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The study of environmental https://arif.uk/buy-cialis-online/ determinants where can i get cialis of health is at a crossroads. Harmonised health data across cohorts followed over decades, novel technologies to gather information on health behaviours and location data, and high-resolution spatial data on environmental factors have made it possible for researchers to unearth insights and relationships never before possible. This special issue of Journal of Epidemiology and Community Health brings findings from collaborators in the MINDMAP Project, an ambitious effort to examine where can i get cialis the environmental determinants of mental health and well-being in older populations across Europe and Canada. The investigators involved in these studies have developed multiple high-resolution spatial datasets to examine a broad range of environmental factors, including area-level socioeconomic measures, crime, the built environment, green spaces and noise. In addition, the MINDMAP collaboration enables validated and harmonised measures of mental health and well-being, including loneliness, depressive symptoms, antidepressant use, anxiety, affect and mental distress.

But the true strength of the MINDMAP collaboration is the potential for innovation by applying diverse study designs, ranging where can i get cialis from mobile health approaches to agent-based modelling, to answer questions about how environmental factors drive healthy ageing. The findings presented unearth insights into potential environmental drivers of healthy ageing.Overview of MINDMAPWey et al provide an overview of the MINDMAP Project, which used longitudinal data from six cohort studies located in Eastern and Western Europe, as well as Canada, that comprised a total of 220â621 participants. Baseline years of these studies ranged from 1984 to 2012, with up to seven repeated data collection periods. Looking across these studies, the investigators harmonised data on 1848 environmental exposures and 993 where can i get cialis individual-level determinants and health outcomes. The domains covered by these rich harmonised data include physical environments, sociodemographic factors, health behaviours, disease status, medication use, cognitive functioning, psychological assessments and social networks.

The resulting harmonised multinational dataset was transparently documented and where can i get cialis stored on a central MINDMAP server for analysis.Introducing the complexity of ageing and well-being, Dapp et al capitalised on longitudinal MINDMAP data to examine the dynamics between depression, frailty and disability within an older cohort in Hamburg, Germany. The authors observed that depression increased the risk of subsequent frailty, and that frailty increased the risk of subsequent depression. Interestingly, the investigators saw that while depression increased the risk of subsequent disability, disability was not associated with higher risk of subsequent depression. Dapp et al provide novel perspectives into the processes between ageing, mental health and disability, and offer suggestions for increasing screening where can i get cialis for depressed mood and functional decline to produce timely and targeted interventions.The importance of theoryTheory may sharpen predictions about how urban environments influence mental well-being in old age. There is a lack of consensus on even basic descriptive questions such as whether the prevalence of depressive symptoms rises with advancing age, and therefore inconsistencies in the empirical literature can only be reconciled and understood with the aid of good theory.

In particular, multilevel studies of neighbourhood environments and mental health are often missing a third, higher, level of organisation, that is, the societal context in which people live their lives where can i get cialis. This is only made possible by careful cross-national comparisons of harmonised data.To give a detailed example of what can be learnt from cross-national comparisons, a recent study contrasted suicide rates in Japan and South Korea, two neighbouring countries which share many superficial similarities (eg, rapid population ageing and high suicide rates overall), yet starkly different suicide rates at older ages.1 Applying ageâperiodâcohort analysis of suicide trends between 1986 and 2015, Kino et al showed that there is a sharp increase in suicide around retirement age in Korea, but not in Japan (an age effect). Furthermore, there was a dramatic temporal increase in suicide during the three decades of observation in Korea (a period effect) whereas rates were relatively stable in Japan. Lastly, the post-World War II generation where can i get cialis in Japan had lower rates of suicide compared with generations born either before 1916 or after 1961 (birth cohort effect), whereas the suicide rate increased linearly with each generation in Korea. Japan provides a strong social safety net for the generation who contributed to the post-war period of economic expansion, while high suicide rates in Korea reflect the simultaneous decline of intergenerational care provision combined with inadequate social security in post-retirement.

Thus, although Japan and Korea share high overall suicide rates, careful cross-national comparative analysis points to divergent social policies as the basis for the stark differences in suicide at older ages. This example highlights how difficult it is to generalise about population variability in mental health without an adequate where can i get cialis understanding of the broader social context (particularly the social policy context) in which older adults lead their lives. Urban contexts are embedded within upstream social contexts. Hence, whether a research study conducted in country X confirmed/disconfirmed the findings of another study conducted in country Y is hard to interpret without considering the âmissing levelâ above urban neighbourhoods.Turning to the MINDMAP Project, Tarkiainen et al argue that the association between neighbourhood characteristics and mental health at older ages has produced inconsistent findings, possibly due to heterogeneity in the measurement of mental health outcomes, neighbourhood characteristics and confounders. In their cross-national comparative study, which harmonised measures of exposures, outcomes and confounders across three countriesâFinland, Sweden and Italyâthe authors found that dense and mixed urban structure was associated with higher antidepressant use at older where can i get cialis ages in Stockholm and in Finland, but not in Italy.

In other words, their study buttresses the idea that there is something more going on than measurement and study design issues, and heterogeneity of treatment effects might be expected depending on the social context. Tarkiainen et al speculate that where can i get cialis their mixed finding might be explained by differences in family solidarity (a cultural characteristic) between the countries, viz. Italy is characterised by strong family responsibility for older people while contact with elderly parents may be looser in the Nordic countries (Indeed, the frequency of intergenerational contact has been put forward as one of the reasons why Italy suffered one of the worst erectile dysfunction treatment outbreaks in Europe.2). Future studies might attempt to incorporate these measures of social context into analysis to better understand the mechanisms at play.Improving exposure assessmentExposure assessment is at the crux of research on environmental drivers of health. Accurate exposure assessment that reflects personal exposure during a relevant where can i get cialis time window allows for more precise estimation of the relationship between an environmental factor and healthy ageing.

Conversely, non-differential measurement error is likely to bias results towards the null.3 Therefore, if the exposures estimated across the studies in this special issue contain non-differential error, it is possible that this error accounts for the majority of null findings.While evidence is growing that environmental factors may drive mental health and well-being as we age, limitations in exposure assessment are the largest barriers to advancing the field. Poorly measured exposure data do not allow us to determine aetiologically relevant exposures in a way that is actionable by individuals or communities. Coarse exposure assessment limits statements about causal inference and provides little information on potential interventions where can i get cialis for policymakers.4 5This lack of consistency in defining exposures could be at play in the study by Tarkiainen et al, where the authors observed inconsistent associations for antidepressant use by levels of urbanicity, land use mix, and population density across areas of Sweden, Finland and Italy. The definition of dense urban structure may differ greatly in Sweden and Finland compared with Italy. Are dense neighbourhoods monolithic apartment complexes or mixed-use vibrant communities? where can i get cialis.

While both scenarios would constitute high density, the lack of a well-defined exposure makes it difficult to discern what the true exposure is that might drive antidepressant use. In addition, urbanicity is defined as âproportion of continuous urban fabricâ. How would one design a randomised trial to experimentally where can i get cialis expose someone to âurbanicityâ?. And, assuming urbanicity does cause antidepressant use, how would researchers advise policymakers on how to change urbanicity?. Do we remove where can i get cialis pavement?.

Knock down buildings?. Plant trees?. Broadly defined exposures create confusion in understanding exactly what causal where can i get cialis question we are asking.Similarly, other studies used non-specific measures of the built environment in analyses, including Ruiz et al, Sund et al and Noordzij et al. Noordzij et al define exposure to green space based on the distance between a participantâs residential address and the nearest green space using data from the Urban Atlas dataset, which contains comparable land use and land cover data across Europe. The use of a harmonised green space metric allows for pooling of the data across all four cohorts.

However, the downside is that we have where can i get cialis no information on the specific type of green space involved. Are grassy meadows comparable with wooded forests?. Are urban where can i get cialis parks comparable with suburban parks?. The combination of these dissimilar green spaces, where some may positively influence depressive symptoms and others might not, contributes to exposure misclassification. The authors in Sund et al mention that urban areas provide an urban penalty by increasing exposure to air pollution, noise or violence, or conversely, may provide an urban advantage by providing higher access to cultural activities or social networks.

