Академический Документы
Профессиональный Документы
Культура Документы
PII: S0168-8510(18)30154-4
DOI: https://doi.org/10.1016/j.healthpol.2018.05.007
Reference: HEAP 3905
Please cite this article as: Rice Thomas, Unruh Lynn Y, van Ginneken Ewout, Rosenau
Pauline, Barnes Andrew J.Universal coverage reforms in the USA: From Obama care
through Trump.Health Policy (2018), https://doi.org/10.1016/j.healthpol.2018.05.007
This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Not Dead Yet: The ACA and the U.S. Search for Universal Healthcare under
the Trump Administration
Thomas Rice
UCLA Fielding School of Public Health, Los Angeles, CA, USA
trice@ucla.edu
PT
Lynn Y. Unruh
Department of Health Care Management and Informatics, Central Florida University,
Orlando, FL, USA
RI
Lynn.Unruh@ucf.edu
SC
Berlin University of Technology and European Observatory on Health Systems and Policies
Berlin, Germany
ewout.vanginneken@tu-berlin.de
U
Pauline Rosenau
University of Texas School of Public Health, Houston, TX, USA
Pauline.Rosenau@uth.tmc.edu N
A
Andrew J. Barnes
School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
M
andrew.barnes@vcuhealth.org
Corresponding author: Thomas Rice, Professor, UCLA Fielding School of Public Health, 650 S.
D
Charles Young Drive, Los Angeles, CA 90095-1772, USA. Phone: 310-206-1824; Fax: 310-
825-3317; email: trice@ucla.edu
TE
EP
HIGHTLIGHTS
President Trump’s administration is undoing some of the Affordable Care Act’s provisions
CC
In the meantime, prospects are that the number of uninsured will grow
1
ABSTRACT
Since the election of Donald Trump as President, momentum towards universal health care
coverage in the United States has stalled, although efforts to repeal the Affordable Care Act
(ACA) in its entirety failed. The ACA resulted in almost a halving of the percentage of the
PT
population under age 65 who are uninsured. In lieu of total repeal, the Republican-led Congress
repealed the individual mandate to purchase health insurance, beginning in 2019. Moreover, the
RI
Trump administration is using its administrative authority to undo many of the requirements in
SC
the health insurance exchanges. Partly as a result, premium increases for the most popular plans
will rise an average of 34% in 2018 and are likely to rise further after the mandate repeal goes
U
into effect. Moreover, the administration is proposing other changes that, in providing states
N
with more flexibility, may lead to the sale of cheaper and less comprehensive policies. In this
A
volatile environment it is difficult to anticipate what will occur next. In the short-term there is
M
proposed compromise legislation, where Republicans agree to provide funding for the cost-
D
sharing subsidies if the Democrats agree to increase state flexibility in some areas and provide
TE
relief to small employers. Much will depend on the 2018 and 2020 elections. In the meantime,
Keywords: Affordable Care Act, health care system, health insurance, health policy, health
reform
A
Since the election of Donald Trump as President, momentum towards universal health
care coverage in the United States has stalled. Most notable was the repeal of the individual
mandate to purchase health insurance in late December 2017. However, outright repeal of
2
President Obama’s signature piece of legislation -- the Affordable Care Act (ACA) -- has not yet
come to pass. Though the Republican Party controls the Presidency and both Houses of
Congress, attempts at wholesale repeal and replacement of the ACA during the summer and
early fall of 2017 failed. Congressional leaders could not muster enough votes in large measure
PT
because Congress’ own budget office reported that repeal would result in 23 million Americans
losing their coverage. 1 As a result, the ACA’s expansion of Medicaid remains fully intact and
RI
individuals continue to receive the same financial subsidies to purchase coverage from private
SC
insurers on the ACA’s insurance exchanges. Political developments, nevertheless, are taking
place at breakneck speed, making it difficult for the world community to know where things
U
stand. In this article, which constitutes an analysis of major legislative and policy changes
N
observed by the authors, we review past progress towards universal coverage in the U.S., present
A
the key issues under debate now, and outline possible future scenarios.
