Chapter 1 Introduction The issue of patient dumping, which involves refusing or transferring patients to other facilities due to their inability to pay for medical services, has been a longstanding concern within the United States healthcare system (Coleman et al., 2021). This problem led President Harry Truman to enact the Hill-Burton Act in 1946 to improve hospitals by providing taxpayer funds for construction upgrades (HRSA, n.d.). In addition, the Act also mandated that eligible hospitals must provide free care to individuals who could not afford medical services as a condition for receiving financial resources (HRSA, n.d.). However, despite its noble intentions, the Hill-Burton Act encountered obstacles that ultimately rendered it ineffective due to legal loopholes (Kafayat, 2022). To address the ongoing issue of patient dumping, the Emergency Medical Treatment and Labor Act (EMTALA), commonly referred to as the anti-dumping law, was established by Congress in 1986 as a part of the Consolidated Omnibus Reconciliation Act (COBRA). EMTALA aims to ensure that patients receive proper screening, treatment, or transfer without being denied care based on their ability to pay. This law makes it illegal for hospitals to transfer patients with emergency medical conditions to other facilities if such a transfer would put their health at risk or if the hospital making the transfer cannot provide the necessary medical treatment. Moreover, EMTALA mandates that hospitals provide stabilization treatment to individuals with emergency medical conditions, regardless of their financial circumstances (Lulla & Svancarek, 2019). This legislation is a crucial safeguard, ensuring that patients needing urgent medical attention are not unfairly turned away or displaced solely due to their financial capabilities. Patient dumping has been a long-standing issue in the United States healthcare system, leading to the enactment of the Hill-Burton Act in 1946 (Kafayat, 2022). While the act aimed to improve hospitals and provide free care to individuals who couldn't afford medical services, legal loopholes rendered it ineffective (Kafayat, 2022). To address this issue, the Emergency Medical Treatment and Labor Act (EMTALA) was established in 1986 as part of COBRA. EMTALA makes it illegal for hospitals to transfer patients with emergency medical conditions based on their ability to pay and mandates that hospitals provide stabilization treatment regardless of financial circumstances. This legislation serves as a crucial safeguard, ensuring that patients in need of urgent medical attention are not turned away or displaced solely due to their financial capabilities (Lulla & Svancarek, 2019). Background of the Problem Implementing the Emergency Medical Treatment and Active Labor Act (EMTALA) has significantly reduced instances of patient dumping (Lulla & Svancarek, 2019). This act holds hospitals accountable for providing appropriate care to every patient, regardless of their financial situation (Lulla & Svancarek, 2019). Doing so ensures that no patient is turned away or transferred solely based on their inability to pay. EMTALA's effectiveness in addressing patient dumping can be attributed to its penalties on non-compliant hospitals. These penalties include fines and the exclusion of hospitals from participating in Medicare (Lulla & Svancarek, 2019). Such consequences strongly incentivize hospitals to adhere to the law and provide necessary care to all patients. The existence of a weak Patient Anti-Dumping law has resulted in adverse effects on the community and healthcare organizations (Budiman, 2020). This has led to an increase in the number of destitute individuals seeking healthcare, with many cases going unreported (Brenner et al., 2021; Budiman, 2020). The problem also affects the poor, underinsured, and undocumented immigrants who lack access to emergency healthcare. Healthcare providers are burdened with financial costs, ultimately inflating healthcare costs for patients without insurance or eligibility concerns. The study aims to analyze the effectiveness of the US Federal Emergency Medical Treatment and Labor Act (EMTALA), also known as the Anti-Dumping Law, in protecting patients and healthcare providers (Kafayat, 2022). Additionally, the study questions whether the current laws are merely for show and do not effectively address the underlying cause of the issue. The focus will be on the impact of the US taxpayer in providing emergency healthcare for the undocumented immigrant community. The consequences of this situation extend beyond the individuals in need of healthcare. Healthcare providers are burdened with the financial costs of providing care to these individuals, ultimately inflating healthcare costs for patients without insurance or eligibility concerns. The study by Kafayat (2022) seeks to analyze the effectiveness of the US Federal Emergency Medical Treatment and Labor Act (EMTALA), in protecting both patients and healthcare providers. The aim is to assess whether the current legislation adequately addresses the underlying cause of the issue or if it is merely symbolic without providing substantial protection or solutions. Additionally, Kafayat (2022) focuses on the impact of the US taxpayer in providing emergency healthcare for the undocumented immigrant community. With limited access to healthcare resources, this population often turns to emergency departments as their primary source of care. The burden of funding and managing the healthcare costs for these individuals falls partly