Future MINDMAP studies should measure and estimate the effects of these specific factors on health.Timmermans et al conducted an analysis on land use and loneliness in older adults where can i get cialis from a cross-sectional analysis of two Dutch cohorts. In the time of erectile dysfunction treatment and increased social distancing, understanding environmental drivers of loneliness is all the more important. The authors find some suggestion that participants living in areas with higher land use mix had lower levels of loneliness, although this finding was not statistically significant. The authors proffer that land use mix could reflect âthe availability of various destinations and neighbourhood resources in where can i get cialis the local living environmentâ. However, land use mix could also be correlated with other factors, such as access to transit, access to green spaces or even something as simple as street benches, which encourage social interaction.

Future research could engage multiexposure models to isolate which specific factor appears to have the greatest impact on loneliness.Li et al evaluated whether a noise mitigation policy in Amsterdam where can i get cialis led to an improvement in mental health. There are theoretical and empirical reasons why noise can affect residentsâ mental health (not the least through sleep disruption). From an exposure assessment perspective, one of the things that researchers seldom bother to assess is how do the residents perceive noise. When people appraise the noise as unpredictable, beyond where can i get cialis their control and not to their benefit, the mental health impacts are much worse. If, however, there are more positive appraisals (eg, residents have been told that the noise will last for a specified duration of time and is associated with some community benefitâfor example, the construction of an attractive neighbourhood amenityâthe mental health impacts will be less).

Self-reported data on noise perceptions, as well as control over noise, would be a worthwhile addition to the MINDMAP Project.Technological advances to address gapsRecent technological advances have provided researchers with tools that can fill many research gaps outlined above. We have where can i get cialis new tools to estimate high-resolution metrics of mobility, human behaviour and psychological processes that occur within a day. Fernandes et al describe the development of a study that incorporates multiple tools for innovative perspectives on these factors. Their research protocol combines global positioning systems and accelerometer data, proximity detection to assess whether household members are close to each other for objective measures of social interactions, ecological momentary assessment prompts up where can i get cialis to eight times per day to track momentary mood and stress and environmental perceptions, and electrodermal activity for the potential objective prediction of stress. These technologies provide moment-to-moment data on how environmental factors influence mood and stress, as well as how these relationships are impacted by social interaction, to provide a thorough understanding of the dynamic processes through which environmental exposures may drive mood changes.

Important studies such as this will unveil exciting perspectives on the fine-scale mechanisms at play and will fill gaps in the literature, which has previously focused on infrequent measurement of mental health outcomes (eg, every 2âyears) or residence-based exposure assessment.In addition to these high-resolution measures of mobility and psychological processes, we now have access to spatial dataset that provides information on the environment in ways never before seen. Ubiquitous georeferenced street-level imagery, such as Google Street View, provides detailed, time-varying information on specific small-scale environmental factors.6 7 Recent advances in deep learning have made it possible for researchers to rigorously and systematically evaluate these images for exposure assessment at scale.8 We can now tease out exactly what is in each image, such as sidewalk availability or tree species, and link where can i get cialis these images to the locations that they were gathered. These images have also been gathered for over a decade, so that we can evaluate how environments change over time. As mentioned above, measuring specific, time-varying environmental features has been challenging, and has hindered the ability of previous studies to isolate key health-promoting features of the environment. Applying deep learning to street-level images empowers the measurement of environmental factors in a high-resolution, specific, where can i get cialis consistent and scalable manner across large areas.

Linking these measures to health will reveal policy-relevant and actionable information on how to optimise environments for mental health and well-beingModelling policy impactsUltimately, the goal of research on the environmental drivers of healthy ageing is to identify potential interventions and estimate how these interventions influence health outcomes. To this end, Yang et al employed an agent-based model to evaluate the impact of a free bus policy on both public transit where can i get cialis use, as well as depression among older adults. They benchmarked this model against empirical data from England and ran several simulations to examine different policy scenarios. The authorsâ model predicted that free bus policies lead to increased bus usage and decreased depression. In addition, improving attitudes towards the bus could enhance the effects of a free bus policy, particularly for those living close to public transit, as well as in scenarios where poorer populations live close to the city centre.

Although these agent-based models contain substantial assumptions, they provide crucial information to decision makers to enact policies that maximise health. Agent-based models also highlight the factors that may modulate the effectiveness of environmental interventions, which may indicate the need for multiscale interventions for optimal outcomes.Commentary on the MINDMAP ProjectWith all of the effort that went into harmonising exposure, outcomes and other core measures across six cohorts spanning seven countries (Wey et al), the findings gathered in this special issue provide novel cross-national findings. The MINDMAP collaboration has laid a groundwork for future research to harmonise environmental exposure data and health outcome information in multiple large studies across countries in Europe. The initial offering from the MINDMAP Project is only the beginning. Perhaps the best is yet to come..

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Due to the June 18, 2021 federal holiday, the grant funding what to do when cialis stops working opportunities were withdrawn. We expect to republish the grant funding opportunities and new application deadlines this week in the Federal Register. Please continue to check OSHAâs website for new information.June 17, 2021 US Department of Labor announces availability of more than$21M in grants for training on workplace hazards, infectious diseases WASHINGTON, DC what to do when cialis stops working â The U.S. Department of Labor today announced funding opportunities for more than $21 million in Occupational Safety and Health Administration training grants for non-profit organizations. The first availability will provide $10 million under the American Rescue Plan Act of 2021 for Workplace Safety and Health Training on what to do when cialis stops working Infectious Diseases, including the erectile dysfunction grants.

To be eligible for these grants, applicants must develop training that focuses on four program emphasis areas. Identifying and preventing workplace-related infectious diseases, including the erectile dysfunction, in industries with high illness rates, those employing frontline workers or those serving susceptible populations. OSHA standards that address what to do when cialis stops working infectious diseases, including erectile dysfunction. Workplace hazards identified in OSHA special emphasis programs or other priorities associated with infectious diseases, including the erectile dysfunction. Applications must be submitted at www.grants.gov no later than 11:59 p.m what to do when cialis stops working.

EDT on July 19, 2021. Applicants must possess a D-U-N-S number and have an active System of Award Management registration what to do when cialis stops working. Obtain a free D-U-N-S number from Dun &. Bradstreet. The second funding availability is for the Susan Harwood what to do when cialis stops working Training Grant Program.

Funding of $11,787,000 is available for Targeted Topic Training, Training and Educational Materials Development, and new Capacity Building grants. Applicants can apply for what to do when cialis stops working a grant under one of the following funding opportunities. Targeted Topic Training grants support educational programs that identify and prevent workplace hazards. These grants require applicants to conduct training on OSHA-designated workplace safety and health hazards. Training and Educational Materials Development grants support the development of what to do when cialis stops working quality classroom-ready training and educational materials that identify and prevent workplace hazards.

Capacity Building grants assist organizations that need time to assess needs and formulate a plan before moving forward with a full-scale safety and health education program, as well as expand their capacity to provide occupational safety and health training, education and related assistance to their constituents. Applicants may apply for and receive both an ARPA âWorkplace Safety and Health Training on Infectious Diseases, including the erectile dysfunctionâ grants and the standard Susan what to do when cialis stops working Harwood Training grants. Applications must be submitted at www.grants.gov no later than 11:59 p.m. EDT on what to do when cialis stops working Aug. 17, 2021.

Applicants must possess a D-U-N-S number and have an active System of Award Management registration. Obtain a free D-U-N-S number what to do when cialis stops working from Dun &. Bradstreet. OSHA awards grants to nonprofit organizations, including community and faith-based organizations, employer associations, labor unions, joint labor/management associations, Indian tribes, and local and state-sponsored colleges and universities to provide infectious disease workplace safety and what to do when cialis stops working health training. The Harwood Training Grant program supports remote and in-person hands-on training for workers and employers in small businesses.