M
Until the major provisions of the ACA went into effect in January 2014, health insurance
TE
coverage was always voluntary. About 30% of the population was covered through the two
EP
major public programs enacted in 1965: Medicare for seniors (later extended to the disabled)
and Medicaid for poorer Americans. 2 Most others received coverage through their employment,
CC
either as employees or dependents, but such coverage was always voluntary: employers did not
have to provide it, and individuals were not required to buy it. Less than 10% purchased
A
As far back as the 1950s those with pre-existing illnesses generally found individual
insurance policies unaffordable because insurers could charge higher premiums to those with a
3
history of illness.” The ACA increased individual coverage by: prohibiting insurance companies
from excluding people or charging more for pre-existing conditions; mandating that all
individuals obtain insurance; and by helping individuals pay for this through income-based
premium subsidies.
PT
Nearly all other high-income countries provide coverage for those unable to afford it, but
this has not been true of the U.S. Until the ACA, only about half of poor adults were covered by
RI
Medicaid and almost 30% of both the poor and near-poor under age 65 lacked any coverage at
SC
all. 3,4 Coverage rates were higher for children in part because of the Children’s Health Insurance
Program (CHIP). Enacted in 1997, under CHIP the federal government matches state
U
contributions to provide coverage for children in families with incomes above Medicaid
N
thresholds, but who typically cannot afford private coverage. 5
A
Medicaid’s limited success in extending coverage to the poor was mainly because
M
program eligibility varied by state; states continue to have substantial powers in determining
eligibility, health benefits covered, and provider payment. Some established significant barriers
D
requirements are also sometimes severe. For example, a parent with two dependent children in
EP
Texas, one of the most populous states, is ineligible for Medicaid if she earns just 18% (that is,
6
less than one-fifth) of the federal poverty line (FPL) -- only $3,700 per year. The ACA
CC
originally was designed so that all poor and some near-poor persons would receive Medicaid
coverage, but that intent was stymied by a ruling by the U.S. Supreme Court, as described next.
A
4
The ACA was passed in 2010 during a period in which the Democratic Party controlled
the Presidency and both Houses of Congress. Box 1 lists its major provisions.
Uninsurance rates among the under age 65 population have almost halved, from a peak of
18.2% in 2010 to 10.3% in 2017 (Figure 1). Researchers have estimated that average spending
PT
of adults (premiums plus out of pocket costs) fell by 12% during the first two years of full
7
implementation - and by over 20% for the poor and near-poor. The ACA did not achieve
RI
universal coverage, for several reasons: First, with the Supreme Court ruling, approximately 4.5
SC
million poor and near-poor people still do not receive Medicaid. 8 Generally, these people are
excluded from the individual mandate because they would have to spend more than 8% of their
U
income on premiums. Second, some people choose to pay the penalty rather than purchase
N
insurance; both penalties and enforcement of the mandate are far milder in the U.S. than in
A
Germany, the Netherlands, and Switzerland, all of which require that people purchase coverage. 9
M
Third, undocumented individuals are forbidden from purchasing on the exchanges and are not
As noted, despite calls to repeal the ACA “on day one,” the President Trump, even with
the support of a Republican Congress, was not able to repeal the legislation -- although the vote
CC
in the U.S. Senate was very close. (Whether the House of Representatives would have passed
the Senate bill is conjectural.) Due to arcane rules in the U.S. Senate, repeal before the U.S.
A
National 2018 congressional elections will be extremely difficult because it would require 60
votes out of 100 – and Democrats and Democrat-leaning independents hold 48 seats.
