aTidmSQXllI8U8qAiYdU/5HdHN3bScveBvqO1UtcdwiXS0RzXCKOUYWkjsoiLVliqx3GYnO8zreU+4z0dUQTrrUfaqOvM4xZwpzMUpDbK2uW25pIbHE+2WPEwyxJrhW1TEtbSQLnbz1G76HDtDeJJ5tf2phMBHzi2SYb3bFlRaQXpJEcL4lPDQUeI9vgRm3xgGw0u6Sf+jpaD0i/vREssQ4pM2aNruWDLyBaauwcfRh1WEpACSgBJTCkBIZWfA/p0EbIxfzHqHzuTzz7whq2+dOJic0kN8ZHwDB8iw0gJkZc72x9+MxOwiL2Z1x0ERdNKSZfcuJYVVQP+U1W8T3kSPWCSkAJnC0CIl7DQb8IXC8ebxCX24YlVSzM49OkqkcTnoYjdDSaCUgCszgRtHa7CFoR0ZFQSNqIeJdwL38oTEis6dHvRkMTS4kxk9ki4lc8rOzyEaUcYwReG4dhdZc4c7/fENcBAkH57+P78yZpZ5E2Rj4Su82CxTK4Yy3XlzCygNeLPyAb39JfWPo3RHW0P+nLYhJBbjM2AWT8RpK1U/BU8X22HjLtVwkoASWgBM4kARXfQ0JbXmx8vfR1d9HZ2UevlAkzwtul8Iu86MjLjZQQS83MlAyz8uIyJP3pRd6OgIpvfTaUgBI4/wgYFbBFVEvSspC4pAdFiIcikjslKqDNYoE2MqSfPOsBgTsYUH0qtWtc7+0Po8e/U8nRde3vW/1NTB9vc+Ipxi+j/z3ww7frU8X3+ffU6oyUgBJQAkrg7wmo+Nan4rwi8Hfie/UW6tbtxNXXT8Qq4QBDGGVxXoHTySgBJaAEziKBQUu5RbzVUwuyyZs/hbw5k4jPHEjVFpEcKm9a6M/iOLVrJaAElIASUALvh4CK7/dDT9uecwQGxXdEYiW761o4JuK7/o0d9Kv4PufulQ5ICSgBJTBIYFB8W0V8pxTkRMV3/pwK4rPSVHzrY6IElIASUALnDQEV3+fNrdSJvJVA0OvD29WHt6dPXDXljU5j7PUhUQJKQAmcwwQG4tKtDokrT4rHnhgvyeA0WOscvmE6NCWgBJSAEniXBFR8v0tgeroSUAJKQAkoASWgBJSAElACSkAJKIF3S0DF97slpuePOAKDCX7ezPsz4magA1YCSkAJnIcEjAzsMeqSdB7eWZ2SElACSkAJvA0BFd/6aJz3BAZjCc/7ieoElYASUAJKQAkoASWgBJSAEjhnCaj4PmdvjQ7svRB4M+GaWFQCAalT65ea6wGf1K0NEJYkbGpleS9UtY0SUAJKYCgIHLd0y45oSL6P7U4HSYnJmKUWuB5KQAkoASWgBC4EAiq+L4S7fAHN8cRSYy5XP57+PjyeflwuF4FgEJPJdAHR0KkqASWgBM4tAiZxMze+p31+P8kpqeQXFGO3O86tQepolIASUAJKQAkMEwEV38MEVi97dgicaPl2u110d3bQ09OJ2+0mFAqdnUFpr0pACSgBJRAlEPU+EvEdkT/S07MoKCzGZrMrHSWgBJSAElACFwQBFd8XxG2+cCb5VvHd09Wp4vvCuf06UyVw3hE4VaiM8T33To7TtX0nYThv7et0bU43tkHxHSai4vud3EQ9RwkoASWgBM4rAiq+z6vbqZNR8a3PgBJQAucDAUOkDgjZEKFgiGBI/l3CZswWC5bTZQiXduGwkfNCPtI2HDFhsVqw22wSX22KWp+NHBihYIBgwC8u4AHxDDLk8IBl2ojBtlit2Ow2rGZz9GfGWEISumOc75d8GsHodQc2AYzhmKJt5Hz52CxmTIaB+xQ3QsX3+fB06hyUgBJQAkrgvRIYHvEdbKDj8FHW7ghhyipk9sXFZFpiGJaCImEftO1l95FO9rnzGD26kOlF8ZydyN5eWnZu50hlM74xM8mvKKVEQtnM7/XuaLt3TUDF97tGpg2UgBI4lwgYwjkSFpHrw+0JSL4KM/a4BDIybcT0ddLf3kVAYqRjHM6omLaJqD7RGh0O+nH7Q/T77djiEslKtRFr8uLt66Grz0eMSUSyLJA+SUbpN8Vii08hKdaOU3KeicSWCadO/AAAIABJREFUjySmDLrw9vfS1ysJK2UFM9ksGNcNxMgYnCkkxMUSb5eNgKi8lvPlEwm48fW2y5i9BMxx0saJLSrcT4ar4vtceth0LEpACSgBJXCmCQyP+PasZ//zL/H1n3mxTFvMV76zhKlOWcCHY3bBHiK7HuTXL1Txh9aL+eA1i7nj0lxsw9HXaa/ZyK5f3suzv99C97X/zsW3LeeKVNBUMqcFN2QnqPgeMpR6ISWgBM4gAUOkGtZovy8oAlasz854kjPTSYhNIDneSVKSjYiRRLK3C3/YS39vB73dvXjCVmKsTsSgLdbrIK5+t/zMSWxuGcWjCihNNER1F+1HDrJtfz0ebxBLfBrBhBzyC/MZnW7B6W2jvb6e5h4TocRcsnKzyXC68LdXc+zoMY52Wui3Z5NTMprygmTSw130t9bS3OWmJ5hEbEYh2bmJpMRIfo2GI9QdbaMnIHNITBBLvQjwEziq+D6DD5V2pQSUgBJQAuccgeER397NHHx5Nd/5jQ/LpPnc8fVFVDhOEN+y0Hc3NVHX4cEVAEtCBik5heSkWYh9KyJvM+2NLdS1e/CFzXJuNmlZ8tIgLwxW49xQL5E9f+aPr1TzaNscrrxqPp9ekD3wOzwEulpoaOigo1928GPsWOJSyczLITvFcVygi0uf30tfi4eIvL3YUmJwd7bS3txBX0gkfHwumdlZ5KdK328dm7+NltpmmtvlJcURhzMtRNOzf2Hnc3twL/9XZt10OZekgKaSOXPPvYrvM8dae1ICSmAoCUTwetx4QyJV00opKpR1ztJHS3UT3eLglV6cir/bhbs7QHx+ulieRYi319PSHZQ2IsAjITyyoHqdmSTl51KW6ifOasdNOsnmHllzD7BtXx3dvR5S8keTWz6Dsmwrkaa97Nuxn+ZuD2GxqPvDMQSk/6yycqbnhLEd2sHuvc1Up1VQOH0i8xP7CO/cwJ7d+znojaE7KBbwzFIyJs1h1tgU8vpElG/ZTX2PB29aKmbD1V3F91A+KHotJaAElIASGMEEzoz4/s9LmGQXt3NXA+01G1i1aj+7a1yYk0SWBuVFI8Yvu+MJ5MxczPS5c5iQBE7PYeqqN7J6XS3VjV7MDjkvJPJXYs7MIsBz5i5k9qRxVMT3E7P/YR56+aCI77lcuWwB/3Jxgrjn1bF91To2bTtEV4xJuhGRHQkScvfTY59AzqTLWXZpAZMzTLiaNrHi7ifY2Qy25bNJj3djqT9Eo1gQ6mrlBaZgKrOvvYYF4zLJc0rG7GAHtevfYOPr29jfI+59FhtJWZnychSLe8M6mne1Yb/uTuZ/+FIWqfg+o389VHyfUdzamRJQAkNEwPju8rj6ZJPZQlzRREqLs0n1NXJwVyMd4kJeMCaBcEM1dfsO0uOQNS4plXinHatYlgmKW3nQTNCaT0FpMfnJfXRVbaTdG0fSuIspSgrRV7ePbZX1dPe5SMobRXb5dMpynFjbD3JgTyV1zV34xE8raEsQ8V9ERlEJFXmxpHbv4tienezuSSKYPYlxo7PJT/AR7miivrGH9p4A9pQMsvOzSIh001d/lCbZkPbK9rYjMV7ix9XyPUSPiF5GCSgBJaAEzgMCwyy+/WL5XsgX75nPRFMP9c//kRWPrmdXwXImfOR6bp3kIC5qoK6jtXIvdaZc7CUVlCaIpfvRX7Li5WoOVXyUOVcv5oay47vnbS+zc8VLfH9tHvEzr+OuDydT3P4Uf366kkda57B02cXcfnESZlcrVVWy2x9OZtSkfDKj5uc+OPw8D/xoHSuq87nkizdw69ISbM2rWX33T1lVm4zzY3fxwWVjmSuuetBP1zNf409rjvJqwZe49qrF3FpYQ3/lY9z7SAM7vBdx8yeXcvXUxAHX8shBtj7wAM8/U43v6jtYIJbvxSq+z+hfExXfZxS3dqYElMAQEghKAjSvxGv7Ig4cyZlkZaeTnWglziY+5eKX7u3txdfXJa7jLvq7pZJDdw994t7dE5Y1KDWf0nIR37YOuvdvY3uVuJinTmTS7IsYmxoQt/M9bKuqw+OXUKiEVGJi08nIz6coO5FEXHi6uun1Sjd2p8xIRL1YwZOTxUOsfy+NlZvZXWemP2kio8aXMSbLQWzIjVss8kGJ746Ll/829eNu3s8xyfdS3yXJ2SxxxCdITLkkiIuRRHGDWdDV7XwIHxi9lBJQAkpACYw4AsMvvicv5t/unsF48xHW/fRxnnmyj9xP3MwVH5tG+SlxeUTzbuTp/32c5545hLe8hMSiBIlJk+yqUhg0xuwl2B9DS2sh5Zcv5fpb5M+OZ3n8qb0ivmdzhbidf0bcziU9DKG+NtqOiYCvPsKR5mZaOtvp6ujg8M4+gvETWfC5W7n+ilEkNq7mtXvuY4u3hJw7v8mSqXGUGkFqknSmf823eXjdAf7quJ0PLbuCf87cQu3KH/Dd/UW0jbuDu5cWMEniugeOFvb98Ze88vAWupZ9nlk3L1G38zP8V0LF9xkGrt0pASUwpASMDOQ+jwePz4dHQp8CQQmVyslidGk84c5e+vtNxJVkkZEg69PRI1RWuQikjqJsciH5DlnnqivZXtlAlytIxqgKxkycQkmin47aKvYcaopmKneKmPf7IvglQCsirulG0jar6PuIYUF3e/DH55E2ZgIVBXYcB7ZybNch2nOnkFUxnryYFtr27eVwbRsueyxhI5mLI43YnHLGlGSQZ2mit2YbdS199EQysdocYp1X8T2kD4leTAkoASWgBEYsgWEV3//1a4n5nryIL91zkVi+uzj65B946c8SD15+HVM/ej0fGSNZXKPo3IRbj3DIHUtAkr2UOGo4+OAfWLm6ke4FNzP76nlcUhxPvLHIS4K13vZ26uolw2piFgWFEeIOP8bDLx3gkfZ5XPWBy/nM1AY6N/6Rn/y1hd2RuVxz7SIWTS8iP7YNf90bPPnAOt6oSmXCZ27i2mWjSRLxveabP2eTq4isf/1/LJmRzFgjwDsoLw+rv80j66t5Ou6zXHflEv6p9BC9Ox7if57oZbd5KZ/51GKuHns8vVukWizf9/PsMwfxLb+TRTer5ftM/81Q8X2miWt/SkAJDAUB47srGDAynUt+EYdRrktKgPX20dwg2jY1i9JxifgPHaCuzotpxjwqJqSQ2tPI/iqxhsc4yMmPwyKhVUZpsaCUDQuFQjjik0lJzyTRJvHgkim9vauPgEu8tyRxW6s7SUSxXfKsiAVbkrh19HnoD9gx2zMpKh9PeVkG6cEaanZso6o+iHPcRUyYVES6t54ju3dx4FAjHhmrBIXhNWXgTCln8uRRlGd34q9fS01tN61+2Qg3sp6LslfL91A8JXoNJaAElIASGOkEhkl8b6DqhZXc/YBkO5+yiC9/+3KmGDHf3RJHvf81nnntGFVtZtJy4rBLchcpC4rd6cBUOoPRE2YwK8NCYvd2Duxcx8tbumhyW0lME/c3Sbhmj5OyKY5kiUsbRemEMUwvM5F45GF+92wlf5Js51dfdwWfm9JOx87HeXh1HVvb0xidkyzZYlNIz0sgy97Cjqf3sv9oClM+9zGuu2YsyQ0reeXrP2Z9fwnZX/w2V81OYVxUfPfS/fL/449rD/BE/Of48NKl/Mv0MLjq2fPyKtas3cMxErCmJIt7YCpp2TE0r17F4e1txN7wH1xy0xIuE6u4Jlw7c39NVHyfOdbakxJQAkNFIBIVpwGflBiTICZ7upHoU9YUq9TVdvnkZzE4EyUZWr+foD9MnGQ+N/maaT12mKOtLnrE/dtiMtKaGdeRpUvKlPX3S2x3/jgmTJ/DmCQfLYd3snFPjbidR4hNycecUkRxcQ7FKdLA1Ulbp8RpmxNISkklxSmeZt21NInnWH2rbHhHkgjH5pCRW0SRrKfpNhlTj6yzXZKsNGLHnpxGSpKDeMmC7mqpobGxjV6f7JZLxnarRZLBnZDuXN3Oh+qZ0esoASWgBJTASCQwPOI73IO7QyzdDWKdTkimoCRFrNYn1PnuraWhRsqXtPTTK/FnlqQc0gpKKRVxnHxSSvEgfrGI1x2rp7ZTXPAkq6o1Lo3UnAIKi8XtLqpqJQFaXxNNnW6a/Umkp6dQkGJYov14mmupr62lUVLFuiKxJKSlk5mVhE1qp4bdYZx5ktAmQ6wFvk66jtTTE5KXnoJRpCZKwhvjZUGsCMHOo5IF1k2bOY/M1FTyEgcLpnkIdtVw+KAknWn1SnmWJOJzckiOiEuf20tMZgHxmamkStr1YSmxNhKftjMwZhXfZwCydqEElMCwEAiHxWotSUWl2hjhGLMkKxO38HACKSKIc3PtmHqlUkhjI31hKSkWCEppMiQ224nFbo+W8xoQuSb5eQi/3y+ro1TwkN/bTANVPXyBkMRfSwI0+UhzItKHRVzOzTER+RglyWTNlnXPcD+Pxp9LFnWTJBS1WWJE9AfwSyb2iFU2wqWNzWzUBI9ID0atb/mEpT/pIygW95DJIRZvcWfXOt/D8pzoRZWAElACSmDkEhge8T1yeejIRzgBFd8j/Abq8JWAEhDBLQJWRGxUiIs1PCIVO2x22cYN+kUYi0AWdzGz1YpFMp2bJZlZdK/4FNzChhCW2t9h+aVJhLBFPqbjyc/C8vNoH/IJGye8eYUYOdci58rHqNFtiHL5P7GpEzGuJ2My2hiu7QPft8bvZQzyL9F2kmDNLGU7T6ztfeLQ1PKtD7gSUAJKQAlcyARUfF/Id/88nPupxHd3dwdut5uQvNCe8g31POSgU1ICSmAkExBPsTfV64CsjhgCeUDpniRsB2OpTzXbqNB9y3FS7PU7QHTi9U91vVNd4rRjEtEu+VPFU83I21KMTazkeigBJaAElIASuBAIqPi+EO7yBTTHQfEdFn9MlyQVMurmetx9kmDIJXGQQbHMGEEAb2eTuYBA6VSVgBIYEQSi31YnfmWJBj+VlXtETMZwUxcreSQSxidu8cniTl9QOErF98i4eTpKJaAElIASGAICKr6HAKJe4twjYIhwv88vHymb4/dJeR0/hgtm1Gqk2vvcu2E6IiWgBM57AkYyOJPhwi5/Gp5Izrg4UpJTxU39pGQv5z0HnaASUAJKQAlcuARUfF+49/4CmrmRAXhAdP8jd8gLCIhOVQkoASVwFgnoJuhZhK9dKwEloASUwFkkoOL7LMLXrpWAElACSkAJKAEloASUgBJQAkrgwiCg4vvCuM86SyWgBJSAElACSkAJKAEloASUgBI4iwRUfJ9F+Nr18BIwkq4ZZXaMRGthSfBjBBqO3ERFw8tKr64ElIASGE4CA4njBhJuGOXOjAznZil9pocSUAJKQAkogQuJgIrvC+luXwBzPbHUmEfKi/X2dMmnM5rt3Khpa5TKOblQzwUARaeoBJSAEjiLBKLfy1JowqgBbmyK2mwO8qXEWFJSylkclXatBJSAElACSuDME1DxfeaZa4/DSOBUdb77ertOFt+a7nwY74BeWgkoASVwMoHB72WLxRwV33a7iO+CEpKSVXzrs6IElIASUAIXFgEV3xfW/T7vZ3sq8d0jlm+3WMENy7ceSkAJKIGRQMDw0nnr8U6rNZyu7al+/2ZfRh0wOU4VovMP2x2/wNuN0WhrNhs1viM4nLEivtXyPRKeQx2jElACSkAJDC0BFd9Dy1OvdpYJqPg+yzdAu1cCSmBICEQiIbESS86KoMjgiAmL1SLi1RDkRpkuo1b2qTNYhI08F0E/Acl1Yew3xkhctc1mxWa1Sqz1QLtQMIDP58Pvl3PEEj34vWmSettWm03Ot2EVoTwgto2P0VdYrhnA75VrS/tQSNodn6lJ+rBa7dF+rDJOo5b3Ww8V30PyWOhFlIASUAJKYIQTGF7x3XuUmgO72LHvCDWtbvp88gLhTCYxdyxlE8ZTMSabrNgYJBTsHDjC9NVsoqaykprYCtLKZjItKwaH5oM5B+7NOx+Ciu93zkrPVAJK4NwiEBa17Pf78MnH5bbJ4JLIyRVRa+2luakDvy9MXHwcdoc9Gj9tlsRlg0ckHBJx7KfHayZkSSQjLYHMeBHI3h7aO3vo94aiwtjviyFschCbImtxggO7OYJJBLkpRuKyA/14+zvo7vPiDdulHwdWS4y0CeBxS8JKayzxaUkkxNlwRPW1Ib+lbdhPyN9Pf68Lr1/+W8S7WcS+keRy8FDxfW49azoaJaAElIASODsEhkV8R1yV1G3fyFMvHKMpksaY2WPISpad95AI7YDE39YeoTGYQnjsAuZVlDA1y3jJOPtH5xs/ZdVfHuO11JsYvex2bptsQoatxwgioOJ7BN0sHaoSUAJRAmERzkERzm6/iaApgdSsNFITU4g1O0lLNmOy+Ojq6SPocxN2d9PX0SGb2WHCVieGtTpGrOQer1dyW0hSyeR8ckrHMSrHRnJMEHqOsm1PNdW1Hdid8cTnlJFbVERBSgy2/iaa6xtp7JVY7KQ8cvMzZEPcS6ilmoaaOlp9ZvoDViIxsTgyiykoyaUgUczpPU201LXS4bJiTs0mMzeJJFMfPbV1NDd34RfxHWO3n7SxruJbH3YloASUgBJQAuJPJmJlyKsv+bb9hBeff4aftn6AyUs/xfeXx2M5ibbskntkZz9y3L3NJy8SnQ30m9OwyotDmlOyosquekR20n1ddfQSSzixiBQH2I3d9pAfb3sdrqCJUHKh7MKbkSZyuHA1HeNYbQttsktvvMQkZ+eRNyqXLBHRJznCRXroqq2htr6DrpATe1IakaPPc2TjK+zKvJ7SSz7GTRNMJL0pvj14WmuprWmi1RXGFxNHUpZx7Xyy7VI6Jdq/l76WPlxdAeyZdtn076XtWD0dvV481kwSM4soyU8mfWCwegwDARXfwwBVL6kElMAwEoiIC7gI7/4A5pQCckcXU5TQQ/ehdg4dspBVYsOZEeRoc4DY2ISo+A11H6OzW7zJQrEijE34XbLGRByYs0sozraQZ/fiNmWJ1dqK032YPfsPsLc6jDNuLOPnjmNscR/hps1UVdZzpN0mAt4uYwBzfBYlU6YwLkfW38Y97KqsY39PIglFFUyrKGSMvYGe6o3srGrhWLdY3q2yhkvyNKtYyGMdNuxiWTfc1Q2rt1FO7MRDxfcwPkJ6aSWgBJSAEhgxBIZFfIdaNrJ30ws8/EIDdYEsxs0YT3FONrm5OeTniBDOTjnJohyoe5Xq1x7ktw0T8Y2/jTsXpzE6IYTr6CrW/uLnPN89Gtuyf+eTF+cyMdmHp6WK1365ggZTDmWfvJ5JuRIDd3g7VavXsrXFRastDoe4wskrDWFfPDHOiUydX8G8Obkk46Fjx0p2vbaWTe1mOkSgZ0rG1bj8VGy1m2k6sJ+m0Tcz9apbuWliDAkmEdS1e6h6ZQ3bGsT1z5qAzRQSYS1vKn558bGK+/zcScxfUEAqjex+8FFW/H47HdOnkjm7iLS+WlxtndSIy2BvfxxFi65m4RUXMy0tBqe6tA/5XxQV30OOVC+oBJTAsBKQzVxfSFy2JRFZVjHF4wrIc8gGsgjcQ7WxZJfYxV1c1patB+jpC5KUkY4zVizRdhHNBMUl3C+rWppsBo+ibFQctOym7vAxyJ9F0ehRJPQfYm9lFXsPBaRdCWNnTWDsqDDW7j0cPXCUQ3V+sW7bCYkVPT5T1ujSMkqz4rB1HKR6wzaqQtLfjLlMz3eQ2naU2kONdCN9xyeK0BbBLmMIe/vwuMS13S974+ZYnHbxdJPM5ifu7Kv4HtaHSC+uBJSAElACI4TAsIjvgbm76Tm4k8p9+9nX0EmX142vrxdPl9Re9puJKZxM2dzLuGRqCeMTOgg2b+I3P6tif+9oPnDnIuYX1NJauZpHt/rZ/noMY1JHccVnFzNrXDOtO9bxwLps7MUX8bnLrSS1r+TpJ9fxpx1ZjL/sCj5+XQUlYiVHXhEa1/6Vlb95mv35S5l4y3Vcat3Gaw+t5q+V6cy57UZuurKY3Oh4PbS8+gAvPbmSrdkfZuIHP8mtY0PEtb3Iy8++zoMbUyiev4RPfGQ6Y+T9xiT2+LatL7DqF39mV8JcRt/+rywb7cX1yE948sENHJ3xCWZ/8gZuKBPLg3H5mmfY+NhP+UXHxcRe9Dm+IhsMhQkj5CkZQcNU8T2CbpYOVQkogWhSMyOxms8ncdZBWRsdGaTKJnV2inhuWUWQ22Ub2S+bwJ29BHwicsXtvLtTwrfc4j0WjsNrySBndBGjs01Ym/exb/tuDrviyZu6mJkTCnH2VrNz936q63vE8p2MM7WQtNx8inLixVXcjaenV1zYDRUdwSKx5BGruJDHi3juPszhdVtolNCxpFkLGCNu7LHi9t7T1YOnr50+dwBXTArxGbnkptuJDbbQWXOQxsYO3OY4mUd81Ao+eKj41oddCSgBJaAElMCwuJ1LJlWvR/KiSvZTWcjfPIL9uPr6MGouu5reYOWzu3lpZyZTPvIBbv3YFEbRSe0ff8jrB7qpnfUpyj3HKHEdonn6cqz1e7BUb6N+2kdIcjWTIaL86MRryLloPgssvfhf/za/e3Edf24qJy0hVcR8EI+EpUVkDJFgH5GQF/MEcYGfXMYCz0s8sd7FK5HL+PzHprO8NPbNIXZs/i0bnn2SN5KvYdSyT3FjkY+4Hf/DQ0+v4Pe1o4mNy2RyclBekIy8r/KyEnIR9vcRU7qYCZdfy/JJYkF45AFe+PNOej9wJ3NvuoTFIrANl/vw4RfZueo+flw7A9Pkf+buJbmUJOsjONQEVHwPNVG9nhJQAmeCQFSAS9y2xy0hTuEIHn8aTls+E8aJJTnOTU1jgPiUTMbkS4x352F272+h3pdNycRyJuZJYrW2KvbsO8bh+i4cSRkUTJjF2KIM7P3HqDp4lPr2bhwWIylbDJ6AZCQX13CLkdXcJPZpSZjWI+FSJmcOJZMmMK7ISqhpL5vF2l4TziJ3yiymF9hJaNzPkR27qRcTd789loAkZesN5JFZPJ4505PIDG+j+dBucWVPkCCsVOKc4n5+PDO7iu8z8RRpH0pACSgBJXCuExgGy3eIvs2Ps33dRt4wzSZj5iI+OEeymp8Y/tX5PC/95jUefi2BMdcv58ZPThPxLRvvTS+wfu0qfrwROttLWD5rHsuun8iYlP3UbH2eB97oZMvGRCZl/H/2zgMwivNM/8/2XrTaVe9CEkKiiN4xmOJe4/iS2Ikd+3LJXXKXdkkuiVP+uVxLcpdm3yU5pxef7RgX3MDYVNNBVCGh3ttK29ts+b/fSsKCgAEbgco7sAhpZ77ym9HOPN/bpuOuv7kB8+elw5AIQGr4E57ZdATPnp6ORevW46N3lCJzJFY70I3B9lZ0y+xQOUzIdG7H07/ch5fqsrDqEx/Ah9flwpE8Sz50bCbh/OJWVGd+ELPvehgfLo3C2PMMXti0G787UoSZqzbg0XsrKJ5u+LSG+uBua0JX3AJ5ZjGyzb1o+s1/4/WnquG+9TNY8pH1uDEF5KBHOr3+ZRx5/b/x444FUFZ9At9Yn4kCy3i/PCbe+Fh8T7xzxiNmAlObAOUnoXJiUkSZtDzr9CSGwwOUCE1G1m3y5ppFVmRyOz9wrAe6rEosX1CMjFgLjjc4Ue/SozDNAAdVDYlGqTQZHRqlcmBypRomewZSLQYoIm44B1xwu7oRDXXCLZFoTpgpAWqQvNH6MeAOIBA3ImYupBwmJZhZbEJqkJKinj6GM71BtMXSYUwvxqzybBRo+uFuPISGlj60e2QIyS2Im4qRT67qMwuV0A0cQUfdaXSFTYiqyMquoYUCFt9T+/Lm2TMBJsAEmMA5BMZAfJPlm1bgW44fxM79tWgciEJuMlJ9UnrAiFG9UQoSI086yGyFsM9YiIVl2ZiRNqKU3eja+RRefPyP2JN6I4of/hIemqNFLmV69de+gte+9wRe9pXB8ODX8PEVmagyi7mIqDIPnDVHcXzLHlT3+uDUUcy3nDLByswwUsZVs0lDfc1FycxyFOh9CB7fjoNbdmFnWwwupQHZGQ4qf2ZDonkPOs7UoKf0QSy49WN4YJaI+fbB3XACxzfvwpEOF3q1VOaF5pKACQZ6UDLp1bBPr0LJnAoS0/1o+uWP8eofD8N9+2ex9MGbsM42LL7PvIhDrz6OH7YvgnLeJ/HtDWz5HovfRRbfY0GV22QCTGDsCMRJMJOlO0Ru4yYH7Lm0WG2myiBBCaGAAnoz1dumBd9Bf4ISmsmhk/rgaqtHZx+5n5MFO041wMVdMEZlysTnn9/rppuOEfmzVmBWaRa07jocJrfzOsp2bjDbYM6fgez8POQZyTcsQOLbRe7ucitMKVRCTOOD1E8Lyk2UWHSQMrDT/ZPyp5OwJyu5NRMZueQOb6N7eJDKkbmC5PIujjPDoqTkqL3N6GrtRb+XwrIMOqh0lO18VL1vtnyP3RXELTMBJsAEmMDEITAG4nv05Ck+rZuSrnUOwEmZXEMJGRQaypxKWb9zclLguECFsXjYjVBfL2UHJ2uyLQ0m0uXCbTsh+RHs60JQRsHctmwS1TKMcmof7tQDV3s72tr74aJaozFKu6azZsCeTVnJU5X03agt2o/uxla0d7qoLxLU1nRYyQPdQAnWYlo7NMZU2MmaoDibIt0Hb1c7Wtv6KH49DspnDq0pjdrOQTZNhHalLQJ/bw/cA37Kwp5BlgcrPZQMZVlPhMjd3tWD7gglgCP39RwrZYblhGtX/TeFxfdVR8oNMgEmMMYExOdWLCYhIizgVJKTEpgjEafknso05OdTLW61C+1tXSSsfRTwJKcY8aGM4irKMH5+VnFh+Y6QFVymoPeVcqrBLZGrOSVFoznI5ZQejcQ6dZOsEa4gcSwj6U5R59QqWc6jEcSlMBJychenhWaVKGNGPxfHh6hOOC2lJ13VNbSILtKpifcotosKkNB9MxpFgvpUkDu6mmqQn1NdhPpm8T3GFxE3zwSYABNgAhOCwBiL7wnBgAc5iQiw+J5EJ5OnwgSmHAGVFzcdAAAgAElEQVQhwknMkniOROKIxWUgHUuimazjsTgJWjmV9qI4bRLeQsySqfscQsmficXeBB1LbcSofrhQ8gqFAkp6ic/HRJzeE32QpVy4qY9UGxXHyoQgJ8Et9pdTU8mF47M9JBCnY6IksuN0oPgztInjqH0aqBD0o4zdfzE2BSVgE/1pdXrk5BbAYqG4LN6YABNgAkyACUwhAiy+p9DJngpTZfE9Fc4yz5EJTG4CQyJ6SNwOiWMSuGeF9bmC+72SGGnv/ONHxPjF2n0/x7H4fq9ni49jAkyACTCByUKAxfdkOZM8j7MPqiMJfgIBP2XwpdhEevnp/yIh0egYREbGBJgAExh3BM73177QAC9Xf4+0df7+l+rj3dp/t2MvcpywsIu1AxW5qwtxr9HqkZtXCKuVkqLwxgSYABNgAkxgChFg8T2FTvZUmOpoy3eISt75PG54KQFRMBgkF0yKa7zUQ+dUgMRzZAJMgAlcQwLCeD865lut1iIjk3K3mJJZU3ljAkyACTABJjBlCLD4njKneupNdMR98hw3yvNiJKceFZ4xE2ACTODaEjgbHX528XPIjf5iLuzXdnTcGxNgAkyACTCBa0eAxfe1Y809MQEmwASYABNgAkyACTABJsAEmMAUJcDie4qeeJ42E2ACTIAJMAEmwASYABNgAkyACVw7Aiy+rx1r7ukaE0gWw6E47zi9hrzNLzdL0TUeKHfHBJgAExjvBIaSric3UR18qCwZFST/i4re430iPD4mwASYABNgAtePAIvv68eeex4DAiMJ1+JU5zYcCiFCSdcikRAlXAsla9uKB0bOuTYG4LlJJsAEJjUBsYApFxkr6T8RSYJeb4A9LQNqtWZSz5snxwSYABNgAkzgahJg8X01aXJb153A6Gznfp8PXo8Lfp97uNQYiW+ZsNTwxgSYABNgAldKYKRUY0SKwJqSirz8QmipbBhvTIAJMAEmwASYwOURYPF9eZx4rwlCYLT4HqrzPQCXy4lAIECW79gEmQUPkwkwASZweQTeLWP4OZUeRjV3/jEX2+/8EYwcJ/a3pdqT4luj0V3eQHkvJsAEmAATYAJMACy++SKYVAQuJL7d7gEW35PqLPNkmMDEIHAxYXwpsStCY87NUCHKco3MmXJZjHrz3doa6n9Ua0MFt5Ou46PbH9rvnXYvNu6Rn4s8Giy+J8Y1yKNkAkyACTCB8UXgmohvkfTqgqmuyAVY3PM5Bnd8XRQTeTQsvify2eOxM4GJT2BI2yYQi8YQjUYRo/vfyCbEq0KhpJeC8k/IMOLGPXrWQthK5NYdiUjJZJFiUyiVUKtUFHMtT7YtSVF6SdQ+vcijJ6mpxY7in3gy1WRyX6VKDZWK+qO+xH1YovFI0cRQu5QXQ+wnkqeJ8YjkaUrqR0X9iK/JMb6j+JPjYPE98a9PngETYAJMgAlcXwJjI74jteg8vB1PPn8Cx1qDsNv10NCNPflcQEmvEtEItPlzUbL8DqyelYlpWj9CvgEMSBokNClwGFVQK64MTLx1B2r2Poen+yqgLLsbjy6xI9NwZW1clb2lOvQe2Y+fP+tDKHMm7n90AWaY1LjC6VyVoUzFRlh8T8WzznNmAuODgBC1MRLGIiFZJCZDOKKHyWpDdq4eKm8vXO1d8NJQoyRwFXIS1Gq6N5DQHdmkcBCBUAxeWSosjiyUZOtgVvng6e5EY3s/vReF3mqHPjUTFoMWenmMhPTI0jZ9JUEdo7uNTKWBXqOGOtYJd1cNHSshrC1CdnEhHKY4ZJEIiXCh04cs6mIRQC7aCrjh7h2ALyzRvVgDmRDgo9Cy+B4f1xmPggkwASbABCYugbER36G9qH31dXzjf3xITF+Mv/vKKlRqFRCprpIucvSSKdVQUqIWrUoB5eBpdJx8E285MyFlr8ItFTZkXKFwjtVuxIFXH8d/tS+Gav7f4js3Z6HQcj1OzCn0vvkivvSfLngLluHz31mPRSkavPN4dT3GNHX6ZPE9dc41z5QJjBcCQsDGyAodisTgk0gUW9ORm50Kq0YBjTwBtUEDiYRzNByBUkOWa18XBro64PQDklwHpUJGx4fh9pNlWmVFOsVSF+RnwqYC1IlBDDTX4dDpDgQkGSxmI5mg5bQ/WdWpT2FZT1rLqe0gHQ9HMbJmlGFmegSa3tM4dYKEe5cJ5mlzUDk3FfbgHrQcO4hjHRq4aHFAryFrt1oFrU4HvU4LDVnKk5ZverHle7xcYTwOJsAEmAATmCwExkh870fd62/iu09GoZ2/Gl/4xjKUvguxhLsF/U2HcciTinj6AizJ1yKFrOet7T3YF8iAQxVErr8Gx2r7UNcF6NILkD+3CrOm56JwONdL7MxLOLz55/hp5wKoqj6BxzZkIN9ED0S+dnTUHMPxmiY09IYgQQVVSiHyyioxd3Ye8kzCJk2JuOI9aK3uQ9OZKGyl5Han7kXtfloU6PFBSilCesl8VM3KQ4mdHkrOzsUDf9NRHDt6CkdbIgjIU1CYF4PO04HfPxeFYtoC/O3X12CehcX3tfqFYfF9rUhzP0yACbxDIIEgJXgkfQ1N9gwUFWYhQ+pEzf5mdHgVKJyVBrlnEM5mJ+QZDphsJGyDtEDrFxZyOeLROFVlIAt0ai7Siki4y9ogkwCfvhQObRiB7hpU13UiHFciNcVCVnNyPx+O0RbCOxLywR9RIKLJRX5RHqbZqbxi2ym0tLWjJ2iG20vjyc9H5XwDjOFODLaTFT6uQUxG90NaHJBFgwh7KTFlMICIXA+FxgCNkt3O+QpnAkyACTABJnC1CYyR+D6Cpm2b8M9PnsBJpxIV9OCRopQhEtTDmFqKqptXYdHifHrAGA5Ra3gN1Zv+A99rnInwwq/iX25Kx3RpI9565nn8204DDMVz8ZH1JUhFgFzizqCvvhlba9ORvfAGPPrIIpQJAV6/CYde/xl+QuJbveAz+MYaM3ID27B//0G8Vp8KjTULc3IoZk4WhPvETtS0DaK1+G6sWLUOH6mUQ5E4il1P/Bl/+n0D/AuWoer2+Zih8CDu6UHHqROoOeyEbsU9WPHAbViSChi7t6F673Y8tS9OD0i5mDszG2kaI9KU9eg8eRJ/eFUFw5wb8KmvribxTVb+q33muL0LEmDxzRcGE2AC155AAmESrkGKp1bYi5GTn4tsbRDezgG4Q4AlTQeppxFdNafRHyORrDVRiS4dtGoloiK+O6GBiu6N0wrTkC7vQAOFLnWFzMieu4qEtAK+tpM4SuI7FFckxbeI5xaveJxc3CNhuDzkWWbKRN6MPORqBxBuPoGWriAGo2rIVVoEE6kwp1GIV5EJFrkfvq5uOJ3kzh7V02J2DjKzrbDR/S7Q2YC2hi4MhmkhwGSCgizio4szstv5tb+yuEcmwASYABOYXATGSHwfwJk33iDL9yBCubPw4CcXolRDt3B6cFAodTClWmEya6EdZhlv3ooTr/8EP2mZgcjcz+HrN9pREt6EHS9txY+O5CF/yc34/IPlyEnuT3Fvp7bgZ9/ZjyZDBdZ+8yGsylXC0rAJh0l8/6hj2PK9nizfxjAkijEPkgUhQQ84FFgOn98L16nnsG3PYTzTuwJz1t6Pb3zQAZvsNPb+4gU8v7Ef2lvvwYa/Xokl6qEBRsil/a1f/w/eUKxF5n1/j78qHURs4/fx0utncGbRZ7HirtW4J2t4Monj6NjyCr5FLvfBwqX49GNrMN/Klu9r9WvD4vtakeZ+mAATGCGQdDuPiURpdL8JUyIzlZEWmu1ItVqQatLCqFeRyzm5iNNLLg8h5OpATyt5ZTnDGFRkwppbhPIiA0yBRjQdPowTTb1IZM3BnCWrUZkex0BjNfYdb0aAxHRGugNajUi+Rre0QAgBH93bbIXIKilAsdmDYGst6up7ESJ3djUJaMq1lnRNp+El/y+PR8hdnQR/OIZQSIJXnYJoRilmleZSeFgf/Gf2o7XLReNKIws4taEcSvImNhbffM0zASbABJgAE3h/BMZIfJPb+Wbhdi5BXbUKn/vmSsx4l5TmFxTfoZew49Wd+NGp6ShbugZfvKcQtuRcOzFwfCee+t4BtOjLseyfPobl+UrYRolvNcV8P3ajDXnROjTX1+Bwkwf93ghkZCWIkfgO9NWisSeAo1iC5TffiS98IBN2nMaen7+Gl170IPUDd2LdQwtQSb2JVX/3yY3Y9+df4S3cgIw7P4kPlPTC/cvv45WtXQj/1dex6s4qLD+7knASPbvewDd/Oghf7iIW3+/v+rzio1l8XzEyPoAJMIGrQCCZ4TwmUex1mERtAL5gDG6PGbb0bMyotELW04nujiCUMypQVGyAvr8DNSe9iJqyUF6ViRRFP5xtrahrIws0ifSUtBxyFS9GuiGOgLOTLNlk0Q72U9hTmBaUtcmEaYGIEu6YHfmlhajIpURq7YfR0tyB7mgK5VQxQEfx3DHKhi6s6yKDeixGIpoSvYkYb8qBimjQi35JDZ+1FJXlhagyUh9N+9DS6UK/zEGWbz2L76twbXATTIAJMAEmwATOLtjTA8MFq4C9L0TJhGtv4Fs/D0M1eyU+9601mD2ccO1C7cabtuDYK/+FHzZXIDz/H/HtdQ6Uhp7Htpe34QfHSXwvW4cv3z8NjuTB7eiv3o7f/9t+tBgrseqxh7FSiO/6F3DwlSfwg/alMKz6FL622AfVCz/A7zaexPHKR7D09nW4b14G0jVkBa99Clte2Yyf1lYgn1zJH/twFtJkNdj9xMt4/nkXbPeR5fuRJZhNDycivnvw2DPY+/ST2CpfjfTbv0hu6vRgdPR/sOm1XXghth7ly2/