Industries with high injury, illness, what to do when cialis stops working and fatality rates. And vulnerable workers, who are underserved, have limited English proficiency, or are temporary workers. Learn more about the Susan Harwood Training Grant Program. # # what to do when cialis stops working # Media Contacts. Denisha Braxton, 202-693-5061, braxton.denisha.l@dol.govMandy McClure, 202-693-4675, mcclure.amanda.c@dol.gov Release Number.

21-1036-NAT what to do when cialis stops working U.S. Department of Labor news materials are accessible at http://www.dol.gov. The department's Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).June 16, 2021OSHA cites Bronx contractor after 21-year-old laborererecting scaffolding suffers deadly fall at Brooklyn building projectInvestigation finds worker's fall arrest harness was not tethered as required BROOKLYN, NY â Falls are the what to do when cialis stops working leading cause of fatalities in construction, a fact sadly illustrated by the death of a 21-year-old laborer, who fell nearly 50 feet as he installed a supported tubular welded frame scaffold during construction of a seven-story Brooklyn building. A U.S.

Department of Labor Occupational Safety and Health Administration investigation of what to do when cialis stops working the Nov. 13, 2020, incident determined Everest Scaffolding Inc. Of the Bronx failed to what to do when cialis stops working ensure the laborer's fall arrest harness was attached, as required. ÂThis tragedy could have been prevented if Everest Scaffolding had provided appropriate training on fall hazards and ensured workers were using fall protection correctly,â said OSHA Area Director Kay Gee in Manhattan. OSHA proposed $300,370 in penalties for two willful and two serious safety violations.

The agency what to do when cialis stops working found the company. Failed to evaluate the feasibility of using fall protection and failed to use feasible fall protection during the erection of a supported scaffold. Did not properly train employees on fall what to do when cialis stops working hazards associated with scaffold work. Failed to inspect fall arrest systems before use. Did not determine if the anchorage for employees' personal fall arrest systems could support at least 5,000 pounds.

View the what to do when cialis stops working citations. The company has contested OSHA's findings to the independent Occupational Safety and Health Review Commission. Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for what to do when cialis stops working their employees. OSHA's role is to ensure these conditions for America's working men and women by setting and enforcing standards, and providing training, education and assistance. Learn more what to do when cialis stops working about OSHA.

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The department's Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay)..

Due to where can i get cialis the June 18, Buy kamagra uk next day delivery 2021 federal holiday, the grant funding opportunities were withdrawn. We expect to republish the grant funding opportunities and new application deadlines this week in the Federal Register. Please continue where can i get cialis to check OSHAâs website for new information.June 17, 2021 US Department of Labor announces availability of more than$21M in grants for training on workplace hazards, infectious diseases WASHINGTON, DC â The U.S.

Department of Labor today announced funding opportunities for more than $21 million in Occupational Safety and Health Administration training grants for non-profit organizations. The first availability will provide $10 million under the American Rescue Plan Act of 2021 for Workplace Safety and where can i get cialis Health Training on Infectious Diseases, including the erectile dysfunction grants. To be eligible for these grants, applicants must develop training that focuses on four program emphasis areas.

Identifying and preventing workplace-related infectious diseases, including the erectile dysfunction, in industries with high illness rates, those employing frontline workers or those serving susceptible populations. OSHA standards where can i get cialis that address infectious diseases, including erectile dysfunction. Workplace hazards identified in OSHA special emphasis programs or other priorities associated with infectious diseases, including the erectile dysfunction.

Applications must be submitted at where can i get cialis www.grants.gov no later than 11:59 p.m. EDT on July 19, 2021. Applicants must possess a D-U-N-S number and where can i get cialis have an active System of Award Management registration.

Obtain a free D-U-N-S number from Dun &. Bradstreet. The second funding availability is for where can i get cialis the Susan Harwood Training Grant Program.

Funding of $11,787,000 is available for Targeted Topic Training, Training and Educational Materials Development, and new Capacity Building grants. Applicants can where can i get cialis apply for a grant under one of the following funding opportunities. Targeted Topic Training grants support educational programs that identify and prevent workplace hazards.

These grants require applicants to conduct training on OSHA-designated workplace safety and health hazards. Training and Educational Materials Development grants support the development of quality classroom-ready training and educational materials that identify and where can i get cialis prevent workplace hazards. Capacity Building grants assist organizations that need time to assess needs and formulate a plan before moving forward with a full-scale safety and health education program, as well as expand their capacity to provide occupational safety and health training, education and related assistance to their constituents.

Applicants may apply for and receive both an ARPA âWorkplace Safety and Health Training on Infectious Diseases, including the erectile dysfunctionâ grants and where can i get cialis the standard Susan Harwood Training grants. Applications must be submitted at www.grants.gov no later than 11:59 p.m. EDT on where can i get cialis Aug.

17, 2021. Applicants must possess a D-U-N-S number and have an active System of Award Management registration. Obtain a free D-U-N-S number from where can i get cialis Dun &.

Bradstreet. OSHA awards grants to nonprofit organizations, including community and faith-based organizations, employer associations, labor unions, joint labor/management associations, Indian where can i get cialis tribes, and local and state-sponsored colleges and universities to provide infectious disease workplace safety and health training. The Harwood Training Grant program supports remote and in-person hands-on training for workers and employers in small businesses.

Industries with high injury, illness, and fatality where can i get cialis rates. And vulnerable workers, who are underserved, have limited English proficiency, or are temporary workers. Learn more about the Susan Harwood Training Grant Program.

# # where can i get cialis # Media Contacts. Denisha Braxton, 202-693-5061, braxton.denisha.l@dol.govMandy McClure, 202-693-4675, mcclure.amanda.c@dol.gov Release Number. 21-1036-NAT U.S where can i get cialis.

Department of Labor news materials are accessible at http://www.dol.gov. The department's Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).June 16, 2021OSHA cites Bronx contractor after 21-year-old laborererecting scaffolding suffers deadly fall at Brooklyn building projectInvestigation finds worker's fall where can i get cialis arrest harness was not tethered as required BROOKLYN, NY â Falls are the leading cause of fatalities in construction, a fact sadly illustrated by the death of a 21-year-old laborer, who fell nearly 50 feet as he installed a supported tubular welded frame scaffold during construction of a seven-story Brooklyn building.

A U.S. Department of Labor Occupational Safety and where can i get cialis Health Administration investigation of the Nov. 13, 2020, incident determined Everest Scaffolding Inc.

Of the Bronx failed to ensure the where can i get cialis laborer's fall arrest harness was attached, as required. ÂThis tragedy could have been prevented if Everest Scaffolding had provided appropriate training on fall hazards and ensured workers were using fall protection correctly,â said OSHA Area Director Kay Gee in Manhattan. OSHA proposed $300,370 in penalties for two willful and two serious safety violations.

The agency where can i get cialis found the company. Failed to evaluate the feasibility of using fall protection and failed to use feasible fall protection during the erection of a supported scaffold. Did not properly train employees on fall hazards associated with scaffold work where can i get cialis.

Failed to inspect fall arrest systems before use. Did not determine if the anchorage for employees' personal fall arrest systems could support at least 5,000 pounds. View the where can i get cialis citations.

The company has contested OSHA's findings to the independent Occupational Safety and Health Review Commission. Under the Occupational Safety and Health Act of 1970, employers where can i get cialis are responsible for providing safe and healthful workplaces for their employees. OSHA's role is to ensure these conditions for America's working men and women by setting and enforcing standards, and providing training, education and assistance.

Learn more about where can i get cialis OSHA. # # # Media Contacts. Ted Fitzgerald, 617-565-2075, fitzgerald.edmund@dol.gov James C.

Lally, 617-565-2074, lally.james.c@dol.gov Release Number. 21-876-NEW U.S. Department of Labor news materials are accessible at http://www.dol.gov.