5
The Republicans were able to make a major legislative dent, however, by repealing the
individual mandate. This was accomplished by including this provision in a major overhaul of
the federal income tax system that passed Congress and was signed into law just before the end
of 2017. Because Senate rules allow budget-related legislation to pass with a majority vote, the
PT
Republicans were able to succeed. The main reason was to fulfill, at least in part the promise
they made to voters to repeal the ACA, but another was more pragmatic. Repeal of the mandate
RI
will reduce the number of people purchasing coverage from the exchanges, which in turn will
SC
reduce federal outlays. This allowed the Republican party to increase the size of the tax cuts that
U
One would expect an uptick in the number of uninsured for two reasons: (1) the financial
N
penalty for being uninsured will be removed beginning in 2019, and (2) premiums will rise due
A
to adverse selection, by an estimated 10%, although most people are protected through rising
M
financial subsidies. Estimates by the Congressional Budget Office project that by 2027, five
million Americans would lose individual coverage; another five million, Medicaid coverage; and
D
three million more, employer coverage. 11 Moreover, the Trump Administration has made
TE
various administrative decisions that will lead to fewer people choosing to purchase coverage,
EP
including: (1) occasionally stating that it would not have the Internal Revenue Service enforce
the tax penalties for those who choose to remain uninsured - this is relevant to 2018, when the
CC
individual mandate is still in force; (2) severely cutting funding for outreach during the annual
open enrollment period, as well as the length of the period; (3) providing negative public
A
statements about the ACA; and (4) choosing not to fund the so-called “cost-sharing subsidies.”
Where, then, do things now stand? The Medicaid expansion remains in place in 31
states; those eligible will continue to receive coverage, which typically has a broad benefit
6
package and little or no premiums or patient cost-sharing. However, because many physicians
do not accept Medicaid patients, due in large measure to low fees, access is often not the same as
for those with private insurance and Medicare. Regarding the exchanges, in spite of the efforts
of the Trump Administration, outlined above, enrollment during the 2018 open enrollment period
PT
was fairly stable. In 2018, an estimated 11.8 million million people enrolled through the federal
and various state exchanges, just 4% lower than the previous year. 12 Enrollment results are not
RI
yet in for the several states that have their own exchanges.
SC
In addition, the administration is proposing other changes that could to lead to the sale of
cheaper and less comprehensive policies at a cost of reducing consumer protections. States
U
would gain more flexibility in defining what constitutes essential health benefits. Individuals
N
would be allowed to purchase health insurance across state lines, which would give people in a
A
state with tougher regulations the ability to purchase from another state where regulations are
M
lower and insurance is cheaper. Regulations governing small employers that group together to
create their own plans (called “association health plans”) would be modified to permit less
D
comprehensive policies. And the sale of short-term policies would be permitted. 13,14 Such plans
TE
do not have to cover mandated “essential health benefits” under the ACA or comply with pre-
EP
existing condition regulations. They are currently limited to no more three months, but the
15
Trump Administration is discussing extending that time period, perhaps up to a full year.
CC
Overall the result would be a market containing some bare-bones plans, which are mostly
attractive to healthy people. By drawing these healthy individuals away from the exchanges,
A
The cost-sharing subsidies have been one of the most contentious issues – but also the
one on which prominent members of Congress are striving to reach a bipartisan solution. The
7
most common plan under the individual exchanges, called Silver, has annual deductibles that
16
average more than $3,000 for those with individual coverage. Since costs like these are
unaffordable to many people purchasing on the exchanges, the ACA also specified sharply
reduced cost sharing for those with incomes below 250% of the FPL. The insurer pays them and
PT
is reimbursed by the federal government. However, the ACA legislation did not include a
funding source for these subsidies, and thus, a federal court ruled them unconstitutional. The
RI
Obama administration was in the process of appealing the court ruling when President Trump
SC
was elected, and he chose not to continue with the appeal.
