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Beyond Law Enforcement: The FTC’s Role In Promoting Health Care Competition And Innovation


January 26th, 2015

By now, the Federal Trade Commission’s (FTC) law enforcement efforts in the health care area are well known. We have successfully challenged several hospital and physician practice mergers in the last few years. We also continue to pursue anticompetitive pharmaceutical patent settlements, following a victory at the Supreme Court in the Actavis case. Speaking of the Court, it is currently reviewing a case we brought against the North Carolina Board of Dental Examiners, alleging that its members conspired to exclude non-dentists from providing teeth whitening services in North Carolina.

Perhaps less publicized are the FTC’s various non-enforcement efforts in health care. Arguably most significant among those is the advocacy that the agency conducts in favor of competition principles before state legislatures and other policymakers. I will discuss our advocacy efforts in the health care space in this post, and then turn to the subject of telemedicine, an area in which FTC competition policy may play a significant role.

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The Importance Of Zip Code In Determining One’s Health Tops 2014 GrantWatch Blog Most-Read List


January 9th, 2015

Happy New Year! We have compiled a list of the ten most-read posts on GrantWatch Blog during 2014, in case you missed any of them.

  1. “Zip Code Overrides DNA Code When It Comes to a Healthy Community” (January 30, 2014). This post by Anne Warhover, former president and CEO of the Colorado Health Foundation, was by far the most-read post. She mentions the Robert Wood Johnson Foundation Commission to Build a Healthier America, of which she was a commissioner, and relevant activities in Colorado. We also feel sure that Warhover’s post set a record for the number of re-tweets. Read more about Warhover here.
  2. “A World of Darkness: What If Thomas Edison Had to Write Grant Proposals to Invent the Light Bulb?” (February 18, 2014). This post by Jeffrey Brenner, executive director of the Camden Coalition of Healthcare Providers and a family physician, came in at no. 2. Brenner is also a MacArthur Fellow. This post was published in partnership with Grantmakers In Health.
  3. “Elevating the Role of the Medical Assistant” (March 3, 2014). This post by Karen Wolk Feinstein, president and CEO of the Jewish Healthcare Foundation, in Pittsburgh, was the third most-read post in 2014. Feinstein is also president and CEO of its affiliated organization, the Pittsburgh Regional Health Initiative.
  4. “Foundations Supporting Stewardship of Health Care Resources through Medical Education and Training” (January 22, 2014). Daniel Wolfson and Leslie Tucker of the ABIM Foundation wrote this post about a convening of medical educators, students, residents, and other stakeholders. The ABIM Foundation and the Josiah Macy Jr Foundation held this meeting.
  5. “The Robert Wood Johnson Foundation: Creating Partnerships to Build a Culture of Health” (September 11, 2014). David Colby, who just retired from the RWJF, wrote this popular post about the foundation’s new focus in its work. As Colby notes, “Health actually is a part of everything!”
  6. “Online ACA Marketplaces: the Value of Consumer Experience Assessments” (June 17, 2014). Marian Mulkey of the California HealthCare Foundation (CHCF) and Claudia Page, a consultant to the foundation, wrote this post about people signing up for health insurance under the Affordable Care Act. Page is a former CHCF staffer.
  7. “The Hitachi Foundation Sheds Light on the New Role Frontline Workers Play in Health Care” (April 24, 2014). Tom Strong of the Hitachi Foundation wrote this post. Like no. 3, it mentions the role of medical assistants, which seems to be a popular subject!
  8. “Toxic Stress in Children and the Importance of Listening between the Lines to What Kids Say” (April 29, 2014). I wrote this post about Nadine Burke Harris’s speech at the Grantmakers In Health 2014 annual meeting in Atlanta.
  9. “If You Partner, They Might Just Come: One Foundation’s Effort to Disseminate Data on Quality of Care” (March 13, 2014). Andy Krackov, also of the CHCF, wrote this post about CalQualityCare.org, which it manages.
  10.  “The Rippel Foundation and the RWJF Push Frontiers for Financing and Sustaining Improvements in Health” (February 13, 2014). Laura Landy, who leads the Fannie E. Rippel Foundation, wrote this post about a “project to explore the conditions needed to build a next-generation health system.”

 

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Medicaid Expansion Post Leads Health Affairs Blog 2014 Top-Fifteen List


January 8th, 2015

As we begin 2015, we present the fifteen most-read Health Affairs Blog posts from 2014. Topping the list is “Opting Out Of Medicaid Expansion: The Health And Financial Impacts,” by Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhander. “Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage,” the authors write, and they offer a state-by-state projection of these consequences.

