Health insurance mandate

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A health insurance mandate is either an employer or individual mandate to obtain private health insurance instead of (or in addition to) a national health insurance plan.[1]

Australia[edit]

Australia's national health insurance program is known as Medicare, and is financed by general taxation including a Medicare levy on earnings; use of Medicare is not compulsory and those who purchase private health insurance get a government-funded rebate on premiums.[2] Individuals with high annual incomes (A$70,000 in the 2008 federal budget) who do not have specified levels of private hospital coverage are subject to an additional 1% Medicare Levy Surcharge.[3] People of average incomes and below may be eligible for subsidies to buy private insurance, but face no penalty for not buying it.[4] Private insurers must comply with guaranteed issue and community rating requirements, but may limit coverage of pre-existing ailments for up to one year to discourage adverse selection.

Japan[edit]

Japan has a universal health care system that mandates all residents have health insurance, either at work or through a local community-based insurer, but does not impose penalties on individuals for not having insurance.[5] The Japanese health ministry "tightly controls the price of health care down to the smallest detail. Every two years, the doctors and the health ministry negotiate a fixed price for every procedure and every drug. That helps keep premiums to around $280 a month for the average Japanese family."[6] Insurance premiums are set by the government, with guaranteed issue and community rating.[7] Insurers are not allowed to deny claims or coverage, or to make profits (net revenue is carried over to the next year, and if the carryover is large, the premium goes down).[6] Around 10% evade the compulsory insurance premium; municipal governments do not issue them insurance cards, which providers require.[5] Voluntary private insurance is available through several sources including employers and unions to cover expenditures not covered by statutory insurance, but this accounts for only about 2% of health care spending.[5] In practice, doctors will not deny care to patients in the low-priced universal system because they make up the great majority of patients nationwide, and doctors would not be able to earn enough by serving only the small number of patients with private insurance.[8][9] Total spending is around half the American level, and taxpayers subsidize the poor.[6]

The Netherlands[edit]

The Netherlands has a health insurance mandate[10] and allows for-profit companies to compete for minimum coverage insurance plans, though there are also mutual insurers so use of a commercial for-profit insurer is not compulsory. The government regulates the insurers and operates a risk equalization mechanism to subsidize insurers that insure relatively more expensive customers. Several features hold down the level of premiums which facilitate public compliance with the mandate. The cost of health care in the Netherlands is higher than the European average but is less than in the United States. Half of the cost of insurance for adults is paid for by an income-related tax with which goes towards a subsidy of private insurance via the risk reinsurance pool operated by the regulator. The government pays the entire cost for children. Forty percent of the population is eligible for a premium subsidy. About 1.5 percent of the legal population is estimated to be uninsured. The architects of the Dutch mandate did not envision any problem with non-compliance, the initial legislation created few effective sanctions if a person does not take out insurance or pay premiums, and the government is currently developing enforcement mechanisms.[11]

Switzerland[edit]

Switzerland's system is similar to that of the Netherlands with regulated private insurance companies competing to provide the minimum necessary coverage to meet its mandate. Premiums are not linked to incomes, but the government provides subsidies to lower-class individuals to help them pay for their plans. About 40% of households received some kind of subsidy in 2004. Individuals are free to spend as much as they want for their plans and buy additional health services if desired. The system has virtual universal coverage, with about 99% of people having insurance. The laws behind the system were created in 1996.[12] A recent issue in the country is their rising health care costs, which are higher than European averages. However, those rising costs are still a little less than the increases in the United States.[12]

United States[edit]

History[edit]

An individual mandate to purchase healthcare was initially proposed by the politically conservative Heritage Foundation in 1989 as an alternative to single-payer health care.[13][14][15][16][17] Stuart Butler, an early supporter of the individual mandate at the Heritage Foundation, wrote:

If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate, but society feels no obligation to repair his car. But health care is different. If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance.[18]

The Heritage Foundation changed its position in 2011, calling the individual mandate unconstitutional.[19]

From its inception, the idea of an individual mandate was championed by Republican politicians as a free-market approach to health care reform.[18][20] Supporters included Charles Grassley, Mitt Romney, and the late John Chafee.[21] The individual mandate was felt to resonate with conservative principles of individual responsibility, and conservative groups recognized that the healthcare market was unique.