on the US taxpayer. The study seeks to shed light on the implications of this situation and explore potential strategies to address the challenges faced by both the undocumented immigrant community, under documented and fully insured patients. Considering these ongoing challenges, Kafayat, (2022) highlights the adverse effects of a weak Patient Anti-Dumping law on the community and healthcare organizations. The author emphasizes that the lack of robust legislation has led to an increase in the number of destitute individuals who are denied necessary medical care or are improperly transferred to other facilities. This not only puts the health and well-being of these individuals at risk but also strains the resources of healthcare organizations that are already struggling to meet the needs of their patients. To address these challenges, policymakers and healthcare stakeholders must work towards strengthening and enforcing legislation related to patient dumping. This could include increasing fines and penalties for non-compliant hospitals, implementing stricter guidelines for patient screening and transfer, and providing additional financial support to hospitals with uncompensated care. Additionally, efforts should be made to improve access to healthcare for uninsured individuals, such as expanding Medicaid coverage or implementing alternative funding mechanisms to help alleviate the financial strain on hospitals (Kafayat, 2022). By ensuring that all patients have access to necessary care, regardless of their financial situation, we can work towards reducing instances of patient dumping and promoting equitable healthcare for all. The more significant problem of patient dumping this research intends to consider is the lack of access to healthcare for uninsured individuals. This issue contributes to the financial strain on hospitals and increases the likelihood of patient dumping. Problem Statement, Purpose of the Study, and Research Questions Problem Statement The persistence of patient dumping in the healthcare system is a significant problem, especially concerning undocumented immigrants and individuals with limited financial resources (Vimo, 2019). Undocumented individuals and those with limited financial means face barriers to accessing healthcare due to a lack of comprehensive data collection, deficiencies in existing anti-dumping laws, and limited healthcare insurance coverage options (Vimo, 2019; Kafayat, 2022). This persisting issue is further complicated by the increasing influx of undocumented immigrants into the United States and the uncertainty surrounding their eligibility for healthcare insurance (Vimo, 2019). The current healthcare insurance coverage primarily relies on Medicaid or Social Security for eligible documented immigrants, leaving undocumented individuals with limited or no coverage (Vimo, 2019). However, the available data on patient dumping and uninsured individuals seeking healthcare is limited and often influenced by political biases, making it challenging to accurately evaluate the extent of the problem (Coleman et al., 2021). This lack of comprehensive data collection and analysis impedes the development of effective solutions and policies to address patient dumping and ensure equitable access to healthcare for all individuals, regardless of their immigration status or financial resources (Kafayat, 2022; Brenner et al., 2021). However, the available data on patient dumping and uninsured individuals seeking healthcare is limited and often influenced by political biases, making it challenging to accurately evaluate the extent of the problem (Coleman et al., 2021). The problem is further exacerbated by the increasing influx of undocumented immigrants into the United States and the lack of clarity regarding their eligibility for healthcare insurance and who should bear the responsibility for their healthcare expenses (Vimo, 2019). According to Vimo (2019), current healthcare insurance coverage for immigrants primarily relies on Medicaid or Social Security for eligible documented immigrants, leaving undocumented individuals with limited or no healthcare insurance coverage. The available data on this issue is limited and often influenced by political biases, making it difficult to swiftly pinpoint correct data concerning the subject of undocumented individuals with limited or no healthcare insurance coverage (Budiman, 2020). The available data on the issue of patient dumping in the healthcare system is limited and often influenced by political biases, making it difficult to accurately gauge the effects of patient dumping and uninsured individuals seeking healthcare (Ghebreyesus, 2017). The lack of comprehensive data collection and analysis hinders the development of effective solutions and policies to address this problem. Moreover, the existing anti-dumping laws have loopholes and deficiencies in enforcement, making them ineffective in curbing the practice of patient dumping (Kafayat, 2022). Without counter legislation or new legislation that strengthens existing anti-dumping laws, patients and healthcare organizations will continue to experience the negative consequences of patient dumping (Vimo, 2019). Additionally, with the projected increase in the number of uninsured individuals, particularly among undocumented immigrants, there is a need to understand the implications of this trend for both individuals and healthcare organizations. Purpose of the Study This study aims to investigate the problem of patient dumping in the healthcare system, focusing