Loss of the cost-sharing subsidies alone means that premiums will rise by an estimated
U
19% in 2018, varying from 7% to 38% by state17 - and by far more (between 35% and 90%) over
a three-year period. 18 N
This is on top of other premium increases resulting from higher than
A
anticipated service utilization. (Premium increases from repeal of the individual mandate will
M
not occur until 2019.) While the size of premium increases varies a great deal by state, they were
substantial during the 2018 open enrollment period (which ended on 15 December 2017 in the
D
19
federal marketplace) - an average increase of 34% for Silver plans. Elimination of the
TE
subsidies, however, may have unintended consequences. This is because insurers raised
EP
premiums in Silver plans the most to offset anticipated cuts to cost-sharing subsidies, which only
apply to those plans in the 4-tier exchange plans (Bronze, Silver, Gold, Platinum). Premium
CC
subsidies to those below 400% of the FPL, which are required by law and are not affected by this
executive order, are calculated using the price of the second cheapest Silver plan. Thus, subsidies
A
will increase for many consumers, allowing them to afford more generous Gold-tier plans,
should they choose to purchase them. Interestingly, it is estimated that the net effect of
8
billion a year over the next ten years. This is because the increase in premium subsidies resulting
from higher premiums for Silver plans will exceed the reduction in cost-sharing payments made
PT
Next Steps - and Beyond
In such a volatile and fast-paced environment it is difficult to anticipate how things will
RI
turn out. One thing is nearly certain: the push towards universal coverage is stalled, if not
SC
reversing course. The individual mandate expires after 2018, and all signs from both the Trump
Administration and Congress are that they want to undo as many other federal rules brought
U
about through the ACA as they can. By doing so, many Republicans expect to make the ACA
N
untenable and redistribute the federal spending back to the states to spend as they wish. This, in
A
fact, was explicit in a recent proposal, dubbed Graham-Cassidy, that, while approved by the
M
Republicans agree to provide funding for the cost-sharing subsidies if the Democrats agree to
TE
increase state flexibility through “innovation waivers” and provide relief to small employers.
EP
increasing the price tag of the ACA, and many Democrats being reluctant to support any
CC
proposals that allow insurers to sell policies in which those with pre-existing conditions are
charged more. At time of writing, the most recent development was a letter from the federal
A
Centers for Medicare & Medicaid Services (CMS), which administers the Medicare and
Medicare programs, that would give states the flexibility to establish a work or community
9
engagement requirement as a condition of Medicaid eligibility. Such a requirement has already
been approved for Kentucky, and nine other states have made similar requests. 22,23
Moving further into the future, much depends on upcoming November 2018 mid-term
election. All members of the House of Representatives, and about one-third of the Senate, are up
PT
for election. If Republicans retain control of both, they will have two more years to make major
alterations to the ACA or even repeal it. Presidential elections follow in 2020. In the meantime,
RI
the prospects are that the number of uninsured will grow and some of the insurance policies that
SC
are purchased will provide less comprehensive coverage.
Because the political future of the country is so uncertain, it is not possible to know even
U
the rough direction of future major health policy reforms. Box 2 lists some of the options being
N
discussed; it is divided into left-leaning and right-leaning proposals. Proposals on the left
A
include the recently-released “Medicare Extra for All” and single-payer. The former, proposed
M
by the Center for American Progress, may be viewed as “single payer light,” in that employers
can choose to continue providing coverage if they wish. On the right, up till now most emphasis
D
has been on repealing the ACA, so there are few proposals that propose reforming the health care
TE
system from scratch. We provide information about Republican plans to channel far more
EP
monies to states through block grants, as well as expanding health savings accounts (HSAs).
HSAs generally are not considered a model for national health systems, with the key exception
CC
of Singapore.
Universal health coverage through universal health insurance remains an elusive goal for
A
the U.S. The country started late but it has come a long way. Nevertheless, it may never catch up
with other industrialized countries because the concept remains controversial even though 60%
say that “it is the federal government’s responsibility to make sure all Americans have healthcare
10
coverage.” 24
Those who disagree hold strong opinions on this topic and the American
Constitution was written to protect minorities with intense opinions. And so it still does today.
PT
None of the authors declare any conflicts of interest. The research did not receive any specific
grant from funding agencies in the public, commercial, or not-for-profit sectors.
RI
BOX 1
SC
Major Provisions of the Affordable Care Act
U
community-rated individual and family insurance policies that were required to cover ten
N
sets of “essential health benefits.” Policies could be sold in four “metal tiers”, Bronze,
A
Silver, Gold, and Platinum, which cover 60%, 70%, 80%, and 90%, respectively, of
M
typical health expenses. The tiers with the more comprehensive coverage generally have
D
higher premiums.
TE
Families earning up to four times the FPL were eligible for at least some financial
EP
assistance to pay for insurance. Various restrictions applied; for example, people with
access to employer-sponsored health insurance, and those with incomes below the U.S.