In 1993, President Bill Clinton proposed a health care reform bill which included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations and an individual mandate.[22][23] However, the Clinton plan failed amid concerns that it was overly complex or unrealistic, and in the face of an unprecedented barrage of negative advertising funded by politically conservative groups and the health insurance industry.[24] At the time, Republican Senators proposed a bill that would have required individuals, and not employers, to buy insurance, as an alternative to Clinton's plan.[18]

Hillary Clinton's plan in 2008 also included an individual mandate.[25]

Massachusetts[edit]

An individual health-insurance mandate was initially enacted on a state level: the 2005 Massachusetts health care reform law. In 2006, Republican Mitt Romney, then governor of Massachusetts, signed an individual mandate into law with strong bipartisan support. In 2007, a Senate bill featuring a federal mandate, authored by Bob Bennett (R-UT) and Ron Wyden (D-OR), attracted substantial bipartisan support.[20][26]

Before the law was passed, per capita health care costs in Massachusetts were the highest for any part of the country except D.C. From 2003 to 2008 (three years prior and two years after enactment) Massachusetts insurance premiums continued to outpace the rest of United States, however the rate of growth year to year for Massachusetts has slowed as a result of the law.[27]

Other states provide community rating and guaranteed issue without mandates.[28][29][30][31][32][33][34]

Affordable Care Act[edit]

Romney's success in installing an individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 Presidential campaign, Sen. Jim DeMint (R-SC) praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured." Romney himself said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."[26] In the 2008 Presidential campaign Senator Barack Obama campaigned against an individual mandate.[35] Obama attacked Hillary Clinton and John Edwards for their support of the individual mandate during primary debates and in television ads.[36]

However, following the adoption of an individual mandate as a central component of President Obama's Patient Protection and Affordable Care Act in 2009, Republicans began to oppose the mandate. In 2009, every Republican Senator (including Bennett, who had co-written the 2007 bill featuring a mandate) voted to describe the mandate as "unconstitutional". (Explaining his opposition, Bennett later said: "I didn't focus on the particulars of the amendment as closely as I should have, and probably would have voted the other way if I had understood that the individual mandate was at its core. I just wanted to express my opposition to the Obama proposal at every opportunity.")[20] The New York Times wrote: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's health care law requiring all Americans to buy health insurance has its roots in conservative thinking."[18]

Other Republican politicians who had previously supported individual mandates, including Romney and Orrin Hatch, similarly emerged as vocal critics of the mandate in Obama's legislation.[20][26] Writing in The New Yorker, Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."[20]

The Affordable Care Act signed in 2010 by Obama included an individual mandate to take effect in 2014.[37]

On August 30, 2013, final regulations for the individual mandate were published in the Federal Register (78 FR 53646),[38] with minor corrections published December 26, 2013 (78 FR 78256).[39]

Constitutional challenges[edit]

The ACA mandate was challenged in federal courts by Republican state Attorneys General. On June 28, 2012, the U.S. Supreme Court upheld the provision as Constitutional.[40] Chief Justice John Roberts delivered the majority opinion in National Federation of Independent Business v. Sebelius, which upheld the Patient Protection and Affordable Care Act by a 5-4 vote. The Court ruled that although the "individual mandate" component of the act was not constitutional under the Commerce Clause, it was reasonably construed as a tax and was therefore valid under the Congressional authority to "lay and collect taxes."[41][42]

There was also disagreement as to whether federal mandates could be constitutional.[43] In 2010, a majority of the 50 states filed litigation contending that the individual mandate was unconstitutional,[44] and newly elected Republican governors campaigned promising to add their states to the list in 2011. The federal district courts initially split on the constitutionality issue, which ultimately was expected to reach the Supreme Court;[45][46] also, state legislative actions may at least cause delay.[47][48][49] The Militia Acts of 1792, based on the Constitution's militia clause (in addition to its affirmative authorization to raise an army and a navy), would have required every "free able-bodied white male citizen" between the ages of 18 and 45, with a few occupational exceptions, to "provide himself" a weapon and ammunition;[50] however, it was never enforced so its constitutionality was never litigated.[51] In 1994, the Congressional Budget Office issued a report describing an individual mandate as "an unprecedented form of federal action." The agency also wrote, "The government has never required people to buy any good or service as a condition of lawful residence in the United States."[52]

