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THIRD EDITION Policy and Politics FOR NURSES and Other Health Professionals ADVOCACY AND ACTION Donna M. Nickitas, Donna J. Middaugh, Veronica D. Feeg PhD, RN, NEA-BC, CNE, PhD, RN Associate Dean Barbara H. Hagan School of Nursing FAAP, FAAN Associate Dean for Academic Programs Molloy College College of Nursing Dean and Professor Rockville Centre, New York University of Arkansas for Medical Sciences Rutgers University School of Nursing Little Rock, Arkansas Camden, New Jersey Editor Nursing Economic$, The Journal for Health Care Leaders Pitman, New Jersey World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Copyright © 2020 by Jones & Bartlett Learning, LLC, an Ascend Learning Company Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. 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Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits VP, Product Management: David D. Cella Cover Design: Kristin E. Parker Director of Product Management: Amanda Martin Text Design: Kristin E. Parker Product Manager: Rebecca Stephenson Rights & Media Specialist: John Rusk Product Assistant: Christina Freitas Media Development Editor: Shannon Sheehan Production Editor: Kelly Sylvester Cover Image (Title Page, Part Opener, Chapter Opener): © Anthony Senior Marketing Manager: Jennifer Scherzay Krikorian/Shutterstock Product Fulfillment Manager: Wendy Kilborn Printing and Binding: McNaughton & Gunn Composition: S4Carlisle Publishing Services Cover Printing: McNaughton & Gunn Library of Congress Cataloging-in-Publication Data Names: Nickitas, Donna M., editor. | Middaugh, Donna J., editor. | Feeg, Veronica D., editor. Title: Policy and politics for nurses and other health professionals : advocacy and action / [edited] by Donna M. Nickitas, Donna J. Middaugh, and Veronica D. Feeg. Description: Third edition. | Burlington, Massachusetts : Jones & Bartlett Learning, [2019] Identifiers: LCCN 2018028645 | ISBN 9781284140392 (paperback) Subjects: | MESH: Health Policy | Policy Making | Lobbying | Health Care Costs | United States Classification: LCC RA395.A3 | NLM WA 540 AA1 | DDC 362.10973--dc23 LC record available at https://lccn.loc.gov/2018028645 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1 © Anthony Krikorian/Shutterstock Brief Contents Acknowledgments ix Preface xi Contributors xiii SECTION 1 Introduction 1 Chapter 1 Nursing’s History of Advocacy and Action . . . . . . . . . . . . .3 Chapter 2 Policy and Politics Explained . . . . . . . . . . . . . . . . . . . . . . .25 Chapter 3 A Policy Toolkit for Healthcare Providers and Activists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 SECTION 2 Population Health 63 Chapter 4 Population Health Care: Access, Cost, and Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Chapter 5 Global Health: A Vision for Action . . . . . . . . . . . . . . . . . . .87 Chapter 6 Mental and Behavioral Health . . . . . . . . . . . . . . . . . . . 105 SECTION 3 Affordable Care Act: From Enactment to Sustainability 135 Chapter 7 Affordable Care Act (ACA) Reframed and Uncertain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Chapter 8 Healthcare Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 iii iv Brief Contents SECTION 4 Health Financing: Payers, Markets, and Models 185 Chapter 9 Healthcare Costs: Follow the Money . . . . . . . . . . . . . . 187 Chapter 10 Private Health Insurance Market . . . . . . . . . . . . . . . . . 207 Chapter 11 Medicare: Protector to Innovator . . . . . . . . . . . . . . . . . 231 Chapter 12 Medicaid and the Financing of Care for Vulnerable Populations: A Story of Misconceptions . . . . . . . . . . . . 255 Chapter 13 Innovation for the Delivery System of the Future: Medical Homes, Accountable Care Organizations, and Bundled Payment Initiatives . . . . . . . . . . . . . . . . . 279 SECTION 5 Health Care and Provider and Care Delivery 289 Chapter 14 Hospitals: Consolidation and Compression . . . . . . . . . 291 Chapter 15 Enhanced Primary Care Roles for Nurses and Other Professionals . . . . . . . . . . . . . . . . . . . . . . . . . 313 Chapter 16 Physicians: It Is Increasingly about the Team . . . . . . . 341 Chapter 17 Health Information Technology and the Intersection of Health Policy . . . . . . . . . . . . . . . . . . . . . 371 Chapter 18 Political Power of Nurses: Harnessing Our Values and Voices . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 © Anthony Krikorian/Shutterstock Contents Acknowledgments � � � � � � � � � � � � � � � � � � � � � � � � � � � � ix SECTION 2 P opulation Health 63 Preface � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xi Contributors � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xiii Chapter 4 Population Health Care: Access, Cost, and Quality � � � � � 65 Lessons from Nursing History on Vulnerability, SECTION 1 I ntroduction 1 Disparities, and Political Advocacy � � � � � � � � � � � � �66 The Face of Vulnerability Today� � � � � � � � � � � � � � � � � � �69 Chapter 1 Nursing’s History of Advocacy Vulnerability and Disparities from a and Action � � � � � � � � � � � � � � � � � � 3 Population-Based Perspective � � � � � � � � � � � � � � � � �73 Political