Gwyszkaaici79W1H9yiv43u8pe+ysdfiHb92IBWz5fl+X05UczOL7SmjxvkyACbx/AqI+tij/JSzMGmitVlgt5OUVdKOnLYCYmtzHi62QOij+utNP4ns2phWTZdzVgppaJ5yBBKx0j5CJ0pvCnZxykERIwGstacjMn4YMYwL+/jY0dTgRCjqhlEXgD6sQ8JP1Wm2CMqcCZYWpyAm1oevwCbSRO3mMrO5KSp5GtcggUTZ0uZ7czi1mmBRhRH39GOyjlycMP8j9PYOs5oV5KLIDKmcTWuua0OuVIDNaqOyYelR9cbZ8v/9rhVtgAkyACTCBqU5gbCzf4Wo07tiNnzxFmV3LF+DhzyzBdMr6Ojp2bDT4ePsu1G7/NX7VXgKp8lH8/XIbCsNvYN9b+/BkXRGK5i7DJ27NH7Z8d2OwZj9e+NkxdOhLsOjv7sWCbHI7byHX9e2/x5Pdc6CZ+yA+s0gNa/cuHNy+G/uaw+ikhwmlLh3G7GLMSO1DxNONNztLUDCX4rLvTIdD1oBDf3gLb2zxwnLzeqy4rwrTh8W3p/ZVHHn5GeyRL0LKio/jzkoVMpQeuNsPYf+W3dh7vAMdcQNlsc3AzGIF9IkAdu7VwjR9Ph6kuVdSqTGO+b42v2osvq8NZ+6FCTCBdwiIz50omaKjcXLR1ttgttlhp899NZXyUiop/4eZymhSNvIIJWWTychy7epCXye9AlGEKemZkNyiphdVCkvW7vb7vNBR8rWC8jkotJIFvb0Wx850IBRTw55KVm1yBQ/5A5TdzQRHfgly7WokBlpQ30ieYYEYjCZjsr63KO0ZoTj0iMwMA5UoS3cYQENBIhKiWHEqLUau6RodWcJjbopPp8WBbiozRncrOWU+F1nPRVz56I3dzvmqZwJMgAkwASbw/giMjfgGxbzRantUuLjRar54UHgXr/PkE0ciHkOMHlQScio9RoFpMvpZsmaqqENKDwAK8bPkXIWVgd6jB4qEqE1KdUhFHNtIG1Han+qYUemWoWRuIpN5NBREKEwPRmTHliuohjgluVFSArhEXNQ4lUFBZV7oO3pQEX1S5ldhfRiuSz7UJf2cXPfi9ICUfO/sWMR7FMdH7fvDdDzNVUV1W9X00ELNJduW09wvtujw/k4dH30hAiy++bpgAkzgehAQnz1xuo9JUfEi93MpTpZqKjtmsiIrWee7H66Obvjp3hJTU4I1uhdptJQPZFSdb3HPSAp5YbEmMS/aE9+Le46c7o0qUR+c7nliE/uIl7hviXuiuOHJFUNlwpSiPvdwW+I+mlwYoHuYGJtoMz7s8CZypot731CdbzqO2hf3MAXdt8Q97PyNxff1uLK4TybABJgAE5hMBMZIfE8mRDyXiUSAxfdEOls8ViYwCQmQsBW6NblILISvEMi0qCv8t4VwFi+5cDEX68Tin4tu1A4dJ9oS+11sX9FPUksP7/OuLY7se16fybbF8Zc4HSy+J+H1ylNiAkyACTCBa0qAxfc1xc2djTWB0eLb7/fD66ZSP+5BBMjdM0ZWn3MCGMd6MNw+E2ACU5rAkLY+V9KORZqVawU5uQhAnQkregrFlefnF0JDGdF5YwJMgAkwASbABC6PAIvvy+PEe00QAiPiW1icAiS+Q0EfwiE//BQfKZEFSiFS/F7SvjNBJsvDZAJMgAlcIwJD7u9D7uihcAhGswU5OXksvq8Rf+6GCTABJsAEJgcBFt+T4zzyLM4jcDb+MhJJJjASNXiTcZG8MQEmwASYwBUTEK7tI17y4v9qilvX6XXJWHTemAATYAJMgAkwgcsjwOL78jjxXkyACTABJsAEmAATYAJMgAkwASbABN4zARbf7xkdH8gEmAATYAJMgAkwASbABJgAE2ACTODyCLD4vjxOvBcTYAJMgAkwASbABJgAE2ACTIAJMIH3TIDF93tGxweORwKjs51HJQkhUeOdXiLuO1nb9gK1a8fjPHhMTIAJMIHxQEAkWUsmWqNNp9PDaDInvx/5rB0PY+QxMAEmwASYABOYKARYfE+UM8XjvCwC55Ya88HjGoSHyo15vd5keRzx0PjutXUvqxveiQkwASYwqQmIz1LxUiqVUKlUyf/bUh3Izs6Dgn7G4ntSn36eHBNgAkyACYwRARbfYwSWm70+BEaLb1Hb2+MarvNNZceE+GbhfX3OC/fKBJjAxCSgUCiSAlxU+Ba1vTOzcqhkI4vviXk2edRMgAkwASZwvQmw+L7eZ4D7v6oEzhff7kEhvgcQCASo3FjsqvbFjTEBJsAErjWBSy0gis/Aq7mdFd8yOVm+WXxfTbbcFhNgAkyACUw9Aiy+p945n9QzZvE9qU8vT44JjGMCZBuWieHFky7Z8bj4XkahLskfJn92sU3skUjE6Rh6JXcTx4lY6+Q7iNPC4TvvDe17oY2Ogows1XKFHAoRYpMcx/Cx1PDoEYj63GK/ZDz3u4yNxfc4vuR4aEyACTABJjDhCIyx+KYHiWA/+noH4Q5EEaGHEblSC7XJBluKFTbd++QVC0EKBeAK0cODSg+LUQX18IPOUMtk6ZS86O2LAGoDLKkGaIaeg3ibpARYfE/SE8vTYgLjmIAQw7FoBOFwlF50nyO3bK0ujqgUgSTFKWZaDbVGk3TfPucWRXOKx6O0TxQBScRYy6FRJqCQ0b1LxFxDQe8rICOhLFMIHU5COinEh2X0kGqnRmJDMdgkvFUkppXiZ0oZIgkZQpLQ8jIoqWPRhJzallE7CSH0xT1ZTjHdWnVybBfaWHyP4wuPh8YEmAATYAITjsAYiW8/Qj1tOL17L46eaUJ7JAp/REKYRLJKSQ8Gcj1M+RUoWrAYC4sdyDdf+KZ/SZo9u1G7+xX8YJ8N8cIb8YUPVaLcMtKWG937nsf2rSfwtr8CFauX447V05BOTx+svy9JdsLuwOJ7wp46HjgTmHAExOdNNBpDIBhFjG4sKq2JLM4OpNlSkJkRhdfdg+6ufiSo2kIiRmJcWMNVSigpgZmwisfpZwFPAH5JhXhaEfKLcjHdJoMm3IKO5kbUtgXhD9LCMrl729ItMKiTan1YmAvNHUU8moDKmEr72GBW+xBsrUPLyTZ0+YFgSjYsObkoyLLApggh7HHDH9dDazLBIPci0N2Mzs5eDEhkJdfoYNCoz2YyHzkZLL4n3GXJA2YCTIAJMIFxTGBMxLdU/xTefn0THj9SirT5d+MLH52JQv0IBSr71Hwctd1BdOuLUJCbgeIU1XtD1LMTp3duwn/sSUWsaAO+8rHZKDfSA4mzGk07NuLZ3QH02Fdh/d0rsaDMjNT31gsfNYEIsPieQCeLh8oEJjAB4QYeIc+rUJS0sCkXmdmZyLHIIQ3GECNrt8khg5cUeTimJC8vskp7mtHX0Yb+kAoSLUDLQVbyYBDehAVaWx6m55iR7tCRv5YKSn8jelvrUdMahETfG3R0DC1iS1ES+STYY2TpjoWD8JFTl1/pQEH5DMwuMELfX4v2hkbU+zTwagpRVF6K2flq6Abr0Xb6FOq6/eiXjNBklSGrrAjTM6h8WF89Gk+2oM8Xg8JihVKtJMv7UCkxsbH4nsAXKQ+dCTABJsAExh2BMRHfkeO/xtYtL+BndTORNudW/O3tJcgzaKDRaaHTUJzZ1cLQswu1u17B9/alQVFxG758Tyoy2l7Gc89tx6bWIsy85S589M5y5J5v6pb64W2sxtsHq3GktgNOrwyS0ggLPZBMm7kAS6qKUJwqsruSv17TG9hxuhuveUpRRQ8qFcFqHD7WjsHslZi5/mYscMSg7DqOmv17cehECxp6vAgqrdDYilG2cAEWLC5HiUlB7u7CNTAMX9tJ1B4+hIP0sNPU70ZQPGhpUmAuWYhZtP+KUhvsWrbNv9dLhMX3eyXHxzEBJnD5BEQsdZws2xIkmQWZMypQmkfu3B3HsXeXBF/CjsoFCXT1tqG+0QN7agpSzSrIExESzsqkm7lwBw/IU5FWnIf8VLKEN7YhFNNBXZoLm7wbA821ON0WQFyhg9VsIEv5UJnEBLmMR8iTzOOJIqFzIKOkBAUpQch6T6GpqR9tvUHEjVboimajrDgbOVIHuo4eRXPnIKLmFCTkcbiiegSMxagsz0OFqReh+n1o6vJiQJ4GFVnANSoFi+/Lvxh4TybABJgAE2ACl01gTMQ34lTiqbMaB17direPNKENRqjMFjisVtiNKTDYc5BeXIyS0jyyFNCq/GUP97wde95G3dub8IO9enhUabi9sAeenla8tdMFbzgXcx+8D3d9ZAnmkqteUvDTgw8Ctdj99PPY8nYH/HM2YOGyhVhGFoqErBcdO17Gvn01aMm7E7NvvQt3FQCm5t/j2Rd34onaYsxZtgZ/vW4aHCoydaiMFF8+AOnEs3j27QEcxVKsvbEKq8os0MUHEah/Cy9t78GewQqsvXkBbl9shtbbiAPP7seZXiUsa1agtIQsHTIPEm278OyTu3GwIw1z//oB3LiGxL8IzuPtigmw+L5iZHwAE2AC74UAWYZDwRBZvimcKlVYvjOQZqCwJr8whZMruCGM3rZWdLV2Uex1gtzSSdDSnUgkOQtKFGttSEd2cSkKSTgHW07j4NEgItZpmLs0B9nabnQ31JLb+ZD4tphIfFMst4gtjwRCCJKbe5is7WmFwk09AIms5A1n6P4nVyEYlyj2W4v00nm0IOCAxlOP46ca0OYMwWYlq7dKDueAEv5ABgpnFaOizANZ3040NQ+g25sJlZrc0mmRfGRjy/d7uTj4GCbABJgAE2ACFyYwNuL7nL7INa6vE319XeiiB5H25lZ0NJ7E0R4d3I41uOPuVbhzaSZS6Jgrtvf2H0TDtt/hhxtPYntbFmYtXk9iewXm2DoR2Pxb/H6PHP2Fd+PhB8jtnFzvtJF2SEeexn9sdGJHZBkefWQF7qswvTNaJ1nStz+D7+7JBMo/iMfuTkOJ9yVsfOEQftU6Fys33IBPr82CNnlEHL7GLdj245/i9WY5PLPWY3qWDukiJo8s5olYF06/2YQzTSkkqD+Mux5aiEp6nhmy+nvg7WhES1M32rsGMeCih6PNb6HTb0fux76GW26bjSXiIY6v2ismwOL7ipHxAUyACbwHAiKzubB+S2SFDgQkROVqWmROhUFL1mirHg67nIQ5JT2LKmDWhBH3NKG1vhmN/ZRELb0MRSWZKFCTF1XdURw4Ooj2wTRkzZyPRcuzkatqRWvNcVQ3+hCXG+BItVLSNhLv8QhcAQV8cKCwtIDcxknotx9FS1svuqNGKFRaREM+RKCEvXguSgvSoPdR7PjxOrT3B6C3mijeXIYBjxq+WDZKKgtRkT+IeOduNLW60BtMp8RwemjULL7fwyXBhzABJsAEmAATuCSBMRDflHym/hA6O7rR45gLR2EOSv/CtH0I+372An7+Bw8c996D+z5NLtx0r1cns7uKP5SURvy5lPrsI8v3to34/hZyo8u/CZ/6xDqyYlM7Ist5qBnVf3ocL+xow5lpD+HWezbgQ9MHkDjxZ3z/j61407cADz6yBvfPsSYzwCa3nrdw4q1n8O+H8qGa+Vf42u2pKPa+SOL7MH7VRuJ73Ur87bocDIWvS3CfeR27fvgzbO00IriErOUU2J6tGyrvIkRgjB66NAY7skrJ7T5PAX3XSex8/QhOtIWhLsmjpDxWWFVkxfC04sRLr6K5X4/0j/4TNtwyB0tZfF/y4r3QDiy+3xM2PogJMIErJDBUTkwkXKOkZxSDLUW88Hkl9PVnIjMrGxUzw2hsakBjnwYVCxdhfi7g7WvFrm4dTNZMLMlVQREg9/JBNwb8KorlNsBMidpS0/QwyCgJm3sATo8fkqeHYsN9VNVDCZ8vhIjWCn3BTJTnGJHiaUDDsTPooX415NqupKzqkaAffrLGx+wlKJqWi1L1ILzHj6ChsRNOqgoSEHcvrR3qnArMKnEgL94G54lqtJE49+vt5HauhYqs8xzzfYUXBO/OBJgAE2ACTOAyCIyB+I4jePwl7N/8Gp6r0SCSV4WVyytQ7FBDQ2VP5CLeumE/9p/04Yx8IVauX4Q7F6dBA4pV2/Q4nnv1GLarb8XKO27Bo2syMMou/ZfT6XoLp7a9gP9HlmpZ6c349sdmoNQ0KnN67DQaKPb8D78+gnrHDVj20D24qYQeTFpYaacAACAASURBVLZsxOvbatFRsAzTq6qwiAR7QtaHrr07cOxEB7zT78LcW27C+sw49A2/xlMvHcHPWhbgxltuxOduyQPp4uQW97XAU/0Cntk3gMNREsyLSrCoUJQzI9fChAddZ/qozJkKWfPKUZbvgu/gn/Hj3zThSLAE6+5bgiVF6cggU7k2WINdP/4ZdhwMQvfQt7Dh3gVYTRO/1NrDZZzfKbcLi+8pd8p5wkzgOhAQC6xxcjsnkSszw5adhgyydMu9g+juEKUvyQuKYsC7BvwYCOpQUJCOLGUf+lpqcao7QtU/FDCR+3eyYpiMSn5JCnIlN8OeV4zy2ekU2tSD3sY6nG71UHx4jHKlUCI3ihV3uXXQ2fJRVpWPPGM3XE3HcLLJB69EceEWA5RUaiwWi1BbcSrvqYUxLRfTytKRqQkg2FGPlo4+9EgpMOVQnHguJSGl+95gC7mst4os6EoYKbZcuJmP3tjt/DpcXtwlE2ACTIAJTFoCYyC+BSt6MIm44KKs5nUnTuJEQw/a3SF4o0poTA44CmahYu5MVJXZQc8rw0rWhZ69L2Dn/gYcVS3B7CWLcMtc27CV+SL83bXoPH0YL9WbkEirxO3LcpGtPy9YOtiBvqOv4ZVDEXSZl2DN+hlYmJ6A1HEMhw9S4rOaFnR7KLWawowUsiaUzaGEa+VpSE+atykjTvvb2H+iFdudRSifVY51M220UDB6iyPcewJnDu/DwVPtaOoJIELx4Cp7PmWgnYVZM8pQmkml1RT0lBXuQHP1YVQfOklx31SfnJLeWAuLkFeSAQM9lIX7w1AtugOlVeROSP2z+L7y3zsW31fOjI9gAkzgygkMlRmTyK2cLOAqM/RUvsui10BFYtxkMMJmozJiQS9cg+TWHfLAN+CiJGmUDI1qgMuopJdIoCbaEAnUJKrxHfBT/hMreUrlmWFW0L693egapDwlcg10VIc7TvuKsmNqQyqyKMTJKGuHt7+dEoaqEZVRLLdG1BAfumskLfHhMIlyEuMayrVCXlZ2SvimFvW9xSK4nLKmB11w9/bD4yWXeC1Zu3W6ZI3woaRuw3XEqS0W31d+bfARTIAJMAEmwAQuRmCMxDcDZwLXhwCL7+vDnXtlAlOVgLCACxEeDlPytaCo+U3C2GiE3RGH3z+IwYEgCWMS0HoSzmo1iVkSuARLiNyRTbQRo5rdUSlCbZElnASyQqmi2Gsq+5W0RAtBLPah2HLqK5bcR57cR03x2Yph0Xz+ORhpM0xx6SLDunCTF4vjchL+ota4isajVpP7u5yqkNBw3pHc77TE4nuqXtk8bybABJgAExgLAiy+x4Iqt3ndCLD4vm7ouWMmMGUJDMloEshJ+Uo1uGMxRCn1iBC1SqUimb8k6WGeFNEXkrhD6Ib0+Lk+T6P3f+ftoX1Gf95dDP7QMe/uR/VuY2LxPWUva544E2ACTIAJjAEBFt9jAJWbvH4EzhXflKRowAm3y0mJinxkMaI6vGQh4o0JMAEmMBYELqCdh7ohvX1xyT0WI7kKbQ4nQFUqlZRpneqQk4C3paYhOyePrPHKs8L/KvTETTABJsAEmAATmDIEWHxPmVM9NSY6WnxLkkRuoH4EAxSHT+6coiwQx9FPjeuAZ8kEmMBVIECCW8SmC7d28eGp1xthtlgpZnwoXn206/xV6I2bYAJMgAkwASYw6Qmw+J70p5gnyASYABNgAkyACTABJsAEmAATYALXmwCL7+t9Brj/MSfwbvGMY945d8AEmAATGCcE2FI9Tk4ED4MJMAEmwASmLAEW31P21PPEmQATYAJMgAkwASbABJgAE2ACTOBaEWDxfa1Icz/XhMDomG8R4x2jsjzRKNW0pezDEy7h0TUhxp0wASYwWQmMlDQTXxWUNE2j0XKc9mQ92TwvJsAEmAATmBAEWHxPiNPEg7xcAiPiWwjvACVaCwf8iIT98IukayTClcnEQZx27XJ58n5MgAlMQAKUDC1GLxXVARelzkKhcDJZWmZ2bjJzOSdLm4DnlIfMBJgAE2ACk4IAi+9JcRp5EiMERlu+/X4fPK5BeNyDCFDW82SpsYvWAmKGTIAJMIHJQoAqjscTUJLQVlCpMOH2Y02xISs7j8X3ZDnFPA8mwASYABOYkARYfE/I08aDvhiBc+t8++EeHIDbPZC0ggvXc96YABNgAhOWgFg8vMz4GfFZKGp0i5dItGZNSUVmFlu+J+y554EzASbABJjApCDA4ntSnEaexIUs3wFyOWfxzdcGE2AClyYg6lmLveJJl2yKWkkKVlHPevRny0XbScQRp8U94eoNyJPHKRTvHPuXxwnLNO0fo6/JQ2RUS1tBx42ExJDbOLUn2ozTDmJMyf2GNzG2oRf1Rf2IOtznZzJn8X3ps857MAEmwASYABO41gTGRnwnKNbW60ffID0taPWwpxmgvWpxthJiIT9cfUFIci30Dgv0ajnIsY43JnA2llE8eLL45guCCTCBSxFIkHCOShHKDSFRbDSJWIUSBgMgRUMIh6Lkpq2GRqulr0rSyOfmixACOkJJHX1hEscyBfQq0L0oStbpoe8ViqGY63e2IVEdCIvjElBTmxplHLI4JYUUgp8EuEKhoH2iiNIPEjIlGbpJZNMfOS0MCLO3GEFScIsX/SwukUePEOLkYn7+YgFbvi919vl9JsAEmAATYALXlsDYiO/QPtS9vhXf+d8wlLNW4B8eW41ZWlrV/4u5iaX8AfSfacWZUz7IcvKQX5WPNNpREWhHb98ATgXssNkcmJVOTzXJrQPOozvwx+8dQIuhAiu+8mEsLdTBcW25vYfeyJoi9aJtbzU6XXKoZi5Cbq4Z6aOfy95Dq3zIuQTY7ZyvCCbABC6HQFJ0R+MIBknokgVZTQnJlAoH7NYUZGfG4ff1obuzD7FIGAkSzBJZqWUkpkXWcBlZqIVVOuAJwh9RIZ5WhLxpeSi3KaGVWtDd3IDadj+kuBomoy4pisVnUyQUpEXBMALKNJizS1BeYEWmgUR+XzOOnW5BrysErVaHcJCEvD0b+eVFSNMOQnI5MeCX04KAkkS3sMjTS0FiPOSFt9+NQERCQqOh8SmS4lxsbPm+nKuA92ECTIAJMAEmcG0JjKH4fnNIfM9ejs9+fTVmXlR8O9Ff14rak17IcwqQPzePxDdZBw7/BC9t24MnvHdhydKb8O21ZijoAUkmGxHfh9BmFOL7fiwu0MFOyWUSwgXvqiayHkpak7Q8UMOX1TT5K5IdI+lGeO5iA4nvSA9a9x5B5yCJ71mLkZdnOU98j3IvvOpzubYX1vXqjcX39SLP/TKBiUNAVEMQQjgk0QKwOQcZOdmgtVCEnVH6eRyWdBl89FaAhHWqkT6v/W1wdjSjL6BAWGagj/cYCeQAvDBDaytAWZYRGamapDeWKtiCgdY61LQFSNRrYTEbk/cOsb9PkiGstSM7Jw1FWVYS+3qo40HA1YTqmiZ0uwLQaSwI+GywZBdi+mwdTIO70FR9CMe6tPBE9dBraDwUx60isW3QG6AjM71Oq/kL13MW3xPneuSRMgEmwASYwNQhMEbiez/qNr+J7z4pLN/L8fdfu+FdxHcrmnZWY/fWfqjnz0PJHDWie1/Eoa2vYUtzEG2JHKQYzZhVWYaytfdjzaJUWGo348//+TZq42kovW8mbKFW9Bw5jiYPlVTRzcTMxSuweu10TDNRHF3fCbTu+S3+1JqBwYIP4uGlOSiz0QmOOBGpexXP7B3Egeg83LKmEutLTUhE/fDUH8Gxg4dw6HQH2lw+BKGiB50UWMoWY87ChVhVbkOqRobEYAO69vwKu50GdBgXo5DGEew4iYMtQbiDGqSRwJ6/dh2WlFiQoSJhHarH4T88j1MdCmhv+QiqqtJRnPAhQmOsOXgY+482oak/CFeEEuVoU8ilfhbmLF2I5YvzkUX9sZH80r+YLL4vzYj3YAJTm4BY5IzD6yahHTcivbwCJQVyaHqPYf+uMJxhO2bOB/pdrThdOwCL1Qp7ihbKRJQWYsmpXJIQlEiYyx1wFOaiUHhl1bfBH6Y62mUFsGv74W6uQU0rWb6hhcmgIet5BG6fGmprDnKnZ8EmNSDc2wF/ShUcDjt03jM4ebqRFmYDZPm2wO/PhI0WBCqrTDDBB3+vG6E4OZ7Lxb2I3ODprhQaoAWB3h4Mhsj5XGWgGt7sdj61r2uePRNgAkyACUwEAtdZfIsYtpM4+tRmPPW/rVDceDNu+cKNqJT8iO3+IV7YuQ9PJ+7F/MXr8ffLzNDojGQVGID35BY89YNXsMeVjcKPPogNi/JRqaM484Hj2P3z32J/twGmD30VG27Mw9z+Pah/+bv4t5p89M74LL55awnmZQgzRBdCh36DH73Wgy2RtXj4/mX4SJUe0sAZHNp4GM1+MxzrV6CswACHbACR+m344+M7UO3MwYJPP4x1K7KQO3ASrZu+gZ9sc+NIygO495aVuGWeFaawC6GTT+NPb3Riq28F7r5/FR5elgZ5+BA2f/k/sKNWBcOn/xk331yA2a5T6Dj4Gva50iDlr8dSIdSNEiJtu/H2736Bza4cKNZ9Fn9FAnxe6mXZ3ifCdTdmY2TxPWZouWEmMKkIhEMhhGihU2HJgiM7CxlmEs8Ui00+5lDqJTi7OtDV0omwcDkn2zWFd5NbtwzBGLl269OQXVyKgpQwIq2ncLA6gICxGFXL85Fv6ENf42myfHvpWAVZt1UISPSZnzUNxQVpyIy1ofHoQZzuBdJmrsSssiyoBupwvGZIfBtosTmuTIHWakOmXQtjwgNvTxd6e7y0MEuW9YxCpBfloshOLu6uFnTV1KLbHYJkSoFSTRbw4dsEW74n1eXKk2ECTIAJMIFJQmAciO8aHH92K579TTsUq9bhpi+swxx6eFDt+x42vrkDv048iKWr7sJXlqmHkbfDeWwX/vT9IbfzlRTzvSRPDWHMRrQDdU/9K16vdqJl7pdx04Y5WBvdj+bXv4fvn85F3/S/w1c20ANSurB89yBc/Uf895ZebA2vxAP3LsT9s1PfOa2Jfjgb69DY2I3WjgEMkJX75NZdcCoLMe3Rb+HO24owx3kSHZu/i/88bkXTtH/AF28uw9JM0USYQtlfw59/dgD/u92BVY/egr/9QAn0UjW2f/2/sPMMJfT568ewenUB5mtHugzC11aHM40taOvohauHvtbsxE5pOmQL/gZfvHUWbsxn2/elfu9YfF+KEL/PBJiAyAwurN8SWaQDAUq2lqBEZwYSvJo0pFvNyMqQk3AGWbiVSNHHIPe3oL2xEXVdCUTtZSiano0iTQcGz1ST8B5Aa78dmRXzMH95HgoNXeg4XU2eUwMY9CphpnhwW2EZSnPpc99Xi9PkpXWirgOJlAKULFqHeaUOKPtPYX91Ddr6w5TjhLyetHS/ExnUaX1ahD0pKGmbyPUWp2SjfTEdPJYSVJbT/cNMC8NNe9HU6YIT6SS+dVArh+LLWXzzdc4EmAATYAJMYPwRGGPxHYVm7g34wjeXo+yCcxcJ106S+H7zHfH9+XWYLRKu7founn1zJ36reASr1n4AX140YvUdEd8H0WqYgeVf+hCWjCRcC7Xg1P99D28cd6Fj/pewYf0srInsReOr/4b/OF0I58zP41u356LCQt3GuhHY+1s8vrkPOxJr8cB9S3B/JSXfaTqELS9W46RTDuvMEuTYLbCpQ/AN1KP62U1o9qYi69Fv4tZbizF3WHz/13ELGos+g8/fVI7lOWKcfqDndTz95GH85u0M3PDITfjk3dOgOyu+1TD+zdexYV0epnXtxcktm7G3Sw1/5iwUZeqRYaK1ga5GdB3eiFfJ0u6a9Sl87pZKrC1g8X2pXyEW35cixO8zASYwVE6MhHQ0RiI1Rl/98HtC6OlLh92RjdlzYmhpF0nTgLJ5i7GoWIPIYAt2dZDbtzEDS3I1UIfJvdztwmBARcdTbLYlBTaq7GFQUlI1NyUSpZClQacEtZa8qPLSYdFKCHsGKKkaJVwLSdDp9DDbM5Bi0kIWdsM56IHf241YsAP9HlAGdR2UyTwnovyZKGU2lLDNo6QbWMZ0zCzNxnRVLzx1h9DS44ZH5YBCTZZxyoLO4puvcSbABJgAE2AC45PA2Ijv4F7UvvoyvvYEPRhkzMADn1iIUkoSQ7YGeiigf+PkSpeajvS8VNh15G73x5fxh5+1QL72Vtz+1VswjzSmqvoJvPLaa/hF8xyklyzGx9fkIz27gNzwPPAd3YLffmcPGg0zsfqbD2HFND2t+dMWbMLx330brxwZRNvib+K2m+fiJtUpdO56HD/Z4sZx5Q24+YbpmJdrg8pFVoY9z+KpI3J05H8Yn35oDe4vbUHnno344e/acTpejHV3LcCcrFSkZVKsnvckdv7oF9hXp0LKJ/8Vt39gOhY5j6Ft09fwL9VWnJn2JXztjkqszhPi2wd0bcLvntiPn2/Pwrq/ux2fvb+MLN8H8cbn/gVv1lIc4D/8M+66JR2Ofc/hxcdfwhFZIbJuuRXzi6zISUuHwXsC7W/8EL8+bURD+efwpdvn4tZpXFDtUr9GLL4vRYjfZwJTncBQzHeYyopFKebbmp2BjDRyOQ+50dtJgpwiqtNzgT5fAE6K086l5GgZyn4MtJEreWcI7rACRhW5odO9LFkXPCqnGG0jxWiXoGIuua/r+9DfUIMTjYPw+ONkTafs6LSrKCWWELXDxa0q4IVCZ0Fe5WKU56VA7mrAsZMNaO3uJ7dzSsKWWoTUDEoEZ4hDEXTC2dMDJ2VCDygo50lWHlnmTbBiEN72Jlok6IeHErlpjMZkObSRjS3fU/065/kzASbABJjAeCQwNuJbokQwZw5j007K+NrsTrrBiWzh4kElHpMjFrUhu3IhFt9UhVl2P/oPk+ve7gGgtAIzbpyBfHp+UMb64Kyrxr5d1ThS2w1ZRhnKV92KZVUO6LuP4/CWBvSoslBy00IU26mci6ArOdF54DXUtAcxkL8BFWW5mGGlJ55gOxoO7cP+g8fRQLXHg8Zy5OZlojLDhV4fie/YNCydW4R5OTokwh1orT6Mo0dOob43BFfcAFtxMXIL7TA01yLipYecxbehbHY6CgKdGDy1CVva9ehzrMH6ykyUpCTz2gKekziwswVvN1hQtrwSN8xNg5pi/Wo3bsaZHgXUN9yBigobcsNOuM4cwJGjNTjWQlYUSQNNRiXysszEoRbtEQP6rcuwZkYeZjjY8n2pXyIW35cixO8zASYg6nBHo1GEyfIdUxihNZhgpsRoapmFEqSZkGpPUM1vNwacA2SJ9iLgokVfbxAxJSU1EyW9hJoWrt10T4tSvW6/Twm1MYWyppthVnnhd/aiZzBM71JcNmUiF3eFpDV6+GsoEECManib0/PIzZ1KkQX70NnthIfKnqk1enqPErzRV4tVD4OWrO1Jxy9yQE+Kd4nczz1w9znh9VIfGh1UerKSi4oco+qQs/jm65wJMAEmwASYwPgjMDbie/zNk0c0RQiw+J4iJ5qnyQSuAgHxeRGLUoLLSAhBcgUPBHQklg3kej4kvl2UAE2l0kBv0FM2cXWyXrfQweeL3Hg8CkmKUCb0WNIiriCRrlGLmtwiVvsvE2WKfoX4j0phqt1NxSnltCBL9cOF5ToZj07Z3STKqh6h+t1RGl+UzObimKEqlnIok/vSYsFwH8KaLoT96I3F91W4QLgJJsAEmAATYAJXmQCL76sMlJu7vgQuJL5dLic9VJOlibIW88YEmAATGE3gHXEs5Gs8+TkhPipkMspULry2zrMmX5iesDr/5TtJwXyR7UKiXOw68hl2/mFD1nbx99w2L9bHaPEtFg2sKanIzMol0a66aB98ZTABJsAEmAATYAJjS4DF99jy5davMYHR4tvv85GrqAs+n5tiMv1JS9PQAy+XbLvGp4W7YwLjlkDy0+BSHwlJ0Xvx7UKHv9v+Iy2df9z5x1x0bMM7XryPoWznKrLAK8maLhLLmc0pyM7Jg0qtZvE9bq9GHhgTYAJMgAlMdgIsvif7GZ6i84tTjZ4QZQYOBwOIhIMIBoOQYtFht9FLPWlPUWg8bSbABCYFAWEdHxLfQ67vwn1dpzPAkZaRdFm/mHV9UkyeJ8EEmAATYAJMYBwTYPE9jk8OD+39ERgqJ0QxmBQvGafsxrwxASbABKYWgSF3+GSiNoorV5D7+QX946cWFJ4tE2ACTIAJMIHrRoDF93VDzx0zASbABJgAE2ACTIAJMAEmwASYwFQhwOJ7qpxpnicTYAJMgAkwASbABJgAE2ACTIAJXDcCLL6vG3rueKwJJCvzDId3j2QEvlBG4rEeB7fPBJgAExgrAiMJ1S+WPX2s+uV2mQATYAJMgAkwgSsnwOL7ypnxEeOYwOhs56FQCH6vhzKdexCghGtxqh8kEzGPvDEBJsAEJgGB5KKiSKymUkOv10Or08NgMCa/JuuF03ssyifBieYpMAEmwASYwKQhwOJ70pxKnoggcH6db49rAG73ILwkwmNUbkeuOLduL1NjAkyACUxUAqKqQyKegFarhdFsJgFupJJiVhiMJhbfE/Wk8riZABNgAkxgUhNg8T2pT+/Um9z54ts9KMT3AAIBsnxT5vMR9/OpR4ZnzASYwGQjID7P5OTNo6byYXqyeAvRbbGkJP/Plu/JdrZ5PkyACTABJjAZCLD4ngxnkedwlsDFxXcAMXI7540JMAEmMNoV+0oW5M534T7/2Eu5eI/eP5mO4gqSUFxonCOfd2q1OuluzuKbr20mwASYABNgAuObAIvv8X1+eHRXSIDF9xUC492ZwBQiMGQNjiMejSJG7toJuQoKhQz0F1QRW/xzUe8YcVw0EoYkRRGHnEJYVBRrrYRSSaEsxFB41kSlSPL9KIW4xIczoZ2tsU3WaZV4KRRIgPqnMUTCEiSxr3AfH8mcljwfQ7HaMhn1Q5ZtuVIFtVpFfSlprMNZJMVewzHdLL6n0EXMU2UCTIAJMIEJTWBsxHesH972Ohw41YEGvx3pRTOxaDp91Y9iFeyFp7sBh7tUiBjyUFWaCodOMaFh8uCvPwEW39f/HPAImMB4IyCEsRQOU/hJAJE4oLY6YNImoPZ3w+uPIpDQQ6PVQadVQzmcF2LEbVsI40jQj3CMxLouBUaTHiaZBIT6EQxFEE5oSWzLEIMSci0lPdNqoFORoJfLSKILPU/hLlIQYb8LQUr8GJFpEI2boVRRfLZNA62K2qU+RD9D1nChqoUYF/Hc9C3dFmVSCBGPnyQ7vUnx3UKQj95YfI+3K47HwwSYABNgAkzgwgTGRnwHD6Jx6//hqz/di1dPSJh1w1rc+8jDuG1pMaZphgfSuxcNO5/Ct98ywZ17K77+0BwsSNfyeWIC74sAi+/3hY8PZgKTioAQsOEgCVchnPU26I0W2Ew6WB12mNQJKAN98AVC8PhCCHudJMTDCMXJOj1sZY5FJYiqCc6wGgprNkpLC1Bi10IFPyItu9DU3Ia2oAMBTSbsGdnITbcgRU1tDfTC2e/DQITasqUjI90Gm8qDYMcZtDX0oMerBMy0AJCqJaFOWptCYuJJsR0ly3kcoaAK5rQ8FJRmIlXZC1fLaTQ0ueGPqaAh8X++ezuL70l12fJkmAATYAJMYBITGBvxHTqA+jd34LtP+iDpvViwLIqj3SXILF6Ov/7gbOSTAJc5D6Ll7Y34911GeLLX4Qsfmokqx4gyF8RDkJx96Bn0wx2mElEqA3QWBxypBhjpuWVoI/e/SAQ+N5kHyFqhN8YQ9A7C6aOHF5UJxkQUFpUcCosNKo2CHpjEFofk8yIaJMuFkawPOvXwz+kdsopIHurXoIfapIVa7O7vx0B/P5yBGMJxOZRaK4w2B+xWJbRJM4WE4KCHHvDiUKdYqcSLKmntOLslJPj6g2TpkEFDY9cOuyhO4mvquk6Nxfd1xc+dM4FxQSBptU4KWYkEsAEycxZKp9mRFe+Dv7MDTkMm5CSwzd5OhNQpgMkGS5ySM3Z3o3eAkjOSezjkCbJUk1U8ooMluwBZuenQR4IwaOmzX08ivW0/Olra0Sk5EFNZoRP3ErrnREPeZIlDry8ML903Iik5MM+Yh0UVDhT7O9F3oBqtTjd8VjOi5FYOWhgQ+SjEQkHQH0BQUkLmKEJRcTZKjH5425rQ2jmAiMYAtZ5e5LY+srHb+bi43HgQTIAJMAEmwAQum8AYie/9qNu8Dd/9ZRTGZUvxyANGxLc8i63H1XDd8EncszILC+SH0bFtI767Qz8kvj88G1V2euCJ+hB2VuPAzqPYc6gLgzGKiYtRhB09KMnlepinz0PFsuVYmm2CXdMD/5l9+OP3j6NZsqHywWmwRlrQ0iqhy1KGgoaXoQoMoHXp57Bw0SystVFN1HgjDj35G7zxVhv8Nz2KFXcswzorifdYCw6/Uo0d2wLIv3Uxls1XIFqzFXsPNKK6nSL06EEuHJdAfxGV56B0xWqsXjsX00yD6H/lN9i9vQanZz6AWWuW4Y5sEvziFETOYKBhD373XBwew2zc+9EZKCE3w6FFAN7GggCL77Ggym0ygYlFICm+6d4RDkfQp3RAlTkNC/L1cHSdQMvJBvSnlUCfqoSxcy+aOgMkoG0wGY0wGciqTQu5Iuba56N7j5os1kXFKLWHIXN140ingRZRc1GVJ0HRvR8tzR3oiTogJxdylZzc0yl+O6bU02KvBhoS7wlyZ9dZ7bA7tNBH++BqbUJnt5eWltXQmU1QUMy4nMYaF2Ml13aPZKTF4nyysGfAoaBFgjPH0OGMIKSghV1yN1erKF58VGw4i++JdV3yaJkAE2ACTIAJjKH4fpMs3xEo56zFFx+bj/LYGex77jm8+HYQqes+jJtJ3OqOPo0f71SjN2MDvvjATMyxReE+/jp2/vIZbA3NgPWOR/ChNRkoTRrEe+E99Gf86ul67Bici9seXIv7VmiRaNiKp/51Kw56cjDjMw/i5mU5KBkxxlviIQAAIABJREFUPbf/GVu3HcWv6+Zh7g3r8YmVPigan8eOXUfxYn0WumSzcdO6lXhwaRTKjmfx4kEvdspvx+0LC7Da1Iiuhho0yqbBVFCJ2bahiyXe9BLe/M1P8dRgBVTr/gmfWenADOU+1G57E//5Zz0MM1biM5+tQiGpb++Bl3D0rW04UrAOmavW42a7HAYOax/T3zoW32OKlxtnAhOIAFmUKamZL5SAJKf4ansmsjKs5HauSCZLk0cCkPl74faS6PX6yOrshicYS+4fJ08luakQGbl5KEoLINpejaN1fWjQzkBhxWwsTfdD3rEHTU0kvmNpUGgtIOcqSJTEjfzCyQpOsd9yijNPkJs4ubrbLeR+Hu7DQGsrenuE+KbvLaakezutEpCFPQK3TwFDRkHS1Twr0YzB5jOo6yZPLVp0Nhm1lBiOErslE8ZRH8Mbi+8JdDnyUJkAE2ACTIAJEIExFt9hKGctxz9880bMJFdxWf9utL69GY8fSEOEEtusyK3HlsZ0+O034h8/PB0zbT2o2/Q8/vSjWsiW3YybvnobZpPv95AzepQeUk5hxw9fwYsv+5D5yAdx74eKYKnfiuf/fTdOx4ux5MsfwdJSI9LOntp+tL29Ay/999uQ5i9DyarpUO3eBnmeFVJ+MQY3HoIuKxuONWWQtm/GYFADw50fQWWGAVlJ1/YgAj0taKqtQU1jCzo7++HqaUV