Next on the list is Susan DeVore‘s overview of health care trends to watch in 2014, followed by David Muhlestein‘s look at the likely growth of accountable care and an examination of declining inpatient hospital utilization by Robert York, Kenneth Kaufman, and Mark Grube. The list also includes two posts from Tim Jost’s comprehensive series on implementing the Affordable Care Act, on waiting periods for employer-sponsored health insurance and Medicaid asset rules.

Stay tuned for the 2014 most-read lists for Health Affairs journal and GrantWatch Blog.

The full top-fifteen list is below:

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Arkansas Payment Improvement Initiative: Self-Insured Participation


January 7th, 2015

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model.

Designed and launched by the state’s Medicaid program and some of its largest private insurers, including Arkansas Blue Cross Blue Shield (BCBS) and QualChoice, the Arkansas Payment Improvement Initiative (APII) has been a multi-payer effort since its inception in 2011. As the APII has developed, participation from some of the state’s largest self-insured employers has increased its scope and impact.

While we’ve referenced self-insured participation in our previous blog posts, we provide more detail in the following blog post on its ongoing development and explore what it takes for self-insured plans to adapt to the Arkansas Payment Improvement Initiative’s payment model. What has been the response from Arkansas employers and plans? What is the effect on existing contractual relationships? What are the hurdles?

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Health Affairs’ January Issue: Aging And Health


January 5th, 2015

The January issue of Health Affairs includes a number of studies examining issues pertaining to aging and health or health care. Other subjects covered include: the effect of Medicare’s Hospital Compare quality reports on hospital prices; how the Affordable Care Act’s provisions impact Americans shouldering high medical cost burdens; and whether California’s Hospital Fair Pricing Act has benefited uninsured patients.

Content on aging and health was supported by the John A. Hartford Foundation.

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Implementing Health Reform: Open Enrollment Progress For 2015 (Updated)


December 31st, 2014

On December 30, 2014, the Centers for Medicare and Medicaid Services released several reports on enrollment numbers covering the second marketplace enrollment period to date.  It released its first monthly ASPE (Assistant Secretary for Planning and Evaluation) report covering October 15 to November 15, 2014.   (press release here  )  The ASPE report for the first time includes some — very incomplete — information on enrollment in the state-operated exchanges.

CMS simultaneously released a snapshot report covering enrollment in the Federally Facilitated Marketplace (FFM) for the sixth week of open enrollment.

The bottom line is that the reports confirm what we all knew already: The first month of open enrollment is going much better than the early months of open enrollment last year.  As of December 26, 6,490,492 individuals had selected a plan through the FFM.  Only 96,446 selected a plan in Week 6, compared to 3.9 million in week 5, emphasizing again the importance of the December 15 deadline for January 1 coverage in driving enrollment.

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Health Insurance Rate Setting: Time To Raise The Bar And Lift The Veil Of Secrecy


December 24th, 2014

Over 15 million Americans stand to benefit from a strong health insurance rate review system, with the number growing each year. But in many states the rate review laws—and how they are carried out—fall short. Health insurance is one of the most expensive purchases consumers make, it is vital to the financial and physical health of their families, and it is required under the Affordable Care Act.

It is, therefore, important for insurance regulators to ensure consumers pay a fair price for their coverage. At the recent National Association of Insurance Commissioners (NAIC) meeting, we, along with two other organizations, presented a set of recommendations designed to strengthen the rate review process at both the state and federal level so that all consumers will be assured fairly priced health insurance.

The Affordable Care Act introduced new, important protections for consumers, while at the same time retaining a large role for state policy and regulation. This framework resulted in inconsistent policies across states. States that expanded Medicaid sit adjacent to states that did not. Some states operate their own insurance Marketplace, while consumers in other states use the federal Marketplace.

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New Health Policy Brief: Reenrollment


December 22nd, 2014

This year open enrollment under the Affordable Care Act (ACA) began on November 15, allowing new customers to sign up for health insurance. Open enrollment also provided current policyholders the chance to change plans and request a redetermination on the amount of subsidy they received. During this second year of open enrollment for the ACA’s insurance Marketplaces, insurers and policy makers are working to keep last year’s enrollees in the system — and the Department of Health and Human Services (HHS) estimates that 95 percent of them are eligible for automatic renewal.

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines the pros and cons of reenrollment options for consumers, whether they are using the federal Marketplace or live in states that operate their own exchanges. Automatic reenrollment means that almost seven million people already enrolled will not necessarily need to flood HealthCare.gov and exchanges during open enrollment. On the other hand, it also may discourage consumers from exploring alternative coverage that might better fit their needs and get a more accurate determination of eligibility for subsidies.