on undocumented immigrants and individuals with limited financial resources. The study addresses the barriers these vulnerable populations face in accessing healthcare, including the lack of comprehensive data collection, deficiencies in existing anti-dumping laws, and limited healthcare insurance coverage options. By analyzing and evaluating the available data on patient dumping and uninsured individuals seeking healthcare, the study aims to develop effective solutions and policies that ensure equitable access to healthcare for all individuals, regardless of their immigration status or financial resources. Additionally, the study aims to understand the implications of the increasing influx of undocumented immigrants and the uncertainty surrounding their eligibility for healthcare insurance for both individuals and healthcare organizations. Coleman et al., (2021) argues that health is a fundamental human right, highlighting the importance of investigating the problem of patient dumping in the healthcare system. This study will address the barriers undocumented immigrants and individuals with limited financial resources face in accessing healthcare, including deficiencies in existing anti-dumping laws and limited healthcare insurance coverage options. The lack of comprehensive data collection on patient dumping and uninsured individuals seeking healthcare is an additional barrier that this study seeks to analyze and evaluate. By doing so, the study aims to develop effective solutions and policies that ensure equitable access to healthcare for all individuals, regardless of their immigration status or financial resources. To reach the goals of analyzing and evaluating the lack of comprehensive data collection on patient dumping and uninsured individuals seeking healthcare and developing practical solutions and policies for reasonable access to healthcare, research will follow these steps: 1. Conduct a literature review: Gather existing research, studies, and reports on patient dumping and uninsured individuals seeking healthcare. This review will help identify any gaps in knowledge and existing policies. 2. Identify key stakeholders: Determine the relevant stakeholders who can provide valuable insights into the issue, such as healthcare providers, government agencies, advocacy groups, and affected individuals. Establish relationships and collaborations with these stakeholders to understand their perspectives and gather data. 3. Design research methods: Choose appropriate research methods to collect data on patient dumping and uninsured individuals seeking healthcare. This could involve surveys, interviews, focus groups, or analysis of existing databases or records. Ensure that the data collected is reliable and representative of the population of interest. 4. Analyze and evaluate data: Thoroughly analyze the collected data to identify patterns, trends, and gaps in the healthcare system regarding patient dumping and uninsured individuals. Evaluate these barriers' impact on equitable healthcare access for individuals with varied immigration status or financial resources. 5. Identify effective solutions and policies: Based on the analysis, propose potential solutions and policies In addition, the research effort's objective is to grasp the consequences of the growing number of undocumented immigrants and the uncertain status of their healthcare insurance eligibility. This comprehension is essential for individuals and healthcare institutions to effectively manage the challenges associated with delivering healthcare services to this particular group (Kafayat, 2022). Patient dumping, defined as the practice of hospitals transferring or refusing to treat patients based on their inability to pay or immigration status, is a significant problem within the healthcare system (Vimo, 2019). This issue disproportionately affects undocumented immigrants and individuals with limited financial resources, who often face numerous barriers to accessing healthcare services. One of the barriers these vulnerable populations face is the lack of comprehensive data collection on patient dumping and uninsured individuals seeking healthcare. According to Vimo (2019), one of the barriers faced by vulnerable populations, including the uninsured, in accessing healthcare is the lack of comprehensive data collection on patient dumping and uninsured individuals seeking healthcare. The lack of data collection serves as a barrier for the uninsured as it limits the understanding and awareness of healthcare providers, policymakers, and organizations regarding the extent of patient dumping and the specific healthcare needs of the uninsured population. Without comprehensive data, it becomes difficult to identify patterns, provide appropriate resources, and implement effective policies to address the issue and ensure access to healthcare for the uninsured. The lack of data collection hinders the development of targeted interventions and solutions that could mitigate the barriers faced by the uninsured in seeking healthcare services. According to Vimo (2019), deficiencies in existing anti-dumping laws create a barrier for undocumented immigrants and individuals with limited financial resources. Although anti-dumping laws are designed to prevent patient dumping, they frequently lack specificity and enforcement mechanisms. While anti-dumping laws are in place to prohibit patient dumping, they often lack specificity and enforcement mechanisms. As a result, hospitals may exploit loopholes or engage in covert forms