3TxMOG1Yid+XDeOzWaZhlJ6t4x2Hs++XPsSNYBP3tH8e9Bb3oOXAULx+yYP5N87BhSfaQGztvY0qAxfeY4uXGmcCEIxCTwghT3LY/Qm7k9FJTSa60ohJkkQjXensQUNihtKXBJuuDt/4o6lp9cFnLUVhZimkGD/ynDqO2tgl1cRtC6RWorCjDXLsfso59FPPdju6wlTzHyeWcxHFCZDIncZxM8EYu78FgGD65FYqMcsyuyMcMfT/89fvQ3OnCoNxOHl20gBwOwC8pIFmLUViYjWL9AFy1x9DS3o+wwUahUYZha/xfomfxPeEuRx4wE2ACTIAJTHEC10R8//3XVmOmlsqlCNjhVpx46dfY+fob2DZgw0nFEixafRO+8JEKzDD70bPnRbz+xCs4al2Kkkf+BvfMUQ+L6SDQ+jJ++/MDeLU2FyseuR1/dVMKlA1v4Zl/24XTsSIs+scPY3m5BRmjTmq05yg6XvshXmgZxG6shlU9F3ffOBdrKtwIHfoFtlTX4nXXTHgHS7Fm4Wzc84FiSnDjQduOZ/DmM9twXFeFrDW3YvUMOwpSZYjU7sCJN36FX3WWIFL1KXzlpmmYm04dJjxAy8v442tteHovMN18BrlzKyCv+hjWFKWgzDTFr7RrNH0W39cINHfDBMY5gQRZoWMxKukloxhqlYjHDlMKjy6ybkehKZ6DHEsM2vbDqBnIAvKXYkmFGqauPehspn0cc2FIpThwUGmxUDhZOiyq0CBGFm6LxYxULS0GU7I2j9uLgLCWOymZmshkLqzdIlSKjolIMYQiFDOuIrepjDJUluWjXN+HAInvlq4h8S1KnQU81LY8BdkV0zEtOwZ57zHUnelDt1cFk5nc3DUXX7Zl8T3OL0IeHhNgAkyACTCB8wiMjfgOvo2aVzbjsSdCUFbdgC99Zx3mUBmxs4nIoq1o3Pxb/PIXm7BxsAqVd30cX/1YFWankLnZT3FudW/ite1kXe7QwpZpQIpGFF8lK3RfHwatJXAs3ICbZ2SjLKUXvtNv4Zff3oXa+DQse+wh3FBpBT1KvbMl3Eh0bsUv/+VPePGYHtM+9Xncd/dsLNZF6OFpFzb952/wm5cGYLjn0/jAxzfgFgfl2UEPmt/ajK3PbEctbFCXFCOLXAQt5BKYGjwJ19Gn8LSzHJE5f4dv3VaG+ZkjMwugf+dv8dJvn8f/9cxC8W0fwWfJnb5YP7zwwJffmBNg8T3miLkDJjDuCQj3bCG8pYiEiNICvT0bOWlmWGVUMiwQREhjpnrZCWgDLoTVZsj0VB4s2IH++ha0dXoQoMSYUWHFFrXAKUlnPEyWc5kB/pTpKCeRvIjczmVtO3DqRBOaAjlk2S5D0TTqw6KAOuyDZ4AypwfC5Dulg96aCluKHnpK6ObtbKYkbQPwROl+aNRQ28BgxAq5tQCzZjiQp2yiOO/9aOqLwZ1wQEex4yoay7k1wEfd3rjO97i/FnmATIAJMAEmwARGExgb8R2jh4yeXtQ0UZZyylBeUu6ARSEbqmE6slGdb3c7xbS5DYhb81GWa4FVMypPeKAbffV1qGntQ5cvCrkuFebMUpSV5qDAOrIfZSb39qO11glfwojUsjzYzSqcW7BMPN744TzdA/dAHNrSbFjt9CCUHEcA7qYuDHQEoSjIQUoOZTKnnybHGQ9Q4rdmNDU0o7GDstfSERpbPtJTNXConRik/iR9AaanGymjOlkuKLYwFo+g98ALOHHoMOpL7sG0RSux3g4oz5k4X4BjSYDF91jS5baZwEQiICzflASNLNDRGMVwk/WbSm9DTYnLLJm5SKUPe7WnBQODPvR76PObMplHyUoOlY7cvBVUQINirGm64g4i3Mgj0QRCIoab6nib1THy4nIn3dlDcTWVMiPrukKdfE8kRSO5TMcmkv2RjEeCSpZJQaqKQWOJi/Y1OroviERrMQTiCsSVZHXXkht81A/JT1VCqLi3TKVPxnm/28aW74l0PfJYmQAT+P/svQd8HdWZ/v/c3nWrercsyWpucjfuNqYEsIEAgbAkIYVsEtI2G/7Zzf6SsKnbEpJAQglZQsImEJqNe28Y96Zm9d6l23v5v+fKAmNssI0lW/I7H1+r3Jlzznxn7ug8521MgAkwgZGK+b6uyPoxcHITDm/dhr0tctiTpmHyrJlYWp6LTEqyw/nVRvdmYPE9ury5NyZw7RMg63WUEpdRDHaQSlOGSZCTAieBTXW+Q1RekjzIo+RSrqTfKZUi+zj9YTwnsdnQkizV4SZr+tBCq1DVMsjlcshpYVm8J4R0iBoTLuoREutRspqLdqRCxNNLRkne5JTdXC4Sp50FLUb7inriEdqf6npQs0P7yMRAPmJj8f1RhPh9JsAEmAATYALXFoGRsXxfW+c4wqOhiV18QiYmT2SlUNAkjkzdH26vGOEhXcfNs/i+ji8+nzoTOA8BIYDP3YQYj+cMpzrb4n1hpX5vEyXCPtjQ+dr5MODD3Z6vrbPdyC/U7oVczc/u87ziO8EErd7w7gLCpY6bbyImwASYABNgAkxg5Aiw+B45ttzyVSBwrvh22gfgoJfH64lbpHgiehUuCnfJBJjAiBAYet5RRRClEjoS3FqdAQlGM3SU0X3Yes/PvBFBz40yASbABJgAE7gsAiy+LwsbHzQWCETIDVS4cwo30TB9f15z1lg4ER4jE2ACTOACBISRXrioy8hdXUqx6nI5hTvRV96YABNgAkyACTCBa48Ai+9r75rwiJgAE2ACTIAJMAEmwASYABNgAkxgnBFg8T3OLiifzgcJXEzsJHNjAkyACYw4gfPEn3/cPuMZ2eMx6kMJ3nhjAkyACTABJsAErl0CLL6v3WvDI2MCTIAJMAEmwASYABNgAkyACTCBcUKAxfc4uZB8GkMEzk64FgoFEQoGqPxPkEoMheg9KjFE2zkV5xkdE2ACTOCKEqB86fH2pFQyTDyTxKNHJEHTGxKuaD/cGBNgAkyACTABJjC2CLD4HlvXi0f7EQSGxXeUSgl5PW543S74fW64PR6q5xumxERUBI5dM/k+YgJMYCQJCMFN7Ys64NFoOF7/Oyk5DWnpWSPZK7fNBJgAE2ACTIAJXOMEWHxf4xeIh3dpBM4tNWYf6IfDMQCv1wuR/Zw3JsAEmMBoERBZx8VanxDhKakZSE5JH62uuR8mwASYABNgAkzgGiTA4vsavCg8pMsncK74dgxSnW8W35cPlI9kAqNI4NyEYZeSLPGjjv2oZGTn9vVR+wssHzW+YfEtk8qQTOI7JZXF9yjeTtwVE2ACTIAJMIFrjgCL72vukvCAPg4BFt8fhx4fywRGn0A8WzdlYgCiJGbDCIej5KpNdavJWiynmGmxCSF8fqFLx8UiiIRD5NodQjhC7t4SKRQKBVRKBaTiOGo7RmEokbDI/UB5ICj8JBI9E5NNYSgyuRJKpRIKuQxSqpc9JKrF/tQm5YoIkst4hI4f3iTUvhibUqWCUkG1tamPoXP44Mbie/TvJ+6RCTABJsAEmMC1TGCExXcM4YFa1B0/jsqmHnTYQ4jK9VAnTkBeSSkmFyUhUX4t4CF35Ggv2o43oa4uAE1hPnLK0pBIM6qhqd8lbBFyce6sxr7jjahpGqR5IU0ohd+hmLxJlZDqrEjOnYSCokIUpKigvoSmR2vXmLMFfQ0HcdhhQdA2HfMmGGHTXKh3N/y9rah4pxNOuRXps4uRblZAN1qDPacfFt9XCTx3ywQulYAQxvRcDMcTIvrg9Ung9+thtmphMvkx0D8AtysIjUYDNb2UZ8T0exbpWFwgu/2U3yGioWRmeiSZSHhHvHA5nXD7IpCTCJeQOPcHSdQrDFDrjUjQkDCXRun3McgQQNhnh8vthTtILuIyBeQkwCNhemTLtVDpKUmamoS2VJTxokUAEuUSkID3ueCxOxEIxyDV6Kgf5VA+iXM2Ft+XelPw/kyACTABJsAExjeBERLfNNnpPYmTb63BwUYvBtLKkGbTwyoJk0XBBWfdKVS1hNBvnoUFt9yAG+dkIUnkwbpqrANA+Bh2/GYdXv27Hdb778VtX56H6ZcznuAxtO94A4/9sh51yMQd909FgYFEtyjEKs7f14Lm061o6kxAxtybsPjWOSixSnBBbXs5Y/iYx0QbN+PE2p/iF3XF8Ez7Z/x0VRaKTRdqtB0Dx7bhD4/vRaNqMhY//hCW5qmAk9txctsp9GfPQtbi+Sil40fjHFl8f8yLz4czgVEgID6n0UgQvkAUvogaWqMJVqsVOrkB1gQVdIYQ7A4nvC4XYkEXvPZBEtNkiZaqICOhK5XE4lZst8uLoMIMY1Yx8rKtyBAPmVAHGqpO41R9NyRSOWJaK6SmDORmpyLHGEbU3o7uNjsGYiYYMtKRaiZx7WxGd3MN2no9cEmToDJnUXK0FKRQcnKppx/2nl70eWIIqM2wpKYg3URWeVcnHdOM1j7KJyFTQq3TkOX8/QKcxfco3EzcBRNgAkyACTCBMURgRMR3tG0Tju7ahCf3mqErvRGPPDQTxdqzqERocrR1LXZvrIZjykpMvnUlZpo9iLR3o7d7AC7SqWFKVCPi5JRqJWIyPVQaA5JtBiSoz0xuwoNwdnfRZMkLb5hcFGmCZbRRNtlEBdQfUPFkWbF3o7O9D4P+CEIyA/SWJKSmmUFzKDFbow5PYO9z2/HWWgcSV6/A/NUTkdjXDw9ZXkJqC4yJ6Ui2KqH7KFN48Djad2/BD570IpS/AN/+8WKUyd5/RwRPv469rz2Jl5wzoJ73NXx9QSryhivQRJ3wdHejvZssN2R9iVHfJmsyMlLJCvNuM2EEXGQpGgzQeUsQlfhpcjgApyeACO2fQGNNTVRBOzzWkAs+yvbd7yfrjFoHm1EFRdxPkvanTOA9A2QVkmpgSTLQ5Jfaa9mJqo2/xK+b8+HMewCPTlchRe7GQFAFqd5GcYtJSNEPn1QnBk/txl/+8wCaVUWY/9h9uCGXLFUdteio7YDXnA3TxAlIo+uviI+fLi5NWnu6+9DloOtCv1WZU2FNSUIy7XMOqkv+KLH4vmRkfAATGHUCEXL9dtMzLKo0wpRTiLxUGeQDPairjEKpVyBpAtA2SGI7qkGWTQ6FuwWDfX30DFIjIlEiGgjCS8I9mEDP5XQr8k0BslobEZIYYIp2ormhGkdresiFXQXbhDLkTMpHrsEFd0slqiqa0O+NwEftQGVC+qQpKMqxwehrQFMNeWp1+gAtWcm1SkhCfvi9VDXB4yMLe4gs7AqYcstQPHUyJpmDCDRXoraiBS6JHDJjQtz6ffafHxbfo35rcYdMgAkwASbABK5pAiMgvu1ofv1/sHPHYZws+Spm3HgT7s2+EIOhKDlhFEa0A3Ubd+HQ7lOopx/9OgVi/c3kCl6LFv0s5N/5CL74iTzMMHRjsO0gduw6jRP1LhLStHOYJjw045GpyaV71g2YMX0yplplJDDJstJdg7odW7GnitoPaqCQktAml0O50gyYy1E+ZyqWTSdXRFThwPNv4u9/a0SgfDoK5mbB0leNziZhpQ7DH83BlFtvxpKVZcgj6wpN286/vU98LyTxvegc8R2E6/DL2PznF7FFuRAptz2Ch6ebka7qhb2xAru3H0VVUy8CFFMYCQ3FOUoNSdBPvgHlUyZhXoaa+u5D7fq3sOU3u9A3MR+mGwqg7qrHQEcnej0heMI2ZM9fioUr52OqRQptx3oc3L4V/3k0B0lTl+G7nypChlDC4SoM7N+IH/6GXO5NM/DVH92CRUkksNv2oGr9f+HJajNaEhbitgw3TJ5OnGz3kDXKD2TMxqSFt+KmaTaa0PbCUbkLL/7iHRLfpVjwL/dgUZYMjk3PYuPvN6F1yicx5UufxvJkIMFZg4ZTb2Pz9no09pHs1lMZHpLbMZqIaxMzkXfDjZhRlIcJhssX4Sy+r+nnDQ+OCcQX4CIUjuMkcS3R0cJiSQFybRS+0tyAEydp8dRiQFqWEzUnq9DaakeCzUaWcApXUinjLuHhIC240rNcqs9GXmE6eVS1obvqCNyaXCROKkeatA8tp0/gYOUgvP4UTJw8BaVT1EgInKTf16O+h5YxKfxJRX8f3EGyvCfmIzN/Asp0boROnUJTXTsceh2CKooZl9LioM4MFa1W0nIwJLS4abYaYVa64etpQFt7F3p9tDig0kKv1cRj08/eWHzzDc8EmAATYAJMgAmcTWAExHczTjz3BHZtrofjxm9h1u0Lscx2GbHTnVtIiG/FmupkmEuW445bSpGmcaB7wwvY9upeHElfhdJVd+D+KRTrJ87IfRDNW/+On2/RwZ67Ct9+MA+TFXuw542NeHaXCalzbsEXHipHYVw1O+DvaMShKorjs2SgbGoCEmLVeOcPr+Hvr7QisOAOLH/4NtyUIolba91H/4yNz/wR+0w3I+uTX8U9JUqkXkh9ByvQ9fZa/PvTJ3GkW4EpM6m8DMUMirhDktEIS+hrVA+jsRBT5k7HlBlZSFSQa/6+p7F7636si96CkiW34uGFVloQoC1UgeZdW/Cr52kimT4PDz+2GFPNYbSv/z3e+vVbqCm8E1Me+TLuKZSANCvQuw/HXn8WT5+0wF76MB69fSLmKHbg8IaN+I9DObBNW4bHzhHfPyDx3W4k8f34sPjehcp1/40nqtJgL/oKvn1nCWbSNRTcIlVv4LmnD2Nbez4WP3IH7l1KvVZtxcu/eBt1yvfEt33977DutxvQMv1+zPrmg1isbUXvC7/BGzu60Tr7s1iyaiFWZZ1JbtR5DI0Nreg2lcCaRfkAWHzzU4oJjGsCYpEsRHHeZEwm67cVpmThrUOiljyR1EqKA48G4RxwwOu0U8IzN5wUX+0h67M/poArmgB9ahYK8hKRFGqlBdpDONbigip3NspnTke6tJss6Iex/wQdH5iI4vJpmDI9BI1rF1pqm9HiSIFUboRSEoIrFEGHIQcp5J0z30z5Pk6eQNPpFvSTFTugUUNG7uRKLe1LHkGSmFjhJe8rM1nXtQGEBjvQQ+J7wEkuSioNiXRtPPkai+9xfevyyTEBJsAEmAAT+FgERkB829G25lfYvvUg3pnwJcy46TZ8puB8YyRzd8QBT1BOglQHvYosC2Le4mvDwOENeGlzI45LS7DwzhW4qTgRNhlNcELHsev3L+OVF46gPz0DxiIbtIEQZaKlcGppkMzlYbKUkCVl9k2463NFKO56Cm+uO4C/KL6E21bchK9Nu1BUOR0bOoE9z23DW2+5kfzJO7DiH8pRTMMRRzgqX8fBV/+ArdEbYF76Fdw/TYeMC2UUC55Ex94NePx3bWhT5WLVg9NRSG6UshhNIltPYu1LB9Gqodjox76BVVMMSImjqceh3zyFtX/djZq0Eqgzk5EY85PLJb1FVvqoLwh7mwJp05dg2Rduxg3pMXStexobfrcRHbMfxLQvfgorEjG0CIFeoOFN/MdTddjaOw2f+9Zy3JlzAsffWo//PizE9xJ8955JSBOrCrHTcB7chB88QYLYUI6v/PBmLBSW79adqNzwS/yqtQS+yV/B95elIp8cBYa2Nhx58vfY8HoDIp/6Gm5+YDKy6zbgzf/ahxr5WeJ7w++x/qlNJL4fwNyv3Y150b3Y9ZM3sbvWiun/8gUsnUNu/x/r1j3/wWz5HgGo3CQTGAECMVqQDAUC8HrJtTscodRnCZQbIwMTc2ixNC2Ejj5KhiZNwIQMLXSBZtRVN6O6RwtDTgmmTjLBFGyg2O5qnKjqRJBiwVOLZqGoaBKSpT1oqj2FwxWD8PmsyC0tQ8lUI4zBKjTX1OF0Jz3XFToS3+G463o4dRJyCiagUO2Ar+IUGmpb4dLpKFZcH0/KFo2KBVNycRdjpbhzlyUH5kllmJepQmJbNZoOV6GbrOIhq5kyppP7+VmZ2dnyPQI3DjfJBJgAE2ACTGAMExgB8U00OnfgyO51eHpDBNH8ZXjwCzdhtk16lqt2P3r2bcaeHQdxOm0B8hZ9Aitz5TD0HkLl3v3YvC8GFblHL7uvGAXvi7FuReWLL2LzqyfROfV2TL5rJVbkGWFVUnmZiIeS8vSjvZXiBJUWpE8kC0XX69i8cQeeO5yH/EW342sPFCBt+GKFBtBxegB+RQJsFHAt3M73PbsJa9Y4YLmTxPdnZqOM+hZe7fZTr+KdV/6IHdKFsC7/R3xqqhbpZ8ewn30DCLdzslT/4CkPAhNvwLceX4qp71rJnejeTNbfraexQ30Hlt68DJ+enUAZz8lN8rXfYNumY3g79V6ULV+Ge6fbYKHjJFFysRwYQGeLAyGKT0wqSINV5ULjuv/Fhic3oL70bkx75GHclXMmoZnrGOrXPoNfva1Ce86D+Po9xVio3Y4Db76Fn+3PRdLcO/Cjh/KQJMbsOUCu/mvx8+c9cGQujIvvBYmUzKidYr7X/QK/OJKKwaKv4/sPlqE8Lr7J5bxlHV58cg82n07D3C/djbtvNENWvRl/+/l+1J/ldm4X4pvG1zLtAcz6xv1YpG5Ay+9/gzW7HXDd9I9YftcMLLecARftg5fi3JvCVqgTkpCdQKV8LjP7HovvMfw04qFfJwSEoBUJ00Q5CXIz10hpjdGOwe4QunuTkDPRgrRMO46cqIddkobZ82agxESLus1tONSugNVsRCHl9hCZzoO0Qhki4S42rckGs9kMrcRHlvJB9Pf3IuhsgEeVClnSdOQZSUT3VqKysg7dA5Qzg3yF5KZMTCgpxqR0OVSDNaippDCjAWrLYoSB8lrE/F6K+fbB4wvAF6TFgpgMkUR6fhYUYlqaHMbWGjQdqUEPxXxHLCbIWXxfJ/cwnyYTYAJMgAkwgcsjMDLim8YSclJc776NOHyKYq1JVMmpHqqaXAmhpMQ6Ukpe4zZQiZZSlC8uxsypGhi6D2Pt73+Hv2xrRE/WDSielIfihCAlzInBT9YLa3oRZi4rxSRlA7pqdmHTvl7UO1QwJ2opwZoESg0lGFNrEZBkISVnImaVJ1ICrwAcdYdxZM127G/3YdCSDItaxHvThI/KyISCycibXII589OQJK/C7t+uwWuv2mG5527c/MV5mHpGfA8e/yv2/d8z2CJdAttN38A/TNch84KW7yNo3b4B3/sVZerNnY9v/fuNmG1W4b2Kal1oWP8K/u+Z7WjMX445X/oHrKLGrIFatFYdxJpdTWh1ABZKLicS98a0FONNVppYwISsiRMxff4EJKu8aNr4J6z/9RrUppTDtHABcqLtCA5Q/KHDjn6nFIayxZi9fAXmiQli6DRaDm/G//31KE4NUjKjKUVIpYRzuapOeJpr8fJ6qm87aQm+8ZNb4zHfwfq3UfHG89jeJUNXyhRkkBu43u+Cy0tJjvoH4TIXI23OStw0VVjEe2A/uRV//Pe30UDZzpf86AEszZFjcO2vseaXa9A040HM+MbncQuZ+I2db+P4wb14cz9NtCmRUloKxW2SY7+SEsbJjBYoCuahLK8A05NEvP7l3dAsvi+PGx/FBEaPwJD49nmpR1pQtIiM45TMUh2iEmF2+uxTUk21ERhwk3cUlf4yq/wIdtWho60dXW4gSAJYxFaL2tvi8x6ghgLkPp5UMBOTp1BlDWkXak8dx+GajngNb6nOAmlCCjJzspBLiSg1wUES+k44Y3rokq30N4Es7L31aG1qQmc/jY3c0K1ZOchIIWu5lPp20fNqkBJgRuhvF8V/m0lkJ8jp930t6GrvQK+LqlgoqOY3lUNjt/PRu4u4JybABJgAE2ACY5HAiInvd2H4utFVW4+GrkH0ecl1XE71Wo3pyMjNQR75bg+Vn6LssvYOVLf2o7XHQxW5/HFXv6CokS0ynwcTYKDY7IlTMpBlUcdrb0f669HS2IQmURqGLCgyKgFjSslC9gSayBlEapyzNyfslMynvr4dPR7KFE5ZcRNo39z8bBKWNNkTGbhjTgy29qGnJwxFcjJsGVSGRtR1FQsJri7Yu8gdHiQQbdlIS5BBfaG03JSt3D/Qj1oqpRbRmMmKQ1nYFe/PgBv19sDZ3oD2UAJiFkowJjKTD7fnakR7E7lYttPkkCqgxVRirBl0XtlIT6CSOPHT6sPpNWT5fmIt2skDIPfOmzAp0E4LHl6EKfuvLbcAEzMNMJ/tNUAWdF97LZqa2tDkpEq1KhuyMqxIMSrQ30sWHakW2QXC2k7uk1Tex9NrhyRBgajCj976RnR0ksVaYoYmMQf5+TQe0/CAyT3eNYiOBjt8UgMsE1Nh0UgQ6m1Bb3MvfAmpSMjKQCIVNB/9aQAjAAAgAElEQVRagKAMwZ1nxkFupQGR7dyWg7TcCZhIdc8/bjkyFt9j8THEY77eCMRLjUXDCJLVOhihnBgyKS3K0rM9RuEoqVRuzOJDb08XPZsGyPsnQn8DyLuJrOQKqn4hU5D4PiuneJgSNoqyY5CpoFar6TlDFSoC/ngN7nidb/G3hN4PUHZzqUIDjZISpFHdbinV7JbGgohSAjc/WbUDMXIZpyobUkrqFqLvRZky4UYup0ed8MQRLuhSytlBKd8QofaCZA2P0F8jmUYbt3ifK7zFNWW38+vtzubzZQJMgAkwASbw4QRGXnzzFRgBAna07lqLfa+8jZ7ST6Dk3puxiCxFH7dM1wgMdNSbZPE96si5QybwMQiIet8krsmFPBCgRcAQiXAl+cMoyJ08FCKBTs5SSrIqi0znJNDFOumFNuGGHqG2oiSPZTIhnIcs5PFD4nXFqaQitRmmRd1ovMQGCWp6XxrfV0ECWlTNGKowIfYV5dDCoj2y0ov9h58tcYFOxwhhLyOh/mFOOiy+P8atwYcyASbABJgAExiHBFh8j8OLej2f0gfFdz/s9gFK6uSNT8x5YwJM4NoiEBev72YJHxK5QhtLJEMlJIc38fsP284t83Xu/ue+f25bl7r/kKb/8DENi29hGU9JpcoXKenXFnweDRNgAkyACTABJjCqBFh8jypu7mykCQyL7yiZzDweqsXrcZHwdse/F+6pQxP6ywwoH+nBc/tMgAmMCwLDolxBuU6EZT9Ez56k5DSkpWeNi/Pjk2ACTIAJMAEmwAQujwCL78vjxkdd4wSG6ghTnCfFfoaCFP9J34tJsET6vvT51/hZ8PCYABMYywRk9LwRLutiMVBvSIDR+G7NxrF8Wjx2JsAEmAATYAJM4DIJsPi+THB82NghQE6sHxorOnbOhEfKBJjAWCTA3jZj8arxmJkAE2ACTIAJXHkCLL6vPFNukQkwASbABJgAE2ACTIAJMAEmwASYwPsIsPjmG4IJMAEmwASYABNgAkyACTABJsAEmMAIE2DxPcKAufmrR0DUihcZziNUSzhC38dTKPPGBJgAExgBAuLpIgqPSUT5MUrqKF6ihJmMMp3zxgSYABNgAkyACTABQYDFN98H44rA2aXGfFRezOkYpNcA3B4PZTuPQEoTY96YABNgAleawFCGcwnUalW8BrichLctMRlmszXe1fCz6Ur3y+0xASbABJgAE2ACY4cAi++xc614pBdB4Nw6306q8S0EuBDfwgrOiY8uAiLvwgSYwCUTGH72qFQkvsnaHRffSSmwWGwsvi+ZJh/ABJgAE2ACTGB8EmDxPT6v63V7VueKb8fgABxk+faSFVyIb96YABNgAiNFQCzuKZXKuPhWKFVIJPHNlu+Ros3tMgEmwASYABMYewRYfI+9a8Yj/hACLL759mACY4fA+TxRhty3P3x77zgqJBj39h4KJxH/Dx9/9j5DrQ3t8177Ii777J/P7EW/vJgxnG+ELL4/6srx+0yACTABJsAErm8CLL6v7+s/7s6exfe4u6R8QuOMwLBAjkSjiJI3ikiMSN+SNpZCJht6SaVSEsZSIZXpvSjCoSCCoRC9wuTBEiVxLA4YktMymQwKEWOtUEJJX8WxgDgmhEBAHCeOiVBLsTP7S8kyrSTLtLBQy+KJGMPhEEJBaj8cpjFFhxI0nmlfHCf+CWEtk8mhJLdypWqoL5lQ72eEf3x/tnyPs7uVT4cJMAEmwASYwJUlMDLiO9iA7uPb8eK6E9jbnYyCmTfi3psnY1qK8r3RO06jq3IP/npKA6+tHJ9cmouJRsXlnV0kgHA0hoiEJlM08aK5G02WQvAefwl7TtZip3wlyqfOwp1FZ/V/eT1d3FG+PgwefgHrawOoMK/CzeUFuCGTJnmjvQV64avditePeFGJKbh50STMy9aN9ihGtT8W36OKmztjApdIIIoQiWF/IIyQ34+gyoCYLR3pBhfM3mZ09Ubg9KkoaZkQ0woIjU1pEhFRJkBvssCqV0Ij9HKERDL9XiYnIR31wO/sQW+/E3YviWYSwOGIEhKFEcakRNgsWmikYcTCJNqlMiglAYTc3Rjo60OvM4pAmNo2036pRujEnwixEiDM6XGzOB1DP0ukJLRJrCvkJOT7OuBo64WbhHhYq6W/N7RQcIYCi+9LvB14dybABJgAE2AC1xmBkRHf/oOo3/omvv9kBQ7U9qBkbiHyb/4Cli+YiRXpMsRlaO87aNj9Nzy+Qw9H5i343kNTMSNJdRn4PXBu+Sm2n/aitvg7WDE7FVM0opkQ3Jv+FS/tOIQXFV/GJ265E9+ZLVT5KGyeNnSveQy/PeTF7pRv4cu3zsE9RVej3Ew3QnufwU/fGsDO2Ap8+f65uLvMNAoArl4XLL6vHnvumQl8GIGwEN1eEr4SHRSJaUhL0sGsVyEq10Ej8UEb88AXUlBpwCDCzi70dPSid5As3xorTOkpSLQooQ464CLx29UzCLtPg4ghGxm5OchPpyzjrhNorDyF090axJLKkFechywjSfeBJrQ2tqK1j/rXpCEpKxu5mXok+NvQV1eBhp4ABmN6aNRKsmTTIq6wkgurfDQIrz8Cb0SD5LxSFBekwRZsQn9THZq6gwgp1FDpNJCy5ZtvfCbABJgAE2ACTOAiCYyQ+D6A2i178OM/BKHJ02PZiiAO7XQirJuG1V+8HVNsEugHDqFl72v42R49nOkr8O1PlWFa4lnim6wgHdWncOx0N9rsIUi1yTBmlKCkJA/FyUJE+zBYewqV23fg4O71OOKSwZW5GBPT8zB7aikmTc+Crfq32LL3HfxV/iksKivEXeZmVDf1o2lQBWPaRBSVl6AgXY/32YKjdgzWHEdFZR0aBqPwxrQwZhYgp7QUJRkaJJwBG2g/gp7BPnTrimEia4iyoxKVjWGE00pRmK+A8sDP8H8HHdiT/FV87saZWF0olhwC8LRVo766BlWtDpo8xiDTJcGUOQmlJbkoSFaRLUdsTnh7+nD6uB8yvQzmTB86Ttej4XQX3AoTdJlTUFiUj0mZKmjfvdBRBHtrUH+KmLQ40SexwmqUIcV3EG9VSFCpWIDPf3ImbisyDh3hIb6nq3Ciqh0dDrIKGdORPKGEJpjpyKZJ7lWw01/kLfvhu7H4viIYuREmcMUICGtwNBIia3cUAz4j9CnZKJtkgNVxHPVNXTihLkKSzoX8UB3a3IkIq1ORrCE38P5+uNw+BCh5WUS4hodIuJMbeYhcwwPkUu4L0++lucik59a0yTpYwodQf/Q0TrTkwVJUjhnTQ1AN7kf1qXrUdGnISk5inVzLA1ES0/R+cWESLD7xXG1AMwlwtV5HFnd13KVdlCX0OrzwywxQZdDicbYGSeEWdNU0o3MgiJjeGHc/l4vShSy+r9i9wg0xASbABJgAExjvBEZMfJ/etI3EdwjquSvw6JfTkHLiZby6uQf7E1fjztum4dakGnTseAU/2aGBncT3P90/BVNt5HbubkVv9UZsOECTsoEkZGaYkKYjSRpxwNnSiE7dRJhm3IgbCyxIspPY3LcHb+98C0ecUniylpEgnYCZZZMwsTQdpponsW39Ovylfx5yS2fj9lKyiFDZqc7Th9HUPojTpqWYtWQpHlpIwh5+9J/ajlNbd+Gw14Bgcj5yTOTWCC88HZ3o6oohqXwJZq6YhXw9eSPufhybNm3AG/67kD1tHpbn0kStl0RsciHycui4/T/FSwed2JvydXzupplYlVpP57UZr+13ocGTTJYaLUhXIzJYi/ba02iyzkT2kntw32QbsvRt6D2wAc8+vgMVSMXE+xej0CSBtq8dTmcbKve2IpQyHeUPP4RFJQakDVSh7cArePmgHdWBLBTm2JBkssKosiPasAvrq1XoSLsNX7pvNm7N98FZfRCvv3AEFYMSpM3NQ7KavBHcvfA6KSN44Tzklc/CDKsMujGowFl8j/dHFp/fmCQQI8EcFOLbAK01HZMKLUiOdKK/z4k2KT1/1b3QD55AZZ0H3Q4VDAlkiT4jhhVC4JKTuR9qRFRGWBI0MCpI0EuV0JlMSFCRKO+uQ2sDCen2EDyRVKSVTEZxGS1ASjow2FyDuoZB9NICbViVAF2SDSkZuchKNMAQ6kLniQq00d+DsNlEi6G0nEmWd78/CAcsMKZkoSRbC629Ea019egJyRDR0jkoyQ2d3M3PTczGbudj8u7kQTMBJsAEmAATGDUCIyu+nwtCPnkxvvXDBSiROtCy7U8kho+hvvABlE+zobD7NfxhvxqdthX4zqfLMMUSQs+hN7Hh13/DAUkREu+4HyvKjMglFRgLtsNdtQZ/fLUXO53z8OBXbsTDC5KgQCcaXvgh1lVF0X3D97FqSSbK4+ZgmoTt+DFe2bYff4vchwUr7sI3F5MVI472KJrfWovvPROGbNrN+N53i1EY2o91z27E8ztkSF+6CLffPJVEthQKiR+uio04suHPeC26AIk3P4Zvz0lAbt3/4NW3NuGP3rtQvvRefHe5gaaGZzZvO3o2/ADPHvFhX/LX8PDKGVg9MYRwwANHUE6TRjUJ7xCiAR8J+wOo3vVnPH3UgoGch4jDFCzJGkTfkU148T/2ot4wBXO+9VmsnKRGvFpsrAkVv/1/eKsKGFj2/2H18kRkHfk71v52C2pzb8KUf/wc7sgBaH2A5qvtcO16Hr/c7MRB9U34/D20AFE4iIF3NuPJXx9DZSwD8z+7HHMnJSMpGkAkFIHMmAiDyQgDecmPkpP+Fb3ZWXxfUZzcGBO4YgRE4rSAj4RtWEqu5CZYKB47OdECLVmQdVIfZFE/fJEYQj4XAoNd6OshF/NADFK1sFqT6I1JEaKXTEIx2cEwJVKT0/MqCYlpiUg1RCBx1KGDFmjbBgEXkmFKykRGBi1E6imreZAWR4Pkwk4WePofIaUVBqMepmgPuisq0drajzA99yTkeu7zxuAOaGGbkI/8XBL6rmq0N7SiqZ/iyzUUP65TvxvjfS4cFt9X7HbhhpgAE2ACTIAJjEsCIyy+AyS+b8Cj31+GyZTIRhJohKNmD55+pRltfQOYkBfCvr48aDKWkOW7CKXmPjRteQUv/mIrqsM6GOcWIIFEqiQskt9QplopJbjx2WBOKcXc26djZoEZSk8tql78OTbVRtE397u45YZCLEgW1yoI1/af4NU9R/E35cO4aelN+NrMMwnXAuSeuGUbHn+aJnzTV+Kb35yISQNr8NLz2/G7QxokUuKdqekKcnMU0zSauMVoYqdSw5c6nVzVF2EVWZtNp/4Hr2/Zjj9GP435C2/HYzdo3/M+dLeje9MP8RwlOtuX8jV8fuVsrMoehKenHlV1LajvcMDtciPgdcPb30XWnxYcdEyEccoqfP2BcizMdKD38BYS38fQmzoNi/75HsxOlUNEa0c99ah46efYUkth87O/htULDTC//Sb++mQ9sOhWLP/mjZhGKwzxMw10InD8L3hisx27wwvx8N2zcEeJcDunZEUdx1Bx5BD2nWhDi91HE2KKc9RaYZm0AOUzpmPuBDpH5XAaobFz77P4HjvXikd6fREQn81IOIAAJVrz+slt3O2BV2tDJIfCiSyDSHU3U6hPOlRJRSjJDEHedwjNDS1ocxnIvVwDJSVXG3rIilckLuR7e+XQWHJRNq8A+YkuuJsrcLK2Dz3OMBQySrxGiThFYrahBOhkzXbSF0UaCqZNxpQCLVTOGlTXtKClNwStVgMJ7eOimPSojcaQZ0VWpB2dJ0+hrd+DsNEKJS0ECFfzC5UiY/F9fd3TfLZMgAkwASbABC6VwAiJ73dQs2ELfvQMie8pC/DNf1uKyeTaHLekxlxwHPk/7Pj7y/jD22Eclc/H0lWUDO3BMpQkhOE8tQ3v/Onv2BcuguETn8Ed82zIGw4Fj3ahtXoQbQNapExMQm6KBmGySlT86adYWxVGx5zv4q6lk7E09Yz43vo4Xtl1GC8pSHwvvxXfmnPGNu2nmPRNW/DDpymmeupyfOdfy1EarcfOv27CKzt9sC29EXfcNRtT3w0GH4Sv9TQqxSTQOglFFinUB3+O17Zux/MkvuctWo3vLdKRReYMfncbujb8G5457MfbGV/Hl+8oxpKul7H5qf/FG6HZsNz2RTy4NAtlVsrO7jiF1q3P4793xFCftBqPfnoGluc4yANgM1742WF0J0/Hosfuw7xMJTlB0sTRXYuTf/oJNp2OoveGx7BqRS5KG97Ajudewg7JDCSt/gLumZuMCeJUB8jLYOOf8NtdQVQn3oEv3T8HdxS4YW9pwvEuIyU9Ihd9ghvPMd+6Dnte+SP+syqfvAE+jR/cU0DjG3t+5yy+L/URwPszgVEgQKW7QiSEvVI9JSkzIElDy5r2NrR5Jeg3U4iPvhtJzlpUd2dBnTEN0/KjUHTvR1PzAHqkeUgg93KTkqzXjn7YB+2weygZGuXjiCrTkJqZi8KJJtjIK6in/iSq2ii3hioViSmJMMmo1NhAB3r67HCE6IFunoCU7BwUZmqR4GlCd00F2h3UltJAidNkcDsoQZs+GdmUI2SChRYl2ypw6nQfnAEZTGZDPAP7UGHx828svkfhXuIumAATYAJMgAmMYQIjJL4Po277LvzXn4KQlczBI9++AcXD4jsOi7LLHnsN6196Ga90FCB50X346l1k/TCTr3PES5luK3F87yHsPdCAdje5KQYjkGvNMCemw5ZZgpwJhSgrNCLNSPbdiBPuk69j1/bdWHdSAnsoHZMXLcP8FSWY0PFH7NlzAK/KH8DiBcvxyIxh8X0EDTt34T9fCEBaPBePfIfc4snKG7bXovfYbuw4Uo/jbR4EoxJyc6S4QGsiUnLSkVU6GZPyJiCX3NFlh5/Aut178VL0bsycfyu+MZdKzgyLb08nerb9DH+ihGkHU76Ih24sxTJNBWq3rseOyl7UuVVUL5ZK6VhogpcaQ2K4EjsbEtBvWYaH75mMxVku9B3biZefOI7upMmY9+gqzExTwizEt6cBVS//Ejvqwuid+Q2smF+A+UYnfD0H8PamPdh7qAXdwnJjykOmRYbUaBOOdCegN3EpPnfXdKyYEKF9K3BkxwkcPkXJg3zk+u6jia6OyvKkURzklFmYUkqeAGYVNFcjQfvH/DCx+P6YAPlwJjASBEQSM6qf7QlSrLTeiuRUG2waskhTXyEVxXfLAtDF3OR2TtnOQ14EBkiYt/SQBZtCf0wZsGZQ3hCbjpJjBigEifJwUPK2iJTqbZO1Wk3HRtxd6O3oQHevE/4o1fq2ZMOclkPPQDUMlEXd6/FTojU1lBTTrZG6EexrRHd7N/pcFDuu1EClpeRtEQkc7gRozZkomGSEVV6HvuYqNJN13R+lOG/NUJz3h20svkfi5uE2mQATYAJMgAmMHwIjI74puU5EZKOleD2QyFTTpEX+AQ9mEbfnhTckQURGQk8pG8oc++5GbbjJWuEJwEexeiCXc5laT4l4aAJGyXbev1FZmCBNsJweuP3klKihDOYGmpRJQ/FxBCnSW0EWC/XwID50fOSm6HfCRW15KUEQRYVDpqIJm94A45nJoug7FvJR1l3KnEtty+VUe/bsMdFEMyomkGGaWFJ8t1ohB50ebRSn6BFt03sRStZDpWrUaspYrqYYSBL6Ucihoh2VMhoDtR30kXs4nbdcQ+MXHpfxjiOIUKw4rUcgRtl7FQpZ/L34FqHMwE5i5iOXTKp5rlSqoSMFLZFQ+3QeKqUYxxl2YbIiud1weCl7MLUlVVKmX4MRZu17NWvH4m3O4nssXjUe8/VAQMR8Rym8JSReJMRDQXr2kPBGYgYyDG5YvE1UQixCzy+qFiEemDKq1U3PLvHECtOxEbKcx2twxzcKQ6JQJPHok4oYcHJHj9fipmex0MdR2jdIpc0iZHEXtcLj+8eDiOgYkaBcfJUroKBwIjnV646ndBMx6fQwFMdKRZgT/Z0Qid5kNA6x70cJb9ELi+/r4U7mc2QCTIAJMAEmcPkERkZ8X/54+Egm8LEIsPj+WPj4YCYwKgREHe2IEONUU1uI3ngMNQloKSlnmYxClKTiRcJbqGJ6T7w/vN8Hnb6HjhPCV7yE0H73GFLeH/ASP7Nf/JgPnO1QX/GXyPcxHC9+kVRYfF8kKN6NCTABJsAEmMB1SoDF93V64cfraX9QfPfDYR+Ax0sJk8jiNjQ5540JMIGrSSD+Kfywz2Jc/L5/e2/3cz/DQmzH/71vG+rj3f/Oem9ozwuFbp+n9YtEJazxEvIworAi8nZSKJRITEqFxRKvUxEX9Pz8uUiUvBsTYAJMgAkwgXFKgMX3OL2w1+tpnS2+fSKe3WWHy0VxoJRhORwJx21ZvDEBJsAERoKAENdCdIvSaApyVTeT8E4wijoVLL5Hgje3yQSYABNgAkxgrBFg8T3WrhiP96IJDJUDGjKJRc+YuVh6XzQ+3pEJMIFLJBC3qQu39qEv4n+2dl8iQ96dCTABJsAEmMB4JsDiezxfXT43JsAEmAATYAJMgAkwASbABJgAE7gmCLD4viYuAw+CCTABJsAEmAATYAJMgAkwASbABMYzARbf4/nq8rlRhmTKpkxljYbSNw1nQmYwTIAJjDkCZ8WMiBJkMpnIcP7hdbfH3DnygJkAE2ACTIAJMIFxTYDF97i+vNffyb2bcE3U7PUHEAh4EaS66L54wrUI1e8VBdM58vv6uzP4jMc6AVGeTGxKpQIatRZKqtGt0mgpwZliKNM5ZxMf65eYx88EmAATYAJMYNwTYPE97i/x9XWCZ2c797jdcDvt8Lid8VJjoTBlO4/X+L2+mPDZMoHxQCAaPVPKS6WCQW+AXm+EnjKJK5XK+OlxKa/xcJX5HJgAE2ACTIAJjG8CLL7H9/W97s7ug3W+B2C398Pr9SJClm/emAATGJsExGdbKpVCSZZugyGBynglwkDiW1i+WXyPzWvKo2YCTIAJMAEmcL0RYPF9vV3xcX6+5xPfDscAi+9xft359MY/gXPFt8lsY/E9/i87nyETYAJMgAkwgXFFgMX3uLqcfDIsvvkeYAJDBESIhShyHyN3bXLYHqo/Lb6I356pex/f78zPUYqpjp71+2GOIqmZNJ7cjPY8z/tDda2H+hFtDNW6pmPOCfGIH35mn3P7EX1IpJKhnAxDLXxgY/HNdzYTYAJMgAkwASYw1gmMjPiOhRAJhuDx05RPTslxtErIOc52rN8rY2L8LL7HxGXiQY4YAZLBsQgilN8gFAwiTDpWPINlsTDooUziWkY/K+Ou2iJbeCxC+4UiCEVioH9CHQ8JdJG8DPQ9vYaEvBRypQoKiq8Wonp4E1o8Su2GQmEEKapDHCWXiP8j1L4McupLKpPTPmGEQyHaJ0ZjGloUEIJdRu1L432IgZJgp/3lChofje3cjcX3iN003DATYAJMgAkwASYwSgRGRnz7D6Nu2078xwsByEvn4pF/WoAStYwmWVdiowml14XeZorhVWhhyrFAS8r+UtqODNShu6cTjZEMGG0ZKEqiiSgvDlyJi3PV22DxfdUvAQ/gKhEQ934kRBn+SUwHoYwbqbUJJtjSM2BTuhHtb0a3PQinj8QuleATwjwELeRaKyzJKUiyaKCN+hDyeeGLyCGhjOJ6DT1bPT0YaG9F94AHXqmKEpyp6SWPC+ZQKAi7y4+gXI/E3ELkZSTCKnUh2H4EHZ1d6AmYqA8FVRqIIijRISElCxkpZljkPgRcPvihgSaB2gz3w9XRiK4eJ9xhBRRaHYlwRdwq/57Qf3/MN7udX6UbjbtlAkyACTABJsAELpvACInvd1CzYQt+9AyJ7ykL8M1/W4rJV0x8N2HwwA7898/b4cqYgYd+vhLT1Jd2/uG2/ahvrMXhcDGSs0qwMFcNxaWo90vrjvceRQIsvkcRNnd17RAgi3WQrM8uL1mP9Tak5KQiTReDIhpEQJEAacgPFb1CGiNZlYOI9DWhpbmbxLESKksyLEYV1CEHnH0ktPud6POQgFebkFo4FaX5GUiR9qK3uhqNzX3Uhg4ynQphP3k3uclyrk+DOSsXE6xKpGjpQUrC2tu8H23NzWjzmOH2a6mPVCTm52NiihJqRwMaq6tQ12KHW5IMdVI+CotykGvxItp5Es2tXeiiY2QqWgxQiUWEITd0tnxfO7cbj4QJMAEmwASYABO4PAIjJL4P4PSmbfjxcyS+J9+AR/9lMcouJL7JRTLsbEdn5SEcPVaFiuZ+2EMShOVGWHNKUDR3AWaUJiFT4kaseTe27dmGNVtP40B1EAqDEXkz8mEsmoNMcqss7G+Easp8WOfMRLEeUMWZeIBgE/Zt6UVLfwomL81Gjuwg6o4dxe7gdKQVzMbtk8jyHXGgv/EEThw8hhOnO9E2GESMLOtKUx7yp5Vj7jyy6pjIHfLyOPNRo0SAxfcogeZurhkCIhY7ShZvbyiGHlUmErNzMDMlCNnxvTjd0AfHxHJYNC6oO0+h1WdCUEPWaQ0NPxhAMEji+YxwD5+JDY9GyUU8Qp5KGhLxE/KRk0YWcH8rOutJTPf4AbWKhHCUrONU4suUhbxsM5LVYTS30zOTBHteBlmoew6htaEeTU4rer2ZtMiZjymTjUjEKbTXnkR1h4Is4QbIqR03CXh9xiQUlBUgQ9WD7roqVDcMQqLUQJegf9fNncX3NXPL8UCYABNgAkyACTCByyRwlcU3BQmSMK575xS27h2AgqwnUxfkIZFi/2T9e3Bw+xH8fZ8V6YsX4zNfLEd+cACDvQdRuXMvnvob1W1OK8N9/7gAxYlmaAaPYPDw63iprQSSojvx1ZWpyNRRVOFANfoPvIy/NtrQPeFefGqWEQWNT2Dt2tfxa+99mHbj5/H4XB9UHRux4WgXjnrLUFyQjenpSsjCnejY8SI2VDpxKuvTWLVkLu4t1VySi/tlXhc+7DIJsPi+THB82JglEBffkRD8FHRtjyZAbUlDfoYJSVIP6esA/KoEKHiPp1gAACAASURBVILdCPfUoqnLA/Ieh0whh5zcylVqTdzrJ0zu41I11c22pkKvilHcNsV3088mDQlqRyNamxrR3k8WbXJnl0lk5EpugyYxG/lFVthCtWivqcMRTzaMuWWYnxmEuucgGmtrUe+20IIAieqJBZiRKYGu/yBa62rQ7jMjqrRCGgvA46WFVcsEpOcXI99IYUUNVWisaoaL3NslJiPkVF5sOCnc2aXG2O18zN6yPHAmwASYABNgAtctgassvs/mHkJooAMd7e3o6rej316P+v3V2LUniMTFN+OT374Ts80Uw4gK9O7chO//1gVf7nx844fLzriduxDpPoKXf7UOpwYSMf3Rz2B5cQK8x3Zi00snECqahnkPLsUEGXlFHvwNNmxbh2f8d6Fs/ifxvaUJ0Ay7nft60NNB4+gg90uqD91Xuxk7q704ofgE7rprBb64NJnGwNu1SoDF97V6ZXhcI01AZBoPBfwgb3CE5Aao9XrYbBRfbTXDQHJZHiZ3c5Ua0qgH/t5mdLT1we4FpFoNJJQcLUJx2SFKihYmi3ggSIKcvI+02RORM8GGLCm5iJ8ii3U1uaqrE5FYUkou5Cpouk+h/tQJHOtXoNc6FZPLp2Fhuh/Ktl2oqahAlSsZfboyTCgqxexcKRLsB0h8V6HNbab2bSS+/XCT+Jba8pBZQG0m+OCrr0R9dSt8JL7lJL5lLL5H+tbh9pkAE2ACTIAJMIFRIjDC4jsE5bRFFPO9EMXnjakmy7erEjVHT2DHO5RwR6pDUqYVGkUAkkA7Wk804vj+MCwLb8KtX78jLr714aNo274Z/+8pLwITF+BbJL6nCxdKsUVdcO19EuuP92OD+hNYntGKArRhi2M5xRQWYfXkIdnsJ/G9Zdt6PBu4C1OWPIDHyj2I1W7D7qP1OEpuklqjAWkmFWSeQfjaDuKdhiBOqpZg9eol+PziNEoRxNu1SoDF97V6ZXhcI0kgnnVcJFE7k1U84PPBPtCPiN6K5KKpyJaR5butHnWhIlgLpmBaOiVgazqAhvo2dEZMiMop6Zl8qJyYeIV8bkrMFkSvpQDpxcVYmBSF5vDbaDjdB2fRXKSWZSMDDrjbO9A3QM9dpQ5hXRJsVgtSdBFK0tYBx2AfBlxhtNdTVnOKC88tT0OKugm9dSdQ0eSHK0RWdArk8fo1SMwrQvHkNCRGW9BWexqn23yQKcnd3aB9N+kau52P5B3EbTMBJsAEmAATYAKjQWBkxLdvPyVcW4/vP2lHYEI5vvDN+SiOx3xTLVgqMxOLyaHSGZCQQGboiqfw6tqdeL6xHCWzF+Ozyych2apHkqQCpzZuxgvPNiM4ZTlWfe8+zLUBCeEKdO7egB//phEdCcW4+9EVmJpGlpgEA8UxUh/hOpwmcf7Hp/biGMUgTrhlBVY+eDfm5JrJnX0IqW//f2HDxjV4MvApzL79U/h2VgWan/1v/OVQAH3zv4jFCwsxPy8VFoUD4WN/wsubKvHXwUVYuWolvn5TBnSjcWW4j8siwOL7srDxQWOYgBDL4TB5DoWpTrfWBpM1CUnaCKKD7RikzOZhaxaMkQFIB3vQpciFKT2Fcmj0or+iAT0+BVR5OZRwjUqJucjTp6cPvYNOeGLkdm5KpcXQHGQkqaH3daK7shrNbXaEKdcGNJQITdQmE7W5KUY8FFPCZ8hGZm4OSmxkZe89gbZWihN3KeAYEBZ3E7S5RZiQk4ikaB8GW2pQ30TiHKkwZRZgYo4ZNkknnE2VaO22wyFJoNJmGqjIPZ4Tro3hm5OHzgSYABNgAkyACbyPwMiI72A9uk/uw182VOJkkwsG/XDdVlF/VkbxhVZkT5uHG26bhakWFxwV72DfAXJRbOqBI0ylb0wZKCylSRll6u053AdVbjHKVi9CQdztnCaZg6dRtX0r9u0nN0iKPQxOWoIF8+bg9oIE6MjCHu08hPrdb+L17mxECm/Dp+cmIcPw3nkHa96g5G4HsD64EBOmLcV9BUFI6JhDBw/jYHUfOgZCiNJEMikzGyXJdjiplM4JZz6mzSzFLeU2dju/hj9ELL6v4YvDQxsRAkJ8RyJUq5tKjAWiCorlNsBoNsCgkkOtUUNjNNNzkbyJvANwBcLwOMnLqLcTPXbKVi6l9yxJsFpEfLeMLNEk2sMRxKhNGZVwlNPzNmAnsdzTCxfFlIfJGi2cmESt7yiZ28XnTSR780VlcKuSkZSagommMGSDNejpptCdYAJZ1akchXCJpyRuioREWJKGEr7JaMyikrhcTosGVM7M0deNfhf1IaXyYxryPCJX+LM3tnyPyO3DjTIBJsAEmAATYAKjSGBkxPcongB3xQTOnaALMSIm6l6vh1xfB+BwDND3VBeeJvu8MYHxSkDc8zHheh4OI0BB2z66/2MklrW2ZJhklGXN0YFBKkUWoHrbQtwKqzJ9VGgxlBY0qUxZkL5GSCTH6CU2EWstJQEs6m0rFbSASl9lMpLe8exnQxSHP2si3jxCSdtEzLgwiFMQeXx/pYK8kcg6HneLJ5d48X4gONSfEO8k4UnIU4JN2ldBfShFH3I6RgzsnI3F93i9c/m8mAATYAJMgAlcPwRYfF8/1/q6ONPzWb6dzsG4EA+TRe88c/rrgguf5PVA4IOCVcSBR+KCmGK5ZWQVl5FFO55/44P7XojQ8GfmTLnt95T3uwdcfFtn9zF81Bkdf67U/sBwolQKLZ7tXKmEwZAAk8kKg9EUF/liG/7sXw9Xms+RCTABJsAEmAATGJsEWHyPzevGo74AgeEJuLDEeT0e+HweBPweeOh7YRGUSmVxax1vTGDcE6Db/Hx3+nsi+kMInGXdvlY4iYUEsampzrhWq6cyaTrodHooVSoW39fKReJxMAEmwASYABNgAh9KgMU33yDjkoAQ4cLNXCSiEjWMw/R9jCxnLLzH5eXmk7ouCAzZyCVk/ZbLhZs6WfLpq7CG88YEmAATYAJMgAkwgbFAgMX3WLhKPEYmwASYABNgAkyACTABJsAEmAATGNMEWHyP6cvHg2cCTIAJMAEmwASYABNgAkyACTCBsUCAxfdYuEo8RibABJgAE2ACTIAJMAEmwASYABMY0wRYfI/py8eDP5fA2dnO4yWX/F74/f54iSORhI03JsAErm0CIi8DVSejamYSaHU6ymxuipcr440JMAEmwASYABNgAmOdAIvvsX4FefzvI3C2+PZ43HDaqc43vdxuNyVdC1PCNSmXG+N7hglcgwREFnbx+ZVRbXEZlUQTCRKtSSnIysqln+XX4Ih5SEyACTABJsAEmAATuDQCLL4vjRfvfY0TOF+db4djgOp8e+PZz3ljAkzg2iYgspcPWbolsCUmIT0jJy7IeWMCTIAJMAEmwASYwFgnwOJ7rF9BHv/7CLD45huCCVwcgWFH7qECXhe3jUb5bxbfF3cteC8mwASYABNgAkxg7BFg8T32rhmP+EMIsPjm2+N6ISAhy7D4J6KjxX0v3LZFvPRwLXvxu/c2ep/cuKPRCOjLBzYRjiGV0Ws4LIOOjcaidEyUjqFjzzki3g9ZqGWixjZ9H+/8zBYX6PHx0LHvjovCPciaHT/uIy4Qi+/r5Q7m82QCTIAJMAEmcP0RGBnxHQshEvTA4fZSrK0PoUAEcYff+OxQDqkmASarBTbt5boSioleCAG3Hz5fFFKtFmqdEgr67UdN7K78JQ4j6HJTUq8wYhoDVFoV1DQf5e3qEGDxfXW4c6+jS0AI20g4hGCQkgoGKEEZCWelKhb/XSgchUKhhEqlgpx+L8R5IED7hiKICXEtRLBIZxYXzFH6Ss9Q+ioSnEGqgFwu4qujCARJqNM7QwnQ4gHZ8bYk4rcxakv8SM9zGfWlUMjIVZxaobwKIrlhIExjoT0pdBuKeH/0E+U7lCkU8dfwAsH5qLH4Ht17iXtjAkyACTABJsAERo/AyIhv/zE07VqHnz5fgcoBGYpKU2CW0yyMrCgxKVlUaDKmMBUiu2gR5s9Mx6RUbVw4X/wWBMKnsPf5rVj/lgvWO2/D0k/PRDHNMy+tnYvv8cJ7NuHwU7/D9g0N8K/6OubdNR8LEwBOD3Ql2F56Gyy+L50ZHzF2CIj7OxyO0KJjCGESxXKVnqzPiUiymJGaEqIEgz3o6ughi3VY6GTal14xOaJqMwy2JKQmJSBBHkHQ7YLXTwJaqaOM4hpoJC54elvQ0dGJARf1oU6C1pqG1DQrbDri43PTQmoAYakaKr0BBmUQIXs7utpaMOAOIiyjnSQkwOUkrtUGKDV6aA1mmBL0sOkjCHU1ob2yAYMh+jNgNsZjuC+0UMrie+zcjzxSJsAEmAATYAJM4NIIjJD4fgc1G7bi8WdDUE1fgn/60UIUvTsumg0Ovo2tL76GV1/rQ8InHsAtn1+JmSRY1Rc9diG+T2D305uwdg2J70+uworPzEbpVRHfzTj8myeweU0dfHf/E264dwGWsPi+6Ct5pXdk8X2liXJ71woBUSov6PfAH5Yips9ASkYqMo0yEsEkosnarU+UwBmSIBSVwaQh67S9CZ0treh0KxHTJcJk1pHI9sFv70Vf7wCJ7CBcYRLlSYUomZqHwlQvgl3HUFnTjy6vCZZkG8x6IOLqwyDt32d3wRHUkedSDvLLSlBaoITWU4mWhibUdwmRLyPBbYJCa6BFUD9kSgPUtmxkWMkC3nkaTcdr0U/iW5JohYys6xdyEGLxfa3ccTwOJsAEmAATYAJM4EoTGCHxfQCnN23Dj58LQ1VO4vvf5qPgfSPvR+Oa3+ONX21B29zPYuaXH8TNaUACAgj0n0bN3kM4dLIetYM00YyRpcWcheziaSifU4qSND105HIuxPeeZzfjrbUkvu++Azd+ZhaKo0FEOitRdfgQDp5sQmOfE16aBsrVFpgLZ2HyrJmYP9EIi5KcLt0d6D34ZxwekKNNPwsZvnYEWk7gUIsP/V41UktnonzpEsyk/ZPOmLEjfdWoPbIf+w/XoabTC0rDi+RJycC+nRg81Q/5Pd/GvNXzsIjF95W+Ty+6PRbfF42KdxxTBES8dhROB1m8pSakFRcjP4MWMttPYv/uCLwyK0rLo2jvaUNDoxuJiWZYDRTWEyZrNYniCLl8h8iNPBAS7uVDWyRIruEKCxJSMpCXa0GitAuOtiq09PhgD2rIZZ2Oo3ihUCRGLuW0P7mth6GH0pyOnAlC+HsR7qlEW3sfegM6cifXQkXPSq/XA/vgICIJ6UgtKkdJugqqzho0HyPxTUNm8T2mbjweLBNgAkyACTABJnAFCYyQ+D6Euq2bSHx3w26ZiNX3T8EEFU0EyWVSEvMjPHASRw93orovD+W3LcatKwuQCif6t72AjdtPYWdsDgrmTMcnppqgoemet24LDh2oxGbHZEyatxKP3JIIi6wG+363DmvWusnyvRq3PDQNuc5aVL6yDxVdchiXLkD+RAOSJQ7EWvfh78+/g6M9qZj5xQdw45JsZDob0PnW9/Dk1g7s09yHm1csxCdmmKAPuBGofg1v7G3Hdu8i3HrnUnx+PsUytu/GX555G283JaD41sWYXZ6OdA25l/urse/5P+Ptwy6o7vknLLtzSHxfbjT7Fby212VTLL6vy8t+XZy0uLf9Xj8CERmUiVlITU9GMlm4oy5StCSpFboAupvJ2t3ciaCI8qH4balMAbVWQzHZUooPl8IfMEBPbt+JKSoohKhWk3u4kcSxrwsDTTVo6eiDN0Yx3HojiW8lggE9FGojbOla6GT0/JbRYqgxAVrY4eusRUtjKwYo74ZMZ4ZGo6N+5CTyyaLutCOsTYJ1YhkKU5RQsvi+Lu5RPkkmwASYABNgAkzgwwmMkPg+gobtb5H4rsZpjxbTZ2XARpO/GE32JHId1NYJyCubiulTc5FFoYJSuBAdOITXfvw6DtQZkPfNL2P54nRMeHfsbejauxXP/udJ9GfPxe3/uhLzbK04/vQbeP1NFyxk+V720CyU0YRzyEjthKujCa3N3WjvGsTgYB1OrN+KVo8N2Z/9Pm67uxQzSXz3bv4RfnVEhhOZj+Jrt0zBimxxLJmIXBux7rm9eHKjDbM/uxoPr+yBY8tv8ctD6bDnfxbfXz0RpebhwbXgyG9/jS1v1cN317cw/5M3YDFbvq/a547F91VDzx2PMAGRVFxYv4W49XrDFGetgjLBBp3ahjSTFlabBL6QlCzVUorJ9iFsb6H473b0eyRkLSexTa7eItt5iALBQ8GhZG2+KIlzSzLyCgqQZyXrdn8tahs60eUAiWkNuYdTe5RALUzHBP0h+MI0CK0JmXkFKMikxUp/MwnwJjR0ByFXaqCn+PFQSIhvJ4nvRNhYfI/wXcHNMwEmwASYABNgAmOJwAiJb4r53rgDPyG3c83MpfjO9+ci70OpuMkafghrf/oq9p/WIfvRr2D5sgzkv3tMCzp3bcHT/1OFwZx5WP2vKzDHSuL79yS+yfJtuXs1bn2wBNndJ3F482Ecb/ZBlpsOq4mSC8l88LnaULF2A1oGDUj9zL/gljvLMIvEdx+J7yeODonvr6wsw425IgrRD/RvwZoX3sEzWxMx+zOr8Lkbe+Dc+iT+551UDOZ9Bv96dz7K3hXfFPNN4nvzW5RwjcT3DSy+r+r9z+L7quLnzkeQgLi3IyS+I5RwTWQVDwZdJHIj6OtPRUZmGkpKgySc69HUp0bJrFmYnq1AsOMUjlS0od8dhdFAYpr8x+MlyISQpy+OATsCJMBTi+dgSlEmEnyNOHmyGnWdDhLSVEVCqTiz/1B6NA9VdnC6/DBll6F46hRkqwfRXl+JisZecjvXIEGvRcDvg8NOlm9DCpIKpqIojSzr7VVoOFIdj/mOJSeShVxBWdDPH/XNMd8jeBNx00yACTABJsAEmMBVJTAy4tu3D1XrNuH7T/ohn7YY//z4CkzVUCbcC54qzQIjDvTt+Su27jxB7t40qZtWhpWTTZSEjawzDTtx/Hg9dgeno2TucnxhhQVGSQV2PvEmXnvdg8RP349V95iRcOJlPPu/9fj/2XsP+Lru+u7/c/de2ntaw3vGjkemE8fZgRDCSOFfoJTVQKG0paUj0FJaXpQ/BUopCTwUHsoOZC87O/GMt2VZ+2qvu/d8vufKimXHThTFsi3rc4IsW/qt8z6/ezif8127Y4244e5N2FBXgpISsexEjuKFb30fL+yJwfTRr+CWD67CpkA7Rh77Ev5tjwb7qr+Iz9+yEjfXKyuMAmNP4Hc/fBnfebwQ6z92G77wR8Ww9LyIXz2wAy/0WNC0ZQNWLy9FuVmytovb+Qv3/wQv7gnBds/f4ab3XYlrHcx2fqF2NcX3hSLPeWeXwETd7GhUg4zKhvzyIslwLho66MNgv9TnNphQUikx3+MBcQM3o05isks1Qxjt6cLRcYvkzShHY7lkNpf7rH98ACPSLhDRSnnEQrhKy1BZ7oQLo/D1t+HIgNwFjRVYUOlCoSGOqHcQo+PjGPdnxNrugrmgBBVV4vJukRwb4+1w9w5gwKfUHNdBb5Q7tgSKx8JBqB2lKG5ajuYisboPt6J7XyuG4ymkHVYpVSahORpJunaGsmMU37O7kzg6CZAACZAACZDAhSMwO+I72YaB/Yfw220pqKubcbO4eVeL2/lb1+CWhD7+DnTulIRrB9txbDyEqCRcM+bVo3bJSqxb34Qml9SuVaqGp7vR8swB7N0bg2395Vh1dQ2KE/0Y2Lsbe/YcQfuoJA1KmeGqq0flAhHPXUcRG0tCv/HdWLSuGk2JYQQO/AqPdqnRk38Ttq6swYoiZYVimgkewJ7n2vDUASsWXLkMW66shlO5RmMHcOy1V/Di7j50jMhYVZUoaq6Bc6AHKklSZNh0G5oua8IiM2O+L9SWpvi+UOQ572wTyJUZExdw8RZHxuCAxWaD0yLCVsS41WKBy5URd/SQWJ29yMSCCI2NweOJICrlwbSOfNhcLjgsehiVhBRK2UcxfatEAGuycs9LeOHzjGPMI55CSS20krXc4sqHw26CRSd1vkX4ZyRsSILIpXa3xIqnAggHRJCPhyUGXQ2NQT9RB9zkgMlZCIdR6o4rtcMVI7tyW1XyfSj/qcVqH/EjOOJFRDK0Z01G+dmp/99A8T3bO4njkwAJkAAJkAAJXCgCsyO+L9TZcN55T4Die95vgUsegGIBV0R4PBFDLCqZzqMWWG0WyXCellrcPng9YegNRlhEkCvu3WoRy+mUEuMtX0mxPItlOqOoYkUQizJWqdTQSjy43iAx5Dp9LrO54tauxHoncvHe6Zy7ey5NughptfRRrNY6aasX0a3VileT/EyJR0/J+ErM92TftIyjzKWSGuBK9nSlvrdWkrLp9ZLUTdam/Oz0g+L7kt/CPEESIAESIAESmLcEKL7n7aW/NE+c4vvSvK48q1MJTFiTpWRiThFPCOqUJEPLiVsRw7nfn9HX6ISCPodAczHkymxnnfPUySZjzl+veXbaWii+z+HF4VAkQAIkQAIkQAIXFQGK74vqcnAx75TAVPEdDosLrtcjbrjjCMnflURVikJQrH08SOBSIjB1R0/W8Z5r56d8dpX/lBcIk4nhCgtLUFldm7O08yABEiABEiABEiCBuU6A4nuuX0Gu/xQCU8W34v4ajUTENTci7rPxiZhV6m7uGBK4qAlMuMJPfFCtVhsczjxxhT97us6L+mS4OBIgARIgARIgARKYQoDim9uBBEiABEiABEiABEiABEiABEiABGaZAMX3LAPm8CRAAiRAAiRAAiRAAiRAAiRAAiRA8c09QAIkQAIkQAIkQAIkQAIkQAIkQAKzTIDie5YBc/jzS2BqzLdS+kgpsZRKSTboTFoqK83VVFTnlyFnI4HTCeTisOW/iWzqOmikXJhaSpQpx+RnjtRIgARIgARIgARIgATenADFN3fIJUVgUggownsi2VoIiVgUYfl7UoS4kriJ2c4vqUvOk5llApmM5CCXF1dGqeltNluktrcJJosVRqOJ4nuW2XN4EiABEiABEiCBS4sAxfeldT3n/dmcXmos4PMiGPDmxHdaLOAnihHPe04EQAJvh4DyuTLo9bns43bJPm63O2EwGim+3w5EtiUBEiABEiABEpj3BCi+5/0WuLQATBXfkUh4os6334OIIr7TUuebBwmQwNsioARrKIW/9DrdROkvVz4cDpdYwA0U32+LJBuTAAmQAAmQAAnMdwIU3/N9B1xi50/xfYld0Dl+OpMhDm+Wb+CtwiBO75urgH2iDvaZ8Ewnt8Hpc75ZH4rvOb4JuXwSIAESIAESIIGLhgDF90VzKbiQc0GA4vtcUOQYMyGgCNpTEv5JmIOESwNqSU6mlmRlE/nJXj+UtllJBJhMJuQrDSVPwWRKQLVaA41WC51YmzXSUX1i7KySRDAtSQSTKSTFk2Myh6Ayt0YSoWmlvVaSosl0OWv1KSkGFcF+Ys6M5D9Q+meykkZN1qfTSSI16XdGMa9offmi5Xsmu4J9SIAESIAESIAESOAkgdkR32kfwiPdONIxArffBmdxPRY15aPMdqaHuyzi3l4MHjiO7nHJSl1Wi+rmGpS7DJhI58ODBKZPgOJ7+qzY8twSUIR0Ih7PhTikoIbOngeLNglNZBShKJBQm2EymSR2WgdkkkgkkoimtVDpzbCadDBqRWTLktQqCY/IxJGMKgkDE8hotJJdXJ8T6jFJW5BUS8IzowFmgwh0aa9RZaDOJpCOxyTJYBTJDKCVpGhaidFWRPvkMSH04wgk1UjJGE6LATZtAtlEGNGEiHpooZc+GklKONUSTsv3ud0nHI0ESIAESIAESGD+Epgd8R3di87tv8CXv/cKHtqjwvIrbsA9996D266oRfkp1h95SowfxpEX/4DvfOcFvPJiFLVX3Yqb/+bD2HpZCapm67p4jqCnvQ3b+/PgqGzG5hWFcGhPPqTO1rQcd/YJUHzPPmPOcCoBxWKdjEcRF2GcNbpglEzgLocFeYWFsOtT0ASH4QvH4BcFHg/6EJDvgbQRamsJCkvLUFFohl0VRNQ7itFgBgl9PvIK8pCnEyE91g23ux+9nhTCKifspdWoqipBpTMLTWgE46N++LI2mAqLUWAV0R3ox3BvL/rHRbyrJTu5xZgT05lsCtFwAsGQ3OfyKlDW3ITGIg1s8CMx1IrDHcMYCapgtVhyLwcovrnLSYAESIAESIAESODcE5gd8R3bjY5nX8Q/PeCDN9KFVdeoMVr5PixZdC0+tEQs2icEeDbpx9jT38drx4/gJf1y9D0fQJHGiZWfex/Wry1D9dTzTQUR8gURiIh1XC2umEY7nPKAaxYjUu7IKJafCPxxHVQ6M1yWqWI6KRYksTLF1VIiRw9jchBjg4M44rHClF+KJTUOmF9/KZBGKiwPtP4wYooBSmOGxS5zWWXON/BPIB7wwx+Uh+qMDKA1weJwwG7Wig2Jx4UgQPF9IajPzzlzbubpFOLiAu5LmKF1lmJBfQFKMmOIjI3DZykRq3QattAYoqZCsYRbYY4OYri7B+6AiO+iBaivMMCRHEBvVz9Gx4MIi/t5JKODurQZNQubsTRf7muH9uDY4UF4KlagctVCNGhHETywHx3tboyIa3pEbUDcUgZDWRNWNbhQmXRj6NARDPrFnV2s7ypxJ0+IRTySNUBTWI+6AhuqrCLyTXZ5WxACRlvQ2jmC0bBWspjbKL7n53bmWZMACZAACZAACZwHArMkvnfh+NMv4ms/SsKxJA833GjAzieTgKkJd31qI5rtahGnPsRHDuPn3z+KsbgK6292of3JYzh63ISln30/rlyviG9Rv/FR9MjD566X96Fz2A9vWCw6WrO4YbqQv3g1Fm1cj3WlFhSp3PC1voif/+YADmcasf6eu3DLQidc8S6MvfwkfnNAg7GyK3Hr1dVYrtuFA8+/iB8eqkDh0ivwydvrUKQWy9DAEXTveA7PHx1Aqych+FXISAylKX8Biusvx6a1dVhZl1zDLAAAIABJREFUaZG1xxBo3YOW3a/iFfc4ev0RZJMiznUGGGz1qG5cjSs2NqG+3AT9ebiInOIkAYpv7obzRUAR35mUvIBLpDCsK4Wlog7rKnSwd72GzmNuEcuLYXckYeqTl5HDKYxlC+C0W2CS+Gqlr0riutVqcerOZk7EXqvF1VzuLX6xeBfUomLpYiwtlN8f2onjB/sxXrcG1avkvpIdxPj+vTjeLj9TG5EQl/SEqgBaxwIsWVKJhvxRxPteRldfCAMhpwwvbuaGYtjKqtFYY4Cqtx9DXWG5HTegrFJeKY4clbGGMBLSUHyfr83DeUiABEiABEiABOYlgdkT3089i3/+UQLmjdfgox9wQP3IA9jba0L8jr/CdSucaPa8gL6dD+JHnk0wL96E9+cfwsH7n8W29jws/fMPYvPlJSjxHsHwsz/Ez/Zp0F3xfrzv1jW4qky5TiLkhx7Hr/7vQTx8tAJX3nU17txagzxEEDj0e7z4wn5sO16MiloLSgtS6BqwoXyp9N28GOWihnXuR7Dz2e34xr46lK+7FX/z7jwUBJ7F73/+Ih7cl4emG27Ce9+1HE1KGdt4GzoPubG3y4bipgVY15RAoudx/OSnB/HyyAJc9b7bcPNVlahULOci9A/+6qd4ZnsLBlZ9AOtuvQG3Voml/bRES/Nyp52nk6b4Pk+gOU1OQOfiqCWxWjAmrt06J/JLSlFeZIFd3HuySqK1WECMy8Pw+EPiTRNCPBZGJC03BI0JRnHv1koyNUm7lqtBHwmHEY5LbLe1ArWNtWgsVUHnbUV3azuODabh0xejqKYBzVX5KDbFJFeGWKvHo4ipjNAZxaquN8Ge75DY8THEh55Fe+co2sZKkTGXoU6Edn2RzDt4BPtfG0FvogpN6xZiRb14+gy1oKVt8IT4tsNooNs5tzcJkAAJkAAJkAAJzAaBWRTf23PiW7dyK77whTos8P8Bv3nQjUc8G3Hnu2qwLNyGV353DIaNm7Hh1oUo8LyMR77+NHb0FmHF59+PG9aVwHD8YTzz9e/j6Z4kAksuR7E1C7M87Co5gVXaKEaP+hGJlmHVh+/C1jtXYpH4eivO5pmhV/DS/d/Fj5/sRV/THdj6qY/ifaucKJ8k6H4Mu55/Ft86IDHoG+7E569OwLLn6/jOSyG8UPw5fObGlbit7iy4B19F65PfxL+312Kk+V7cd1MlluVNsby2/hQvPv0/+PbYzai47MP4x+tckNxxPM4TAYrv8wSa07xOQNlzaUlkFovFEU6J9TqtkvATJ4pqa1FszEIf8iBmKIRBXLotiQF4ujswOBJAVMJjspJMLSXB4nER5CprIQorq1BZJvcMlQehvnaJ9x6A6GsJpbFAJRbypGLFFmu3UUm4pleymsv9UBKm+ZN6xGxVaKyvRoNpAKH2F3GwI4oRyypUL2pCc54XSfdeHBD39Va3BZbCJizesAgLq8StXQT5oWOD4qaegcMmlnmzSSzyExnapx7Mds5NTwIkQAIkQAIkQALvjMDsiu8HEtAuuwpf+MpGLFIF0PrQI3jy/2xDvFRiwBdtgN92Nd67qQ6b68LA2A787788iz19hVj++Q/gehHf9u6nsf+H/4mHB4oRveKj2Lq2RNww9dDKQyiSEt89HkIkLnGKlRUoKXPAIqI82bsTR/f14LkeKY0T75AH1hA6VWuwYsNG3LpBXC8VXu5HRXw/lxPfZZffgS9u1cLZ/VP86MFjeMR3PW5/9xb88UbnSZfxuB/jQ1FkLDY4dG6M7fkJvvN0FEeMt+ITH7wKNzZInHnuOqThff67eOKRx/GE671Yct178YmVVtgm49Lf2bVi72kQoPieBiQ2OWcEsnIvSqVEAKska7lSEiwlydRGBxFK62BtWoUqUwAa90EcDdTCuGA9NjRL9M2QJKQ8ehxdUSvCcMDmKkBBaQmK8wxyzxpDcLATfQMjGIsoolsypEsCN4Ne3MUlF7rkTpPvcYnhlntfMIKwJKaIZbQwlTageslSLBK3d5OEz7TvO47WTB70CxZjSZFZZokgHpWs5kkVEiLUdXorHAV2OCzyKjMq4Tzi6h4OjiAlX4EYEMtKaI/Eik8tJ07xfc62DQciARIgARIgARKYpwRmR3xHX0HLo0/ib78Xg27VNfirf92KVWKVzvY9iQMPfh9f+6UfQ/V34U++9Me4udkk7uIeZAZfxv/cJ5ZvdyFWfekjuP6KctQmPUj1vIRHXzyGF7p0KC4rQGWePDhqJHGQWJQiHrlq2UJxn2xEc0kUwa4XsP0xKVumW4bL7rwWq+rMUPc8g92/+wOedBdBv/a9uO26KixLbcOexx7DP++uR5m4nd/34XqUqofRtX0bnn9sH1p1BbDUigVKkrapDSmk/CqEQ/lovHwZ1q0rhT3hxqGHn8SLr7ZjoKAarnInSiR2U5UYx0BbCNFMFZbedDXWbJCSaXLe9Do/f58uiu/zx3q+z6S4nacl4VpSYr6T+jzYCsslc7kJ1pRf7hfiDm4W8ZtNQh/xIWLMg84qv4v2YqilDd2jWaREMJfViVdQqSR1lBd3GW83+txy/wqkRPzqYTLooRcXcE1arOThCLyxfNjLpH2dHZa0F/5+yXYelruLsxiFJQ64NHLvGWlHr1jLBwNKcI7cK+X+o7i0JyQpXEZ5aSlfQb8JOnM1Fq1fiEWVcn8blpCfI+Il5M3ALpZvs5RDU2qMK+c39aD4nu87nudPAiRAAiRAAiTwTgnMjvhOj8AnSX1ea0lDnS/W6tUVyFdShWe9iI8NYE+r1Lw1FmLZ8gLk63LB0shGRtC+f0Ay7hqQv0weSostE1Zq5UhIzGT7IRw6PoDuEUlGJFnFtU4p0dPYjIUNUjZH3LpV3k6MuNvQpa2BsVxcKp2SfHyiMxB1o+XACPok+VDVshrU2SULe28PDo5JiZ78cqxY4IIlp5Dl4TTUjY4jx3CkrR9jEseZMhWhpF7mWVSHartmSgI1qb/r7cAxadvSNQKPxGqqzUWoaFqC5kXVqGaR8ne6N2fUn+J7RtjYacYElHjtjGQ8TyOdlSoHBgO0Uq/bZBZrc3E5XCap8+3vlZjvGLxiUo5HJaO51NROGSQ22+aCVUocqiVpW0rKlUkGNrE2S01vMW8ruleRvkpMuErEfEwqMPhj4qKutcvYRhgkaZtWlRW3c+W+Ki/+UlJbPBZCSMqJJWQdBpNRanZPeOQoMeXSZOJv8pdoVGp6Z6QMmcMMm0ks3/HARL+MBgYR/IrF+0SHHBXW+Z7x5mBHEiABEiABEiABEjiFwOyIb0ImgQtE4Ezi2+cbRyQSESulZM/nQQKzQkCErQjoRGIi9jslilVttMCoSUOTCIo4Fyu5lC1UYrV1Yo5WZSXRmbRVLNJJxW1dEd8njqkWZ0WIaySbuVa+dBqR0tIvmUzKl4j9KX3Ukjk910bG1mnfWBRxckxFhGdljExGLN4ydzqn+TXSR14cSL+T7XJq/Yzi25lXAIfDJVb5iWQWk5+5WcHKQUmABEiABEiABEjgEiJA8X0JXUyeykkhoAiCcDiEYMAnsax+seyFcy7CE+LiVHdaciOBc0Ugt7OUPSb7LyPJIbNZ+XvOki0WbrFUn6Jmc/+Y7l48KYbP3kdR1hOW6ukcU73KJyzjZz6Uz5Iyql6vh9Vqg9XmlJJkThiMSjkIiu/psGYbEiABEiABEiABEsg9+cmD1XSf1UiMBC56ApNWOMWSGI9K3G0sikQ8imhM3HJFfKtVJ617F/3JcIEkcBEQyMj/RSifK4NY1Y0ms4hwk7i+W2j5vgiuDZdAAiRAAiRAAiQwtwhQfM+t68XVvg0CimBQrI8Z8a3NJZviQQIkMGMCOZ+RXFy6lDjLpV2frtV+xlOyIwmQAAmQAAmQAAlcUgQovi+py8mTIQESIAESIAESIAESIAESIAESuBgJUHxfjFeFayIBEiABEiABEiABEiABEiABErikCFB8X1KXkyfzRgJKoSUlRdWEiyxTHHCPkMCbEzhTxvPTa36TIQmQAAmQAAmQAAmQwNsnQPH99pmxx0VMYGqpsXgshlDIL9nOg4jGYxL7zVJjF/Gl49IuFgInQrmVVJzKZ8ZisaKopFwynVsvlhVyHSRAAiRAAiRAAiQwJwlQfM/Jy8ZFn43A1Gzn0UgYfp8n9xWWUmNKtnMlYRTzRHH/kMDZCZysf5FFWmqQ2x1OVFbVweF0EhsJkAAJkAAJkAAJkMA7IEDx/Q7gsevFR2Cq5TuiiG+viG+/B5FIROp80/J98V0xruhiJaB8lpTPzIT4roVDvvMgARIgARIgARIgARKYOQGK75mzY8+LkADF90V4UbikOUmA4ntOXjYumgRIgARIgARI4CImQPF9EV8cLu3tE6D4fvvM2OOdEzhTQrKzJfebaDuRBvBsx9S+00l2dvpcM+lz+loovt/5vuAIJEACJEACJEACJDCVAMU398MlRYDi+5K6nBf9ySgiN5vNIJNJ51y00+mMyGo1NFoNtBpNLsu+orUn2mWlXUbiqJNIJBJIJpNISnv5Ra6NRq2FVqeH3qCHTqeFWq1GVtqnlHbJhPRJSt6CNDLSXi0dlN/rpL1O2uu1Ovn3xFyZjMyTljniCcRlnrSMocRxK79TqzXQ6Q3Q66WfVvum+Q8ovi/67ccFkgAJkAAJkAAJzDECsyO+k70YP/4aHn6xFS3dfuh1mtyDYe7IStytPKjGjBWw167FNRsXYl2NFZqLHVzuAVvKVikPsRoladdk8aqLfeHza30U3/Prel+os1X2mSKMFVEciycloZ8WOpMdJeUWGBM+BPqHEBERnjWbRSDrRIhrkRHRHU+mkdDaYLbnodBhgEkrt0S5r6jV8pWJIRH0wufxIpxSIS1iXEl4ltHZYHAUIM9mgVWXgdy0c0ZzTTaGZMgL77gfobj0Nxqg0agQj2cQSxthkhjtggIrrFq5V8n9K/cSIB1GxDMCnzeIhMogfUwTQv8MWQgpvi/U7uK8JEACJEACJEAClyqB2RHf0R1offxR/O1/jiBYugQf+sRaNBoUK1BOfecsPWmNBXpbEcpKnCiy6d7EAfN09D4kuvfh1/cPIFzQhC2fXYOas3tvnqPrJsm6/B3Y9WgLusatqLxhPZobXSg8R6NzmHNHgOL73LHkSG8koLx0U6zcihU6HFVDbXCgoLQQLkUYG3Sw2Q2ACPK4lLdLQ8R2ZAze4UGMBRIIaApgzK9BTWUByqwJpHwDGB0YwGAgi4S5FMUVVajM00AfdMN9rBXHBpOI5NejprEBzYUamKKDGHH3oG80haixGIXVtSjP18IU68Zgdwc6+uPwhvWwFJSjbEEdassMMEb7MNzpRvdoFilXDcpry1FpFwv6cCf6OvowFkpCbbPlrOGnC3CKb34CSIAESIAESIAESODcEpgd8R3bidYnn8M/PwDYNmzB3/z1SpRPZ92JYXjdHWIt92AkkILWUYz86kZ5WM1HqSEOeLrQdvwV7Ni+B79+XB5uC2twzfvWoKqiGbXV9VhRLtYniItlsBsdx7vQMxRAMGWAzlqE0gULpI0Trsl1JMUCNNIGb9aImKEY5sAA/ANudHlTiKicKK2pw4KGchQaFSNTAoiOoevIEMbDBrgW1qK4yIxc1dusF+NdnehslwfpSApxtQkmVynKGupRXWKFYzrnzTbnjADF9zlDyYHOQiARiyCaSAEijMtqqlFnDGKoxY3ekQSKG4ugTcbg6xOPn+JCOPJFrPv6MTwWwHjKBZOzGOWuNDTREQwN+BAWK3VSXMSjYuFOFDaicuFirChIIrvnFXQdH0dm2VWoXlIOy1gLjuw9BPdICGqrBalUCiFTMSx1S7Gm3o5S+X37nhYcTpfCvHQN1tYakT+2H+6jh9AZ1CGQMSCltiJqqsWC5nosL49CNbAbPV0DGE7mQa23wqjXTbwcPXFQfPMjQAIkQAIkQAIkQALnlsAsie/X0Pnso/inB9rQEbNh7cZqFOnEjTIeE2t3Hsovuw7LljWhwQKI1yWQGEGkfw8e334MO9visBZa4BJXyUwqinhMh5JVV2L1hoWoihxA62vP4Znth/HM7jjUziIsv2oJCmpWY8nyRbimYBQdL2zDrj1t6DLlQ2/RwibPkupUGOPDRtiKlmLDrRuwpMkBh1iy+x75Mn6+14u9ptuxpiYfjTYPBoeC8Ha3oF9VAvXyO3HbNYtxXbWI79FX8LOvPI2d7iKs/Mt7cMPGQtjdB3HoD89hb18QgZJimDQpaNJexORBuzNYgZo1V+COW5ejzqWD2MN4nAcCFN/nAfI8nyIeVcR3EtpiEcu1Nag0BDDSNoB+TxaFtQ7o/H3o338Qo2kNUvZ8mMwmmMUlXCcu4YrXjxKzLXelXMw2VBmE/VEEw2oYKhvQsLQWteYgfLtfxfF2H7KLN6B+aQ2K4gMYaD2KDhHLgaQaKZ0DmvwquMRa3lRhR0GoBaMtu3Bc1wB9w+VYYpWXk4cPorO1D0G7HSqHGYmQCh6PBQV19Viy0oa8ZCv6OzrRMSzr0JhhMRtPiQGn+J7nG52nTwIkQAIkQAIkcM4JzJL43oP2bU+K5VvcLW3VuOU9S1Ctl/hHiXnUGi1w1ixERUUJikWRymMfED6G8T2/xdd/OYzXMmtwz4evxM2rK2CNSuzj8DgSRjvM5WWwS2C4Bm0IvPIEvvTtAML1V+Evv7YJi5Qxgq+h5+Vf4puPZzBScCM++ZFrcaWY2yc80sfR9YtvSAx6Cw4u+gQ233Ij7nZ2wbf9q/j35wLYXfAxfOTdm3HXYklapDT3/x4P3f8SvvNCFTZ94GZ84W6xJvlexW+++gx29hZg6efeh80bxE00MIYxtzzkWl1yTnmwKX2TYuV67TH8/F8fQqt+OVb8xV9i60o7ai76oPZzvrcuyIAU3xcE+7yZVHE7VxKrKW7nERHBKpMTeUVFKMkTMWuWZGaS3yIZjSEeDkmitLAI61H4xsbFA0duAHozDJLoTNHcuTFicYQjknhN54K9rAELagtQrpO2vYfQ0T0Id8CIlD4f+Yo7ekUhCk0SZx4OIBSVOHDJO5GBXuzURrjyxWodOQbv8Z3oNzTCUL8edQYfIkcPo6t9CDFxK1fZTYiHsvD6xCJeVYeFy/NRkO3FQGc72gZicmOVl5NW8ynXkeJ73mxrnigJkAAJkAAJkMB5IjBL4lssME8+K+I7BeOaa/AXf78BDW95QgF4W/fgwI4d2H18CL2+JFRaB6wFNahdsxYr1i7GIklQZMYB9D/3NO77rxCiNetx731bcJlFJHbHQ9j9xH/jm0ObYFrzCXx9qzMn7ieP9F4R388+jf+OfQgbt9yDv27oRPD5f8I392pxqOqz+LMbFmNzldJaHkS92/HoT3bgv55wYc09N+Lee6pg9+3A774qlu/efCz53PtFfJehPBZEcLgH/X1d6O4fxKC4kY6NBzA67sbAoRZomq/D6j/5W9yyyoYFORM/j9kmQPE924Q5vkIgnU4hGYsholjBk/L+MCreNK4SNC/Ogz7ih2cgCq24pJdWGmH2dqP3uBtD3hhUYl1OSYK1mCRIyxrssJVUo7KyGMUWCavxiRh2y9d4BPHsRBZzJX48FpdwloySqlzEvfIST3FTD4aQtJUhv3kFltW7kNd3CN2vHkSbpQa2tWuxPD8BTcsedB7txJjRibTFKPHnanjChShvbMTKJRrYQq/B3d6DHp+8NtRaYTHJfFMOim/udRIgARIgARIgARI4twRmSXwrMd/b8U8/FPF92bX44j9sROObrTs6iuBYF3oTEpHtakBj3oQ7erb7UTz7f76J/ztcj/Tmv8e911ZiVd5+DDz5OL70vSBijdeK5VsErvLMGGnB4N4H8R+/HkO3aSPe/9GbsbnRCPFsB1LdOPij7+KJnb3oX/9JXHfr1bjZ0AnvM/fh3/eqcbDqXnxm63LcUKvYvUV8jz+Nh0R8/+DpQqwV8f3ZD1bCJpbv3973FHYOlGH5Z9+DrcvHMPzYb/Gfv/KLBX4j7vqTLbi80olCvbiMHnsCf/jaj/FaeiFq/+zvcOMaJ5oovs/tzj3LaBTf5wXzvJ1EKSsm4dYivkUIWywwmUQTRwMY6osjqXGgbnEh1KO96G0dQbJpNZpWitU64UbfoWNo7fFJlQcHtDaxOpeUoKTYAXvWj+BgO/p75d7kiUgGcrO4qVtlXANUOhncYIPdYoBVLSE4/jGMeALwJSU5mqEIlXVNaGwQizh6Mdp2GIfbg+hLiKW8fiGWLixBmXYAvo79ON41DrdHjaS9Co66RViyQPqqBsVSfhDuAQ8i+jwxfJulXJkmVw5t8qD4nrfbnCdOAiRAAiRAAiQwSwRmSXwrMd+PSMx3C475DVixuhz5upxDt1JXJ1duLGaQUmN167B542JsKI0gNLITO15tw54WSYSWkkzAkoBIY1BDa3KgePFaLBHr99ICAxyKW+bxl/GH/3kKLx0ZRqppCWxLr8Sm9Wtxk4wztv9FvLbjNewLZhEW105tWmrhisUoq6lG1YJV2HjNQtSXmWDwdaD/ya/g+wc0OFipiO9l2PK6+H4GDyvi+5kCXPbBSfEtlu+viPjuLxG387tw/XJJlHR4Ox55vA3HR5U4dTv0GjuKFpbDmR5G34OPYti4GFV/8mVsXeNA46lGpVm6nByW4pt7YDYJKPsrJeXCUiK+VfainMt5sU0LjVio5ZYFk80o4TXiUh6OQ2+Se15sFGO9negZCcCvK4KjvEkSSErSNYcO+qwIas8wRsakNJm4sEMtuSH0UutbiQ2PDIiLeADDGbmflNSisVzKkqWD8PtCiEiSSJPNDqdBrO+BPgz2dokoDyOuskgVR8Ud3QStsxSlVWUoc8qwQY9kQRdLu8kFl10FTWhAsqa7MeyJI6bWwyjWeK3U/D79oPiezZ3EsUmABEiABEiABOYjgdkR31mxAonr5Zg8PPr8ESTjaSm787o95USpMal/ay1EabGUGrNOPPhlw/KQODIimc6jCCez0FpckiStAiX5OnE3n3qkkAmOYlzaDoelrq1kMy8oLEKFTT1RLzzlwdjAMEa94hKa0YlVx4H8slIUOfQSJXniSEusZVjKAImhO67Lg8tqlBq6uVWIWSuMoC8Cn9TuNTqsyHPIw3U6isBYWFxMNTDkizu8FOjVIiUlyGSeEQ9Gg/JALg+yJpcLVhnLGAtDJQ/TakchzPIQbpj1cmjzcfu+8ZwpvrkPZpuAYv3OxWyLCE/Ku0Qls0QqaYZZ7lcV1TYY4x743X0IiHt4THnxl85CJXW+xY8cWfm3Sn6eiotYlzrhUpg7VwNco5Za3MpI8odWLNASOS7e5eJynlLEtNxHpJ3yO8mcId/lS/qqsklJ3iZrkTuRRmsU4a7J1QtPSCb2WEzuTTKiRsbSSny4Rvqo5SdZmTudTMko8mLTIKJbiUE/Q43v3J1QKQkp52mXeuGVVbVwyHceJEACJEACJEACJEACMycwO+J75uthTxJ4RwROEd+S9Mrv88LvF9faiNRqlzjdyRR872gSdp7XBJSkazlxKgJ4UognRYinJZZbnctoLsJY+btWXvyJRVkt4jeX2Vx+nhGreFr6ZZS+U8p6nQSqyolhlYh0RXArYntiDmWuU3uoVCKqlTYytlrE+ynHiRcEU/vlWsjYGkXsnxDzEydy5pVQfM/rbc6TJwESIAESIAESmAUCFN+zAJVDXjgCr4tvETdKMqyAd1zEt2TND4fFLVj8LxRhc+GWx5kvJQITajZ3RpN7akLGnr7DTsZRn97+bDim9phsc/ZRpfXpHc6wtpzOfn3CM/Q5bTGniO9KsXw7afm+lLYvz4UESIAESIAESOD8E6D4Pv/MOeN5IqC4zKaUWFzJkJXOiMttTnmcSdacpwVxGhKYYwQUAa7Eg5skIZtixedBAiRAAiRAAiRAAiQwcwIU3zNnx54kQAIkQAIkQAIkQAIkQAIkQAIkMC0CFN/TwsRGJEACJEACJEACJEACJEACJEACJDBzAhTfM2fHniRAAiRAAiRAAiRAAiRAAiRAAiQwLQIU39PCxEZzhcBkwjUltDsp8d6JRAzJRFzKQklZJslAPZGominX5sr15DovBIGTeRGUz4zeYJDyiXYY5DsPEiABEiABEiABEiCBmROg+J45O/a8CAlMim+llFNEMpxHwgHEIiGEpNRYUgS4UpZpslTURbh8LokELjgB5TM0eWQkUaHFakNRcTlsNjs/Oxf86nABJEACJEACJEACc5kAxfdcvnpc+xsInFLnOxKGz6OUGpus8y2lxniQAAlMi8BkqTGH04XKKik15mCpsWmBYyMSIAESIAESIAESOAsBim9ujUuKwOni2+/1UHxfUleYJ3O+CJxS55vi+3xh5zwkQAIkQAIkQAKXMAGK70v44s7HU6P4no9X/cKf89lCGaa6cCurfL2d4to9kYDgjMdkv5NNlLaKO/gb+0zd85NzvJ774KzjT0x/+vqmNqf4vvD7iisgARIgARIgARK4tAhQfF9a13Penw3F97zfAucPgIhXRQorScmU2Oh0OiVfE6JardFAK19qReEq/5YvZW/m2qWSiCeSuRwEqVRGJHUWahlHI+01Or0kOJMvrU7yE0gfyV2QkvbJRALxKe1lsJyQ12i00OmVPgbotJoT60kjJe2VJIOJpKxJ1icD5cS2kvNAq9VP9NHrpL/kQDhLAkKK7/O3lTgTCZAACZAACZDA/CAwO+I72Y3Rll347bYWHOkOwGTUQiNPfpmsPITq7bAV1KBu0XIsWdqIhhIt5nMO3ay3HYP7f4/HBwvgL9uKO1YUo87JbNwz/fhRfM+UHPu9HQI5IZ1O5zLqxxMphCMiZk0OlFZaYIp74e8bRFhEbcZkElGsE8GrnRDdySySOjusznwUOQwwaUV657Lwq6DNxhAPjsM75kEwkUVaJX3kd1m9DUZXMfLsZtj00jY8bk1zAAAgAElEQVStCHZFSMt9IhFA1DsAnz+IcMYg7dVIq/WAKR+uPCcKrDrokJ7I9C/CW6MWMR4ahX98BL4IkNKYYBKxrxHhfvpB8f12dgTbkgAJkAAJkAAJkMBbE5gd8R3dgdbHH8OX/3Mc4crl+Mhn1qPJKBYWxSiUkuzT4x04tuc4jvRoYN1wPTbdeDnW5qlhnI+as/8VtDx8H75xrAZDiz6Pf7ilEevK5iOIt96s02lB8T0dSmwzUwKKSM6IhVuxKIeiYqk2OVFUVog8qwUWvQYWmwFZpcRdKIysCN14ZAzewX6MBGIIqItgKqxFbWU+ysxRxMf7MTzQj4GACHJTGYqqalBdoIMp3Ie+1la09Mfhc9ShZmEjlhRpYfL0YLivC73+JIJZF6yl9SiryUe5MYxEzzF0HOlFV1hKgtUsRGNTCSqtQcSH2tDXN4o+vwZpeyWKKmtQU2qCLdwPz7EWDIyKaLc4oTYaodMofugnyVB8z3SXsB8JkAAJkAAJkAAJnJnA7Ijv2C4cf2o7/vmBFAwrr8Ln//EKNJ8+v3cfOl55CN95IotA0VX40z9ehxUV5pNW8MQQxjtacLhjFP2+FNTmQjjKmtHUWIG6vBPiNDKCgG8Yx+KunBWoMt6JfvcIjg2mobIUorS5CQsWlKFcDEG5iMmYD+GhoxjNWBHVFcLo7YBnQB5YfRrEtYWoalbGL0ZBcgijbUfR0u3BcMQIe3UjFixpQLVDM8VKH0V0rFseeDvQPeBDIKuDyuhCQW0D6hrkAdcqLqHKOafjiA4exlhcztNSh/yMBzF3J9pGxepVtwh1th74nv0G/vt4GQYaP42/2roAq4uVxYYRaDmC/ogGyfJmVBZY4NJxG78VAYrvtyLE379TAolYBJG43JMKF6C8phq1Bh/6D/egZySFsuYi6JJReHq80BUXwFGgRSYwgNHxELwpB4wOuS850lBHxzA8JFbrZEZc1ZOIiJiPFTSgYuFirCpMQ39wNw4cHsbxipWoW92Ey41exA/swOGjHTgekXtJCtDJ/bB0uby4rLOhcPgI2ncexcFIAUxL1+CyJgsKYi1wH9yDw+0BDPrExd1RBE3VaixbsRAr7QEk23aju3cIHk0+YDBDLy7oU9U3xfc73SnsTwIkQAIkQAIkQAKnEphl8R2Hdtkm3Pu3V2OpUeIfT5k7gdT4bjz6lZ9gh9uCis9+EZuvLkNzbAiBjm144tUevNZvQV6+FQWKSTwbQXh4GIECeeDcsBWb6/NRHX0Jx7f9El99JoVhy0LcvbEEhfoIBnsGER3px2sj5XAsugof+sBKrC4yQTV6EJ0P/x1+tjeGA5bbsK7Biea8EMYHgxg6dgDukA6Z6rVYsbgSTc40IkMDGDq+C4e8Jngq34WbblyLO5dbYMgM4vhD27HjFXEZzyuEvlAEukoEv8+N1u4sQtbluO5dV+HKy0qRn/Bg7LG/xu/lfF4xfwhrVlZjuXUMI8MGWJtWormgDwER3z9sq8Dwoj/Hl7ZWYFlqP9r3vohnWtKIla3C2g2r0FRqRT7F91t+fim+3xIRG7xDAvFoBFFxNdcWifiurUGVUe4hnUMY8maQV22H1teH/gMHMZJSI2XLg0lcz80mo4jbiaRp4jUubwPVE27j2TRCYhUPhcWyXdWAhqXVqDGJNfroQRw+0IN+lVUs2c2oq69ATZ7EhQc9GBny51zGzS552ecSS7vcd4a6u9HnTSEQFxdyezEc1bVYUJ2PYm0UoeERjHtEbOvFOl+UD5smjHi/vKjs9SCQlLAfpx16o/7Eek7Cofh+hxuF3UmABEiABEiABEjgNAIXUHxnkQrvw3P/+C281KqH+TP/gJu3VKDkwO/w7Pd+gRfSi1Dwrg/jltUFaLRpxGrthv/gb3H/74bxXOQa3PPJzfjQ0g64n/g1vvEEEKi6AZ/52DXYWKScYRwY34af/ON2vOwuwYa/uQc3ritB8fhhuB//Z3x7twrHKj6JT995BW6qU9ongYPfxw9+vR+/GFqLrXfehE9trYItN9TTeP7H2/Cvf8jDknfdgHs/vgwViCLQL1b0qAqG0nxYLeJ+GhfXT99ebP/Bz/HktnFY7r4XN3/salwOP+Lb/wEPPNeFJ00fw7tv2Yr/b7UkOpq8EEPiJfD4N/CfHaUYKN6Ceyp64W0fwCveBmySddws5y/P3DymSYDie5qg2GxGBCbcztMSu50SAS5DGOxwFhWj2GVDnkWErEGLVCyORDgi7eSFoX8E3hHx0EmqkRHxa5QkZ4roTqfEJV3ahaNikTYUwFkhwrvahRL1KALuw+joGUJPwIB41o48cRWvrpH7l1HuU1K7PpiU+6HeCrvDCqsuhoSnA/2dnegakJcAIuJ1eZUoXlCPuhIrHJmQxKPHEcsaYRT3cqtVA11KYsr7O9DTNQCvWNG1dhHfBpMkiFOfkv2c4ntGW4SdSIAESIAESIAESOCsBC6g+B5FrPUJfPfbB8RtfClu/4vbsHlhCiPb/hc/+7dtOJowwrF2ASxqecKVJEVKwLiSqTcWzIejdCWufO96bCw7ht7tf8A3XylApv56/NX7F6HBptjXfciM7Mav/2079vTkYfGf34PrNpSiYuyQiPWv4T+O5aGr/rP4ixsasb5MmsvDaPrg/+KBbX14OLAJ77n9cnx4jbhiSqIiMUvjuV+8jP//QRMWvus6fPrjq1CRiSA01IdhcR/vGRnGwLAPnvEAvAEv+o/sQyBqRNndf42bPyjWb5UfyWf/Hj94dQhPuT6FP7puIz6wRPv6BckO70PbY1/DAy8PY7duA5Y3lqN8xA3fqBrWLR/ApuuWYxPV97Q/whTf00bFhjMmINZriftOxiWkJCIu6JIcLSix1va8UixckgdD2Iux3jA0dXXilm6FzS9W6dYeDHoiyIoFXDzNIV0lKZoTzrJqVFYWotAQRnrcLdbofgyOR+ALideQXWLJ61egsTIPtmCHeMMcQteg3E+sVmTE0yapKYCxZCmWLixFja4dvu4dOBqvgLpsHZa64lC17kPrwXYMa4yIiehPw4i4rgp1jU1YXieW9vBxuLu60T0uFnhpYxbr99SSaRTfM94g7EgCJEACJEACJEACZyQwS+J7J1qf2Iav3i8x36uvwRfvmxrznUDW24ajL2zD888fxj7HJiy8/mbcs9qFIkMM3v1P4+UfP4hdqiXIv/OjuH29CzWTWjU7goHjXgz4rCiuL0KFSqzGzz2Ef30lH+k6Ed/3LMMiicsGvEgP7cQv//VZ7HbnY9kX/ghbRHyXjx1Ez2P/hG8fdaKjTsT3TYtwRYU8eIr4Tu3/GX74tBsP+Tfhzjs24iOXF4qbvIhv/zPY/nMR33+wYdFdt+Dzf5wHa/sjuP97u/B0fy02/dEtuOOaJWiwS/bhdAt2/td/4bE/tCF2259j88eux9UivlPbv4z/enkATzo/jXu2XIE/WnbSfzw7uAutj/0LvrO/AANNn8Nf3LUYG12SPOmlh/GD33mQqN6Euz58A5ZKwiWZgsdbEKD45haZTQJZKdklRmsR32Jhtogbt0UyiMcCkghNLNBqO2oWFUI1Jm7nrSNINa1Cw/IKVMTdcB9uxfEe8YKRjOg6EdVFpaUoKRLLddojmdHb0NsnotsbQ1JthtFklvplSclbkYfCpjVYWFsIV6wP7taj6OwaRFCEe0Qtmc315XAVNWDp4hJU6Nvh7dyBY4lqqCvWY1leEpr+o+hqOYY+EfLerBaJrEM0diXqmxuxsE4HS+go+kR8d43L/UgnrvFGpe7EyYxrFN+zuZM4NgmQAAmQAAmQwHwkMEviez+6XngU//LjIzg6rsXiZSVwSrxjBlpoJbGP2SIPnbZSFJeLBWZVPRZUSlzjJP2kZOgd34fdL+3Dq/sGMZ5LSJSRZ0OxEuUXwlbYhPI6SRi0MA8V2T1of/FRfPPVPKRrN+ML71uC5tfF92785t9fwN6+PCy99wPYfHkJysYOo/epr+O7LU501X4an72hGRvLT4jvg7/Aj7f14tHABtxx6+X40NpJ8b0dz/1qB777sEUs3zfg0x+uhst7AC8/vgPP7hlCTCf1fLVmWMsqUVlvRWz38+jfNwD1TX+GTR+8BldqxFL1/H24f8cQnnF8HO8Xy/f7l0wR3wO70fb0N8XtvAojTZ/CX15fgxWK63y8D6Pbf4Ff7opgv/063H7zYtzQ6IDkjuPxJgQovrk9ZpOAsr9SSamjnRYPG1shnIVFKLFJOS+lxreUUjRLtvOM/D4RjksctVjIJSnkmLsb7vEggnqJxZZ7Xk2FJF2z6yV3hMSOeyUe2xtAKCVvGNU6GHQi5pV7pZKNfGwEQzEX9AW1qK6Q+G2zlAuLBOAPSXkzuRMYxF3cYpS7akSSpvXKHEOSuyImseX5laioLEdFoQhqyZURC4cRiomoNlhhshphUkvMt2RaHxoQt/NQCiopZabXGydivqccFN+zuZM4NgmQAAmQAAmQwHwkMDviO5uUJN9hcZ0MIRQUi5AkJ1JyDInjOFQaA/RmJ1z5DjjfrMC3UvPWM4oxf0QsPZlcP12un4hwk4yjXK20WIriEn8dF2u3VpKeWfSQZ1c5ZDbJMh6WREaJlMQ42qX2rkHisjOS5C3ql5hJSYSkFTdRkzzs5oKvpX1CYimjEseZNUhyJEmGNvEL+VVUHl7j4kqukhcAJthtktBI+XkqjKhvHOM+SWgkiZW0RjNMDhtMKnkYllJDMNrFMiZxlvJvSJb1YFySp6lt8rBskJJEUx5yZZ3JaABBWWdaa4ND1iQVi04ccUSEny8sD/VS49du1p6WtG4+btk3P2eKb+6JWScgAjydUcqNiet3KoOMiO5kQuplW1yoqJZ7QNwDn1sSKSptNDqJo5bKBxrlHqWXO40K2ZTchxIJJJXMa/JzrXxpJKRGfiNfUu9beaGnllreUhdcQsvFTV2DjFqTcwmXyPHc/Uqis+XfSjSOeOeINR7ye8g9Ui1ry2YySGROjCZtJtoqYyt3YKV/WtYk3aQeuFYn92Op8a2MdfpB8T3rO4kTkAAJkAAJkAAJzDMCsyO+5xlEnu7FQ+B08e3zjsPv8yAisblpSZTFgwTOGQFF6IrwTYvYTaXSyMj3yUPRshqNvCwTYavkqlC+FMWr1AjPZOR7ru+UotpTFqW0VUk2dJV8V6zg0uFEn4nvk3t8QjCLXFfaifh+3XKtzJOZWI8yj+JJrsw00VzaT44tlm5F0J9tHVPFd1V1HRwO5zlDx4FIgARIgARIgARIYD4SoPiej1f9Ej7nSWGiCI9wOIRoKChJsYIISZboZDIpAmXCgsiDBM4lgckt9bqeVn5wFnH9ukCfug2n6PAzS/KTq50oWDZ7x1QxrmR2t9hsKC6pgM1m52dn9rBzZBIgARIgARIggXlAgOJ7Hlzk+XiKioBIimtvPCGhCfIVjyfE6ihOv4oFkgcJkMCbEJiSdE0s7XqDATa7E0ajkdRIgARIgARIgARIgATeAQGK73cAj13nBoGzudXOjdVzlSRw4QnQW+TCXwOugARIgARIgARIYO4ToPie+9eQZ0ACJEACJEACJEACJEACJEACJHCRE6D4vsgvEJdHAiRAAiRAAiRAAiRAAiRAAiQw9wlQfM/9a8gzOAsBJbt5Rso9pZVM1K9nfZ7NVFW8FCRwZgJKCbFcabBchnEli7k2V36M7tzcMSRAAiRAAiRAAiQwfwhQfM+faz0vzvSUUmOS7Tzg9yEQ8EqpsfCJUmMTIogHCZwvArn3PvKHXq+D2WyRBGZGWK12OF35OQE+uWfP13o4DwmQAAmQAAmQAAmQwIUhQPF9Ybhz1lkicLr49vu8IsA9CJ8ivqm+Zwk/hz0DAWVPThXfBhHfSvZwim9uFxIgARIgARIgARKYXwQovufX9b7kz/YU8S2C2+/1wC/iOxKJnLB8X/IIeIIXKQGdTrF8m5ET3w4R305avi/SS8VlkQAJkAAJkAAJkMCsEKD4nhWsHPRCEaD4vlDkOe9bEaD4fitC/D0JkAAJkAAJkAAJXNoEKL4v7es7786O4vsSuOQSlJ8LDFCCpZVvyr8m/pf714kfnzzRE27dZ0ylJ2Opc5nO5OtEx8m/TriDZ2ScqWEISk6AE8nR5PvEfpromskobZVZTg1bmGg/8fVmNeUpvi+BvclTIAESIAESIAESIIF3QOC8iO9sPIRILIF4Sh5cVVqoDWZxv9RBf3robTYtrsEZpLLywKzWQKs58RA+7ROUh+m0ZLeWh+S0zKNRxlBPuzMbXgIEKL7n6kVUbgZKZjL57KZSSEiG+mRGPv/qLLRIifKVz7ZKB624bmu1cg9RBHEmjUQiKfeVifuGtIBK2okEFiE8IZrVSmZxrfTR6yW5mVr6ZJBMTIyfVsbMie8s1KKu1Sf6qNTSR2eATqfPzZNKyhwyT0raZ06Mr6xTmUMts6llXLVGWZfypZF5lHN5Y14Biu+5uje5bhIgARIgARIgARI4NwRmT3xnY0gMHUHboYPY09KLnmE/vIE4Mhp5oNXY4apbgYWXb8S65jxUWTVyNmmg82Fse+kA/m/3IizbsB4fva4CtrOeZwKhoT6MD/iRzCuHo6II+Ygg+sq38NtdXXjKcg9u3LQBH1yqPzekOMqcIEDxPScu0xsWqYjgVCqJaDIrYldErQjsTGEV8vKNqMj2IDrmwcC4ZkL8irhNywu6VFZkuc4Bo6MQFUVW5BmlpFw8jmhKXrpJXLVJFUV8vA8jQyMYi4qIFhmvUhsBrQ2O4iIUFdlh0SaRjsSRkLH08kLQkAkgMtqLwUEfvGH5ncYgc+TBll+KinIXXMYMMtEoogl5MWA0wWyQ9URGMD7oxvBYEEmNGTqDJSfCRcOfYqWn+J6be5OrJgESIAESIAESIIFzRWB2xHe8H4OHnsEvf/Iq2rWNWPX+u3HlwlLUWWTZqTF4Dm3DUw/K1yEdym59L971gWuw3Azo236Gh5/Yhe93rMTa67bgL28ph/z4LEcQQ/t24vjeHkQWrEP1+iVYoI4gsf3v8OMXWvF766fxnuuvxSfWGM4VK44zBwhQfM+Bi3TaEtPirRKLyFdCvGGKKlAqIrfYIpZvtUmszSo44ZMeOiRVJujSUjqutxPdfWGMGSpRuqAOTSViqfb0Yai7DX0eH4aj8sItbwHKFizAojIDLJ4O9BxuQdeQWKtLG1G9qB6VjgSyox3o7x+Sn4fgT9igcdZhwcI6NJQkoB7ah5ZD3egKl6Fg0XIsacqDI+ZG7/FjaOkYgS9uRMZcjrLaBixqKkSRphte92Ec708jlDTDYjbmLO1TD4rvubc3uWISIAESIAESIAESOJcEZkF8JxHY9UO89NwL+HXqDiy68jbcu0ky/J626tR4B4aOdmDMXg1rQxOqzRno2n+Fx7ftwX+3NWLx4krcXueH+2gXjvVEkS5sROXa9Vi3rB6LHMpgIRHfO94ovp+/Dz99qQ0PWf4U79p8Df5k1YTlO+M5jq4De7D3UCfahsKI6fNhKWnG0nUrsWZ5OYrpnn4u99UFG4vi+4Khf9sT52KkxQ08lYzDGzMjbijHoiWVaDD2wnNkF3bEShEpKMFK1X6xYEfQE62Ey2GFNRtBxB9FRGOB0WaCRZNAzB9ALJ5GVizOyXgYo+IzE5XP95qmCizT9MPfshvtA1H4jOWwuqwwZkJIBv2IZrRIy2c/FgHGRh0oqG3CistdKFG3on3/cRzutcFZvxjLFhfAHu9Df8tBtHW44Uka4UEl8soX4rKVpag29MHTfRSdIymE0hYR3wYJe6H4ftubgh1IgARIgARIgARI4BImMAviux9Hf/JtPL+9BaPXfB5rb74GNxSeKQLydKoS19nxezz50OP4/qtmOJddgffeshI1+jDiowfQtvcofr/TgdL1m/HxP1uDRo1P5vkWHr7/BYxu+Qw2ffa9uMEUh/aFv8ePXhTxbf0k3n3D9fhYUx8Sx57ET7f142BoAdatb8KyCnENTXkR7d6LbceycJvX4vbNi3Blk10cU3nMZQIU33Pt6kkctVi+g2ENYmLjLq0tR02pDsaYD56EWL7VGThTrRjq7Udnv8R1q8U93KS4dhth0Ilrt5xuVuK6cz7eEgMej8XgDyWgcVSivHERGko10I+1ovdQG0bCaaRs9lwMuPifT9yUZO6olKELpIxI5dWiQSzpi/NiyA7twfHWY2gfN8CnqkBJTZNYuMtQLveYTFCs7zGJNzc6YTSqoAt2Yahd5hgKIG10wSg1vPU6JS791ARstHzPtb3J9ZIACZAACZAACZDAuSUwK+K75X/+A89va8HgVZ8T8X0tbiqepvg+/ms8+swu/LBtMVZcfR0+d3uNPI4rxxA8e57CA1/fh+HStdjyj+/BxvwoBn75HTz+P6+KyP8YLv/TO3CtMQ61iO8fv9iBh+1/irtvuwLvwXbsuP/7+F2fE/EVt2N9ox0VZkmQJNazdKgVL/2mBYe6irD+3g/ijruXokFJ0nRuGXO080iA4vs8wj6HU6Ul3jsWSyKclqRlZgfyC1yw5hXCZtIgTx2SjBBi0ZZPpjo6hsBgL0ZGAoiqJImaySI/zSIRiyIUlRhtvR3W8gWorSpBuSEkeSeOortH4r5D4gGjs0qiR30uK3lGmU/iw4NxFZKGQuSVVqOx1olijRcBdxvauwbQN5ZExiDrqGpAVWUeig0BJMa9GPUlkdBZoLfkIc8plnFxkc+Od2HY3Y2hoIhytVjkTWL51ii5LE4eFN/ncMNwKBIgARIgARIgARKYgwRmQXxLIrRdD+DZZ57FL0Jb0HT1u/G5LXmwnw4n2IPxnv04nCiHtmQ1VhZmYHaL+H5qN37YuRxrrr4an7256kTCNTcGdz6P//3WAYyUXobNX343Nryp+O7EI46P4+7bL8Mdkaex/ZsP4KkRG5LrrkVdPuBQMiUrmZVV8nCcNcFZUIm6lcvQUJ8vD/rTeVEwB6/0PFkyxffcu9DKNcuI1TqZSEj28gSiwQBC4kLuK1uK4ko7VuAARt1Z9GM1li6vktwRbfC2ixv5oAqjUauIafFXMdpgL6lEWXkRShXrtKcHA70DGBR39Rgk+ZpFQl8MOqmGIEndJGFaJCkfdFMhHBJjXl3uRIEuiOio3Gfc/Rj3RaWPGkFtGVTOenE5L0W9qQeeY8/hcGcAg1GnVGLQIBJJQ2WTXBYrV2NZnQsWXwfcB8VK74sh43JKxnTdKS/yKL7n3t7kikmABEiABEiABEjgXBKYBfEty0sOYujws/j9z59HS7IS9TcrFudS1JgVwRtD2nsU+7ftxat7wzBsug5X3H411klac33nz/DQYzvxvfYVuGzzZnzxjlrkwrvRjYGXt+En/7YfI2XrsOWrd+OKggj6f/ZNPPzASxi5/lPY+Jn3YIs8dKu3/xV+8FwrHrTdi7tv3YKPVxyF55Vf4Ud7tXAX34Q7rmvChiqTlDmTLMWJMXQdkjjOoSwKltWhqrYQVpntjUWCziVyjjWbBCi+Z5PuLIydE94pRLJGpE35KM23StUCcev2jqFXXSKJyQ2ozxyDz6vFuG4xGuqcyE+0TsRejxkQs9ajrKYKlWVihVZLKMmgxGp39cE9KnkispK93GyB2aKHVj7v6aS4pUMs5Y5iFJdVoKrADLvKIy8B29F+vBfjwShSenFnlz56rQrhuEks6WVYsKgGTeWS3dwn7uUizt2SM8KfUDKtS9WG0nJUVUuSOGtUrOxt6OwcgVcyqxttVhHfkl19CjKK71nYPxySBEiABEiABEiABOYQgdkR3zkAUvYn0C6xlgex+7V2tPSNYywYBwxWmPIrUNG4AsuWLsOSWqVEUC74EnA/g5d3t+D3fQ1oXr0K79tUKo/KyjGEscOv4cn/FYtXwSJc9pFrsMwRx9jTv8Irjx2Cd/XtWPruq7BGn4Bq33/jkf1uvGB8N66+bA3uaBarWDaI0dZd2LdzFw52jGLAE5eHbDuMxVWoaliGpc0Sz1njgEtKDTHmew7t3jMsleJ77l2/bDYtLuDiOp4xwOQS7xNJiGbVSgVti03iu3USeuJFOi4eNVL6Kx6UsmFDw+gPqBDLq0JpaRnqHJIlXe4f2ZSUN5SY75hSFlzc1LUyhpL0TJMVd3HxtOnr1yCMKpSIh0uxU+mTQiYp7WMJxKW8mUotMeS5PirpE4FvZCQXxx2XcmZ5IrKL8y2wasRnJpmQLOyK44wOOo38JR6Af2QIXm8QMSmlqJESZHql1BhjvufeZuSKSYAESIAESIAESGAWCcyi+D6TMpKfXQxmZbG2ia/qLGLl0BeKAMX3hSI/83mVa5ZzPU+L63lSif2OIZ5KI2orgT3PiHL0