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Shutterstock where can you buy cialis over the counter Counsel for the American Hospital Association (AHA) and other groups have put drug companies on notice that they need to immediately halt their practice of eliminating drug discounts cialis experience for contract pharmacies. The letter was sent to AstraZeneca, Eli Lilly and Company, Novartis, Novo Nordisk, Sanofi, and United Therapeutics. In it, the AHA, 340B Health, the American Society of Health-System Pharmacists, Americaâs Essential Hospitals, the Association of American Medical Colleges and the Childrenâs Hospital Association directed that the drug companies discontinue the practice and follow guidance from the U.S. Department of Health and Human cialis experience Services. Under the federal 340B drug pricing program, as a condition of their Medicaid and Medicare coverage, drug companies must sell discounted prescription drugs to Critical Access Hospitals, who in turn, pass those saving along to their patients.

In August, the drug companies announced that they would no longer provide 340B discounts to contract pharmacies. This would have negatively cialis experience impacted many rural hospitals who regularly contract out http://www.physio-hanko.at/therapeut/ their pharmacies to save money. In late December, Health and Human Services Secretary Alex Azar issued an advisory opinion stating the drug companies are required to provide those discounts to contract pharmacies. ÂThe Office of the General Counsel (âOGCâ) has received numerous requests from both manufacturers and covered entities to address whether it is proper for a drug manufacturer participating in the 340B Program to refuse to provide covered outpatient drugs at the 340B ceiling price to a covered entity for drugs distributed at the entityâs contract pharmacies. For the reasons set forth below, we conclude that to cialis experience the extent contract pharmacies are acting as agents of a covered entity, a drug manufacturer in the 340B Program is obligated to deliver its covered outpatient drugs to those contract pharmacies and to charge the covered entity no more than the 340B ceiling price for those drugs,â the opinion said.

The letter from the hospital associations threatened legal action if drug companies do not comply. If the drug companies continue the illegal practices, the litigants âwill continue to seek to require that HHS enforce the 340B statute, covered entities are reimbursed for damages caused by the illegal policy, and the matter is referred to the HHS Inspector General for the imposition of civil money penalties,â the letter said..

Shutterstock Counsel for the American Hospital Association (AHA) and other groups have put drug companies on notice that where can i get cialis they need to https://www.dashub.info/site/testimonials/alain-dhaese/ immediately halt their practice of eliminating drug discounts for contract pharmacies. The letter was sent to AstraZeneca, Eli Lilly and Company, Novartis, Novo Nordisk, Sanofi, and United Therapeutics. In it, the AHA, 340B Health, the American Society of Health-System Pharmacists, Americaâs Essential Hospitals, the Association of American Medical Colleges and the Childrenâs Hospital Association directed that the drug companies discontinue the practice and follow guidance from the U.S. Department of where can i get cialis Health and Human Services.

Under the federal 340B drug pricing program, as a condition of their Medicaid and Medicare coverage, drug companies must sell discounted prescription drugs to Critical Access Hospitals, who in turn, pass those saving along to their patients. In August, the drug companies announced that they would no longer provide 340B discounts to contract pharmacies. This would have negatively impacted many rural hospitals who regularly where can i get cialis contract out their pharmacies to save money. In late December, Health and Human Services Secretary Alex Azar issued an advisory opinion stating the drug companies are required to provide those discounts to contract pharmacies.

ÂThe Office of the General Counsel (âOGCâ) has received numerous requests from both manufacturers and covered entities to address whether it is proper for a drug manufacturer participating in the 340B Program to refuse to provide covered outpatient drugs at the 340B ceiling price to a covered entity for drugs distributed at the entityâs contract pharmacies. For the reasons set forth below, we conclude that to the extent contract pharmacies are acting as agents of a covered entity, a drug manufacturer in the 340B Program is obligated to deliver its covered outpatient where can i get cialis drugs to those contract pharmacies and to charge the covered entity no more than the 340B ceiling price for those drugs,â the opinion said. The letter from the hospital associations threatened legal action if drug companies do not comply. If the drug companies continue the illegal practices, the litigants âwill continue to seek to require that HHS enforce the 340B statute, covered entities are reimbursed for damages caused by the illegal policy, and the matter is referred to the HHS Inspector General for the imposition of civil money penalties,â the letter said..

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Are ARPâs higher subsidies worth cialis 2.5 daily review it?. But 2021 is not a normal year. The ARP has made significant changes to subsidy amounts and eligibility, and a lot of people will find that switching plans enables them to best take advantage of the enhanced subsidies. For example cialis 2.5 daily review.

A person who previously enrolled off-exchange in order to take advantage of the âSilver switchâ approach to cost-sharing reduction funding, and who is now eligible for a premium subsidy in the exchange. A person who enrolled in a Bronze plan during open enrollment but is now eligible for a $0 premium or low-premium Silver or Gold plan (depending on location) due to income or unemployment compensation. A person who was eligible cialis 2.5 daily review for cost-sharing reductions but selected a Bronze or Gold plan during open enrollment because the Silver plans were too expensive, but who can now afford the Silver plan due to the extra subsidies (cost-sharing reductions are only available on Silver plans) If you switch plans, will you have to start over at zero?. The good news is that many states, state-run marketplaces, and insurers have taken action to ensure that accumulators will transfer to a new plan.

(In virtually all cases, this does have to be a new plan with the same insurer â if you switch to a different insurance company, youâll almost certainly have to start over at $0 on your accumulators.) HealthCare.gov is the exchange/marketplace thatâs used in 36 states. Its official position cialis 2.5 daily review is that âany consumer who selects a new plan may have their accumulators, such as deductibles, reset to zero.â But insurance commissioners in some of those states have stepped in to require insurers to transfer accumulators, and in other states, all of the insurers have voluntarily agreed to do so. Washington, DC, and 14 states have state-run marketplaces, and several of them have announced that insurers will transfer accumulators. Which states are helping with accumulators?.

Weâve combed through communications from state-run marketplaces and state insurance commissioners to see which ones cialis 2.5 daily review have issued guidance on this. But regardless of where you live, your best bet is to reach out to your insurance company before you make a plan change. Find out exactly how theyâre handling accumulators during this enrollment window, and if they are transferring accumulators to new plans, make sure that you adhere to whatever requirements they may have in place. That said, cialis 2.5 daily review hereâs what we found in terms of how states and state-run marketplaces are addressing accumulators and mid-year plan changes in 2021.

States where all accumulators will transfer as long as your old and new plans are offered by the same insurance company In some cases, these accumulator transfer rules only apply when switching from off-exchange to on-exchange. In other cases, they apply to any plan changes, including from one exchange plan to another. Colorado District of Columbia â The marketplace has confirmed that cialis 2.5 daily review all accumulators will transfer. Idaho â Idaho only allowed people to switch to a plan offered by their current insurer, unless they had a qualifying event.

Note that Idahoâs erectile dysfunction treatment/ARP enrollment window ended April 30, which is much earlier than the rest of the country. Maryland â Plan changes cialis 2.5 daily review are limited to upgrades, but the marketplace confirmed that accumulators will transfer. Massachusetts â All insurers have agreed to transfer accumulators for people switching from off-exchange to on-exchange plans Michigan â Deductibles will transfer, although some insurers will only allow this if youâre upgrading your plan. (Two insurers are allowing deductible transfers even if youâre switching from a different insurerâs plan.) Minnesota â Minnesota is currently not allowing marketplace enrollees to switch plans during the erectile dysfunction treatment/ARP enrollment window, although this may change within the next several weeks.

So for now, the accumulator transfers cialis 2.5 daily review only apply to people switching from an off-exchange plan to an on-exchange plan. All four of the insurers that offer both on-exchange and off-exchange plans have agreed to transfer accumulators to the on-exchange plans. New Mexico New York Tennessee Vermont â Like Minnesota, Vermont is currently only allowing people to switch from off-exchange (full-cost individual direct enrollment) to on-exchange plans. Accumulators will transfer for cialis 2.5 daily review those plan changes.

West Virginia â The WV Office of the Insurance Commissioner confirmed that both insurers are transferring accumulators, with the exception of a transfer between an HSA-qualified plan and a non-HSA-qualified plan (mainly due to IRS regulations for how HSA-qualified plans must handle out-of-pocket costs). Wisconsin â Covering Wisconsin, a nonprofit enrollment assistance organization, notes that accumulators will not transfer if people select a plan from a different insurer, which is to be expected. In some states, rules are slightly more complicated Alaska â Deductibles will reset to $0 if a policyholder is switching from off-exchange to on-exchange (or vice-versa), but will not reset if the move is cialis 2.5 daily review from one exchange plan to another, with the same insurer. California â The marketplace has confirmed that insurers will transfer accumulators for plan holders switching from an off-exchange plan to an on-exchange plan or from one exchange plan to another, as long as they stay with the same insurance company and the same type of managed care plan (ie, HMO to HMO, or PPO to PPO).