In a September 2010 working paper,[53] a forthcoming article in the NYU Journal of Law and Liberty, and a lecture given at NYU, Randy Barnett of Georgetown University Law Center argues that the mandate is unconstitutional under the doctrine of the Commerce and Necessary and Proper Clauses, and that enforcing it is equivalent to "commandeering the people." Penalizing inaction, he argues, is only defensible when a fundamental duty of a person has been established. He also asserted that Congress fails to enforce the mandate under its taxing power because the penalty is not revenue-generating according to the Act itself.

The U.S. Supreme Court decision upholding the individual mandate was rendered in June 2012, in the case of National Federation of Independent Business v. Sebelius.

Criticism of individual mandate[edit]

Insurance lobbyists (AHIP) in the United States advocate that the mandate is necessary to support guaranteed issue and community rating, which limit underwriting by insurers; insurers propose that the mandate is intended to prevent adverse selection by ensuring healthy individuals purchase insurance and thus broaden the risk pool.[54][55] The mandate has been considered at the heart of health care reform proposals in the United States[56] and "absolutely necessary" pre-condition to universal health care, since any non-compulsory reform would fail to expand coverage.[56][57][58][59] A 2008 AHIP/Kaiser forum cited Dutch and Swiss mandates (see below); AHIP's published report does not mention penalties but says Switzerland "enforces the rules in many ways..."[60] In October 2009, Kaiser Health News reported that "The insurance industry is clearly worried about the mandate being defanged."[61]

Some studies of empirical evidence suggest that the threat of adverse selection is exaggerated,[62] and that risk aversion and propitious selection may balance it.[63] For example, several US states have guaranteed issue[64] and limits on rating,[65] but only Massachusetts has an individual mandate; similarly, although Japan has a nominal mandate, around 10% of individuals do not comply, and there is no penalty (they simply remain uninsured - see below). Without mandates, for-profit insurers have necessarily relied on risk aversion to charge premiums over expected risks, but have been constrained by what customers are willing to pay; mandates eliminate that constraint, allowing insurers to charge more.[66] Governments that impose a mandate must subsidize those who cannot afford it, thus shifting the cost onto taxpayers.[67][68][69]

The insurance mandate faced opposition across the political spectrum, from left-leaning groups such as the Green Party and other advocates of single-payer healthcare to right-leaning groups such as the Heritage Foundation, FreedomWorks, and the Cato Institute as well as some members of the U.S. Senate and House of Representatives.[21][70]

Opponents such as Michael Cannon, Director of Health Policy Studies at the Cato Institute, make a philosophical argument that people should have the right to live without government social interference as a matter of individual liberty. He has stated that federal, state, and local governments are not willing or able to raise the necessary funds to effectively subsidize people who cannot currently afford insurance. He has also stated that the costs of increasing coverage are far higher than other reforms, such as reducing the amount of errors and accidents in treatment, which would accomplish as much or more benefit to society.[56]

Public opinion polls from 2009 through 2012 continued to find that most Americans rejected penalizing people for not buying health insurance.[71][72][73][74]

Employer mandates[edit]

In the United States, the Patient Protection and Affordable Care Act (PPACA) includes both employer and individual mandates that take effect in 2014. The PPACA's employer mandate requires that all businesses with 50 or more full-time employees provide minimum affordable health insurance to at least 95% of their full-time employees and dependents up to age 26, or pay a fee by 2016. In the two largest EU countries, France and Germany, Statutory Health Insurance (SHI) mandates employers and employees pay into statutory sickness funds. In France, private health insurance (PHI) is voluntary and used to increase the reimbursement rate from the statutory sickness system. The same applies in Germany where it is also possible to opt out of SHI if you are a very high earner and into a PHI but if a person has reached the age of 55 and is in the PHI sector he or she must remain covered by PHI and cannot opt back into SHI. Persons who are unemployed can usually continue their payments through social insurance and the very poor receive support from the government to be insured. Most workers are insured through compulsory membership of "sickness funds" that are non-profit entities established originally by trades unions and now given statutory status. In Germany and France, as is the case with most European health care finance, the personal contribution to health care financing varies according to a person's income level and not according to their health status. Only 0.2% of Germans are uninsured, mainly self-employed, rich and poor, and persons who have failed to pay contributions to the statutory insurance or premiums to the private health insurance. Between 1990 and 2000 the share of French SHI income coming directly from employees via salaries fell from around 30% to just 3% and employer direct contributions also fell. The difference was made up by a rise in income from government taxation, thus widening the mandatory contribution base to the health insurance system.[75][76]