Iu4JYCRoglZnhN6gl/xquVRrSCXiiIswV/ql5WOt/Fwl4ln+zC1I+bdOLNBaqRuei/WWOuFKfHlCBHRSUdAyhkqSryl9xDie+64REa7Ea+v12tx35XaRSqWkfRppWWNGMrQrP1SWoJa+WhlfpxPruriZK+7oE2t740HL98z3CHuSAAmQAAmQAAmQwKVA4PyK70uBGM/hoiYwKb4VgRSNiHuwTxJo+T0IhaS0lAgnxRrJ4+IikLsir/8hSlcORSRnRSQr1zEt/igqRUSLK3ju+smX0jzXUhHuZz0d5TcT11sR3hOHIvSnf/4ne53e50xjT07xxjUp56HX62G1WiX23AirXTxtXAUnxL3yAoD7cvpXhS1JgARIgARIgARIYG4SoPiem9eNqz4LgamW75iSATvgQ0ip5yxJtlIigE5IMfK72AkoGntCNr++0pykPZNwfivdenqft2o/OeN0+72lmJ8Q/Irl22RSLPdGWMSl3mpzUHxf7PuQ6yMBEiABEiABEiCBc0iA4vscwuRQFxmBSXdm+T7F7nmRLZLLmQ8EJmz1E0fOyK24utPaPR8uPc+RBEiABEiABEiABE4+B4ql8C3tNhK8Ux4AACAASURBVORFAiRAAiRAAiRAAiRAAiRAAiRAAiQwcwK0fM+cHXuSAAmQAAmQAAmQAAmQAAmQAAmQwLQIUHxPCxMbkQAJkAAJkAAJkAAJkAAJkAAJkMDMCVB8z5wde5IACZAACZAACZAACZAACZAACZDAtAhQfE8LExuRAAmQAAmQAAmQAAmQAAmQAAmQwMwJUHzPnB17kgAJkAAJkAAJkAAJkAAJkAAJkMC0CFB8TwsTG5EACZAACZAACZAACZAACZAACZDAzAlQfM+cHXuSAAmQAAmQAAmQAAmQAAmQAAmQwLQIUHxPCxMbkQAJkAAJkAAJkAAJkAAJkAAJkMDMCVB8z5wde5IACZAACZAACZAACZAACZAACZDAtAhQfE8LExuRAAmQAAmQAAmQAAmQAAmQAAmQwMwJUHzPnB17kgAJkAAJkAAJkAAJkAAJkAAJkMC0CFB8TwsTG5EACZAACZAACZAACZAACZAACZDAzAlQfM+cHXuSAAmQAAmQAAmQAAmQAAmQAAmQwLQIUHxPCxMbkQAJkAAJkAAJkAAJkAAJkAAJkMDMCVB8z5wde5IACZAACZAACZAACZAACZAACZDAtAhQfE8LExuRAAmQAAmQAAmQAAmQAAmQAAmQwMwJUHzPnB17kgAJkAAJkAAJkAAJkAAJkAAJkMC0CFB8TwsTG5EACZAACZAACZAACZAACZAACZDAzAlQfM+cHXuSAAmQAAmQAAmQAAmQAAmQAAmQwLQIUHxPCxMbkQAJkAAJkAAJkMD/a+88vNs6kqx/AQIgmACQBHPOQdk5ze7fvjO2x5JlBYo5Z4AgkXP+fv1I2pJHtnX8SXtmPY1z5sgjPbz3+nZ1d92qWwWLgEXAImARsAhYBP48Ah+EfDdLV0rFTnV6kVMyX1NTLjVdXnm7wgoNDmok3KWQz/Xn3/r//DfrahbiujiP6CyWVr7aUL0pud1+tXb2a2B0SMP9bWr9tx5nnbfL6jKSUvxKCgyF1RfulPc9vnM1ZewoolznoNr6+zToMTfPKZtKKnJSVWt3N1h1Ozj971pTQ7X4kS4iEZ2kmyo0OhUeGNTEVFhBb8t7RODmVvWCmslTHUWudJysqd5oqsVtRozR8GnUJE97UIHxKQ31BxUGp/9dPN7/kP/4jg0uyegqmtLVJfY32KtwX5d8f/zFd7uiFFPi4pw9LKNMsa5awy2Xl/XZM6KBoUGNdXvkmKP9vIZATbnLGHOSk3t4QN29QXWZf61dKHGV01mqTT2s2ZGBtr8wak3lT/c59yqq9E2qO9SmbvfbhttUrZzU5dGxLmIpZesu1Vm1bta0OS/l8am9e1D9gyMaDHnV+tZ7/C/CWGM8l/u6LLiV7ZxSH+/U++99QL13cGrZlNKRU2XawvLjx/Rz2H2A3f69v7e9oUXAImARsAj8eyHwfsl3JaNqbFtbJxmdlbvV3RdQX5fXOaCa1bxSl1dKFyXv4JyGxyHhHfgY1/RB9VJRpUpV8FCYQ4s8/na1trb8QuaaXFOtciVeiId78ofjjzSbkI+qQ16v/94lV6PB38FIWlxqNOuqliqqNT1qaW1TG6TfzV0a5YKK5ZqqcEhXC9/j3/w+tzxvsBbuXeG9+L55rwZv621tlb/N+4bj3aiUVKlwjasVn8knv5d3eOs885KVM10eH2ljr6BsS0Ddg30Kd3nUar5QTOK8Xug8B4XondLSHCQ85JPbGSNBDBeOGYOumfdheIIMtLUZEgA5KBr8aqoZVNwe+RiIm+trDbAEFzO2a6grKhd437oh/Lwn13rbIPpe940jATaQu1oNF7DJMxtVlU1wAOfQ7fXJ1+aXjwk1GPLCyqQKymVdauvuUlc7/1Aucj2Ym38GBRcT5WI+W1wuBxsf5NShjbUyl5r3YGzOdV7u3S6/IY6Mt14pKLG7oePdHV32zCo4u6jZgE8hf111npGK1+Xp6FCgp+MXwtXEQSxy3wrXmKe4cVp5Xz9ju54P8MeOqoytiY24VVUFIIGNh4KDH3KFzf02qQJf5jqfvNDRi01FixU1xycVbO/TcLhXA2FwbGKLpZKKvAOPYVw+eX62uxujqNfAGJzBvsF/18sl3gT79LaqnecD1Zuf0oUaJy/0/WFTJ81xLY13qLfDzOc1+cbEIYatag2G1NnOPW4d9UZZJTPXvEiD2XXj0Pv591tTuH7IjY2Xwc7EU8xctRocmI/b9zDzYdaTWTf8Xc2sU0Az8+b2MuZWn1p/DRo4VJnfErbg2Bnz62VN+3FYb1+vWa874zd2bfColquqmYXMWLwGMy9PqIFlydgg9ujh3ZnPVmPbztiLBGLyymakthD2F/D/MneMvWxsgeebsZvv+tt4T/aE3/1U4ypCMjZ2CI6V2xUkqNIbalUbK6sBWYqcRJQotcs3dkczE/2aDt6M5h3G+/sPvvnXBphhV2bNNV1u5ox59fO/n718/r7B+mKuDH5MBv9NMMgZo4/94Nfza+4LBpUyOLIPsi6b2Lpja+xj13CwHthDzXw2mH+zn9VYF3U3z2W/wxT4YPvYabHE3xvob+/RfrO/s1dUSwmdrm5pfy8h9/y0hmenNcSe0dFScNZ6Is9/s2Z7gq+FSP5ovIzV2EgDLOrYSL1cxkb4O4K5LT7WNobH8n6nT7NaUpnvl836N7YLXl4/+/5rwSpnn+WZzj4LBlVsne2Qs4V9j3Vh7PfNI4Jr2HvLXFsz1sfFqfXHimZZe4tfa4rg4MRbN5SaiqkTbX63qljdp8678+rzeLAz826Mt3il+MWVEjnW7eC8RmcmNBlwX58TzsfMKfNRZM2YbY358ICHOQ+c89bMR8VsQG552bDfeGf29AY2U2XnbOGscl6vXlalhI0YuzP7sRkvdsftrj/lnPKbf9dm3KPowDdaHG/XjBNZuf5ume+WMa4Ga93YrNfsu7zI7XMbzlqvXo+uxt7o7Atmi/YzBzznNRZrznNnDsxe48wBNseKd5sz2tmX2GMZe6Fk7sG5ZfYrP2fLr5c2a7Ji5sY5D5hQ9mL/zf5xfSljZW+rsbc4m6i53pxdbHXOfsW5aM5yY17GX0gd7ep4c13RwLg65+5qJtCqHgzCnJ32YxGwCFgELAIWgXdF4L2S72Y+psLeYz2P+nXV85keLQc10f6rV+EArhnPxm0IGU53PqKryIn2IewpHLvr0xpnvyWkwMCYZqaHIPAeuYk6X7z6UefqxLH7VFM9HvVwmyaHovn7swLfmf9cU4NtCl2e6nz9GUTFr2JHSK2lAkSnV8HhSc314AheHmtn/1JpHndLQJvuLvWOjGtqdhCCx0FfvlT25FD75wnF8lA54/zh0LT4ITg4Q8apGiawYF63cL6jyFlEFy3j6h0e0+yAGdu/TkGzVtTV6hMdXUK8Rz/R+GgYB+ZXFzaLSm6+1NFpXMmhBxqdG9VEA5K7/k8dJrJKBYfkwYlsqbeqpXdak6GSPPkT7Z7kCGzU5DLMGEei5gQDOtQKiZ+fGNVMv+H2hzo9OtdJAmfEOPYmjoHD12ztV3hwVNOQunZ3SonIkVZ/jCkPIfN1e1XFCzLOh8jMN0KMfXJUS8PGyYvpcCui4+MWDSxNajxcU+lwWwfRtKIlnEZYZEspTuZQKnXOaOH+nO4MetVI7uvoIKozssYmimLIpgcyQDpBwxODGuWZtdMNHWxv6eAKcu/pUEtoTOHwsO7NEagoJbW5VpZ/YEhzd4axiKqKV8eKEdQ4SpSVw4E08wWjk7tzQD0j85oehbC2VgjgnGr1yZlOT7LyBVsYu4dgRhnCX1fFP6qe0VndnSAogg28+THRBLL8p2C9dqSTs5SKBBI6R0YVHrmjyeGgBhpRXfEO+5GMcmRKDTdyQ2ZcnqB6xyfIjPMuDNMdWVfkcFeblbDKEJxAI8efPdjOuJZ5tgmcvPEpRdU4X9eTi25lAvf1zZ0W/XpZvX49uXhscldnx+c6SDWZP3AwBNiFgxoe18jEuCa7IaP1uBLRQ+0eJSFG12vPOMf1li6192IPU2TdevgOxO1q9QcdR8516euBwOEAY5Pm2kKlXZ3hMS3cndAQpMpHUKWaPdExdnYUxfE1QQauc0MOGv6w+scmsMdedUJiKpEDna3/pFMyy1lvt1zg5cX+azjvdQ9BqbaGulqwed4tX8ir0eJXs2tG45PjWhzFORZKgJ0zHR5IfXOTmprqQQVRUfGC9Xh4qv1UQ2VIhkM9jPKme1QD4+OaJkjS8WYEwtlzeCMl9jew6RNl+xc1MDurmaDrTTVH4UDRs4S2UygMBoa1zDqo5FD5HJ0x3oJKPO/N8Y5rbjysTvjmbwd1GDh4ZqPY1eGZItm6cx9H3cBe6TPvPTGrybBfHZ64KrEdPd1IopqpK0CkxQPrKDmsGiIwMKXRqQlNE7TztUAIIcTx432dRJKKl1AgQQ4bEA63r0vB0TlNjg9AkCHlR0+1fZ7SgYbAkLXFXldpMzbQp6H2tJIHhzoko502QUw2Du5EgKRLbYNTGh8MqdeXVmxnWztbh4qmIUed7Wrrm1Z/35gW+9OqZhJaOw9qaHhEyzNYL/OcjRwy3nNFMuwb2IkJ0JnQjK8bdcEk79bLeHOHutxe0XrKpSsUJn5DGSFfbE2Qcb/CcwuaYo80WchfL5vbNdEgqJlPHmv3kL2cTd/t8zg5ZhfB0pb2bo1OEOQcCnDvpjIbz3R8uKMoa6AMFfZizy4Ms1AlqNE5pNm7U5roZ181do2dnx+zH5zlVGCxu3wd3JX9NxOTuoLqWPpc00NdGvlN8n2unce7ZJJ7NfT1A43xwm8oh6qXKsb29dNGmfUxpPsfjXPmEGqFmF8d7enkIk0giJkwwVmjhmkNKjQ2r5lRzjpd6vTFvq6a7HsPlzXY4bneM5jX/M4LnSXLSgxwvvS7FDb2e3CuswSBH2NyLIUGZ2drYEhj85Ma6fOrvYZtb3+v7QS7fv+Xmh/1a8KXVzl9rP2DC51dmQCi+R57rxtj7xhw9pmZ0aDa2EqLh2sQ11c6qbSyb4K1i3kwgd1mG3v0kGbm2B+HO7C7hpJrT9g/dnXBmVzmDPMQMG5xEZBq6SaQENBAG2dRvahE1gShCRR5+1BGzWlxqlfDQXMmE0TgjI+enOowzpjM2sC23JwJntA4aqkpzQwQfPLklUsd6dWTqBLJIqoWzgL8kjr+AieXqp3TGpuZwn5b5YpuaG9zU/uXKGHc7WoJjiiICmZpakhTf2klx7u6kvY6i4BFwCJgEXhXBN4r+YYJS/kLRc7jOk/g0JF5bDFZBRyVZgvOfne/esN96u80LgqR7eqV9p6sceg31br8EEJL9tBI2Ro43NsvdHiW0XngnibmxzTngvi8+kGHdcj30pea7fWo94Z8R57/U6eQ7xqZhtlhZH6xQx2/fKLtali+2Y/0cBrnkPeoZyKKrLzQPpmrxvQDLQ6HNOjneVWI/+mZknW/3BC6/pYLxQ+P9erEp+DYtJYW+26kg0T/z460vXqhUu+Ihu8vaBA/493UdzgJlQutfn+iJBm1ya+XNNLZ9naZbGqT9znWD6lJBXCmPurluRvfajVSUm7kEy2SEZ8JmFRBTfGf/ke7Ud5/4mstzPVrshWmm1rVkx8vdVIY1IMvFzSLs2gy+NnIGQEHsmRtnfLgtJSzCWWTCRxgZKLhCc399x3NtpWVOl7Xix8uIcyjmvxoSVNI4DvcGWXP9/Ti6ZVqvWRfv55Sv+I6XIW87bo0dG9GszM4QT9bHq4Y0t3j9WOdZZFQzsxrbBCHv5pV9iKitCGnfmTqlZyK2TiZ7ARksST/BCT9b/c1xtzWT3Z1ur2hi75Fdc/hXHFzN4Q/enKi1ecldU1M6969oNoL+1pZudRBtlfTyzOaGSOIYDLzRYID6wQDzsryzd/V3FxYgRpZzW/3dHTlV989spcQ4sE23rXCPX841HnGr5HP72oS1QbCjLd8ILPFqHa/31K8pUMDX3+kcZPNj+zqZG1dR62Dap+9pyUcMpMUbRbPFN9f06tom4qhu/poAeexsKnjjQ29LIyobXJBn873KPR7+sXylZpnK3qyn9NuPqjBbjJl2J1RYsgTUHioXyMj3dfONWuqlDjQ01WIkntIiw/mNNLTArEoqpq+0HEMcu0LIf2tKbUJNsd5uWfvanxqWKPO5BEY2lvVyRHZff+iBhemtdxOQGPtW60TcEj1P9AkWbiFfjJjIpv58nvsD3Iw8YVmZ7vUlz7UwdMdxTxh9dy7r5lwqzrd0PTsuS62VrSD9Lg4/LHuTnNtckcHKz9pt96n1un7ujNBaQGEu3Sxpe0fX+qA9du+9KnuTTHmVgIKFwdaeXKuIo7v7H/NaIRgyPH6gXZ2XBq4O6flaa+aqT09e5nQZb1fc/ewuX5sD2e8nr2ArJBtFGMnUBIwKo03PiazH9XBxpngkI49z00jL/3dnbSsfPxEez/uKG7Ge/8+xL5VXWa8OYJxmyvaTfmUG3xEUCWk8V8H2m7vTZlOJfJKz45duvTManlxEOJpglvsoQnsdR35e6qD/WYRIg/Ji2zoycssq29Ydx7NaRxba2sWmPoDvXjJ3iWCeo9mNOyLKHtwoJeX/WonsPNwqftaBk7pRv7iUC9X0wTTRjW/SDAk+lybO6yh1iVNLkzo3jDZfefavAoZAp+RMnu4W/4OF8EG1nD8VFeJAmSK4OD0vP52P8TaLCtGwGx/61ItywsQl1ENmluUNnW0H9OL016undbD8aLqsVU93atjJ3NaWhjQVNhk0AmOJQ8Y75lOnPGy93QklNt8ppeJgOoDS3qwCFHu4vzIniq5/VwvsoOqDt7XJ5MmC/n2yWpkrlDokEVutqtp1AF1Sn0yOV2eRnSZLGD/DzT7aEHTLKfy6rfa3Ie4BZc0ODOrOyNd6nA1lNt9qr39CMTzY40uDWmyTsnQ03XOnXYF7j+CgHWo25gUwcbD5xB4gl5ahnxDPkffurZN5tuQ7x1lCAAMfHFfI94bgvzzMIxCJ66978i2Frzq/nxZY54Y73KoV4kBAn/jerBAMNi5Pqtc5FAv1rJy9RDwWGSuk+vaY+87a7+vuTEC4UHO50pUr55dKF3v0uTdQbWi8jg/oMQCbIcJTC2EboKO2S0CWCday44rNDKpB/3skcePtRFjBx74XIuTLQrFtrTz8kTp4JgG7ixrBgB8nOvV+CFrfUPbpV65Jh7pAUS9/fy5tte3dNw+T8BkWff4uw6uLUFqz3b3tdtEQTS7rPs9LtW2v9PG/rliPcsanmY9jBDIYV+6XHms9U2UJ713Nbq8qPtDKFkIMpy82CGYXlHX/WUtTKOYS+3o5StKUpoDTsB3jP3PZ4JrtZiOnu1Q/uBR1z3snO83E5ta+cep4o1ejX50V9PDBF697JWpfT3/4VxpT69mv+E8Qh5Rj3KWra8oEpxSYPGO5jkg3u3s/91NxP6jRcAiYBGwCPyHIfB+yffr4EGgc/GMEhlkr4Z8u5GPZdIqkEWudk9pENba3zzSyzUi8a5hffH5iLpeL2yrHUICT/XdfpfCo/N6NISjv/GjDqtEnZe+0DRRakO+RVbu4sX3OEENVRa+0swQme/bQzI0pS4OyTlYiR/nJBU70soPCbWQ5V36bFrdfP1fE9RIifcfa233VC+zIfmRxPUidb6Wa+JF8bx6kcj46IL6DaELSZ1/oGS9hgXHshLTxvdkI8ptGvnynsaQyb7VX0xukK060o+5GYXG5/QwlFNu47EOSuRFlr/UVK9X4WvtNkRlQxGyL5tJssW8X4eR6prMRccwkvYJghF+BYwszsh3cbjPzslS5Mhk+5Fsk6lsQcKdPIBQB/o19vVdTUG+0ycHWntZUmByQst3h28Idd0hGrtPdpULkdWA1I8IwrwG+d5zafAupBeyck2+80qfk8XbuyCrM6Lw5BQZejKPRjaPfLEQPSATF0e2jbfbgbQXBYFyOSXITLmGRjX21QONk/VrHG3rZGdTsb4FhchwLTCPXsj3xemp1l5AvqdmtTBFFu/gudbSYWUHPtHHpI/gpr+4r9EtRfc3teG7D4GHtHmPtPfTpVK1bi1+MUcWxWTBDJZk/Z6s6zxeUcenOFt9ZKLfuhnUVc5Dvv+5rQTZsYGv7mqiFSK7t6P11bwCkNWFRZONv/2YfNCZNp6d6ziKVPPjOY26j3S5d6A9/yOCK8N6yIN+V7iICqNx9kpPjqo6rhBgQd0RxHCaTeyxpQ3pPcGl3k7HEWzE1nVFVn1Fd9QxOqPPh9927xxTtKMfnpE9qgzp009H1Rd4LefWiKh8fqD/2SZgFp7Xp5MuFXae6iDPnCxifxDaPmd4rOU9AmIXBR12fayZkaq6Mgd6vtWq7qFxfXr/dQQhtwQddrZTWosP6d4dlBKs/yNknLHeRYUWZjXPAEySsHxJkGztmaLYjn/poeZwcjsINBWT59p+vK1sFzL/rxY15krrfOMA+3M75HumFzXCzqpWKrNqGV10xv4vCe7f3OCN5v5ChxsnZG8b6r83p7kZyP9vXO/IYmvHujyP6qfNNoWHR/XZ/fBrVzPe4qZ2t9KMN6w7y5D+1owOIQ9XOZNhRCJPEGRgYUphb1ZFlDoR36g8iw+1FDTj/eXjBEMgXIlxCNokCh3IxYsdFCRtY/oa4/Eijb39xF8QiIyT0Zt9pO7CsRp7K9ojuFFD8t/tMeUOrEEygEayXkpW1T41rdG7rNHoimLRqqJ97KEjrZq4fQH2mHLuQtEDsrzct4QKpR3peNCTViab11GKbCOZxC/v95BZLCm6iVpl+wryTeBjdhzyjYi5tK1jCN7KGeQbKfpyIKXL9afa947Ku/BQQPPGeHMEq27HG2yvKxgha+pblo/nPMDwnOVNKYai6/rnWaeSbfP6fD6g3t/aiCtx5ehBcnCW1BU1y55OCDX7jpKXyl/FVB4lM3yXshaWQHkNhVEso/z8FxqDOI/dQNs4fanzkzNttT4kc9qu0ca2Xm6w3vxj+upzSKzTg8EswKbiK5xHCQIcs59rjADv2O9mvn+ffBOl0PZ3W4pxZvR8vKBghqDfqzXtNQZ5tp85RUJuzibUCE0k06VUVW0TqEA+QznQktfV9qG2KVfpZX1NDqBWIbC6lhuUa3Bad3qvdPliXasbcQIbnHWmnArVkFNO4iaTzZJIVQmMTC/o4wnGd/qT1i9bdBXGRgeSql+cauUgoIm5cd2ZCbxmsXmy/1t6sV4kODOhT++gJstu6mDvWMkJ8CPQN30rSW8SWLza1d833CiP2K8WMbzj52SYCcoyB+PDKAduoE1tPNfp+bmyU5+gYBlwgiUmWBjd2NLhXlIt95Y13k9Icv2Jnp/Wdd4IaYiNuIXgiVG4mZKaRiapZltAbQsfQ9SRuxPcWvsxI1doiFjJFIoB5zBQtXDBHs857GJtf/UR5Juz8pzzc+OVIqFJdS3cc/al9nc6+39z07H/YBGwCFgELAL/gQi8V/LdMHW8uTw0kywGDk7nr52OEsRza0vfR8LqGB6CKBUVWUd+nOnQ+Gd3NE4Hl1sy2rx8ifwvqpXipIZnZnSvM6P46mPt18ja3vmblvBznePeZBp+/FHHRRyHu19pjsx30CHfL3XWNaHOhfvCL8OJrqpwRZbq6baSHf3q+/iRJjk5f87UlrIqGBm6l/roFBlM4yxmhjTAe84jxzY1acTkOZTJwJkL23DgID1mjO/adKVJfWZ654kOaVJ2gXzY1L0vQGR+4Yqw5jKEdn2Vawqq4ahMkOUeqeWVXMEpLCHdXSTwgAyw3zyURlxXZNeOz2O67CLj2u5XEMfayP58nQEFQt0KdiKva0kqS+DhxdOEykjM578gy9FxU9tMDfrGt1u6qHVp8G93IN+84wkOyYuiOsaQ9z4cu8YZ/HLgt/PjvgohpOFfzpN3uyXfbod8L6Aw8FLbf7mD7DeHMzgEQSKdSjLj5nOpxDHZmRdk2pHsLeAgDjg1+GRjM4da/W5PqQ4yEN88hKDSgOiADPH2pi4H76mPjPaiww8vId9kZCDfnWTJ7yxSk3pJpn6/pvMWAhXLQxq/9qCcd07vrOD0nSuFhH9sYVCDEL7tHy+UrIQ0//mcBruo0zdZkUYCFcamIomauhzy3a2et24Ir5PvTvV/dR/y7VH5cFN7K8fKDdP0jAzlNJN6bRdZ1a82kI6WqO2c0P379Dqo7eh871A7BAQCYPwQQvFbklnnFq/LzoMP9Ldl92sKg1+9ZP5QmdM9PTkPqUmt/Od3yfL+bKAEYHLYMN56my+unRenOrv0aeijZU2ZDN/trZKbujg81E/pEYUmCXxRTlDYfKL9HOoSHOKpgXYNOoWlELNdyDdy65PuT5Eo+9Sb2dP6c6TRZFTnPqW3wy2nb+ZUPXqu1ZOaTiBS9xfI1qNYMOQ72j2n4Pziz5mkUuxM52vPFWkn8LP4keaYzy6zfhNn2jbBny6++9WCRm/I986uId+zWhqhbv1sXT8edaoYmMHpJ4Dyc2qKGtw8MtcadbUdrA/P28IdyM4PIHobZO4ok+iZm9cy0hiSvTcfiEnxCIn5pXYv2tQ/iWOO0mTveUJ1JLqzn80j4b6tnGG8xy+0dlzRkXdBd2d7NBls8g7U1jrSdLNOKaHoQNpMcKWw/0xrqW4VyKw+hBT03b53I6nTlxCX04J8S/dQavD+9NV4uo4d+sf1OdEmE4i5Nnfe6/G6zvJeBckC9jdOVTzY1XZjSp1I5JeGqLk3+5hTn15ULg/N6mCfoJbYdfgU0llTJPwFUuEOIUzgA6uDlB9R5/4iN6G+0Ul9MktG3ODBvdOH+wRHO9TZO6lvHl6T7/P1De1vJ+RDVTI1Q8mQuU2FjOdeTC8N+SbzfW8gowLPe3EVUqHvIz2YYT97bbxnK8h7GW/rEntkZ453W9O+e0HekTk9IJVuZMxCfVKnFONxtEvpjgV9NkdQ4peJ+nm+pDQBQhQeBH00T0AAGfXYj+1msQAAEXJJREFUTR1vJbKnvVfUXPfOKsz7GjJXgXwfXKSUm/lMoyixJm/st0bPhbPjM+22QR6nezUu1u9P50o2+zT/5V36lxihssGFAMQz1gTlL7WFzzU5EtLoH8jOczQiHWYfMbLzX84S6pxNdv8MNcOJV/XuGT1aRCGTXdPRDnuYZhWi8d8ia9H0A3DR7+J6Tgl2tHcq2IciyNRMI1u/ohTolGBsrkINc+xSoekJDRCIDIBN9McX2BbBOHpqDNF/ZABFiLO0jSKJngl5ZOsdAYJ7XoLoB4+1FYd896O+GqPhZXRX669y8ozNaP4BZUG3Swr1TflgRT9FvEoF7uoTFnDgclV7uwdkze9TzjGFmuZmilhP6YMtPbnskWdwWZ8AVnMflUGM83j2M4IX3SiLrq9NUqJyQnlXZuIjDU4Ma9axmRw+xLYO99P4BUuaHqEu/hgVyaFXidYx3WPd9SLV90LATZ+RQraoCuUZvm6w7CyqSOPMFUO+A2D5OWueejE0WaoQYN35gQCrq509/pFDvt1nlG+svVK0d17dPGuJdfeuZ/+vdmn7fy0CFgGLgEXgPxiB90q+awWkfYYwURt41SS6jGPZ1eZU1wExNYS5NE3O+P99SGGpQx7tIGqP7OzgiK7RZSTI7Uj3/EYeRnO2eEEV6kD7cMrHIAY9FQ7jg5+0iRT9FMFzD6Qp4KMOLEVtdCShQmBMPY++0J3hVgWJUB+/4qAOkPle/kiLOO9OJpKsa+liW3unNAYq0Jymq11dJitMHXqRTnAuusv2zUGeuqhZpBb2aAeJG81wPDSy6sLjdJlawxwHeNmrrqERjUwNknnAUUlGlEzQCdVNbWd3rwbRG98mQt60LdPYJU5WmCDAFhlc7uMJBmnYZWRx5v3IgKVzyri61TGCQzPeg0SfaH0hq/OfvtWxId8EHmYH/JAfk3nLKbq9q0iE+mxPG02IkKqa7LLjA6admsUGWUVDigebER28OqK+EhXAcB9NkExGAEKSTipKxrmGVHHib4+0GEBCfIRs72kBcjulO59M3GQDqhD4Q23+c1f5nmGuXdIoAteTlX1tk3kcQeY61p0mK/NCr849KuHszRAIMc2M6JdEiT/yzBGIRp1SgpVTZatetQ33Og6iG8lsPk6DK+r+NTqt6a8/0zSOjTdG3R/lBxu5TuZ3WhODPdT04wTGI7wfwQG6e9//eIS5xYnc3qFOMK4sdY9tXW3cF3yo9YzTsKjRTp0v2ehJErH18pGe/T2qTK0H6fyChp0mXYZ8x7X9/Sq1izUFvvyILNFvZ75LOTKw/9jQlZGd/+1TTdDIqzMfVz66oy0c2Vgduwq2O43PGsU0TcGQ2YYm1D+Lc8g7tJ//hAwXLP0fK0SW6pOBPyLfMRquPdf3+2VKJkzmmyCL/5eUi8nCunw0PnPq4iFe1HKfbiGvjIFVVy/iAuwL57yJyiHd6KGJGHXXZi6QiJ9Csg/yfrn8kBfjEJva4zjqBFDtmVnUxGSPespk0J79w8l815a/QV2CJPiGfJe2/kFfhKwOe75Bjt6jRU9SmZN17ZzzHSTeQfTxbdQeN4r88gFZOTd2NrYI7iH2gaNNygJWFQ0vqXvpjhZZpIZHFqMnOl2hj0PHqNrvfKZFMqMByLdRXmyQBcwGBjT238uaoBTldHVPlGJq8D5EGfm+F8f/dH0HiTn1qB3dams3TaxookUDv3QN2+D5C+MhhaiBfeunlkI2e6zNbaTPGeq9gz0KMIZWU8ldIQiWzlCfz7jGkUSP9WgAxYQZ764zXrp7c207420W80qkKk6QaRTSNxRC6vqb8gZKRci0HaK2OTxH3g0h7iCqZ+aslqMuv8LeiAJhEWXJUIB1Hd3U4xWUI5RIDLAmQkH2hVJe1RylOU32oKFZR6of8mexSWT0u+zLFXDopg7ZaS4GMYRYZdhzg6OsZZQUvsMfKB+o6azvG6TtnZpzIm6sC+S3kbNjvTwlRNbaqeFen9MfoVm80BUdzE+zYZqBzevrT4ao460qc8R+vrqtCOUQbmrKx0N97PPHSpxd6Okx5BsVzMdL7HZlyhq2jnXgjJfAD00AbsebrBJgdcZLvXmJQN72mlZdd+QfX9THqBmchoKFc9VPX+m784CSncv6epHyi3/JfJudkMaNBCCOt5EW+4OQLkpfzHlk7Jxu9skkGd5xArEEzBYwvsrqP7TLeZKd+1oTE2FRyeB8TE38ycGxtto/UXhmXPe7qIE+pazgOK5IvUcdnEchogKNXIaGmvQMoDdC8OFXNEf8Ldl5nb2e+3234vQr8U4j725puZExgy9nQS4HOcTyOyl9GiNQOwTZbCFTnKX3wg5N7dLV6zltJ3LnajIOM6dgFxoc0OT0oIipsLfmVEMpsYI0eyvWqXbG+nCxXxOORp79kFKF2Dn18AnaT6Jq6EYN5TFnSDFD00gywF3UmXPWTXTRi2H3W61dumm4RvB7qk0T1SgKLaTnBG0y9LXowWa91GZXUTGlspSSDVEfT+O9QaJ6Dcj43vorHTXo7RAa1gBz5cUOcyn2RxMsmlrgWoI17rrSz/6u/Tjn/QJ7yihBq5s5SLx6rEPUB+mpzzQ8NerMlwlunr0yAZ+4PPeQjc8P4ytcocDY02mMNcEe0E6wzRHV1SvKZFAi+TmjZ0c13E3wML6n598RmOGd7nyNJP6WfLPHb37LHk/N+eB/fapx9nh/AqXL5lOtp33K0HtiuD9MIDKkfurM7cciYBGwCFgELALvisB7Jd/XD6VjKM11EpcJfm4FcnfdGtfpjuvhIAyEw/x0CtnK1+RazUpKySg/UZNGLsnZ6KI+vLV7gPrwXvVDCK4vNe3G89ck7ZLMRJnaZRqf+FrbFYLBtVI/rfYeddEoy4ejn6eWOe/FacV5Ns11X3e1mzQhSscuaL5DDTWNe9xesgdIqfv4aZzwz9kTnkd34wQd2mMJ5JZ0+zYddn1d3Qr106AMZ/GW/5QN+Y4nlYJ8d/XgIP8m+X5tWqrINq+udEETtQLdVk1HXRcNzXyd/GQXxC8M6b6FyHQiLsYh2NRJN0P9jLFFbRCPKvWRj5/x3PqA7n06j0P1mhNw8Vy7ZEhe5Og4PLOkr2aQV5cuFY8xnrSZF57n6wQ/6rkhCz6y5p5uaqJbIRn5DOMx3cRxzntvu4nTHRcHP0PDmZqvnX46OH04T/kkP/2VBXqYG5RbmfNL5UznW9M52ZQbmGZAddO1mXkaHVEvhZn+XIwSAN4DR6hiOuvyHq3Oe9DgrZMGO0HGaGrpcSgbOTCKJXWR89KYJ6wxPNB2vmXer6UdyTpy62vlQOXna+PMq+keTjRHwTAqB35+65r4mC6/kCRIaa1BkKafABH12s4/8azMJWUR2JUXyXmn6TD91lVkOn8XlKHZURmb9vdDbj23XfkZK2NLkF2KZZmzGtkwmlJ1MGd95uf1bjKUTQhVPg+WLZBFMO51atl/50PnbgwfO0w5mJlu7a93RG/yW2MuY8MQy3AvtdTOc7DZBE4oWbwMjQxrjMYD+egdopEZL/Lz2OpZpaMQqWQWx92UVtC0C/y7+0xvhttOyGS+4xfKM54GYwkg1Sem5qzJepoaVBr95Xx9OLnIzZ0bE2jL0q05CukrVB1bc3AI00+B7vS3vmqVYFw+nVLJkCICXHBIJ5NUh7gWknEVsJmWED/fxgQjsqbbNuUM2F+VDuvG/jqY80KK90+TDe02Gdzbbudkt6jxjWI3abLdTlfn1oB6Bhg7dvpOP3RVY10mCZARiMjedFV20fDNFwyzLxEUo9v8L1sY8nsz3gvWF8/7rfH+4aZMEKqciimC7DnFfZqmZ0ZbSD197Ak9zK+5QT1K+cie/rnZUL7SofkhmgaSqSs0IU00gwybX09gf33jJ9foGZC4ZN+kRrtkOn2jjGmlEWUPJK2Xkg8fTa4aqahSmFnRz/zC0E0lyO2nARaZC2rJWevGRox819dF0zG6TLdUaTpIc7Ug9u1kxFG+lNNRRa7YQ0ywoxvyHSTPT4OseJ61S4C1l2Zwzoema2a8UX5uMXk7Xmyhh58V/Hm8xRTZyrTSLmrKO7BfJs9RidC8sllIKobiqQLx68NITKDv7UuWYIOzj9BMkr3PNNUye4P5ZQFzXjTbejk/WJ+MuUlfhEwBAhkgQNnh/zlg0mD9FSCVmRb6iCC7p2efY+dV7nvJnuf8tBj7t+n+397S4H6cTQQeAnSDf7s02ewj7AGxGAEAgiTIvVnFNzaFbRFM7eztU28fgaJ/GReHBX0C4s6cgqFp1G3mtJMMNXNqSPDr898kG59l/nIV7ts7TEDsVw0b2ftKV9S/x2ngVjTWZH7FIEggmbN64EbBxh5TA5s0wfPSGzZSoXzhUlcXBMEx/ApnlJefPewM81Nc3X7xKOeTomneyd62rlDEeAk4ByjfavDTCW7O7AB79BAbh9PRH1t0zjrT4dzMAb/OQIsY51NOXtF4kaA850A7+F4relDEJCHwmbLcJrgUIMBwY1uV9KWz/6XZg8x5YPbIDnrOhHtD1HVfB6Eq7CnxGKcQZ1qI88D4JaaZYIM9Po1dlvmeH5LdgVLGawKYJBhisYQuMuTH+cmx4X5KR27t+Q8XuL3AImARsAhYBCwCzq86md6m9vN/DwGya9WCksd0vUUWekHyzBBZ44o7nb7pVtuOPHxomqZH3R1O5t5+LAIWgf/jCFADXLw80U97dHVGGfAZtdb2l47+j8/pf8DrZ/bWdG4k46PIzqfIvNvj6D9g1u0QLQIWAYuAReBtCFjy/VewC36ypUp3nJrzg7TXHxdZMw/dc99a2vpXGLMdg0XgPxIBU7pyrZQxv8fs/ByZ/VgE/s0RaJLRNj9zZ3533IXNWqv9N58w+3oWAYuARcAi8MEQsOT7g0Frb2wRsAhYBCwCFgGLgEXAImARsAhYBCwCFoFrBCz5tpZgEbAIWAQsAhYBi4BFwCJgEbAIWAQsAhaBD4yAJd8fGGB7e4uARcAiYBGwCFgELAIWAYuARcAiYBGwCFjybW3AImARsAhYBCwCFgGLgEXAImARsAhYBCwCHxgBS74/MMD29hYBi4BFwCJgEbAIWAQsAhYBi4BFwCJgEbDk29qARcAiYBGwCFgELAIWAYuARcAiYBGwCFgEPjAClnx/YIDt7S0CFgGLgEXAImARsAhYBCwCFgGLgEXAImDJt7UBi4BFwCJgEbAIWAQsAhYBi4BFwCJgEbAIfGAELPn+wADb21sELAIWAYuARcAiYBGwCFgELAIWAYuARcCSb2sDFgGLgEXAImARsAhYBCwCFgGLgEXAImAR+MAIWPL9gQG2t7cIWAQsAhYBi4BFwCJgEbAIWAQsAhYBi4Al39YGLAIWAYuARcAiYBGwCFgELAIWAYuARcAi8IEReK/ku9lsql6vq9FofODXtre3CFgELAIWAYuARcAiYBGwCFgELAIWgb8CAi6XSx6PR+bPv/LnvZLvWq2mfD6vSqUit9v9V8bNjs0iYBGwCFgELAIWAYuARcAiYBGwCFgE/j8RMIlbr9erjo4O58+/8ue9ku+/MlB2bBYBi4BFwCJgEbAIWAQsAhYBi4BFwCJgEfizCFjy/WeRs9+zCFgELAIWAYuARcAiYBGwCFgELAIWAYvAOyJgyfc7AmUvswhYBCwCFgGLgEXAImARsAhYBCwCFgGLwJ9FwJLvP4uc/Z5FwCJgEbAIWAQsAhYBi4BFwCJgEbAIWATeEQFLvt8RKHuZRcAiYBGwCFgELAIWAYuARcAiYBGwCFgE/iwClnz/WeTs9ywCFgGLgEXAImARsAhYBCwCFgGLgEXAIvCOCFjy/Y5A2cssAhYBi4BFwCJgEbAIWAQsAhYBi4BFwCLwZxGw5PvPIme/ZxGwCFgELAIWAYuARcAiYBGwCFgELAIWgXdEwJLvdwTKXmYRsAhYBCwCFgGLgEXAImARsAhYBCwCFoE/i8D/A79tPfvzh+iMAAAAAElFTkSuQmCC" width="633" /> <br /></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com0tag:blogger.com,1999:blog-1509187841033628660.post-7955576467188290462023-03-26T09:37:00.008-07:002023-04-01T16:43:50.753-07:00Fantastic (& fantastical) hospital charges: The industry + insurers + Pharma making money hand over fist!<p><span style="font-family: verdana;">On March 15, 2009, in “<a href="https://medicinesocialjustice.blogspot.com/2009/03/bargaining-down-medical-bills.html">Bargaining