CC
A
Provided coverage free of cost-sharing requirements for specific services (e.g., annual
Required that insurers sell coverage to applicants regardless of health status (called
“guarantee issue”)
11
Liberalized Medicaid coverage so that (as passed originally) everyone up to 138% of the
FPL (except legal immigrants, who may have to wait five years before obtaining
2012 the U.S. Supreme Court ruled that requiring states to expand their Medicaid was
PT
unconstitutional. Nineteen states have chosen not to expand Medicaid even though 90%
RI
Required that most people have health insurance or pay a penalty, a provision called the
SC
“individual mandate.” Employers with more than 50 employees were also required to
U
delayed.
N
Required that employers that provide family coverage to workers cover workers’ children
A
until the reach the age of 26.
M
D
TE
EP
CC
A
12
BOX 2
“Medicare Extra for All” State-Based Block Grants and Spending Caps
PT
Example: Proposal by Center for American Example: Graham-Cassidy, H.R. 1628. 27
Progress, “Medicare Extra for All. 26 Provides Proposal to repeal and replace the Affordable
RI
universal coverage in part by expanding the Care Act. It was not passed by the U.S.
Medicare program to anyone who chooses to Congress. The bill contained many provisions,
join, as well as all newborns and individuals including allowing insurers to sell plans not
SC
turning age 65 - who are automatically compliant with the ACA’s mandatory benefit
enrolled. Employers have the choice of package, and allowing insurers to sell across
continuing to provide coverage, or enrolling state lines. A key component of the proposal
U
their employees into Medicare Extra. Has calls for block grants to states, replacing ACA
broad benefits package including dental, premium subsidies and funds allotted to the
vision, and hearing services. Cost sharing
requirements and premiums are income-related
N
Medicaid expansion. It allows states to devise
alternative ways of subsidizing and regulating
A
and free for those below 150% of the poverty coverage. States can use the grants “to expand
level. Provider payment rates are the same their Medicaid programs …, establish high-risk
M
irrespective of the source of patient insurance pools, provide premium and cost-sharing
coverage, and are based on current Medicare assistance to insurance enrollees, make direct
fee levels. Government would negotiate payments to insurers, and pay health care
D
Example: Proposal by Senator and 2016 Various modifications to U.S. laws regarding
A
13
the age of 65; and (e) allowing HSA funds to
be used for medical expenses incurred up to 60
days before establishment of the HSA. 30
PT
RI
SC
U
N
A
M
D
TE
EP
CC
A
14
References
1
Congressional Budget Office. H.R. 1628, American Health Care Act of 2017. 24 May 2017.
https://www.cbo.gov/publication/52752 [Accessed 4 November 2017]
2
Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human
Services. Overview of the uninsured in the United States: A summary of the 2011 Current
Population Survey. 13 September 2011.
PT
https://aspe.hhs.gov/basic-report/overview-uninsured-united-states-summary-2011-current-
population-survey [Accessed 4 November 2017]
3
Ibid.
RI
4
Kaiser Commission on Medicaid and the Uninsured. Medicaid: A primer. 2013.
SC
https://www.kff.org/medicaid/issue-brief/medicaid-a-primer/ [Accessed 4 November 2017]
5
Medicaid.gov: Program History
https://www.medicaid.gov/about-us/program-history/index.html. [Accessed 12 February 2018]
U
6
Kaiser Family Foundation. Medicaid income eligibility limits for adults as a percent of the
N
federal poverty level. 1 January 2017. https://www.kff.org/health-reform/state-
indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-
A
level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2
2asc%22%7D
M
spending and premium contributions among implementation of the Affordable Care Act. JAMA
Internal Medicine 2018;178(3):347-355.
TE
8
Vox.com. We asked 18 states if they’re expanding Medicaid now that Obamacare is here to
stay. 29 March 2017. https://www.vox.com/policy-and-politics/2017/3/29/15072636/medicaid-
EP
496-509.
10
Kaiser Family Foundation. Health coverage and care for immigrants. 11 July 2017.
A
https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-for-immigrants/
[Accessed 4 November 2017]
11
Jost, T. Mandate repeal provision ends health care calm. Health Affairs 2018;37(1):1-2.
12
Kaiser Family Foundation. Marketplace enrollment, 2014 - 2018.