of patient dumping (Vimo, 2019). This study aims to analyze and evaluate existing anti-dumping laws to identify their shortcomings and propose potential amendments or new legislation to strengthen patient protection. Additionally, limited healthcare insurance coverage options further contribute to the problem of patient dumping. Many undocumented immigrants and individuals with limited financial resources do not have access to comprehensive healthcare insurance, leaving them vulnerable to being turned away or transferred to other facilities. In the broader context of patient dumping, one feasible study area that can help address the problem is to investigate the current healthcare insurance coverage options available to populations affected by patient dumping, such as undocumented immigrants and individuals with limited financial resources. This study would assess the viability and effectiveness of implementing state-funded or community-based insurance programs specifically designed for these populations. By examining the existing healthcare insurance coverage options for undocumented immigrants and individuals with limited financial resources, researchers can identify the gaps and limitations of the current system. This would involve studying available insurance plans' eligibility criteria, coverage adequacy, and affordability. Additionally, analyzing the challenges these populations face in obtaining insurance coverage, such as bureaucratic barriers or lack of awareness, would provide insights into the specific obstacles that must be addressed. The study can also explore innovative solutions to expand access to insurance coverage for these vulnerable populations. This could involve proposing and evaluating the feasibility of state-funded or community-based insurance programs that cater to the needs of undocumented immigrants and individuals with limited financial resources. Assessing the potential impact, cost-effectiveness, and sustainability of such programs would be key components of the study. Overall, this study area would contribute to addressing the larger problem of patient dumping by focusing on the underlying issue of healthcare insurance coverage for vulnerable populations. By proposing innovative solutions and evaluating their feasibility, this research can provide valuable insights and recommendations for policymakers and healthcare providers to ensure equitable access to healthcare for all individuals, regardless of their immigration status or financial resources. Qualitative Research Questions 1. How do barriers to accessing healthcare, such as limited financial resources and lack of comprehensive data collection, impact the experiences of undocumented immigrants seeking healthcare services? 2. What are the fundamental deficiencies and enforcement loopholes in existing anti-dumping laws that contribute to the persistence of patient dumping in the healthcare system? 3. How do biases and limitations in data collection hinder the accurate evaluation of the extent and effects of patient dumping and uninsured individuals seeking healthcare? 4. What are the experiences and challenges healthcare organizations face in providing equitable access to healthcare for undocumented immigrants and individuals with limited financial resources? 5. How do healthcare professionals navigate and mitigate the impact of obstacles and limitations in data collection when evaluating the extent and effects of patient dumping and uninsured individuals seeking healthcare? Population and Sample This researcher aims to address the problem of patient dumping in the United States healthcare system, specifically focusing on undocumented immigrants and individuals with limited financial resources (Budiman, 2020). The researcher highlights the barriers these vulnerable populations face in accessing healthcare, including the lack of comprehensive data collection, existing anti-dumping laws, and limited healthcare insurance coverage options. The study investigates the effectiveness of the Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the Anti-Dumping Law, in protecting patients and healthcare providers (Lulla & Svancarek, 2019). The study will focus on undocumented immigrants and individuals with limited financial resources who face barriers to accessing healthcare in the United States (Budiman, 2020). These populations are vulnerable due to their legal status and financial constraints, which limit their ability to afford healthcare services and access comprehensive data. In order to gather data for this study, a qualitative research design will be employed to gain an in-depth understanding of the experiences and challenges the target populations face. The sampling type will be purposeful, explicitly using a criterion sampling approach. This means that participants will be selected based on specific criteria, such as individuals from advocacy organizations who work closely with undocumented immigrants and who have knowledge of their limited financial resources. Given the sensitive nature of the research topic and the potential challenges in accessing and recruiting participants, a relatively small sample size of 10-15 participants will be utilized. This smaller sample size will allow for a more in-depth analysis of individual experiences and perspectives, providing rich data for the study. The primary data for this study will be collected through interviews or focus groups with the selected participants. These interviews will explore the barriers they face in accessing healthcare and