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Implementing Health Reform: Wraparound Coverage Excepted Benefits And Draft 2016 Letter To Issuers (Updated)


December 20th, 2014

In December 19, 2014, in what one hopes were their last major regulatory actions before the holidays, the Departments of Labor, Health and Human Services, and Treasury released a proposed rule on a new excepted benefit for wraparound coverage, while the Centers for Medicare and Medicaid Services released a Draft 2016 Letter to Issuers in the Federally Facilitated Marketplace.

This post will describe the wraparound coverage proposed rule.   It will be updated in the next day or two to analyze the letter to issuers (issuers being the Affordable Care Act word for insurers.)  I will note briefly, however, that the letter to issuers is very similar to the 2015 letter to issuers, with two major exceptions.  First, because open enrollment for 2016 begins on October 1, rather than November 15, as in 2015, the time frame for completing regulatory review begins earlier and is quite compressed.  Second, the 2016 letter picks up on a few new regulatory initiatives for 2016, such as attempts to provide more accurate provider directories and formulary information.  These changes will be explored more thoroughly in the update to this post.

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The Dane Difference: Why Are Dane County’s Exchange Premiums Lower?


December 18th, 2014

During the next few years, states and the federal government will likely seek solutions to control costs and improve quality in the Affordable Care Act (ACA) health insurance marketplaces. State and federal policymakers should look carefully at the decades-long success of the Wisconsin State Employee Health Plan (WSEHP) in controlling the rapid rise of health insurance costs in Dane County—where Madison, Wisconsin’s state capital, and the University of Wisconsin, are located—as they seek to improve the effectiveness of the ACA’s marketplaces and health insurance costs in general.

The WSEHP consistently obtains substantially lower health insurance premiums in Dane County than in Wisconsin’s 71 other counties. In 2013, an individual plan in the WSEHP was about $1,400 cheaper annually in Dane County, or 16 percent less than the average in the rest of the state; and a family plan was about $3,500 cheaper, also a 16 percent difference. This Dane difference has existed for at least a decade, with the gap slowly widening over that time.

Why does WSEHP get much lower premiums in Dane County than in the state’s 71 other counties, and what lessons can policymakers learn from this difference?

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Implementing Health Reform: Enrollment And Reenrollment For 2015 (Updated)


December 16th, 2014

The December 15, 2014 deadline for reenrolling in qualified health plan (QHP) coverage to assure continuous coverage as of January 1, 2015 has come and gone.  Individuals who were enrolled through the federally facilitated marketplace (FFM) for 2014 but did not return to the marketplace to shop for 2015 plans will be passively reenrolled in their 2014 plan or in a plan similar to it.  The 2015 open enrollment period lasts through February 2015, and individuals can return to the FFM at any time before then to change plans.  But the change will not be effective for January 1.

A number of state-operated exchanges—including New York, Massachusetts, Idaho, Rhode Island, Washington, Minnesota, and California—have reportedly either extended the date by which individuals can enroll or reenroll and still have coverage effective January 1 or given individuals who had begun the enrollment process as of December 15 extra time to complete the process for January 1 coverage.  The FFM has not extended the deadline.

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California’s Proposition 46 And The Uncertain Future Of Medical Malpractice Liability Reform


December 10th, 2014

On November 4, 2014, Californians voted against Proposition 46, an unprecedented statewide ballot initiative that would have, among other things, raised the $250,000 cap on noneconomic damages to $1.1 million and indexed it to the rate of inflation in future years. The margin was significant — 67 percent voted against it.

For nearly 40 years, noneconomic damages, which entail payments to patients for pain and suffering resulting from medical malpractice (as opposed to economic damages such as lost wages and medical costs), have been at the forefront of debates over the U.S. medical liability system. Currently, 22 states have caps on noneconomic damages of varying sizes in place. If it had passed, the ballot initiative would have raised the cap on noneconomic damages in California from among the most restrictive to the least restrictive among all states with caps.

Opponents of Proposition 46, and supporters of malpractice reform more generally, argued that raising the noneconomic damages cap would have increased malpractice awards and subsequently malpractice premiums, which would be passed on to patients and insurers as higher costs.

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Section 1332 Waivers And The Future Of State Health Reform


December 5th, 2014

Editor’s note: This post is part of a series of several posts stemming from presentations given at “The Law of Medicare and Medicaid at Fifty,” a conference held at Yale Law School on November 6 and 7.

The Affordable Care Act (ACA) turbocharges state innovation through a number of provisions, such as the creation of the Center for Medicare & Medicaid Innovation, funding for states to establish customized insurance exchanges, and Medicaid reforms such as health homes and projects geared toward the dual eligible population. Yet another component of the law holds even more potential for broad reform. Buried in Section 1332 of the law is a sparkplug for innovation called the State Innovation Waivers program.