See also[edit]

References[edit]

  1. ^ D. Andrew Austin, Thomas L. Hungerford (2010). Market Structure of the Health Insurance Industry Congressional Research Service. Library of Congress.
  2. ^ http://www.euro.who.int/__data/assets/pdf_file/0007/96433/E89731.pdf
  3. ^ "Medicare Levy Surcharge". PrivateHealth.gov.au. 2000-05-24. Retrieved 2012-03-29. 
  4. ^ "Department of Health and Ageing - Private health insurance - glossary of commonly used terms". Health.gov.au. 2011-01-07. Retrieved 2012-03-29. 
  5. ^ a b c http://www.euro.who.int/__data/assets/pdf_file/0011/85466/E92927.pdf
  6. ^ a b c T.R. Reid (April 14, 2008). "Japanese Pay Less for More Health Care" Morning Edition (NPR). Accessed August 13, 2011.
  7. ^ http://unpan1.un.org/intradoc/groups/public/documents/APCITY/UNPAN020063.pdf
  8. ^ "Sick Around The World". FRONTLINE. PBS. 2008-04-15. Retrieved 2012-03-29. 
  9. ^ "Sick around the world". Frontline. April 15, 2008. 17 minutes in. PBS. 
  10. ^ Robert E. Leu, Frans F. H. Rutten, Werner Brouwer, Pius Matter, and Christian Rütschi (January 2009). The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated Competitive Insurance Markets The Commonwealth Fund Accessed August 14, 2011.
  11. ^ Administering Health Insurance Mandates, Steuerle, C E and Van de Water, Paul N. National Academy of Social Insurance
  12. ^ a b Underwood, Anne (September 18, 2009). "Health Care Abroad: Switzerland". The New York Times. 
  13. ^ Ezra Klein (25 April 2011). "Obama revealed: A moderate Republican". Washington Post. 
  14. ^ James Taranto (19 October 2011). "ObamaCare's Heritage". WSJ. 
  15. ^ "Ezra Klein - An interview with Mark Pauly, father of the individual mandate". washingtonpost.com. 
  16. ^ "Laying the Groundwork for Universal Health Care Coverage". The Heritage Foundation. 
  17. ^ "Was the Individual Mandate a "Republican Idea"? - The Volokh Conspiracy". The Volokh Conspiracy. 
  18. ^ a b c d Cooper, Michael (February 14, 2012). "Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later". New York Times. Retrieved July 2, 2012. 
  19. ^ Louis, Patrick. "Individual Mandate Unconstitutional, Unenforceable". Heritage.org. Retrieved 2012-03-29. 
  20. ^ a b c d e Klein, Ezra (June 25, 2012). "Unpopular Mandate". The New Yorker. Retrieved June 19, 2012. 
  21. ^ a b Murphy, Patricia (August 24, 2009). "Individual Mandate Flies Under the Radar". Politics Daily. Retrieved September 4, 2009. 
  22. ^ "CBO | The Budgetary Treatment of an Individual Mandate to Buy Health Insurance" (PDF). Cbo.gov. 1994-08-01. Retrieved 2012-03-29. 
  23. ^ Smith, Ben (2010-03-23). "Obamacare vs. Clintoncare - Ben Smith". Politico.Com. Retrieved 2012-03-29. 
  24. ^ Cohn, Bob; Eleanor Clift (September 18, 1994). "The Lost Chance". Newsweek. Retrieved July 2, 2012. 
  25. ^ "Hillary Clinton: Excerpts of Remarks on Health Care". Presidency.ucsb.edu. 2007-11-28. Retrieved 2012-03-29. 
  26. ^ a b c Lizza, Ryan (June 6, 2011). "Romney's dilemma". The New Yorker. Retrieved June 19, 2012. 
  27. ^ "Health expenditures by state of residence: Summary Tables, 1991-2009" (PDF). cms.gov. Retrieved 28 March 2012. 
  28. ^ Government Accounting Office (September 30, 2003). "Private health insurance: Federal and state requirements affecting coverage offered by small businesses" (PDF). Government Accounting Office. pp. 41–43. 