New Jersey â Deductibles will transfer, possibly even to a new insurer (which is fairly unique. We arenât aware of this cialis 2.5 daily review elsewhere, other than the two Michigan insurers that are offering it). But additional out-of-pocket spending will not transfer to the new plan. States where the official word is that âit dependsâ Several states have addressed accumulator transfers so that consumers know to be aware of them, but are leaving the decision up to the insurers.

In these states (listed below), some or all of the insurers cialis 2.5 daily review may be offering accumulator transfers, but consumers should definitely ask their insurer how this will work before making the decision to switch plans. Connecticut Nevada New Hampshire Ohio Montana North Dakota â the ND Insurance Department is recommending that consumers reach out to their insurance company to see how this is being handled. Oregon â As of April, the state was still working with insurers to sort out an approach for people switching from off-exchange to on-exchange, but according to OregonHealthCare.gov, accumulators will not transfer when a person switches from one marketplace plan to another Pennsylvania Rhode Island â There are two insurers that offer plans in Rhode Islandâs marketplace. One has agreed to transfer accumulators and one has not, but the marketplace is still working to address this cialis 2.5 daily review and itâs possible both insurers could end up allowing accumulators to transfer.

Washington States where the official word is that accumulators will not transfer Some states have fairly clearly indicated that insurers will not transfer accumulators if policyholders make a plan change. But even in these states, itâs still worth checking with a specific insurer to see what approach theyâre taking, as some are still developing their approach during this unique time. Illinois cialis 2.5 daily review Virginia What if my stateâs not listed?. Insurance departments in the rest of the states havenât put out any official guidance or bulletins regarding accumulator transfers, although these may still be forthcoming as the erectile dysfunction treatment/ARP window progresses.

Keep in mind that it will be July in most states before the ARPâs benefits are available for people receiving unemployment compensation in 2021, so this is still very much a work in progress and likely to evolve over time. States that have not yet issued specific guidance or cialis 2.5 daily review clarified insurers positions on accumulator transfers include. Alabama Arizona Arkansas Delaware Florida Georgia Hawaii Indiana Iowa Kansas Kentucky Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Wyoming If youâre in one of these states, your insurer may or may not be transferring accumulators when enrollees switch to a new plan in 2021. If youâve had significant out-of-pocket medical spending so far this year, be sure to reach out to your insurer to see how theyâre handling this.

And if a representative tells you that accumulators will transfer, itâs a good cialis 2.5 daily review idea to get confirmation in writing. And if your insurer initially says no, keep asking over the coming days and weeks. Weâve seen some insurers start to offer accumulator transfers after initially stating that they didnât plan to do so, and itâs possible that other insurers might follow suit. To switch or not to cialis 2.5 daily review switch?.

So what should you do if youâve already spent some money out-of-pocket this year, and youâre going to have to start over at $0 on a new plan?. Maybe youâre enrolled in a grandmothered or grandfathered plan and your insurer simply doesnât offer plans for sale in the marketplace. Depending on where you live, this might also be the case if you have an ACA-compliant off-exchange plan, as cialis 2.5 daily review not all off-exchange insurers sell plans in the exchange. And as noted above, it might also be the case even if you want to transfer from one ACA-compliant plan to another.

(But check with both the insurer and the insurance department in your state before giving up on accumulator transfers in that situation.) Really, it just comes down to the math. Will the amount youâre going to save due to premium tax credit (and possibly cialis 2.5 daily review cost-sharing reductions, if youâre eligible for them and switching to a Silver plan) offset the loss youâll take by having to start over at $0 on your deductible and out-of-pocket exposure?. If you havenât spent much this year, the answer is probably Yes. If youâve already met your maximum out-of-pocket for the year, itâs probably going to be a tougher decision.

But donât assume that itâs not worth your while cialis 2.5 daily review. Depending on the circumstances (especially if you were previously impacted by the âsubsidy cliffâ and are newly eligible for subsidies), your new subsidies might be worth more than youâd be giving up by having to start over with new out-of-pocket costs. And if youâre part of the way toward meeting your deductible on a Bronze plan and are newly eligible for a free or very low-cost Silver plan that includes cost-sharing reductions, you might find that the new plan ultimately saves you money in out-of-pocket costs for the rest of the year, even if your accumulators donât transfer. Louise Norris is an individual health insurance broker who has been writing about health cialis 2.5 daily review insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health insurance marketplace updates are regularly cited by media who cover health reform and by other health insurance experts.Itâs been a widely held conclusion in the health insurance industry and among health policy types that one of our biggest hurdles lies with the challenge of getting coverage for âyoung invinciblesâ â Americans old enough to vote but under 30. That label itself is tied to a widely held perception that â because of their youth â âtwenty-somethingsâ believe theyâre healthy enough that they simply wonât need all of the cialis 2.5 daily review bells and whistles of comprehensive health insurance (any time soon, at least). As an agent and an avid observer of health insurance trends, I know itâs not that simple.

Young adults, in many cases, are keenly aware of their need for comprehensive coverage. But â despite various federal and state efforts to make coverage more affordable and accessible (including provisions of the American Rescue Plan) â cialis 2.5 daily review there are definitely barriers making it difficult for young adults to enter the individual health insurance market. Last week, I spoke with Carolyn Kettig, a young woman whoâs determined to get coverage but facing barriers that many young Americans face. Carolyn Kettig is a professional actor in New York, and has thus far maintained health coverage under her motherâs policy.

But that will end this summer, when Carolyn cialis 2.5 daily review turns 26. She shares her story with me here, and Iâve added my own commentary wherever it might help readers in similar situations understand their coverage options. Before we begin, itâs worth noting that because Carolyn lives in New York, she has access to a Basic Health Program. New York and Minnesota are the only states that offer these programs, cialis 2.5 daily review and theyâre an excellent coverage option for people who are eligible to enroll.

But if youâre not in New York or Minnesota, youâve still got plenty of options. Thatâs particularly true now that the American Rescue Plan has been enacted, making premium subsidies larger and more widely available. For many young people, the American Rescue Plan makes robust coverage much more affordable than it used cialis 2.5 daily review to be. (Previously, it was common for young people to feel like their only truly affordable health coverage option was a plan with a deductible that may have felt impossibly high).

Louise. Whatâs your cialis 2.5 daily review current insurance situation and how is it changing this year?. What are your options for coverage?. Carolyn.

Iâm lucky enough to currently be cialis 2.5 daily review covered by my motherâs health insurance. She has a very generous insurance plan and Iâve been privileged to, thus far, be fully covered. Unfortunately, because Iâm turning 26, Iâll be losing coverage this spring. As a professional actor, my early twenties were filled with countless side jobs that cialis 2.5 daily review supported me as I sought acting work in New York City.

None of these jobs ever came with healthcare benefits, which at the time was okay as I was covered by my motherâs plan. Three years ago, when I landed my first big theater job, I had the opportunity to join the actorâs union, which among many other wonderful things, provides working actors with comprehensive, affordable health insurance. The only catch, and itâs a fairly large one, is that an actor must work cialis 2.5 daily review a certain number of weeks in order to qualify. Even without a cialis, finding steady work in the theater is difficult.

Factor in a cialis that shutters theaters for over a year and causes the union to hemorrhage money â¦ needless to say, healthcare coverage in my industry has become a near impossibility. Iâm hopeful that live entertainment will return in a vaccinated world, but until then, Iâm doing my best to make enough money to cialis 2.5 daily review pay my bills. Iâm grateful to be employed part-time as a program director for a teen program. My job has kept me afloat during this devastating time, but, unfortunately, does not come with healthcare benefits.