Advocacy toward Health Equity � � � � � � � � �77 Nurses as Advocates � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �4 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �81 Advocacy and Public Health Nursing � � � � � � � � � � � � � �6 History and Political Advocacy � � � � � � � � � � � � � � � � � � � �9 Chapter 5 Global Health: A Vision Nursing Strong � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �11 for Action � � � � � � � � � � � � � � � � � � 87 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �13 The Politics of Global Health in the United States of America � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �89 Chapter 2 Policy and Politics Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �98 Explained � � � � � � � � � � � � � � � � � � 25 Introduction � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �26 Chapter 6 Mental and Behavioral Policy Defined: A Framework for Health � � � � � � � � � � � � � � � � � � � �105 Government Action � � � � � � � � � � � � � � � � � � � � � � � � � � �26 Introduction to Mental and Behavioral The Policy-Making Process � � � � � � � � � � � � � � � � � � � � � � �31 Health � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �106 What Is at Stake for Nurses and Other Federal Government and Presidential Efforts Health Professionals? � � � � � � � � � � � � � � � � � � � � � � � � � �37 to Improve the Nation’s Mental Health � � � � � � �107 State-Related Mental Health Policies � � � � � � � � � � � �109 Chapter 3 A Policy Toolkit for City and Community-Directed Mental Healthcare Providers and Health Care Efforts � � � � � � � � � � � � � � � � � � � � � � � � � � �110 Activists � � � � � � � � � � � � � � � � � � � 43 Policies Encouraging Consumer-Directed Mental Health and Behavioral Health Introduction � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �44 Services (The Recovery Movement) � � � � � � � � � �111 Stakeholder Power� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �46 Challenges in the Provision of Mental Health Expertise � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �48 and Behavioral Health Services � � � � � � � � � � � � � � �112 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �51 Groups Requiring Additional Political Toolkit Case Studies� � � � � � � � � � � � � � � � � � � � � � � � � � � � � �52 Protection � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1 � 12 v vi Contents Lower Socioeconomic Status–Related Mental SECTION 4 H ealth Financing: Health Policies � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �113 Payers, Markets, and Veterans’ Use of Mental Health Services and Policy Issues � � � � � � � � � � � � � � � � � � � � � � � � � � � � �114 Models 185 Policy Innovations to Improve Mental Healthcare Outcomes � � � � � � � � � � � � � � � � � � � � � � � �115 Chapter 9 Healthcare Costs: Follow Ongoing Challenges: A Look to the Future of the Money � � � � � � � � � � � � � � � �187 Policy Making in Mental Health and Behavioral Health � � � � � � � � � � � � � � � � � � � � � � � � � � � �116 Health Care Is Different � � � � � � � � � � � � � � � � � � � � � � � � �188 Summary � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �118 Resource Allocation and Market Role � � � � � � � � � � �189 Cost—The Main Problem � � � � � � � � � � � � � � � � � � � � � � �193 SECTION 3 A ffordable Care Act: Health Policy—ACA and Beyond � � � � � � � � � � � � � � � �198 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �200 From Enactment to Sustainability 135 Chapter 10 Private Health Insurance Market � � � � � � � � � � � � � � � � � �207 Chapter 7 Affordable Care Act (ACA) History of U�S� Health Insurance Reform � � � � � � � � �208 Reframed and Uncertain � � � �137 Health Insurance Plans � � � � � � � � � � � � � � � � � � � � � � � � � �209 Health Reform in the United States: Recent Employer-Sponsored Health Insurance� � � � � � � � � �214 and Past History � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �138 Health Insurance Exchange Marketplace � � � � � � � �215 Overview of the Patient Protection and Laws and Regulations Impacting the Affordable Care Act � � � � � � � � � � � � � � � � � � � � � � � � � �145 Provision of Health Insurance � � � � � � � � � � � � � � � � �215 Financing Health Reform � � � � � � � � � � � � � � � � � � � � � � �149 The Health Reform Changes Impacting Quality Improvement and Prevention Private Insurers � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �216 Initiatives � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �150 ACA and Its Impact on Employers � � � � � � � � � � � � � � �216 Constitutionality � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �150 Private Insurance Industry Response to ACA � � � �218 States and Health Reform � � � � � � � � � � � � � � � � � � � � � � �152 Health Insurance Legislative Changes on the Key Issues Going Forward � � � � � � � � � � � � � � � � � � � � � � �153 Horizon � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �219 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �157 Opportunities for Nursing� � � � � � � � � � � � � � � � � � � � � � �219 Quality Patient Care and Care Coordination Chapter 8 