Also known as 2017 waivers or Wyden waivers, 1332s offer wide latitude to states for transforming their health insurance and health care delivery systems. According to the statute, states can request that the federal government waive basically every major coverage component of the ACA, including exchanges, benefit packages, and the individual and employer mandates. But the cornerstone of 1332 waivers is the financing. To fund their reforms, states can receive the aggregate amount of subsidies—including premium tax credits, cost-sharing reductions, and small business tax credits—that would have otherwise gone to the state’s residents. Depending on the size of the state, the annual payment from the federal government for alternate coverage reform could reach into the hundreds of millions or even billions of dollars.

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How Do Alternative Payment Models Fit In With State And National Reform Efforts?


December 1st, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Oregon model.

The Affordable Care Act has affected health care at almost every level. Extensive experimentation within states continues to create changes. Given all these shifts, it is helpful to step back and consider how alternative payment models (APMs) fit in with these reforms, and why they are critically important.

Many describe the Affordable Care Act as a means to expand coverage, with relatively little emphasis on controlling costs. This is an oversimplification — accountable care organizations are designed to address costs. New “productivity adjustments” in the Medicare program are also intended to check spending growth. But these changes, while real, represent a patchwork approach to controlling costs that probably do not address the underlying problem.

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Implementing Health Reform: Minimum Essential Coverage And The Multi-State Plan


November 24th, 2014

Two earlier posts this past weekend analyzed the massive Department of Health and Human Services 2016 Benefit and Payment Parameter Proposed Rule, released on November 21.  Also on November 21, the Internal Revenue Service of the Department of the Treasury released a final rule on Minimum Essential Coverage and Other Rules Regarding the Shared Responsibility Payment for Individuals, while the Office of Personnel Management released proposed modifications to the multi-state plan (MSP) program rule.  This post explores these rules.

Minimum Essential Coverage

The ACA requires Americans to either maintain “minimum essential coverage” (MEC) or pay a tax.  There are a number of exceptions to the requirement, however, and the concept of MEC can become quite complicated.  The final rule published by the IRS provides guidance as to the meaning of MEC and the rules governing some of the exceptions.

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Implementing Health Reform: 2016 Benefit And Payment Parameters Proposed Rule, Insurance Provisions


November 23rd, 2014

On November 21, 2014, the Centers on Medicare and Medicaid Services of the Department of Health and Human Services released its proposed Benefits and Payment Parameters (BPP) RulePart I of this post examined the benefit provisions of this proposed rule. This post will analyze the parts of the rule that deal with the insurance market reforms; the reinsurance, risk adjustment, and risk corridor programs; health insurance rate review; and the individual and SHOP exchanges.

New Definitions Of ‘Plan’ And ‘State’

The regulation begins with a modified definition of the term “plan.”  The terms “plan” is important in the ACA regulations.  A plan has been defined, with respect to a health insurer, as the combination of a benefit package, metal tier, and service area.  The new definition adds to this combination cost-sharing structure and provider network, so that plans that differ in their cost-sharing structure (deductibles, copayments, or coinsurance) or provider networks are different plans, even if they are offered at the same metal tier.  This definition becomes important, for example, in determining whether a plan offered outside the exchange is the same as a qualified health plan (QHP) offered in the exchange and can thus participate in the risk corridor program.  The proposed regulations later propose that the unreasonable rate review regulation applies at the plan level.

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Implementing Health Reform: 2016 Benefit And Payment Parameters Proposed Rule, Consumer Provisions; Hardship Exemptions


November 22nd, 2014

On November 15, 2014, the marketplaces reopened for 2015.  Anecdotal reports indicate that in most places enrollment and reenrollment are running smoothly.  But the Centers of Medicare and Medicaid Services (CMS) of the Department of Health and Human Services (HHS) is looking forward to 2016.  On November 21 CMS published its massive 2016 Notice of Benefit and Payment Parameters (BPP) Proposed Rule  with accompanying fact sheet.  It also published the draft 2016 actuarial value calculator and draft actuarial value calculator methodology for 2016.  Finally, CMS published a guidance on hardship exemptions for certain individuals.

Not to be outdone, the Department of the Treasury, Internal Revenue Service released its final regulation on Minimum Essential Coverage and other Rules Regarding the Shared Responsibility Payment for Individuals, together with a Notice regarding Individual Shared Responsibility Payment Hardship Exemptions that May be Claimed on a Federal Income Tax Return Without Obtaining a Hardship Exemption Certificate from the Marketplace and a Revenue Procedure setting out indexed adjusted percentages of income that will be used for determining the level of contributions expected of individuals before premium tax credits become available, the affordability threshold for the shared responsibility payments unaffordability exemption, and the threshold for determining whether employer coverage is affordable for purposes of determining eligibility for tax credits.