down the medical bills”</a>,
</span></p><p class="MsoNormal" style="margin-left: 0.5in;"><i style="font-family: verdana;">I told the story of my hernia
surgery – outpatient, in at 7 am, home by noon – and the $10,000 hospital (not
doctor) charge. My insurance company paid $1,600, told me to pay $400, and the
hospital wrote off the $8,000 as “contractual adjustment”. But if I was
uninsured I would have gotten a $10,000 bill!</i></p>
<p class="MsoNormal"><span style="font-family: verdana;">That was outrageous. Not so much the amazingly high charge, rather
the fact that they were willing to accept $2,000 from an insured person, while
they would have dunned and bankrupted an uninsured one, someone more likely to
have less money! Of course, that would only be true if they had agreed to do
such an elective surgery on an uninsured person in the first place.</span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Things have, apparently, not gotten better. Maybe worse. I
recently had another outpatient surgical procedure (different hospital,
different town) and the hospital – again, not doctor’s – charge was over
$69,000! I was there for a few hours! Now I have Medicare, and a Medicare
supplement plan, so I paid none of it. Medicare paid $2400, 80% of their
approved charge for that procedure, and the supplement plan paid the rest. But
$69,000 as a charge? I thought that the old one, charging $10,000 for a
procedure that the insurer would pay $2000 for, was bad, but charging $69,000
for a procedure that you know Medicare has approved for less that 4% of that?
What is the point? </span></p>
<p class="MsoNormal"><span style="font-family: verdana;">Maybe an billionaire, or a royal from another country, will
show up at this hospital and be willing to pay $69,000 in cash. Dream on. But
the vast majority of the people that you would bill this amount would be
uninsured because they couldn’t afford insurance. And the hospitals do not expect
to collect anywhere near that amount from them, but they will keep billing
them, and ruin their credit, and eventually sell off the bill to a collection
agency for about 10 cents on the dollar. That agency will increase the dunning. <br /></span></p>
<p class="MsoNormal"><span style="font-family: verdana;">So what is the point of having such a high charge on the “chargemaster”
(the name for the pricelist no one sees) if the only people who are going to be
billed that much are those who are least likely to be able to pay? There has to
be a reason, and there are in fact several, which include hoping that some
insurer will, if not pay the whole amount, pay a fixed percentage of the billed
charge, and so the higher the charge, the higher the reimbursement. But, of
course, this makes no sense with Medicare (which has fixed approved charges that
it will pay for procedures regardless of what the institution charges) or with
insurers for which they have already negotiated reimbursement; in fact, the
latter is usually determined as a “multiple of Medicare”, e.g., 2 or 3 times
what Medicare pays. There are other arcane reasons, many of which have to do
with the complex interplay between the “providers” (hospitals) and the payors
(insurance companies), and who has the most clout in a certain area in a given
situation. Assuredly, the interest of the patient does not enter into this
discussion.</span></p><p class="MsoNormal"><span style="font-family: verdana;"><i>[I was going to add the following paragraph as a comment, but I thought it belonged here...]</i></span></p><p class="MsoNormal"><span class="x193iq5w xeuugli x13faqbe x1vvkbs x1xmvt09 x1lliihq x1s928wv xhkezso x1gmr53x x1cpjm7i x1fgarty x1943h6x xudqn12 x3x7a5m x6prxxf xvq8zen xo1l8bm xzsf02u x1yc453h" dir="auto"></span></p><div dir="auto" style="text-align: start;"><span style="font-family: verdana;">A colleague pointed out another important reason why the prices for services in “non-profit” hospitals are so high. They don’t pay taxes because they are (supposed to, but often don’t) deliver “community benefit”. One way this is measured is reducing the debt of those who can’t pay! So if you can take, say $3000 from an insurer for a procedure but your “official” charge is $10,000, then if you accept $3000 from an uninsured person you can call the $7000 “community benefit”! And if your charge is ostensibly $69,000, you can meet the requirements for your tax-free status without losing a dollar…</span></div><span style="font-family: verdana;"><i> </i> </span><p></p>
<p class="MsoNormal"><span style="font-family: verdana;">Trying to find a pricelist with any meaning is almost
impossible, but it doesn’t have to be that way. I go to the dentist in Mexico (I
don’t have, but it accepts, US dental insurance). They can tell you before they
do anything exactly what it will cost. Cleaning, $60. Gum trimming, $160. Same
for repairing cavities, making crowns (on site, in an hour) or implants. No
surprises. In the US, not even the doctors or hospital administrators know what
the actual price will be for the patient.</span></p>
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJKgmoCFZPXO6d6zbv3a0kNjzP7ewUk_eD2E_XAwPsOcaLfhDfm3ifmqAU6hvRAIA8oR1kaegZXoSGykwPhjo_mnI8zPrHmmEklHD9So9QWmH_XAdLTWYTuLQRjF7OJNGiL5aJz3L_THXYO-gtrvGMz-sQ6tfvk08oNOEsNveZYpTPTLD7wWYM4EOfLQ/s1287/health%20dontcare%20_real%20life%20adventures.jpg" style="clear: left; float: left; font-family: verdana; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1287" data-original-width="893" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJKgmoCFZPXO6d6zbv3a0kNjzP7ewUk_eD2E_XAwPsOcaLfhDfm3ifmqAU6hvRAIA8oR1kaegZXoSGykwPhjo_mnI8zPrHmmEklHD9So9QWmH_XAdLTWYTuLQRjF7OJNGiL5aJz3L_THXYO-gtrvGMz-sQ6tfvk08oNOEsNveZYpTPTLD7wWYM4EOfLQ/w278-h400/health%20dontcare%20_real%20life%20adventures.jpg" width="278" /></a></div><span style="font-family: verdana;">This absurd pricing is yet another example
of a “healthcare” (or maybe “healthdon’tcare”) system that is predicated on
making money for the power players, and the technical details about which of
them benefits most (sometimes, in the case of inner-city and rural hospitals,
suffers most) dominates the policy discussion and political rule making.
Politicians like to talk about regulating health insurers (and sometimes hospitals),
and for sure drug companies because of their exploitation of patients. They
rarely, however, do anything much about it. When they do something, it almost
always 1) is very watered down by “compromises” with the big-contribution
lobbyists from the regulated industries, and 2) when it does help people by
reducing their cost, it always continues to make money for the (maybe) regulated
companies, just a little less exorbitant than before.</span><span style="font-family: verdana;"> </span><p><span style="font-family: verdana;"> Drug costs are a prime example of both. The legislation that
created the Medicare drug plan (Medicare Part D) passed during the George W.
Bush administration. The positive benefit to patients was that, prior to it,
many Medicare patients did not have coverage for their prescription drugs and
often went broke trying to buy them; it required all Medicare recipients to
have a plan.<span style="mso-spacerun: yes;"> </span>The obvious benefit to the corporations
was that now all Medicare recipients had to buy drug coverage from an insurance
company, and drug companies would now get paid for all these people’s
medications. A less obvious, but incredibly important benefit to drug
manufacturers was that the Part D legislation forbid Medicare from negotiating
drug prices! So big bonus – everyone has to have drug coverage and they have to
pay what we charge! Medicare is the only civilian purchaser of drugs (and other
healthcare services) large enough to force prices down, as they do for hospital
services (see the anecdotes at the start of this piece). But that they might do
the same for drug prices really worried Big Pharma – after all, the VA and
TriCare, the only other purchasers big enough to have real clout, <i>did</i>
negotiate lower drug prices for their members, and this decreased their profits.
Indeed, in most states Medi<i>caid</i> negotiates drug prices, and the manufacturers
don’t like that at all. Luckily (for them), they have hundreds of highly paid
lobbyists in DC, and make millions in contributions to politicians, so they
were able to get this great deal. A great example is former Rep. Billy Tauzin
(R, LA) who was chairman of the House Energy and Commerce Committee when Part D
was passed, and, <i>“On January 2005, the day after his term in Congress ended,
he began work as the head of the <a href="https://en.wikipedia.org/wiki/Pharmaceutical_Research_and_Manufacturers_of_America" title="Pharmaceutical Research and Manufacturers of America">Pharmaceutical
Research and Manufacturers of America</a> (PhRMA). a powerful trade group for <a href="https://en.wikipedia.org/wiki/Pharmaceutical_company" title="Pharmaceutical company">pharmaceutical companies</a></i>.” (<a href="https://en.wikipedia.org/wiki/Billy_Tauzin">Wikipedia</a>)
</span></p><p class="MsoNormal"><span style="font-family: verdana;">Drug company profiteering is also a good example of the
second point, that drug companies always continue to do fine and make big profits
even after a reform has decreased them a little. A more current example is the
push (including from the Biden administration) to lower the cost of insulin, a
drug that is literally a daily necessity of life for those with Type 1 diabetes
and very commonly needed for the much larger number of people with Type 2
diabetes. The <a href="https://aspe.hhs.gov/prescription-drugs">2020 Prescription
Drug Pricing Report from the Office of the Assistant Secretary for Planning and
Evaluation of the U.S. Department of Health & Human Services</a> states
that</span></p>
<p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: verdana;"><i>The average gross manufacturer
price for a standard unit of insulin in 2018 was more than ten times the price
in a sample of 32 foreign countries:$98.70 in the U.S., compared with $8.81 in
the 32 non-U.S. OECD countries for which we have prescription drug data. The
U.S. prices for the mix of insulin used in the U.S. were 8.1 times prices paid
in all non-U.S. OECD countries combined. </i>!!</span></p>
<p class="MsoNormal"><span style="font-family: verdana;"><a href="https://www.verywellhealth.com/insulin-prices-how-much-does-insulin-cost-and-why-5081872">Verywell
Health</a> reports that “As of March 2022, the price for a vial of insulin
ranges from $50 to over $1,000, and a pack of pens ranges from $45 to over
$600.” <a href="https://www.bbc.com/news/world-us-canada-47491964">News organizations
such as the BBC have reported on the impact of this on actual people</a>. No
wonder limiting the price of this life-saving drug is something concerning to both
Republicans and Democrats. President Trump talked about it a lot, and President
Biden is actually moving to limit the cost. With the administration-backed
Inflation Reduction Act, not only did the price get controlled, but Eli Lilly
(one of the 3 major manufacturers of insulin for the US, along with
Sanofi-Aventis and Novo Nordisk, and the company that was given the patent for
insulin from Banting and Best for $1) announced a 70% reduction in their
charges. <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/03/02/fact-sheet-president-bidens-cap-on-the-cost-of-insulin-could-benefit-millions-of-americans-in-all-50-states/">The
White House briefing fact sheet</a> on this legislation’s effect is interesting,
and contains some information on who in the US has diabetes. <a href="https://www.cdc.gov/diabetes/library/reports/reportcard/national-state-diabetes-trends.html">The
answer is a lot of people, over 11% of the US population, and minority groups,
the poor, and the poorly educated have an even greater burden of this disease.</a></span></p>
<p class="MsoNormal" style="tab-stops: 336.15pt;"><span style="font-family: verdana; mso-tab-count: 1;"> </span></p>
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDHJuuPS8vSxqSOCuIDk48nlJbCrAlLx1SMerhGWg4JgsBawfYg6ibUK1FkapShmyzTo5PWT6kgycv6Xhadb6d52Jwg4xeNRKTnj_ujP17xx0xwrVTLOn0MEjh96xn3Ia32InttkbfFiwxmbu7pTaKOomj9ieaIPknvGwj3U-W2iJ8FLp5WpvYSNTq7Q/s2033/Diabetes%20by%20ethnicity.jpg" style="font-family: verdana; margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="959" data-original-width="2033" height="189" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDHJuuPS8vSxqSOCuIDk48nlJbCrAlLx1SMerhGWg4JgsBawfYg6ibUK1FkapShmyzTo5PWT6kgycv6Xhadb6d52Jwg4xeNRKTnj_ujP17xx0xwrVTLOn0MEjh96xn3Ia32InttkbfFiwxmbu7pTaKOomj9ieaIPknvGwj3U-W2iJ8FLp5WpvYSNTq7Q/w400-h189/Diabetes%20by%20ethnicity.jpg" width="400" /></a></div><span style="font-family: verdana;"><br /></span>
<p class="MsoNormal" style="tab-stops: 336.15pt;"><span style="font-family: verdana;">But don’t cry for Eli Lilly, or
the other insulin, or any drug, manufacturers. That they will be doing fine and
continuing to make huge profits <i>after</i> the price restrictions go into
effect is further evidence that <i>before</i> they were making outrageous,
unjustifiable, and indeed (given that insulin is needed to keep many people
alive) murderous profits.</span></p>
<p class="MsoNormal" style="tab-stops: 90.2pt;"><span style="font-family: verdana;">It is hard to discuss rapacious
profiteering in health(don’t)care without drug companies, but let us not lose
sight of the fact that the insurance companies and the big hospital and “health
systems” are also making out like bandits, ripping us off, and endangering our
health. </span></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2tag:blogger.com,1999:blog-1509187841033628660.post-14722040456276598922023-03-01T09:29:00.005-07:002023-03-01T11:56:10.478-07:00Making people healthy or making money: What should be the goal of our health system?<p><!--[if gte mso 9]><xml>
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</p><p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">In the February 16, 2023 issue of
<i>The Nation, </i>epidemiologist Gregg Gonsalves writes about <a href="https://www.thenation.com/article/society/doctors-american-medicine-public-health/">The
Fight for the Soul of American Medicine</a>. It is a particularly good and
thorough review of the corruption of American medicine by the quest for profit,
and the growing resistance of many physicians to its adverse effects on
themselves and, more important, the health of their patients. </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">He cites several other recent
articles that emphasize different aspects of this situation. <a href="https://www.nytimes.com/2023/02/05/opinion/doctors-universal-health-care.html">Eric
Reinhardt, writing in the <i>New York Times</i></a><i> </i>about physician
burnout, calls for increased unionization of physicians to counter the power of
the corporate controllers of US medical care. Gonsalves also cites a<a href="https://jamanetwork.com/journals/jama/fullarticle/2801097#:~:text=In%20the%20mosaic%20floor,%2C%20%E2%80%9CHail%2C%20Profit.%E2%80%9D">
<i>JAMA </i>Viewpoint</a> by former CMS administrator Don Berwick calling out
the many ways that greed perverts and destroys American healthcare, using the
old Pompeiian phrase <i>Salve lucrum, </i>“Hail Profit”, and naming it an
existential threat. Finally, he cites an article in the <i>Journal of General
Internal Medicine </i>by Gondi, Kishore, and McWilliams called “<a href="https://link.springer.com/article/10.1007/s11606-023-08056-z">Professional
Backgrounds of Board Members at Top-Ranked US Hospitals”</a> which identifies
the fact that US hospitals are run by people with finance, not healthcare,
backgrounds:</span></p>
<p class="MsoNormal" style="margin-left: 0.5in; text-align: justify;"><i style="font-family: verdana;">At top-ranked
US hospitals, the most common professional background for board members is
finance, far exceeding representation from physicians, nurses, and other health
care workers. Over half (~56%) of board members are from finance or business,
while a small minority (~15%) have clinical training or are from the health
services sector.</i></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">Gonsalves notes how the
perversion of healthcare, particularly medical care, by an explicit profit
motive leads to the US having both the greatest cost and the worst health
outcomes of the wealthy countries of the world, but then goes beyond that to
further criticize our reliance on medical care as the avenue to people’s
health. He cites the <a href="https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/#:~:text=Medical%20care%20is%20estimated%20to,socioeconomic%20factors%2C%20and%20environmental%20factors.">National
Academy of Sciences estimate that medical care accounts for only 10-20% of
health</a>, with social determinants (and, one could convincingly argue, social
determination) accounting for the other 80-90%. Social determination is found
in the structure of our society, conceived perversely on democracy and
plutocracy, rooted in the extermination of one set of peoples and the
enslavement of another, and the racist roots that continue to poison our social
structures today. Social determinants – including poverty, housing, food, education,
childcare, and others -- are well documented, and are profoundly poorly
addressed by us in the US. </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">This is more than coincidental.