I make very little money and live paycheck to paycheck, which leaves me relatively few options when cialis 2.5 daily review it comes to insurance. I will most likely go with New York Stateâs Essential Plan, which is the best option for low-income people who make too much money to qualify for Medicaid. Louise. The Essential Plan is New Yorkâs Basic Health Program (BHP), which is available to people earning cialis 2.5 daily review up to 200% of the poverty level.

(For a single person in 2021, that amounts to $25,760.) The Affordable Care Act allowed for the creation of BHPs, but New York and Minnesota are the only states that have opted to establish them. The Essential Plan provides robust health coverage with no monthly premium, and it has much lower cost-sharing than we typically see in the individual/family health insurance market. The Essential Plan is also being enhanced as of cialis 2.5 daily review June 2021. Previously, some enrollees had to pay $20/month, and there was an extra premium for dental and vision coverage.

Dental and vision are now included at no cost. Louise. How much is the need for coverage weighing on you and other people your age?. Carolyn.

Iâve lost sleep over this!. It weighs on me heavily. Having grown up in New York, I have a long history with some of my doctors, most of whom will not accept my new insurance plan. This means that I will either be forced to find new doctors or pay hundreds of dollars out of pocket for routine check-ups.

Iâm also aware that, even with insurance coverage, an unexpected hospital stay could cost me thousands of dollars. It makes me enraged to know that, in an emergency situation, I would avoid going to the hospital because of the cost. Louise. The Essential Plan provides much more robust coverage than people may be used to seeing elsewhere.

There is no deductible, emergency room visits cost $75, and inpatient hospital stays are only $150 per admission â and these fees are waived altogether for enrollees with income up to 150% of the poverty level, or a little more than $19,000 for a single person. This is better coverage than most people have even with higher-end employer-sponsored plans. Carolyn. I know that Iâm not alone in this.

Especially since my generation is now living through a global health crisis, I think my peers are more aware than ever before of how broken our healthcare system really is. Moreover, as a white, cisgendered woman from a middle-class background, Iâm cognizant of the privilege my identities afford me and deeply disturbed by the ways in which our healthcare system disregards and harms BIPOC, low-income families, LGBTQIA+ youth, and undocumented workers (many of whom are essential workers and yet have little access to healthcare coverage) among many others. Alongside the climate crisis and the fight for racial equality, I believe that healthcare reform will dominate the American political landscape for the next few decades. Louise.

And there are other issues, such as the ACAâs family glitch, and the Medicaid coverage gap that exists in the dozen states that have refused to expand Medicaid, that havenât yet been fixed. Fortunately, lawmakers in Congress are continuing to push forward on these issues, and voters can reach out to their elected officials to express their opinions. Louise. What do you see as challenges in this situation?.

Carolyn. Iâve mentioned many challenges already, but I think chief among them is simply how confusing and difficult it is to make informed choices. Reading about insurance options requires learning an entirely new language and navigating nearly impenetrable websites. Louise.

For folks who are confused by the terminology and concepts that go along with health insurance, our glossary is a great resource. Weâve incorporated plenty of details, since thatâs where the nuances always are. And weâve focused on explaining things using plain language thatâs easy to understand. Help from the American Rescue Plan Louise.

Are you aware of the changes that the American Rescue Plan has made?. Do you think it will make it easier for you to access coverage?. Carolyn. Iâve read a bit about the changes made by the American Rescue Plan and am thrilled that this administration is attempting to expand access to healthcare (even though Iâd love to see more substantial reform).

Assuming your 2021 income doesnât exceed 200% of the poverty level (about $25,760), youâll be eligible for either The Essential Plan or Medicaid in New York, both of which are already robust coverage with no monthly premiums. But for others in a similar situation who live elsewhere, the American Rescue Plan implements a variety of improvements that make it easier for young people to transition to their own coverage. Among other provisions, the American Rescue Plan. Increases the size of premium subsidies and makes them more widely available.

Makes coverage more affordable for young people. Ensures that people who are receiving unemployment compensation this year can enroll in robust coverage without having to worry about the cost. Louise. What do you expect to happen with your coverage this summer?.

Its official position is that âany consumer who selects a new plan may have their accumulators, such as deductibles, reset to zero.â But insurance commissioners in some of those states have stepped in to require insurers to transfer accumulators, and where can i get cialis in other states, all of the insurers have voluntarily agreed to do so. Washington, DC, and 14 states have state-run marketplaces, and several of them have announced that insurers will transfer accumulators. Which states are helping with accumulators?. Weâve combed through communications from state-run marketplaces and state insurance commissioners to see which ones have where can i get cialis issued guidance on this. But regardless of where you live, your best bet is to reach out to your insurance company before you make a plan change.

Find out exactly how theyâre handling accumulators during this enrollment window, and if they are transferring accumulators to new plans, make sure that you adhere to whatever requirements they may have in place. That said, hereâs what we found in terms of how where can i get cialis states and state-run marketplaces are addressing accumulators and mid-year plan changes in 2021. States where all accumulators will transfer as long as your old and new plans are offered by the same insurance company In some cases, these accumulator transfer rules only apply when switching from off-exchange to on-exchange. In other cases, they apply to any plan changes, including from one exchange plan to another. Colorado District of Columbia â The marketplace has confirmed that all accumulators where can i get cialis will transfer.

Idaho â Idaho only allowed people to switch to a plan offered by their current insurer, unless they had a qualifying event. Note that Idahoâs erectile dysfunction treatment/ARP enrollment window ended April 30, which is much earlier than the rest of the country. Maryland â Plan changes are limited to upgrades, but the marketplace confirmed that accumulators where can i get cialis will transfer. Massachusetts â All insurers have agreed to transfer accumulators for people switching from off-exchange to on-exchange plans Michigan â Deductibles will transfer, although some insurers will only allow this if youâre upgrading your plan. (Two insurers are allowing deductible transfers even if youâre switching from a different insurerâs plan.) Minnesota â Minnesota is currently not allowing marketplace enrollees to switch plans during the erectile dysfunction treatment/ARP enrollment window, although this may change within the next several weeks.

So for now, the accumulator transfers only apply to people switching where can i get cialis from an off-exchange plan to an on-exchange plan. All four of the insurers that offer both on-exchange and off-exchange plans have agreed to transfer accumulators to the on-exchange plans. New Mexico New York Tennessee Vermont â Like Minnesota, Vermont is currently only allowing people to switch from off-exchange (full-cost individual direct enrollment) to on-exchange plans. Accumulators will where can i get cialis transfer for those plan changes. West Virginia â The WV Office of the Insurance Commissioner confirmed that both insurers are transferring accumulators, with the exception of a transfer between an HSA-qualified plan and a non-HSA-qualified plan (mainly due to IRS regulations for how HSA-qualified plans must handle out-of-pocket costs).

Wisconsin â Covering Wisconsin, a nonprofit enrollment assistance organization, notes that accumulators will not transfer if people select a plan from a different insurer, which is to be expected. In some states, rules where can i get cialis are slightly more complicated Alaska â Deductibles will reset to $0 if a policyholder is switching from off-exchange to on-exchange (or vice-versa), but will not reset if the move is from one exchange plan to another, with the same insurer. California â The marketplace has confirmed that insurers will transfer accumulators for plan holders switching from an off-exchange plan to an on-exchange plan or from one exchange plan to another, as long as they stay with the same insurance company and the same type of managed care plan (ie, HMO to HMO, or PPO to PPO). New Jersey â Deductibles will transfer, possibly even to a new insurer (which is fairly unique. We arenât aware of this elsewhere, other than the two Michigan insurers where can i get cialis that are offering it).

But additional out-of-pocket spending will not transfer to the new plan. States where the official word is that âit dependsâ Several states have addressed accumulator transfers so that consumers know to be aware of them, but are leaving the decision up to the insurers. In these states (listed below), some or all of the insurers may be offering accumulator transfers, but consumers should definitely ask their where can i get cialis insurer how this will work before making the decision to switch plans. Connecticut Nevada New Hampshire Ohio Montana North Dakota â the ND Insurance Department is recommending that consumers reach out to their insurance company to see how this is being handled. Oregon â As of April, the state was still working with insurers to sort out an approach for people switching from off-exchange to on-exchange, but according to OregonHealthCare.gov, accumulators will not transfer when a person switches from one marketplace plan to another Pennsylvania Rhode Island â There are two insurers that offer plans in Rhode Islandâs marketplace.