Healthcare Quality � � � � � � � � �165 Strategies � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �220 Quality Care and Public Policy � � � � � � � � � � � � � � � � � �166 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �222 Human Error � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �167 Chapter 11 Medicare: Protector Patient-Centered Care � � � � � � � � � � � � � � � � � � � � � � � � � �171 to Innovator � � � � � � � � � � � � � �231 Error Measurement Tools � � � � � � � � � � � � � � � � � � � � � � �172 Agency for Healthcare Research and Quality � � � �172 Introduction � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �232 Patient Safety Indicators � � � � � � � � � � � � � � � � � � � � � � � �173 Evolution of the Passage of Medicare: National Database of Nursing Quality Timeline and Milestones � � � � � � � � � � � � � � � � � � � � �233 Indicators � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �173 Current Medicare Structure � � � � � � � � � � � � � � � � � � � � �236 National Error-Reduction Efforts� � � � � � � � � � � � � � � � �174 Overview of Medicare Spending � � � � � � � � � � � � � � � �241 Public Quality Reporting Systems � � � � � � � � � � � � � � �176 How We Pay for Medicare � � � � � � � � � � � � � � � � � � � � � � �241 Centers for Medicare & Medicaid Services � � � � � � �177 Medicare Quality Improvement Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �178 Organizations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �242 Contents vii The Future Outlook: The Way Forward � � � � � � � � � � �243 Baseline Information � � � � � � � � � � � � � � � � � � � � � � � � � � � �294 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �247 Challenges Facing the Community Hospitals � � � �298 Hospital Strategies in a Competitive Market � � � � �301 Chapter 12 Medicaid and the Financing The ACA and The Rationalization of Hospital of Care for Vulnerable Care � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �303 Populations: A Story of Healthcare Policy, Health Reform, and the Misconceptions � � � � � � � � � � �255 Role of Hospitals � � � � � � � � � � � � � � � � � � � � � � � � � � � � �306 Introduction � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �256 Chapter 15 Enhanced Primary Care Health Outcomes in the United States in Roles for Nurses and Other Relation to 10 Developed Nations � � � � � � � � � � � �257 Professionals � � � � � � � � � � � � �313 Populations Served by Original Medicaid � � � � � � �259 Original Medicaid Is Different Program in Why Primary Care? The Case for Change � � � � � � � �315 50 States and Washington, DC � � � � � � � � � � � � � � � �260 Overtreatment, Overuse, Waste, and Traditional Medicaid Costs and Variation Healthcare Harm � � � � � � � � � � � � � � � � � � � � � � � � � � � � �315 by State � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �261 Support for Value-Based Care as a Bipartisan ACA Medicaid � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �265 Approach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �317 Who Is Left Out � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �266 How Payment Reform Shapes Needs and Opportunities in Primary Care � � � � � � � � � � � � � � � �318 Health Insurance and the Health of Vulnerable People � � � � � � � � � � � � � � � � � � � � � � � � � � � �267 What Skills Do Nurses Need in These Advanced Primary Care Settings? � � � � � � � � � � � � �324 Chapter 13 Innovation for the Delivery Nursing Education � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �329 System of the Future: Medical Mental Health � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �331 Homes, Accountable Care Dental Care � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �331 Organizations, and Bundled Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �332 Payment Initiatives � � � � � � �279 Chapter 16 Physicians: It Is Increasingly Introduction � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �280 about the Team � � � � � � � � � � �341 The Innovation Center: Promoting Care Delivery Models for the Future � � � � � � � � � � � � � � �280 Medical Professionalism � � � � � � � � � � � � � � � � � � � � � � � �342 Rationale for New Models� � � � � � � � � � � � � � � � � � � � � � �281 Physician Supply: Who Are the Doctors? � � � � � � � �343 The Four Major Healthcare Service Delivery How Are Physicians Practices Organized and Models� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �281 Reimbursed? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �348 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �286 Physician Accountability � � � � � � � � � � � � � � � � � � � � � � � �353 Medical Errors, Physician Practice, and the Barriers to Quality Care � � � � � � � � � � � � � � �356 SECTION 5 H ealth Care and Overcoming the Barriers to Quality Care � � � � � � � �356 Provider and Care Conclusion: Choices and Interests � � � � � � � � � � � � � � �358 Delivery 289 Chapter 17 Health Information Technology and the Intersection of Health Chapter 14 Hospitals: Consolidation Policy � � � � � � � � � � � � � � � � � � �371 and Compression � � � � � � � � � �291 Introduction � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �372 Hospitals’ Role within the Delivery System � � � � � �292 Federal Origin and Influence in Development Hospitals in a Historic Context � � � � � � � � � � � � � � � � � �292 of HIT � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �373 viii Contents Nursing and Health Information Technology � � � �378 Transforming the Care Delivery System � � � � � � � � �415 Nursing Terminology and the Data of Pathways to Nursing as a Career Choice � � � � � � � � �416 Nursing Care � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �380 Specialization and the Evolution of Nursing A National Action Plan: The Macro Roles � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �419 Perspective on HIT � � � � � � � � � � � � � � � � � � � � � � � � � � �381 Current State of the Profession � � � � � � � � � � � � � � � � � �419 Nursing and the Electronic Health Record: Enhanced Nurse Licensure Compact � � � � � � � � � � � �421 The Micro Perspective on HIT � � � � � � � � � � � � � � � � �382 21st-Century Nursing: Evolving Roles Health IT: The Intersection of Data Security for Nurses � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �421 and Health Policy � � � � � � � � � � � � � � � � � � � � � � � � � � � �383 Policy as a Tool to Influence Nursing Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �391 Professionalism and Nursing � � � � � � � � � � � � � � � � �425 Conclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �427 Chapter 18 Political Power of Nurses: Legislative Resources � � � � � � � � � � � � � � � � � � � � � � � � � � �427 Harnessing Our Values and Federal Agency Sites � � � � � � � � � � � � � � � � � � � � � � � � � � � �428 Voices � � � � � � � � � � � � � � � � � � �403 Other Related Sites � � � � � � � � � � � � � � � � � � � � � � � � � � � � �429 Origins of the Nursing Profession � � � � � � � � � � � � � � �405 Nursing Definitions: Past and Present � � � � � � � � � � �406 Index ���������������������������������������449 Nurses and Policy � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �407 The Nursing Workforce � � � � � � � � � � � � � � � � � � � � � � � � �413 © Anthony Krikorian/Shutterstock Acknowledgments It is with sincere appreciation and gratitude that my professional hopes and dreams. Thank you we would like to acknowledge the many individ- for making this such an exciting journey and uals, including family, friends, professional col- always believing all things are possible. To my leagues, and students, who have made this third children, Nick, Lili, Kate, Luke, and JP, your joy edition possible. Special thanks go to those pro- and love have fueled my energy and enthusiasm fessional nurses who have gone before us pav- to live my life by the words of Mahatma Gandhi: ing the way by being stewards of the discipline, “Keep your values positive because your values advocates, and activists in promoting nursing, become your destiny.” Always be positive and be public health, and policy. As the editors, we are an example so that others may follow. profoundly grateful to continue in their foot- steps, fulfilling our promise to safeguard the — Donna M. Nickitas health of society and ensuring that future gen- To my husband Robert and our son Rob- erations of nurses recognize how health and ert Guy, who have awakened my soul and are public policy are instrumental to their educa- my inspiration in everything I do. They have tion and practice. taught me to love unconditionally, enjoy life, To my co-editors, Donna J. Middaugh and live with purpose, take risks, and strive for ex- Veronica D. Feeg, your enduring friendship, men- cellence. Robert Guy: You have become such torship, and insight have made this book possi- a compassionate, dedicated nurse! We are so ble. With your profound trust and unwavering proud of you! Also, to the memory of my mother, commitment, this third edition is offered in the Alpha Duff, a teacher, who taught me to never ongoing quest to ensure all nurses harness the stop learning. power within and bring their voices and values to the bedside, boardroom, classroom, and halls — Donna J. Middaugh of Congress to promote policies that educate and inform the public about what nursing is, not just To my husband Alan, you are my rock and what nurses do. my enabler. You have always given me space to We also would like to acknowledge the do what makes me happy and wings to make me superior oversight and dedication of Tricia soar into new endeavors without fear of failing. Plummer, our team administrator, who help You make the days easy for me to be produc- coordinate all the essential activities that made tive in my own way. You give me understanding this third edition such a seamless success. Tri- when I’m unraveled; you give me comfort when cia, your professional skills and support were I need it most; you give me love in all you do. greatly appreciated. To my daughter, Kelly, you are my sun and To my husband, Michael, whose love, pres- the light of my life. You have become my teacher ence, and encouragement has allowed me to fulfill and my sage with your wise guidance and words ix

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