their experiences with patient dumping. Supplementary data sources, such as literature on patient dumping and the Anti-Dumping Law, will provide a broader context and support the findings. The research will take place in geographic locations in the Southwest US. By targeting this population and sample, the study can benefit the organization or institution and the broader healthcare system. Identifying the value of the study can help healthcare organizations and policymakers recognize the importance of addressing patient dumping and providing equitable access to healthcare. Significance of the Study The significance of this study lies in its examination of the persistent problem of patient dumping in the American healthcare system, specifically concerning undocumented immigrants and individuals with limited financial resources. Despite the implementation of anti-dumping laws such as the Emergency Medical Treatment and Labor Act (EMTALA), patient dumping continues to be a pressing issue (Kafayat, 2022). The value of this study lies in its ability to aid healthcare organizations and policymakers in recognizing the importance of addressing patient dumping and ensuring equitable access to healthcare. By measuring and improving the outcomes of this study, evidence-based interventions and policies can be developed to effectively prevent patient dumping and ensure that all patients receive appropriate care. Patient dumping, which involves the involuntary transfer of vulnerable patients to other healthcare facilities or discharging them prematurely due to their inability to pay, poses significant ethical concerns and challenges in providing emergency care to undocumented immigrants (Brenner et al., 2021). The American healthcare system has implemented laws to address this issue, such as EMTALA, which requires hospitals to provide emergency medical treatment regardless of a patient's ability to pay. However, patient dumping remains an ongoing problem, with undocumented immigrants and those with limited financial resources disproportionately affected (Kafayat, 2022). Moreover, eliminating unintended consequences, such as the financial burden on hospitals providing uncompensated care, can promote financial stability for healthcare organizations. This can be achieved by exploring alternative funding mechanisms or expanding insurance coverage options for vulnerable populations. Finally, recommending potential study modifications can provide healthcare organizations and policymakers with actionable recommendations to strengthen existing anti-dumping laws, improve data collection on patient dumping, and expand access to healthcare services for undocumented immigrants and individuals with limited financial resources. In conclusion, this dissertation on patient dumping in the United States healthcare system, with a focus on undocumented immigrants and individuals with limited financial resources, has the potential to contribute to the field by addressing a long-standing issue. Targeting the population and sample, identifying the value of the study, measuring or improving study outcomes, eliminating unintended consequences, and recommending potential study modifications can all benefit healthcare organizations and policymakers. By addressing the barriers and challenges vulnerable populations face in accessing healthcare, the study can help pave the way for more equitable and inclusive healthcare systems. The potential benefits of identifying the value of this program of study include: 1. Improved patient care: By identifying gaps in the existing healthcare system and anti-dumping laws, this study can contribute to developing policies and interventions that enhance patient care and ensure that all individuals receive the necessary medical treatment, regardless of their ability to pay or immigration status. 2. Enhanced healthcare access for vulnerable populations: By evaluating existing healthcare insurance coverage options, this study proposes innovative solutions to expand access to healthcare for undocumented immigrants and individuals with limited financial resources. This could include advocating for establishing state-funded or community-based insurance programs specifically designed to meet the needs of these populations. 3. Strengthened anti-dumping laws: Analyzing existing anti-dumping laws and their enforcement will provide insights into the deficiencies and loopholes currently existing within these laws. This study can recommend potential modifications to strengthen patient protection and hold hospitals accountable for providing appropriate care to all individuals, regardless of their ability to pay or immigration status. 4. Identification of unintended consequences: By examining the impact of patient dumping on healthcare organizations and the financial burden imposed by providing uncompensated care to uninsured individuals, this study can shed light on the unintended consequences of the existing system. This understanding can inform policymakers and healthcare stakeholders about the potential collateral effects of patient dumping and the need for additional support and resources to mitigate these consequences. 