One has agreed to transfer accumulators and one has not, but the marketplace is still working to address this and itâs possible both insurers could end up allowing accumulators to transfer where can i get cialis. Washington States where the official word is that accumulators will not transfer Some states have fairly clearly indicated that insurers will not transfer accumulators if policyholders make a plan change. But even in these states, itâs still worth checking with a specific insurer to see what approach theyâre taking, as some are still developing their approach during this unique time. Illinois Virginia What if my stateâs not where can i get cialis listed?. Insurance departments in the rest of the states havenât put out any official guidance or bulletins regarding accumulator transfers, although these may still be forthcoming as the erectile dysfunction treatment/ARP window progresses.

Keep in mind that it will be July in most states before the ARPâs benefits are available for people receiving unemployment compensation in 2021, so this is still very much a work in progress and likely to evolve over time. States that have not yet where can i get cialis issued specific guidance or clarified insurers positions on accumulator transfers include. Alabama Arizona Arkansas Delaware Florida Georgia Hawaii Indiana Iowa Kansas Kentucky Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Wyoming If youâre in one of these states, your insurer may or may not be transferring accumulators when enrollees switch to a new plan in 2021. If youâve had significant out-of-pocket medical spending so far this year, be sure to reach out to your insurer to see how theyâre handling this. And if a representative tells you that accumulators will transfer, itâs a good idea to get where can i get cialis confirmation in writing.

And if your insurer initially says no, keep asking over the coming days and weeks. Weâve seen some insurers start to offer accumulator transfers after initially stating that they didnât plan to do so, and itâs possible that other insurers might follow suit. To switch or not where can i get cialis to switch?. So what should you do if youâve already spent some money out-of-pocket this year, and youâre going to have to start over at $0 on a new plan?. Maybe youâre enrolled in a grandmothered or grandfathered plan and your insurer simply doesnât offer plans for sale in the marketplace.

Depending on where you live, this might also be the case if you have where can i get cialis an ACA-compliant off-exchange plan, as not all off-exchange insurers sell plans in the exchange. And as noted above, it might also be the case even if you want to transfer from one ACA-compliant plan to another. (But check with both the insurer and the insurance department in your state before giving up on accumulator transfers in that situation.) Really, it just comes down to the math. Will the amount youâre going to save due to premium tax credit (and possibly cost-sharing reductions, if youâre eligible for them and switching to a Silver plan) offset the where can i get cialis loss youâll take by having to start over at $0 on your deductible and out-of-pocket exposure?. If you havenât spent much this year, the answer is probably Yes.

If youâve already met your maximum out-of-pocket for the year, itâs probably going to be a tougher decision. But donât assume that where can i get cialis itâs not worth your while. Depending on the circumstances (especially if you were previously impacted by the âsubsidy cliffâ and are newly eligible for subsidies), your new subsidies might be worth more than youâd be giving up by having to start over with new out-of-pocket costs. And if youâre part of the way toward meeting your deductible on a Bronze plan and are newly eligible for a free or very low-cost Silver plan that includes cost-sharing reductions, you might find that the new plan ultimately saves you money in out-of-pocket costs for the rest of the year, even if your accumulators donât transfer. Louise Norris is an individual health insurance broker who has been writing about health where can i get cialis insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health insurance marketplace updates are regularly cited by media who cover health reform and by other health insurance experts.Itâs been a widely held conclusion in the health insurance industry and among health policy types that one of our biggest hurdles lies with the challenge of getting coverage for âyoung invinciblesâ â Americans old enough to vote but under 30. That label where can i get cialis itself is tied to a widely held perception that â because of their youth â âtwenty-somethingsâ believe theyâre healthy enough that they simply wonât need all of the bells and whistles of comprehensive health insurance (any time soon, at least). As an agent and an avid observer of health insurance trends, I know itâs not that simple. Young adults, in many cases, are keenly aware of their need for comprehensive coverage.

But â despite various federal and state efforts where can i get cialis to make coverage more affordable and accessible (including provisions of the American Rescue Plan) â there are definitely barriers making it difficult for young adults to enter the individual health insurance market. Last week, I spoke with Carolyn Kettig, a young woman whoâs determined to get coverage but facing barriers that many young Americans face. Carolyn Kettig is a professional actor in New York, and has thus far maintained health coverage under her motherâs policy. But that where can i get cialis will end this summer, when Carolyn turns 26. She shares her story with me here, and Iâve added my own commentary wherever it might help readers in similar situations understand their coverage options.

Before we begin, itâs worth noting that because Carolyn lives in New York, she has access to a Basic Health Program. New York and Minnesota are the only states that offer these programs, and theyâre an excellent coverage option for people who are where can i get cialis eligible to enroll. But if youâre not in New York or Minnesota, youâve still got plenty of options. Thatâs particularly true now that the American Rescue Plan has been enacted, making premium subsidies larger and more widely available. For many where can i get cialis young people, the American Rescue Plan makes robust coverage much more affordable than it used to be.

(Previously, it was common for young people to feel like their only truly affordable health coverage option was a plan with a deductible that may have felt impossibly high). Louise. Whatâs your current where can i get cialis insurance situation and how is it changing this year?. What are your options for coverage?. Carolyn.

Iâm lucky enough to currently be covered by my where can i get cialis motherâs health insurance. She has a very generous insurance plan and Iâve been privileged to, thus far, be fully covered. Unfortunately, because Iâm turning 26, Iâll be losing coverage this spring. As a professional actor, where can i get cialis my early twenties were filled with countless side jobs that supported me as I sought acting work in New York City. None of these jobs ever came with healthcare benefits, which at the time was okay as I was covered by my motherâs plan.

Three years ago, when I landed my first big theater job, I had the opportunity to join the actorâs union, which among many other wonderful things, provides working actors with comprehensive, affordable health insurance. The only catch, and itâs a fairly large one, where can i get cialis is that an actor must work a certain number of weeks in order to qualify. Even without a cialis, finding steady work in the theater is difficult. Factor in a cialis that shutters theaters for over a year and causes the union to hemorrhage money â¦ needless to say, healthcare coverage in my industry has become a near impossibility. Iâm hopeful that live entertainment will return where can i get cialis in a vaccinated world, but until then, Iâm doing my best to make enough money to pay my bills.

Iâm grateful to be employed part-time as a program director for a teen program. My job has kept me afloat during this devastating time, but, unfortunately, does not come with healthcare benefits. I make very little money where can i get cialis and live paycheck to paycheck, which leaves me relatively few options when it comes to insurance. I will most likely go with New York Stateâs Essential Plan, which is the best option for low-income people who make too much money to qualify for Medicaid. Louise.

The Essential Plan is New Yorkâs where can i get cialis Basic Health Program (BHP), which is available to people earning up to 200% of the poverty level. (For a single person in 2021, that amounts to $25,760.) The Affordable Care Act allowed for the creation of BHPs, but New York and Minnesota are the only states that have opted to establish them. The Essential Plan provides robust health coverage with no monthly premium, and it has much lower cost-sharing than we typically see in the individual/family health insurance market. The Essential Plan is also being enhanced as of where can i get cialis June 2021. Previously, some enrollees had to pay $20/month, and there was an extra premium for dental and vision coverage.

Dental and vision are now included at no cost. Louise. How much is the need for coverage weighing on you and other people your age?. Carolyn. Iâve lost sleep over this!.

It weighs on me heavily. Having grown up in New York, I have a long history with some of my doctors, most of whom will not accept my new insurance plan. This means that I will either be forced to find new doctors or pay hundreds of dollars out of pocket for routine check-ups. Iâm also aware that, even with insurance coverage, an unexpected hospital stay could cost me thousands of dollars. It makes me enraged to know that, in an emergency situation, I would avoid going to the hospital because of the cost.