15
https://www.kff.org/health-reform/state-indicator/marketplace-enrollment-2014-
2017/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2
2asc%22%7D [Accessed 2 March 2017]
13
Morning Consult. Higher demand seen for short-term insurance as ACA mandate set for
repeal. 21 December 2017.
https://morningconsult.com/2017/12/21/higher-demand-seen-for-short-term-insurance-as-aca-
mandate-set-for-repeal/ [Accessed13 February 2018]
PT
14
Vox.com. Trump’s executive order to undermine Obamacare, explained. 12 October 2017.
https://www.vox.com/policy-and-politics/2017/10/12/16458184/trump-obamacare-executive-
order-association-health-plans-short-term-insurance [Accessed 4 November 2017]
RI
15
CNN Money. Obamacare. 20 February 2018.
http://money.cnn.com/2018/02/20/news/economy/trump-obamacare-short-term-health-
SC
insurance/index.html [Accessed 2 March 2018]
16
Kaiser Family Foundation. Impact of cost sharing reductions on deductibles and out-of-pocket
limits. 22 March 2017. https://www.kff.org/health-reform/issue-brief/impact-of-cost-sharing-
U
reductions-on-deductibles-and-out-of-pocket-limits/ [Accessed 4 November 2017]
17 N
Kaiser Family Foundation. How the loss of cost-sharing subsidy payments is affecting 2018
premiums. 27 October 2017. https://www.kff.org/health-reform/issue-brief/how-the-loss-of-
A
cost-sharing-subsidy-payments-is-affecting-2018-premiums/ [Accessed 4 November 2017]
M
18
Covered California. Individual markets nationally face high premium increases in coming
years absent federal or state action, with wide variation among states. 8 March 2018.
http://hbex.coveredca.com/data-research/library/CoveredCA_High_Premium_Increases_3-8-
D
18.pdf
TE
19
National Conference of State Legislatures. Health insurance: Premiums and increases. 10
October 2017. http://www.ncsl.org/research/health/health-insurance-premiums.aspx [Accessed 4
November 2017]
EP
20
Kaiser Family Foundation. The effects of ending the Affordable Care Act’s cost-sharing
reduction payments. April 2017. http://files.kff.org/attachment/Issue-Brief-The-Effects-of-
CC
2017.
https://www.congress.gov/bill/115th-congress/house-bill/4695/text?format=txt Accessed 13
February 2018].
22
Centers for Medicare & Medicaid Services. Opportunities to promote work and community
engagement among Medicaid beneficiaries. 11 January 2018.
https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf [Accessed13
February 2018].
16
23
Kaiser Family Foundation. Medicaid and work requirements: New guidance, state waiver
details and key issues. 16 January 2018.
https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-
waiver-details-and-key-issues/ [Accessed 13February 2013]
24
Ibid.
25
Kaiser Family Foundation. Health Coverage of Immigrants.
https://www.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/ [Accessed 12
February 2018]
PT
26
Center for American Progress. Medicare Extra for All. 22 February 2018.
https://www.americanprogress.org/issues/healthcare/reports/2018/02/22/447095/medicare-extra-for-all/
[Accessed 2 March 2018]
RI
27
https://www.cassidy.senate.gov/imo/media/doc/LYN17709.pdf [Accessed 2 March 2018]
28
Antos, J, Capretta, J. The Graham-Cassidy plan: Sweeping changes in a compressed time frame. Health Affairs
Blog. 22 September 2017.
SC
https://www.healthaffairs.org/do/10.1377/hblog20170922.062134/full/ [Accessed 2 March 2018]
29
Medicare for All: Leaving No One Behind.
https://berniesanders.com/issues/medicare-for-all/ [Accessed 2 March 2018]
30
International Foundation on Employee Benefit Plans. Five proposed health savings account (HSA) changes. 22
U
August 2017.
https://blog.ifebp.org/index.php/five-proposed-health-savings-account-hsa-changes [Accessed 2 March
2018]
N
A
M
D
TE
EP
CC
A
17
A FIGURE 1
CC
EP
TE
D
M
18
A
N
U
SC
RI
PT