5. Financial relief for healthcare organizations: By proposing alternative funding mechanisms or expanding Medicaid coverage, this study aims to help healthcare organizations understand their financial burden and options available in providing uncompensated care to uninsured individuals. This can contribute to the financial stability of healthcare organizations and reduce the strain on their resources, ultimately leading to more sustainable healthcare practices. In conclusion, this study on the problem of patient dumping in the healthcare system, specifically focusing on undocumented immigrants and individuals with limited financial resources, holds significant value in improving patient care and healthcare access for vulnerable populations (Vimo, 2019). By identifying shortcomings in existing anti-dumping laws, this study can enhance the overall healthcare administration system and promote better access to healthcare for all individuals. Nature of the Study Synopsis This qualitative study aims to investigate the problem of patient dumping in the United States healthcare system, with a specific focus on undocumented immigrants and individuals with limited financial resources. The study aims to understand the barriers these populations face in accessing healthcare, including limited financial resources, lack of comprehensive data collection, deficiencies in existing anti-dumping laws, and limited healthcare insurance coverage options. By analyzing and evaluating the available data on patient dumping and uninsured individuals seeking healthcare, the study aims to develop effective solutions and policies that ensure equitable access to healthcare for all individuals, regardless of their immigration status or financial resources. The study also aims to explore the experiences and challenges healthcare organizations and professionals face in providing equitable access to healthcare for these populations. The study will contribute to the existing literature on patient dumping and provide evidence-based interventions and policies to address this issue. Justification of the Research Qualitative Method and Design A qualitative research method is appropriate for this study as it aims to explore the experiences, perspectives, and challenges faced by undocumented immigrants and individuals with limited financial resources in accessing healthcare. This method gives an in-depth understanding of the complex factors and barriers contributing to patient dumping. Using qualitative interviews, the study can capture the subjective experiences of individuals and healthcare professionals, providing rich and detailed insights into their perspectives. Qualitative methods also allow for flexibility and the ability to adapt the research approach based on emerging themes and concepts that emerge during the data collection process. The study will utilize semi-structured interviews with undocumented immigrants, individuals with limited financial resources, and healthcare professionals. This approach will enable the researchers to gather in-depth narratives and personal experiences related to patient dumping and healthcare access. The interviews will be audio-recorded and transcribed for analysis. The research design will follow an interpretive phenomenological approach, which focuses on understanding the subjective experiences and meanings individuals attach to their experiences. This design is appropriate for exploring the lived experiences of undocumented immigrants and individuals with limited financial resources, as it allows for a deep exploration of their perspectives and the contextual factors that influence their access to healthcare. The qualitative method and design align with the research problem, purpose, and research questions as they aim to explore the experiences, barriers, and challenges these populations face in accessing healthcare. This approach will provide valuable insights into the extent and effects of patient dumping and inform the development of policies and interventions to address this issue and ensure equitable access to healthcare for all individuals. References Budiman, A. (2020, August 20). Key findings about U.S. immigrants. Pew Research Center; Pew Research Center. https://www.pewresearch.org/short-reads/2020/08/20/key-findings-about-u-s-immigrants/ Brenner, J. M., Blutinger, E., Ricke, B., Vearrier, L., Kluesner, N. H., & Moskop, J. C. (2021). Ethical issues in the access to emergency care for undocumented immigrants. Journal of the American College of Emergency Physicians Open, 2(3), 1–8. https://doi.org/10.1002/emp2.12461 Coleman, E., Corona, E., & Ford, J. V. (2021). Advancing Sexual Pleasure as a Fundamental Human Right and Essential for Sexual Health, Overall Health and Well-Being: An Introduction to the Special Issue on Sexual Pleasure. International Journal of Sexual Health, 1–5. https://doi.org/10.1080/19317611.2021.2015507 HRSA. (n.d.). The Hill-Burton Program. U.S. Department of Health and Human Services. https://www.hrsa.gov/get-health-care/affordable/hill-burton/index.html Kafayat, I. (2022). How Covid-19 Put the Spotlight on the Emtala. Touro Law Review, 38(1), 357–382. Lulla, A., & Svancarek, B. (2019, March 14). EMS, Emergency Medical Treatment and Active Labor Act, USA. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539798/ Vimo, J. (2019). All (immigration) politics is local: Immigration politics in US cities from Hazleton to San Francisco. Migration Studies. https://www.academia.edu/51998946/All_immigration_politics_is_local_Immigration_politics_in_US_cities_from_Hazleton_to_San_Francisco Brenner, J. M., Blutinger, E., Ricke, B., Vearrier, L., Kluesner, N. H., & Moskop, J. C. (2021). Ethical issues in the access to emergency care for undocumented immigrants. Journal of the American College of Emergency Physicians Open, 2(3), 1–8. https://doi.org/10.1002/emp2.12461
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