  29. ^ Georgetown Health Policy Institute (February 2009). "Individual market rate restrictions (not applicable to HIPAA eligible individuals), December 2008". Kaiser Family Foundation. Archived from the original on 2011-07-28. 
  30. ^ Georgetown Health Policy Institute (February 2009). "Individual market guaranteed issue (not applicable to HIPAA eligible individuals), December 2008". Kaiser Family Foundation. Archived from the original on 2011-07-18. 
  31. ^ Georgetown Health Policy Institute (February 2009). "Small group health insurance market rate restrictions, January 2009". Kaiser Family Foundation. Archived from the original on 2011-07-28. 
  32. ^ Codispoti, Lisa; Courtot, Brigette; Swedish, Jen (September 2008). "Nowhere to turn: How the individual health insurance market fails women" (PDF). National Women's Law Center. Archived from the original (PDF) on 2010-01-06. 
  33. ^ Lazar, Kay (April 26, 2009). "Prickly policies; Age-based pricing for health insurance has some consumers cutting back on coverage". The Boston Globe. p. 1 (Business). 
  34. ^ Appleby, Julie (August 31, 2009). "Health insurance: How much more should older people pay?". Kaiser Health News. 
  35. ^ Drobnic Holan, Angie (20 July 2009). "Obama flip-flops on requiring people to buy health care". Politifact. Retrieved 17 April 2016. 
  36. ^ Cline, Andrew (29 June 2012). "How Obama Broke His Promise on Individual Mandates". The Atlantic. Retrieved 17 April 2016. 
  37. ^ See Internal Revenue Code section 5000A, 26 U.S.C. § 5000A.
  38. ^ "Individual Mandate Under ACA" (PDF). Congressional Research Service. March 6, 2014. 
  39. ^ Codified at 26 C.F.R. sections 1.5000A-0 through 1.5000A-5.
  40. ^ "Supreme Court Upholds The Health Care Law". MSNBC. 2012-06-28. Archived from the original on 2012-06-29. Retrieved 2012-06-28. 
  41. ^ Haberkorn, Jennifer (2012-06-28). "Health care ruling: Individual mandate upheld by Supreme Court". Politico. Retrieved 28 June 2012. 
  42. ^ Cushman, John (2012-06-28). "Supreme Court Lets Health Law Largely Stand". New York Times. Retrieved 28 June 2012. 
  43. ^ Seelye, Katharine Q. (September 26, 2009). "A Constitutional Debate Over a Health Care Mandate". The New York Times. Retrieved May 4, 2010. 
  44. ^ "Wisconsin to join U.S. healthcare lawsuit, says Walker". Westlawnews.thomson.com. Retrieved 2012-03-29. 
  45. ^ "Court rejects health mandate". StarTribune.com. Retrieved 2012-03-29. 
  46. ^ "Virginia judge rules health care mandate unconstitutional". CNN. December 13, 2010. 
  47. ^ Davey, Monica (September 29, 2009). "Health Care Overhaul and Mandatory Coverage Stir States' Rights Claims". The New York Times. Retrieved May 4, 2010. 
  48. ^ Fender, Jessica (December 30, 2009). "Efforts already underway in Colorado to blunt federal health care reforms". Denver Post. 
  49. ^ http://www.ksn.com/news/local/story/Kansas-one-of-37-states-challenging-federal/qUmTDv06EkSlykagQW2qKQ.cspx
  50. ^ Conason, Joe (2010-03-25). "So George Washington was a socialist, too! If the individual mandate is unconstitutional, how could our first president require every citizen to buy a gun?". Salon.com. Archived from the original on 2011-01-21. 