Finally, the Office of Personnel Management released a lengthy proposed rule proposing modifications in the multi-state plan program.  These rules, proposed rules, and guidances will be addressed in a series of posts over the next several days.  This post will address primarily the consumer-facing provisions of the BPP proposed rule, focusing on changes in benefits.  A second post will follow, discussing the provisions of the rule more relevant to insurers, such as proposed changes in the reinsurance, risk adjustment, and risk corridor rules.  A final post will discuss the IRS rule, which is primarily a finalization of proposals and guidances already made public, and the OPM multi-state plan rule.

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Dear Governor-Elect: Some Health Policy Counsel


November 18th, 2014

Congratulations on your election on November 3. It is a mandate for your vision and leadership.  Now, like the proverbial dog who has caught the meat truck — where to begin with this business of governing?

As you contemplate the work in front of you, I would like to offer some (unsolicited) advice about a possible state health policy agenda, borne from my own work and observing states across the country. The recommendations are non-ideological and substance-neutral.  You will look hard to find a reference to the Affordable Care Act (ACA) here. The challenges states face in health care are so large they defy simple solutions and require collaboration across our widening ideological divide; energy spent attacking the ACA is energy diverted from these challenges.

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Medicaid At 50: From Exclusion To Expansion To Universality


November 14th, 2014

Editor’s note: This post is part of a series of several posts stemming from presentations given at “The Law of Medicare and Medicaid at Fifty,” a conference held at Yale Law School on November 6 and 7.

For almost five decades, Medicaid has been a safety net with gaping holes. Medicaid has provided invaluable health care access for the “deserving poor”—the impoverished blind, disabled, children, pregnant women, and elderly—but they only comprise approximately 40 percent of the nation’s poor. The Patient Protection and Affordable Care Act (ACA), as part of its comprehensive insurance coverage architecture, rendered all Americans earning up to 138 percent of the federal poverty level (FPL) eligible for Medicaid. Through the effort to “provide everybody … some basic security when it comes to their health care,” the ACA adopted a universal approach to health care access. Universality is a fundamentally different philosophical approach in American health care, and an important progression away from the stigmatizing rhetoric of the “deserving poor.”

The Supreme Court nearly thwarted the possibility of universality by holding the Medicaid expansion unduly coercive and rendering expansion optional for the states. Ever since, states have been exercising that option, deciding whether to expand in a highly dynamic dialogue that has occurred both intrastate and extra-state with the Secretary of the Department of Health and Human Services (HHS). This dialogue has resulted in four waves of Medicaid expansion, each of which has exhibited greater boldness on the part of the states in their proposals to HHS, and greater flexibility on the part of HHS in accepting state ideas for expansion. On a spectrum of federalism, the waves move from cooperation to assertions of state sovereignty. But, Medicaid’s new universality provides an absolute backstop for HHS in these negotiations, a point at which federal policy should not accommodate the rent-seeking behavior of the states.

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Risk And Reform Of Long-Term Care


November 14th, 2014

Editor’s note: This post is part of a series of several posts stemming from presentations given at “The Law of Medicare and Medicaid at Fifty,” a conference held at Yale Law School on November 6 and 7.

The 50th Anniversary of Medicare and Medicaid offers an opportunity to reflect on how U.S. social policy has conceived of the problem of long-term care.

Social insurance programs aim to create greater security—typically financial security—for American families (See Note 1). Programs for long-term care, however, have had mixed results. The most recent attempt at reform, which Ted Kennedy ushered through as a part of the Patient Protection and Affordable Care Act (ACA), called the CLASS Act, was actuarially unsound and later repealed. Medicare and especially Medicaid, the two primary government programs to address long-term care needs, are criticized for failing to meet the needs of people with a disability or illness, who need long-term services or supports. These critiques are valid.

Even more troublesome, however, long-term care policy, especially in its most recent evolution toward home-based care, has intensified a second type of insecurity for Americans. This insecurity arises when someone becomes responsible for the long-term care of a loved one. In a longer forthcoming article, I argue that this insecurity—which I call “next-friend risk”—poses a serious threat to Americans and needs to be addressed. (I borrow the phrase next friend from a legal term for a person who in litigation represents someone with a disability who is otherwise unable to represent him or herself. Although not a legal guardian, the next friend protects the interests of an incompetent person.)

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