Gonsalves refers to a book by Bradley and Taylor<a href="https://www.amazon.com/American-Health-Care-Paradox-Spending/dp/1610395484">,
<i>The American Health Paradox: Why spending more is getting us less</i></a> (which
I discussed, along with a <a href="https://www.nytimes.com/2011/12/09/opinion/to-fix-health-care-help-the-poor.html"><i>NY
Times</i> op-ed they wrote</a>, in a blog post <a href="https://medicinesocialjustice.blogspot.com/2011/12/to-improve-health-us-must-spend-more-on.html">To
improve health the US must spend more on social services</a> Dec 18, 2011). The
essential point of that book is that, while the US spends far more than other wealthy
countries on medical care (twice as much as a few and three times or more as
much as most others), it spends far less on other social services and social
supports. Furthermore, as Bradley and Taylor document, the US is unique in that
of all its spending on social service <i>and</i> medical care, the vast
majority is on medical, dwarfing expenditures on food, housing, childcare, job
training, and social supports that are far more important in maintaining health
and preventing disease, while medical care is focused on treating disease once
it is there (for those who can access it, at enormous cost). </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">These are all true things. Our
society spends most of its “social services” money on medical care, and it is
directed at the most expensive types of care, those that generate the most
profit for the big corporate and venture capital players in the hospital,
nursing home, and ambulatory care fields as well as the better-documented
profiteers in the pharmaceutical and insurance industries. The burnout of
physicians from overwork is real and is simply what industrial workers used to
call “speed-up”, the demand for more production in the same hours (and for the
same pay). In industrial workers, speed-up was and is well known to increase
the rate of accidents, both minor and major, and to destroy the psychological
health of those workers, so that it is unsurprising that it does the same to
doctors and other health workers. What is more surprising is that it has taken
so long for them to realize it; over a few decades corporations have taken over
almost all of health care delivery, with independent physicians and physician
groups that own themselves almost disappearing. </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">Most hospitals, or “health
systems”, are controlled by large corporations – or so they are called if they
are for profit. The non-profit health systems, however, including academic
health centers, behave scarcely less like corporations, chasing increased
revenue (if not “profit” <i>per se</i>), and are, as Gondi et al., demonstrate,
just as likely to be led by people with financial backgrounds, rarely medical
ones. The good aspect of for profit relative to non-profit hospitals is that
they, at least, pay taxes rather than be the recipients of government largesse
through being tax-free in return for ostensible, and increasingly unrealized,
community benefit. The bad side is that they provide even less community
benefit, and generally have worse quality care, than non-profits. In addition,
the positive side of the non-profit ledger is enhanced by inclusion of those
hospitals in rural areas and inner cities that actually do care for the needy. These,
however, are the very ones that are at greatest risk of going bankrupt, and
closing because their patients are uninsured or are underinsured, including by
Medicaid and even Medicare. A <a href="https://www.nytimes.com/2022/12/09/health/rural-hospital-closures.html"><i>NY
Times </i>article recently addressed the increasing closure of rural hospitals</a>,
and an even more recent one <a href="https://www.nytimes.com/2023/02/26/health/rural-hospitals-pregnancy-childbirth.html?searchResultPosition=1">documents
how many rural hospitals are closing their maternity units,</a><i> </i>because it
is a high-cost, low-revenue “service line”, causing rural women to have to
travel dangerous distances for pregnancy care and delivery. </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">In terms of other healthcare
operations, such as physician practice groups and nursing homes, “private
equity”, venture capital groups, are playing a larger and larger role. Nursing
homes have long been primarily private, and of generally poor quality, but they
are increasing being acquired by such private equity or health corporations.
Those physician practice groups that are not already owned by hospital systems
(including academic ones) are often being acquired by the same groups. The
results can be disastrous for their patients, particularly when encouraged by
the government, as in the ACO/REACH program which I recently discussed (<a href="https://medicinesocialjustice.blogspot.com/2023/01/privatizing-medicare-through-medicare.html">Privatizing
Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!</a>,
Jan 20, 2023). Of course, one reason these (misad-)ventures are successful is
that their downsides tend to only be apparent once you need care, when you are
sick, when the less obvious odious characteristics of such arrangements can
stymie you effective access to care. And, of course (and thankfully!) most of
us are not sick at any given time.</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">I have often written that profit,
in any form, does not belong in health care. This is absolutely true. The most
egregious forms are the corporations that make and sell pharmaceuticals and the
insurance companies that existence as parasitic middlemen between health care
and patients, not only sucking off money but also limiting care in ways that
actually and frequently harm people. But that is only the tip of the corrupt
iceberg. Being “non-profit” does not prevent a health system from acting
in the same fashion, to maximize revenue, and reward “successful” (i.e.,
money-making) management accordingly in seven figures. </span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">It is time to have no incentives
of any kind that allow any person or organization in health care to make money
beyond that which is required to run a high-quality operation and pay workers a
reasonable salary or wage. Indeed, the impact on the health care of patients
should be the sole criterion for anything that is done or reimbursed.</span></p>
<p class="MsoNormal" style="text-align: justify;"><span style="font-family: verdana;">AND, then, we need to start
taking much of the money saved by having less or none going to insurers,
pharma, and hospitals and health systems and spending it on ensuring everyone
has good financial health care coverage and the social systems needed to
support the social determinants of health are in place.</span></p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com4tag:blogger.com,1999:blog-1509187841033628660.post-72569160748345438072023-02-06T09:43:00.003-07:002023-02-08T10:53:56.808-07:00Universal health coverage would save money. And lives. And make life a lot better for people.<div class="MsoNormal" style="text-align: left;"><span style="font-family: verdana;">Two recent Gallup polls confirm long-standing problems with
the US health system. <a href="https://news.gallup.com/poll/468176/americans-sour-healthcare-quality.aspx">Americans
Sour on U.S. Healthcare Quality</a> finds that<i> </i></span></div><p class="MsoNormal"><span style="font-family: verdana;"><i>For the first time in Gallup’s
two-decade trend, less than half of Americans are complimentary about the
quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The
slight majority now rate healthcare quality as subpar, including 31% saying it
is “only fair” and 21% -- a new high -- calling it “poor.”</i> </span></p><p class="MsoNormal"><span style="font-family: verdana;">It is important to read that carefully; it does <i>not</i>
say that “for the first time in two decades, Americans find problems with U.S.
healthcare”. It says that for the first time fewer than half rate it as “good”
or “excellent”. And “a new high”, 21%, say it is poor. This is very significant
because the opinion one has about healthcare varies tremendously depending on whether
one has needed it or not. If you, and your family, have been healthy, and have
rarely if at all needed anything other than, perhaps, immunizations or
checkups, then you are likely to perceive the system as better. Even then, you
probably had some difficulty getting an appointment, getting through to find
out the results of any tests you had, and difficulty communicating in general. And
it likely cost a lot. If you were just a little sick, it can be irritating,
frustrating, and even risk your health to some degree. But if you are <i>really
</i>sick, and especially if you need to be in the hospital, it is very unlikely
that your experience was even “fair”.</span></p><p class="MsoNormal"><span style="font-family: verdana;">This is something that a lot of people, and a lot of pundits
miss. When you don’t need health care, everything is fine, and your insurance
is good and pays for all of the nothing you use; indeed even being uninsured is
fine. It is just that pesky problem of it not being fine when you need it. Like
anything; you don’t regret not having a down coat on a balmy Spring day, or an
umbrella when it is dry. There is an old story about a traveler coming across someone
whose roof is leaking in the rain. The traveler asks why he doesn’t fix it. The
man responds that when it is raining it is too wet to get up on the roof, and
when it isn’t, “my roof is as dry as anyone’s.” This is fine as a joke, but not
as<span style="mso-spacerun: yes;"> </span>healthcare strategy. When you or a family
member is in a car accident, or gets a cancer diagnosis, or needs major (or
even minor) surgery, or your newborn needs to be in the intensive care unit, is
not the time to start to think about your health coverage.</span></p><p class="MsoNormal"><span style="font-family: verdana;">And, yet, that is what many people do, are forced to do, to depend
upon hope and prayer. While for some this could be in part an issue of distorted
priorities – health insurance is expensive and I could be buying a nicer house
or a bass boat –this is not the usual reason. It is more often “health insurance
is expensive and I need to pay the rent and buy food and put shoes on my
children’s feet”. And if their budget allows them to actually buy health insurance,
it tends to naturally be the one that the buyer can afford – and is often inadequate,
and have high patient responsibility (co-pays, maximums, and other costs). Thus
“having health insurance” deludes you (and many pundits and policy makers) into
thinking that you have taken care of this issue. Until you need it.</span></p><p class="MsoNormal"><span style="font-family: verdana;">Which brings us to the results of another Gallup poll, released
at the same time, <a href="https://news.gallup.com/poll/468053/record-high-put-off-medical-care-due-cost-2022.aspx">“Record
High in U.S. Put Off Medical Care Due to Cost in 2022”</a>. <i>“The latest
reading, from Gallup’s annual Health and Healthcare poll conducted Nov. 9-Dec.
2, is the highest by five points and marks the sharpest year-over-year increase
to date.</i>” Not a surprise given the information above. You can put off going
to the doctor for a checkup, or a cold, or a vaccine, or even for treatment for
a significant chronic disease like diabetes, high blood pressure, heart disease
– at least if is not bothering you <i>too </i>much – but it is not very wise,
since ignoring such conditions is one way to get you really sick, and into the
hospital, and maybe into intensive care, and maybe, even, die. However, since we
don’t have a universal health program in the US, too many people simply cannot
afford to get healthcare, especially anything that is costly. I am tempted to
say that there is a price list, and, like buying a car or a house or a coat,
you shop within your means. Except, of course, there is no price list, and you
hardly ever know what a medical procedure will cost. And there are often no
good alternatives to the expensive treatment; in this way it is definitely <i>not</i>
like buying a perfectly functional, if less fancy, car.</span></p><p class="MsoNormal"><span style="font-family: verdana;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: verdana;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8x5JoxwBFxSmI37AImBWWFOSPWddekP1-TXUQiTSv3t8gcC43JHo4D_IWLMIxFK-BUiVYH-UUL1xBpo78zP5ksIvNKTK5sOVoB7U2B-QiAJlXgAp4vIN9egJXSRRd7_Qle3_weS9QsKdXOw0wcoeY_FOfsNdyMGIXlPuQRicAIZpZ3FbNHQYWarlYig/s2046/Put%20off%20treatment%202001-22.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1129" data-original-width="2046" height="354" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8x5JoxwBFxSmI37AImBWWFOSPWddekP1-TXUQiTSv3t8gcC43JHo4D_IWLMIxFK-BUiVYH-UUL1xBpo78zP5ksIvNKTK5sOVoB7U2B-QiAJlXgAp4vIN9egJXSRRd7_Qle3_weS9QsKdXOw0wcoeY_FOfsNdyMGIXlPuQRicAIZpZ3FbNHQYWarlYig/w640-h354/Put%20off%20treatment%202001-22.JPG" width="640" /></a></span></div><span style="font-family: verdana;">A third important article was published in June 2022 in the <i>Proceedings
of the National Academy of Sciences USA. </i>“<a href="https://www.pnas.org/doi/10.1073/pnas.2200536119">Universal healthcare as
pandemic preparedness: The lives and costs that could have been saved during
the COVID-19 pandemic”</a><span style="mso-spacerun: yes;"> </span>by Galvani,
Parpia, Pandey, and Fitzpatrick, estimates that during the pandemic a universal
healthcare system would have saved 212,000 lives and $105.6B from COVID alone,
in 2020 alone. This would have risen to about 338,000 lives through March 2022,
a<a href="https://www.scientificamerican.com/article/universal-health-care-could-have-saved-more-than-330-000-u-s-lives-during-covid/">s
reported on in the <i>Scientific American</i></a>, and would have been <i>on
top</i> of another $438B saved from other causes besides COVID. That is a lot
of money. And a lot of lives. More than 100 times the number of lives lost in
the World Trade Center attack. And (see the polls from Gallup) that is not
counting the people who didn’t die, but could have. Who lost their health,
their ability to work, their life savings, their ability to provide for their
families.</span><p></p><p><span style="font-family: verdana;">So what is this “Universal Healthcare” thing? Some kind of
pie-in-the-sky dream of liberals that would bankrupt the US? No, it is what
they have in every other wealthy country in the world, and many that are not so
wealthy. Those countries that don’t consider health and healthcare to be a
consumer luxury, that consider it to be about people’s health rather than something
for the private sector to profit from. Remember, that $105,600,000,000, and
that $438,000,000,000 (2020 alone) is not going into the garbage. It is going
to health insurance companies, and health care providers (by which we mean not only
– or even mainly – doctors, but rather hospitals and “health systems”) and
their suppliers, especially drug companies. This is detailed in the latest
publication on this topic (regularly updated, and rarely improving) from the
Commonwealth Fund. “<a href="https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022">U.S.
Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening
Outcomes</a>” shows that the US is the only wealthy country that does not
guarantee health care coverage to all its people, and still spends 2-4 times as
much as those other countries. The money goes, of course, to private profit. There
is a name for this: corruption and graft. And words for it. Mostly obscene.</span></p><p class="MsoNormal"><span style="font-family: verdana;"></span></p><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: verdana;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjps4jG-7NDEPmNJp7lJGJW40zVk3qFPbKVe-yheXIR5kcsobC7nfVq8rmQ8heVxMf6VStk6CPQ9EDJ9AjSnLJ0CEAIUYxfIchffus5w9iCaEx4Szq-AMWXMdSLr5DDrQ67N4yinGCCRr0NqPkIFtpqlgyfIPmQEgZC9noKtpsoR2_KJ7QAF1thT-eNfA/s1932/Commonwealth%202022%20US%20does%20not%20guarantee.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1134" data-original-width="1932" height="235" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjps4jG-7NDEPmNJp7lJGJW40zVk3qFPbKVe-yheXIR5kcsobC7nfVq8rmQ8heVxMf6VStk6CPQ9EDJ9AjSnLJ0CEAIUYxfIchffus5w9iCaEx4Szq-AMWXMdSLr5DDrQ67N4yinGCCRr0NqPkIFtpqlgyfIPmQEgZC9noKtpsoR2_KJ7QAF1thT-eNfA/w400-h235/Commonwealth%202022%20US%20does%20not%20guarantee.JPG" width="400" /><span style="font-family: verdana;"></span></a><span style="font-family: verdana;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiApDJjlSJoUo66mj7ZH6_GbD7-M40XetprwHR9jZR97cezhixcGp82Ln5CMleAegId1T57HqAhlp9HBBDApUbwEE7yCOqV6QF4W4WzVd6tSMleSNpiRvKr4uUegrKEVfkPS6hGr1tAbiVK4x4772G6e9pGUUsEsKfC0ME82AqZRHxzPUQfs7pKCvxTDg/s1849/Commonwealth%202022%20international%20spending.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="928" data-original-width="1849" height="201" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiApDJjlSJoUo66mj7ZH6_GbD7-M40XetprwHR9jZR97cezhixcGp82Ln5CMleAegId1T57HqAhlp9HBBDApUbwEE7yCOqV6QF4W4WzVd6tSMleSNpiRvKr4uUegrKEVfkPS6hGr1tAbiVK4x4772G6e9pGUUsEsKfC0ME82AqZRHxzPUQfs7pKCvxTDg/w400-h201/Commonwealth%202022%20international%20spending.JPG" width="400" /></a></span></span></div><span style="font-family: verdana;">So why don’t we do something about it? We have tried – President
Truman tried to get a national health insurance system in 1948. Defeated,
sadly, with support from labor unions who thought it would undermine their success
in getting health insurance through negotiations with employers (there’s a
quaint memory). Medicare, a national health insurance system for seniors and
the disabled, was passed in 1965 under President Johnson. So was Medicaid, a
state/federal partnership to provide coverage for many (but certainly not all!)
poor people. In 2010, under President Obama, ACA (Obamacare) was passed, which
extended health coverage to many (but certainly not all!) of those left out,
who were unable to afford individual health coverage but were not poor enough
to get Medicaid (and in most states that is desperately poor!). <span style="mso-spacerun: yes;"> </span>But nothing comprehensive, nothing that covers
everyone, nothing that guarantees you won’t be broke and in debt at the end. Nothing
that resembles the systems in <i>any </i>other OECD (i.e., wealthy) country. <span style="mso-spacerun: yes;"> </span>Why?</span><p></p><p class="MsoNormal"><span style="font-family: verdana;">Because private corporations make lots of money, from you,
and from your employer, and from the government, and very much do not want that
to go away. Indeed, as I discussed recently (<a href="https://medicinesocialjustice.blogspot.com/2023/01/privatizing-medicare-through-medicare.html">Privatizing
Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!</a>,
January 20, 2023), the private sector is expanding its leech-like sucking of public
funds through privatization of Medicare by programs like Medicare Advantage and
ACO/REACH. And are willing to spend some portion of that huge amount of money
on lobbying – and making contributions to – members of Congress, to make sure
that their profits are maintained at the expense of the health and lives of the
American people, not to mention their money.</span></p><p class="MsoNormal"><span style="font-family: verdana;">It is<span style="mso-spacerun: yes;"> </span>that simple.
The health and lives of people vs. the profit of corporations. Don’t be fooled
by liars or obfuscators. It is time to end this incredibly expensive boondoggle
that costs the lives and health of so many of us. Write your Congresspeople and
demand Medicare for All, or any form of completely universal healthcare, now.</span></p><span style="font-family: verdana;">Or sooner. </span><p></p><table border="0" cellpadding="0" cellspacing="0" style="width: 88px;"><tbody><tr height="19"><td class="xl67" height="19" style="height: 14.35pt; width: 66pt;" width="88"><table border="0" cellpadding="0" cellspacing="0" style="width: 88px;"><tbody><tr height="19"><td class="xl67" height="19" style="height: 14.35pt; width: 66pt;" width="88">
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
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<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
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<w:LsdException Locked="false" Priority="19" QFormat="true"
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<w:LsdException Locked="false" Priority="31" QFormat="true"
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<w:LsdException Locked="false" Priority="32" QFormat="true"
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<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
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<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
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<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
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<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
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</tr></tbody></table>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com1tag:blogger.com,1999:blog-1509187841033628660.post-24934013788927102422023-01-20T09:47:00.005-07:002023-01-21T09:33:26.343-07:00Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!<p><!--[if !mso]>
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</p><p class="MsoNormal"><span style="font-family: verdana;">The things to remember about “Medicare Advantage” plans is
that 1) they are not Medicare, and 2) they may offer little or no advantage. They
are a form of private insurance, cost Medicare a lot of money, and in some
situations (especially when you are sick) can indeed hurt you.</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">Let’s get to the first. Medicare was created in 1965 to
provide universal health care to senior and disabled people. It was a tremendous
victory for those who had fought for decades to have a universal health
insurance system in the US. It was also strongly opposed by those who thought
their pocketbooks might be hurt, specifically the AMA, as well as other
right-wing forces that just opposed everything that might actually help most
people (and thus most Great Society, and even New Deal, programs). The
supporters never envisioned that Medicare would be the end of the road,
especially when, in the same year, Congress passed Medicaid, a federal-state
collaborative program that was aimed at helping the poor access health care.
They assumed that it would be expanded to finally include all Americans. <br /></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">Of course, many of the opponents of Medicare didn’t give up
either. The AMA, while never contrite, shut up about it after it became clear
that rather than hurting physicians’ incomes, Medicare was a bonanza for them,
ensuring payment for services had often previously been unable to collect for.
Those who hate programs that benefit people, of course, are still around. But
the most insidious and dangerous threat is from those who see any government
program as a way to make lots of money, especially if it can be privatized
without much risk to the private sector investors. This is really how Medicare
(and many other public programs) have been most insidiously and effectively attacked
-- by privatizing its programs to guarantee lots of money for the profit of the
private companies, and largely insulate them from risk.</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">Enter Medicare Advantage (MA). <span style="mso-spacerun: yes;"> </span>MA plans are largely run by insurance companies (and
sometimes by venture capital groups) and are called “Part C” of the Medicare
program, but they essentially take people out of Medicare and put them in a private
managed care program. These companies then get the money that would have gone
to the Medicare program (we’ll call it Traditional Medicare, or TM) for you.
Plus they get extra money. Why do private companies caring for you under MA get
more money than TM allocates for you? Because they do, right. Because the pro-for-profit
“caucus” (PFPC) of the Congress, from both parties, wanted to increase the
portion of people in Medicare entering MA. So these companies could make more money.
And contribute more to the members of the PFPC. <br /></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">Remember the old phrase “feeding at the government trough”?
That is what these companies do, very well. Virtually no public function that
is privatized becomes more effective at delivering service, since the amount of
profit generated is increased by providing less service. To the extent that it sometimes
seems to look better, it is almost always because of 2 things: that the public
services were starved for funding in the first place, making them look bad and
justifying the call to privatize them, and that private companies’ inefficiency,
corruption, and overall bad acting is harder to ferret out than government
agencies’. </span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">How do MA plans make more money? In the traditional HMO
manner, they limit access to a “panel” of doctors and hospitals. These are not
necessarily the worst ones in your area, but they are the ones that the plans
have negotiated the best deals with, for which they pay the least. They attract
members with some perks like vision care, hearing care, etc., which can be useful
if one is generally healthy. And of course, MA plans vary in quality and in performance;
some of those covering state employees by contract have performed better
possibly because of having a more educated, informed, and influential client
base. But this is not always the case; <a href="https://wendellpotter.substack.com/p/nycs-call-to-move-retirees-to-a-medicare">see
the example of city workers’ resistance to Mayor Eric Adams of NYC trying to
push retirees into MA. </a><span style="mso-spacerun: yes;"> </span> <br /></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">And do not consider for a moment that the goal of any of
these programs is to provide excellent health care: it is to make money. And
that they make money is demonstrated by the aggressive marketing that
Medicare-eligible people get from these companies, not to mention television advertising.
The Commonwealth Fund recently published a piece called “<a href="https://www.commonwealthfund.org/publications/explainer/2023/jan/role-marketing-medicare-beneficiaries-coverage-choices">The
Role of Marketing in Medicare Beneficiaries’ Coverage Choices”</a>, which describes
this in detail. ‘<i>Soaring private plan enrollment has led to a sharp increase in
marketing and sales efforts, some <a href="http://www.finance.senate.gov/imo/media/doc/Deceptive%20Marketing%20Practices%20Flourish%20in%20Medicare%20Advantage.pdf" target="_blank">misleading and inaccurate</a>.’ </i>It goes on to explain in how MA
works and how they market. It also notes that about 1/3 of Medicare beneficiaries
used an insurance broker; a boon to that private sector industry as well. MA plans can
keep 15% of the money they get for profit and overhead, having to spend only
85% on actually delivering care (which they call the “medical loss ratio”!)</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">The way that MA plans make money is enrolling lots of
people, many of whom are healthy (Wow! Free gym membership!) and don’t cost
them much, and then submitting bills that make their patients look like they
are as sick as possible thus inflating their bills (called “upcoding”). At best
this an effort to maximize revenue from Medicare, which there is no incentive
to do in TM. Plus, if they can get certain poor people enrolled, they can
collect an additional $350 for each one regardless of whether they actually provide
any care! This was implemented with the theoretical idea of increasing equity
by incenting the enrollment of poor people, but really has the opposite effect
since those folks now have their care restricted when they are sick by the
private insurance company, while under TM it would not be. And, of course, they
make money by <a href="https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html?searchResultPosition=2">fraudulently
overbilling Medicare for billions of dollar</a>s, winning the<a href="https://www.beckershospitalreview.com/rankings-and-ratings/10-healthcare-names-get-shkreli-awards-for-bad-behavior.html">
Lown Institute’s 2022 “Shkreli Award”</a> for bad behavior by corporations!</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="mso-spacerun: yes;"> </span></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglZhtREf5CyPjCq0Dz_ttKR1mSPQsT_xvvgMmU4LM_bqfNqdaTzSZUSu7HOutzy8zXLgh8cAHbbXAj14CitJbpuLxh668NmAy-f2P3MrPmElp5ZGGGd4flBCnAi6xemrVQfN0bBa3lzmSuwYlAIPDPRm4uVKr2r-Kg2RQ8UjUN6tyTMR1Msed8bjddvg/s1498/MA%20Billing%20fraud.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1028" data-original-width="1498" height="275" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglZhtREf5CyPjCq0Dz_ttKR1mSPQsT_xvvgMmU4LM_bqfNqdaTzSZUSu7HOutzy8zXLgh8cAHbbXAj14CitJbpuLxh668NmAy-f2P3MrPmElp5ZGGGd4flBCnAi6xemrVQfN0bBa3lzmSuwYlAIPDPRm4uVKr2r-Kg2RQ8UjUN6tyTMR1Msed8bjddvg/w400-h275/MA%20Billing%20fraud.JPG" width="400" /></a></div><br /><p></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;"><span style="font-weight: normal;"><span color="windowtext">MA
is not the only way Medicare is being privatized. As I have written before</span> (<span color="windowtext"><a href="https://medicinesocialjustice.blogspot.com/2022/09/private-equity-profiteers-in-nursing.html"><span style="mso-bidi-font-size: 12.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">"Private Equity": Profiteers in
nursing homes, Medicare Advantage, DCEs, and all of healthcare</span></a></span>, Sept 16,
2022; <a href="https://medicinesocialjustice.blogspot.com/2022/02/direct-contracting-entities-scamming.html">Direct
Contracting Entities: Scamming Medicare and you and bad for your health!</a>,
Feb 7, 2022),<span color="windowtext"> the Center for Medicare and Medicaid Services Innovation
Center (CMMI) implemented Direct-Contracting Entities (DCE), which was renamed REACH as of January 2023
(without any other significant change). REACH has allowed the creation of mostly investor-owned
companies that contract with primary care practices (often already owned by corporations, not owned by the doctors)
and <i>voilà, </i>all of those doctors' patients are in their REACH group, which then gets the money that Medicare would have paid for you. What is really tricky is that, unlike MA, you didn’t
have to choose it; they choose for you by contracting with the group (often corporate) that owns your primary care practice! </span></span></span><span style="font-family: verdana;"><span style="font-weight: normal;"><span color="windowtext">And your doctor may not
even know that s/he is in one! </span></span></span><span style="font-family: verdana;"><span style="font-weight: normal;"><span color="windowtext">You can only get out if you can find
another doctor who is not in one – particularly difficult in rural or urban
underserved areas where even finding a doctor is hard. Not to mention that REACH is even more lucrative than MA, as it allows the private company
to keep 40% of its take as profit and overhead, spending only 60% on
patient care!</span></span></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">The effort to privatize Medicare is absolutely the wrong way
to go. The way to go is to keep the structure of Traditional Medicare, where anyone
can use any doctor or hospital, where there is no profit taken out, and
overhead is about 2%. And then increasing its benefits so that it covers 100%
(not 80%) of approved charges so people don’t have to get a Supplement Plan, as well as cover dental, vision, hearing, etc. This is affordable, since it could be funded by money now
used to generate huge profits for private investors, but could actually be used
to improve our healthcare. While we still need to address access in terms of
geography and specialty distribution, eliminating the profit motive will make
major steps toward access and improved quality. </span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">Then we can have Healthcare for All.</span></p>
<p class="MsoNormal"> </p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2tag:blogger.com,1999:blog-1509187841033628660.post-26115196980908815622023-01-02T09:30:00.000-07:002023-01-02T09:30:34.048-07:00The People's CDC: Getting out accurate information, not what is popular<p><!--[if !mso]>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="line number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="1" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
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<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
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<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
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<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
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<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
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<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
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<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
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<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
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<w:LsdException Locked="false" Priority="21" QFormat="true"
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<w:LsdException Locked="false" Priority="31" QFormat="true"
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<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
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<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
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</p><p class="MsoNormal" style="margin-left: .5in;"><b><i><span style="color: red;">COVID
is not over. Even if you want it to be. You can still get sick, get
hospitalized, and die. People who are more vulnerable are even more likely to.
Masks still are protection. Even if you don’t want to wear them.</span></i></b></p>
<p></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">I’ll say it again later. I think I’ll keep repeating it. It’s
good, and nice, to want positive things. There are a lot of things that I want.
World peace, for one. A reversal of global warming. An end to world hunger.
They are not happening. And, unlike COVID, people could end them if they wanted
to, as a group, as a world. COVID is a virus and doesn’t care what we do, but
there are things that we can do to decrease its threat to health and life. We
mostly know what they are – immunizations, wearing masks. Limiting interpersonal
interaction, especially with large groups and groups with people we don’t know.
We’ve been doing it for several years.</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">But we’re tired of it. We don’t want COVID to be around. We
don’t want to wear masks, especially those uncomfortable N-95s (i.e., the ones
that work best, the ones that protect <i>you </i>from others; most masks only
protect <i>others </i>from <i>you</i>). We want to get together with our
families, most especially around important events like the holidays, even if we’re
not sure if they’re infected, or were vaccinated, or even if we know they haven’t
been. Or if they have been exposed by going to places – like school and work –
where they are more likely to be exposed. And we want to, some of us, go out
like we used to, to movies and museums and clubs. We want to party. We want to
go back to what we think of as normal. But…</span></p><p class="MsoNormal"></p><p></p><p><!--[if gte mso 9]><xml>
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</p><p class="MsoNormal" style="margin-left: .5in;"><b><i><span style="color: red;">COVID
is not over. Even if you want it to be. You can still get sick, get
hospitalized, and die. People who are more vulnerable are even more likely to.
Masks still are protection. Even if you don’t want to wear them.</span></i></b></p><span style="font-family: verdana;"></span><span style="font-family: verdana;">And so we get infected, and maybe do ok. Especially if we
have been immunized. Especially if we are relatively young and healthy and not
immunocompromised. It’s not fun, but I survived, right? Oh, yeah, Uncle George
didn’t. And Cousin Minnie, who had cancer, and my friend Kim, who has diabetes,
almost didn’t, they were hospitalized on a ventilator. And yes, I admit it, I
got sick after a <i>small </i>Christmas – or Chanukah, or Kwanzaa or New Year’s
– party where I thought I knew everyone and they were my ‘pod’ and I was safe.
And, yes, a bunch of people got it. So lucky that none of them have been really
sick!</span><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">You get the point. But the other point is that we <i>want</i>
it to be over! We don’t <i>want </i><span style="mso-spacerun: yes;"> </span>to
wear masks! We <i>want </i>to get back to normal! And the government, including
the CDC, hears you. They want you to be happy. They want you to support their
policies so you will vote for them in the next election. So they say things
that are more likely what you want to hear. Like most people don’t need to wear
masks indoors in most situations (read: you don’t need to wear a mask. People
who do are overreacting). Like you are non-infectious after 5 days, and can go
back to work, and if you are infectious still, too bad. Like “the pandemic is
over”, comment that President Biden made in a television interview, this past
September. Hopefully, you are not coming into contact with people who are susceptible
and vulnerable. They want you to like them!</span></p><p class="MsoNormal" style="margin-left: 40px; text-align: left;"><b><i><span style="color: red;">COVID
is not over. Even if you want it to be. You can still get sick, get
hospitalized, and die. People who are more vulnerable are even more likely to.
Masks still are protection. Even if you don’t want to wear them.</span></i></b><span style="font-family: verdana;"> <br /></span></p><p></p><p><span style="font-family: verdana;">
</span></p><p class="MsoNormal"><span style="font-family: verdana;">To say that “the media is complicit” sound trite, like a bad
meme, like what you hear from the right-wing fringe. Whether it is or not
might, I suppose, depend upon what you mean by “complicit”, but most of the
media certainly reinforces this “it’s gonna be all right!” message. This
particularly takes the form of disparaging those who point out danger. Recently,
for example, the <i>New York Times </i>ran a piece called <a href="https://www.nytimes.com/2022/12/26/us/covid-masks-risk.html">“The Last
Holdouts”</a>, about those folks who continue to wear masks. It was on page 1
on December 26. However, in the same issue ran another story updated from
December 13 titled<a href="https://www.nytimes.com/2022/12/13/well/covid-flu-rsv-masks-tripledemic.html">
“It’s Time to Wear a Mask Again, Health Experts Say: A high-quality,
well-fitting mask is your best protection against infection from the
coronavirus, influenza and R.S.V.</a>”. That, in the print edition, was at the
bottom of page D6! What is the message? If you ever found the latter story, you
<i>might</i> be convinced, but the main big story was that masks are for sick
people, immunocompromised people, paranoid people – not <i>you!</i></span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">And now the <i>New Yorker</i> magazine has entered the arena
with a piece about the “<a href="https://peoplescdc.org/">People’s CDC”</a>, a
group of physicians, epidemiologists, public health professionals and others
who, very concerned about the upbeat “Pollyanna” messages from CDC, have gotten
together to try to disseminate accurate, if often unpopular, information. By
writer Emma Green, under a head “Annals of Activism”, the title is “<a href="https://www.newyorker.com/news/annals-of-activism/the-case-for-wearing-masks-forever">The
Case for Wearing Masks Forever</a>”. Well, good. But is that title sincere or snarky?
Maybe the subhead gives a clue: ‘A ragtag coalition of public-health activists
believe that America’s pandemic restrictions are too lax—and they say they have
the science to prove it.’ Oh, they’re ‘rag-tag’! Like internet conspiracy
folks! Well, no. They are people like </span></p><span style="font-family: verdana;">
</span><p class="MsoNormal" style="margin-left: .5in;"><span style="font-family: verdana;">‘Mindy Thompson Fullilove, a
professor of urban policy and health at the New School…who has spent her career
studying epidemics: first AIDS, then crack, then multidrug-resistant
tuberculosis. She has seen how disease can ravage cities, especially in Black
and working-class communities. From the beginning, Fullilove was skeptical of
how the federal government handled the coronavirus pandemic. But these new
recommendations from the C.D.C., she said, were “flying in the face of the
science.” Not long after the announcement, she sent an e-mail to a Listserv
called The Spirit of 1848, for progressive public-health practitioners. “Can we
have a people’s CDC and give people good advice?” she asked. A flurry of
responses came back.’</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">That doesn’t sound negative. But, overall, the tone of the
article <i>is</i> snarky and dismissive of the People’s CDC. It is also laced
with red-baiting as well as “realism” in the form of comments from former CDC
director Tom Frieden. While he praises ‘the organization’s [People’s CDC] guide
to self-protection for immunocompromised people, and agreed that some of their
recommendations, like universal masking in times of high COVID spread, were
good ideas in theory,’ he added</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal" style="margin-left: .5in;"><span style="font-family: verdana;">“But is that going to happen?
Absolutely not,” he said. The next best thing is to try to get people
vaccinated and boosted and to increase access to high-quality masks and
Paxlovid. “If you’re giving recommendations that no one’s going to follow,
that’s not only nonproductive,” he said. “It’s counterproductive, because that
undermines your credibility.”</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">Let’s do polling and find out what people want to do and
recommend that! Of course, if they get sick and die, your credibility could
also suffer…</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">One of the big things the<span style="mso-spacerun: yes;">
</span>article sees wrong with People’s CDC, apparently, is its emphasis on
collective action and the health of the community, including efforts to protect
its most vulnerable members. This, of course, is contrary to the idea that “it’s
all about me”. However, despite its tone and basic support for the current “it’s
gonna be all right”, the article is worth reading for the perspectives and data-driven
information provided by members and supporters of the People’s CDC, who say
things like “There’s a struggle going on right now for the soul of public
health.”</span></p><span style="font-family: verdana;">
</span><p class="MsoNormal"><span style="font-family: verdana;">People’s CDC takes issue with the way that the C.D.C.
emphasizes individual choices over collective action. The current CDC director,
Rochelle Walensky, has said, “Your health is in your hands.” Well, as much as I
wish it were not, and that CDC and Walensky and the rest of the government,
federal, state and local, were doing what needs to be done, I guess it is. And
if it is you should wear a mask when you’re indoors with others. Preferably an
N-95,</span></p><span style="font-family: verdana;">
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</p><p class="MsoNormal" style="margin-left: .5in;"><b><i><span style="color: red;">COVID
is not over. Even if you want it to be. You can still get sick, get
hospitalized, and die. People who are more vulnerable are even more likely to.
Masks still are protection. Even if you don’t want to wear them.</span></i></b></p>
<p></p><span style="font-family: verdana;">
</span><p class="MsoNormal"> </p>
<p></p>Josh Freemanhttp://www.blogger.com/profile/10248920527894775520noreply@blogger.com2