  51. ^ Yglesias, Matthew (2012-03-23). "Did the Militia Act of 1792 set a precedent for Obama's health insurance mandate?". Slate Magazine. Retrieved 2012-03-29. 
  52. ^ Seelye, Katharine Q. (September 27, 2009). "Court challenge seen in health insurance mandate". The San Francisco Chronicle. 
  53. ^ Barnett, Randy. "Commandeering the People: Why the Individual Health Insurance Mandate is Unconstitutional". ssrn.com. SSRN 1680392Freely accessible. 
  54. ^ "Transcript - Obama's Deal - FRONTLINE - PBS". pbs.org. 
  55. ^ "The Individual Mandate — An Affordable and Fair Approach to Achieving Universal Coverage". New England Journal of Medicine. 361: 6–7. doi:10.1056/NEJMp0904729. 
  56. ^ a b c "Ask the Experts: Individual Mandates" (PDF). Kaiser Family Foundation. January 31, 2008. Archived from the original (PDF) on October 6, 2009. 
  57. ^ Paul Krugman. "A Plan Set Up To Fail". Paul Krugman Blog. rather than simply have single-payer, you have to do three things. 1. Regulate insurers so they can’t refuse or charge high premiums to people with preexisting conditions. 2. Impose some penalty on people who don’t buy insurance, to induce healthy people to sign up and provide a workable risk pool. 3. Subsidize premiums so that lower-income households can afford insurance 
  58. ^ "There Will Be No Obamacare Replacement". Paul Krugman Blog. Retrieved 2017-03-29. 
  59. ^ "Health Care Politics In One Sentence". Paul Krugman Blog. Retrieved 2017-03-29. 
  60. ^ "America's Health Insurance Plans -". ahip.org. 
  61. ^ "Will Insurers Balk At Weakening of Individual Insurance Mandate?". Kaiser Health News. 2009-10-02. Retrieved 2012-03-29. 
  62. ^ "Adverse Selection in Insurance Markets: An Exaggerated Threat". The Yale Law Journal. Retrieved 2012-03-29. 
  63. ^ Grönqvist, Erik. "Does Adverse Selection Matter? Evidence from a Natural Experiment". repec.org. Retrieved 2012-03-29. 
  64. ^ "Individual Market Guaranteed Issue". Statehealthfacts.org. Kaiser. Archived from the original on 2012-04-26. Retrieved 2012-03-29. 
  65. ^ "Individual Market Rate Restrictions". Statehealthfacts.org. Kaiser. Archived from the original on 2012-05-06. Retrieved 2012-03-29. 
  66. ^ Cowen, Tyler (October 25, 2009). "How an Insurance Mandate Could Leave Many Worse Off". The New York Times. Retrieved May 4, 2010. 
  67. ^ http://www.ct.gov/sustinet/lib/sustinet/referencelibrary/sustinet_jama_re_cost_shifting_9-2-09.pdf
  68. ^ http://mdpolicy.org/policyblog/detail/a-bad-exchange
  69. ^ "5 painful health-care lessons from Massachusetts". cnn.com. 
  70. ^ "2009-09-14 The Green Party responds to Obama's speech: Mr. President, make health care a right for all Americans". GP.org. Archived from the original on 2012-01-20. Retrieved 2012-03-29. 
  71. ^ ABC News. "As Health Care Law's Trial Approaches, Two-Thirds Say Ditch Individual Mandate". ABC News. 
  72. ^ http://msnbcmedia.msn.com/i/msnbc/sections/news/090729_NBC-WSJ_poll.pdf
  73. ^ http://i2.cdn.turner.com/cnn/2011/images/06/09/healthcare.pdf
  74. ^ "U.S. Voters Back Public Insurance 2-1, But Won't Use It". Quinnipiac University. July 1, 2009. Retrieved September 4, 2009. 
  75. ^ http://www.euro.who.int/__data/assets/pdf_file/0018/80703/E85472.pdf
  76. ^ http://www.euro.who.int/__data/assets/pdf_file/0009/80694/E83126.pdf

External links[edit]