Louise. The Essential Plan provides much more robust coverage than people may be used to seeing elsewhere. There is no deductible, emergency room visits cost $75, and inpatient hospital stays are only $150 per admission â and these fees are waived altogether for enrollees with income up to 150% of the poverty level, or a little more than $19,000 for a single person. This is better coverage than most people have even with higher-end employer-sponsored plans. Carolyn.

I know that Iâm not alone in this. Especially since my generation is now living through a global health crisis, I think my peers are more aware than ever before of how broken our healthcare system really is. Moreover, as a white, cisgendered woman from a middle-class background, Iâm cognizant of the privilege my identities afford me and deeply disturbed by the ways in which our healthcare system disregards and harms BIPOC, low-income families, LGBTQIA+ youth, and undocumented workers (many of whom are essential workers and yet have little access to healthcare coverage) among many others. Alongside the climate crisis and the fight for racial equality, I believe that healthcare reform will dominate the American political landscape for the next few decades. Louise.

I agree that our healthcare system is in need of extensive reform. The American Rescue Plan, enacted just last month, is the first major change weâve seen since the Affordable Care Act was signed into law 11 years ago. It includes some substantial improvements designed to make health coverage more affordable and accessible. But these improvements are temporary unless Congress takes additional action to make them permanent. And there are other issues, such as the ACAâs family glitch, and the Medicaid coverage gap that exists in the dozen states that have refused to expand Medicaid, that havenât yet been fixed.

Fortunately, lawmakers in Congress are continuing to push forward on these issues, and voters can reach out to their elected officials to express their opinions. Louise. What do you see as challenges in this situation?. Carolyn. Iâve mentioned many challenges already, but I think chief among them is simply how confusing and difficult it is to make informed choices.

Reading about insurance options requires learning an entirely new language and navigating nearly impenetrable websites. Louise. For folks who are confused by the terminology and concepts that go along with health insurance, our glossary is a great resource. Weâve incorporated plenty of details, since thatâs where the nuances always are. And weâve focused on explaining things using plain language thatâs easy to understand.

Help from the American Rescue Plan Louise. Are you aware of the changes that the American Rescue Plan has made?. Do you think it will make it easier for you to access coverage?. Carolyn. Iâve read a bit about the changes made by the American Rescue Plan and am thrilled that this administration is attempting to expand access to healthcare (even though Iâd love to see more substantial reform).

I donât think that I will be impacted directly by the bill because I already live in a state that offers an affordable plan for people in my income bracket. Louise. If you lived in another state, the American Rescue Plan would make your coverage more affordable. But youâre correct. Assuming your 2021 income doesnât exceed 200% of the poverty level (about $25,760), youâll be eligible for either The Essential Plan or Medicaid in New York, both of which are already robust coverage with no monthly premiums.

But for others in a similar situation who live elsewhere, the American Rescue Plan implements a variety of improvements that make it easier for young people to transition to their own coverage. Among other provisions, the American Rescue Plan. Increases the size of premium subsidies and makes them more widely available. Makes coverage more affordable for young people. Ensures that people who are receiving unemployment compensation this year can enroll in robust coverage without having to worry about the cost.

Louise. What do you expect to happen with your coverage this summer?. Do you have a good idea of the plan youâll be on after you transition away from your momâs coverage, or is it still up in the air?. Carolyn. Fortunately, through The Actors Fund, I have access to a professional who will guide me through the process of finding a plan, although Iâm fairly certain I will end up on the Essential Plan.

Iâve been told to begin the process a couple months before I lose coverage, so thatâs coming up very soon!. I also have many friends who are in a similar situation or have already gone through the process, so I expect Iâll be texting them a whole lot. Even though Iâm anxious about navigating the system on my own for the first time, I feel well supported as I approach this transition. Louise. As youâre going through this insurance transition, what do you feel are the most important things for other people your age to keep in mind?.

Difference between viagra and cialis

Rebecca Teng, MDAustin Obstetrician and GynecologistMember, Texas Medical Association Committee on Reproductive, Womenâs and Perinatal HealthWhile traditional obstetric care often focuses on the time of a womanâs pregnancy through the time of the delivery of the baby, there is a growing recognition about click for source the difference between viagra and cialis need for more attention to the time after she delivers. During this postpartum period â increasingly referred to as the fourth trimester â a new mother will need medical care, and she needs health insurance to help her obtain that care. Medicaid, which covers 53% of all Texas births, should cover women not only throughout difference between viagra and cialis their pregnancies but also for a full year after they give birth. During the pregnancy, women see the physician more frequently than at any other time of a typical healthy personâs life. Visits ramp up near the end of pregnancy, as physicians who provide obstetrical care and their medical teams are looking for any condition that may affect the mother or an infant and might change their recommendation about the babyâs delivery.

After delivery, the postpartum difference between viagra and cialis period is a time of potential vulnerability for the new mother. As every parent knows, the arrival of a newborn, no matter how loved, means many sleepless nights, new stress, and relationship challenges. But this period is especially dangerous for those who might have unstable insurance coverage or who are uninsured. Even before the difference between viagra and cialis cialis, one-quarter of Texas women of reproductive age lacked health insurance. Without coverage, women are less likely to access primary, specialty, and preventive care services to be healthy, increasing the risk of preventable issues and tragedies.Following childbirth, postpartum women need ongoing treatment for any underlying chronic health conditions, such as hypertension or diabetes, or to treat complications that might arise in the following year, some of which are life-threatening if untreated.

These complications include severe postpartum depression and heart disease. In addition, healthy pregnancies do difference between viagra and cialis not begin at conception, but well before. Once a woman becomes pregnant, an obstetrician-gynecologist or family physician caring for her cannot undo cumulative years of poor health stemming from little or no care prior to getting pregnant. For example, if a woman has had uncontrolled diabetes, this can increase the risk of birth defects in the infant and the risk of complications. One example is shoulder dystocia (a condition when one or both of a babyâs shoulders get caught inside the motherâs pelvis difference between viagra and cialis during labor).

Another is a potentially greater need for the mother to have a cesarean delivery (commonly known as a C-section, surgically delivering the baby). Also, if deliveries are less than 18 months apart, there can be a higher risk of preterm labor, growth issues, and placental issues. According to Texasâs own expert difference between viagra and cialis panel, womenâs lack of access to regular, preventive primary and specialty care before and after pregnancy contributes to Texasâ high rate of maternal deaths. Nearly one-third of new mothersâ deaths occur 60 days or more postpartum â the same time many low-income women lose their pregnancy-related Medicaid coverage. Among Black women, the numbers are far worse.

Black women difference between viagra and cialis account for 31% of maternal deaths but only 11% of births. As tragic as maternal deaths are, they are only one part of the story. For every woman who dies in conjunction with having a baby, 50 to 100 women suffer a severe illness or complication, often with lasting consequences. According to the American College of Obstetricians and Gynecologists, nearly seven in 10 women report at least one physical problem in the first year after delivery, and one in nine women may experience difference between viagra and cialis symptoms of postpartum depression. Extending womenâs Medicaid coverage for a full year after they have their baby would prolong their care to help address and resolve these complications.Fortunately, the Healthy Texas Women (HTW) program â and the new Healthy Texas Women Plus program â help fill the coverage gap by providing low-income women preventive and basic primary care before and after pregnancy as well as some specialty services for the 12 months following delivery.

HTW Plus, launched in September 2020, builds on HTW by providing one year of limited specialty care coverage for the three conditions and illnesses most likely to contribute to maternal mortality or morbidity. Postpartum depression, which one difference between viagra and cialis in eight women develop. Cardiovascular and other coronary conditions. And substance abuse disorders. However, these programs do not provide comprehensive coverage like Medicaid does, meaning women with complex medical needs will not have coverage for all the difference between viagra and cialis services they need.

Comprehensive coverage matters. Women who live in states with prolonged coverage are more likely to have ongoing access to health care before, during, and after pregnancy, and they are more likely to get postpartum treatment when they suffer severe complications. They also are less likely to die after having their baby difference between viagra and cialis. Extending postpartum Medicaid coverage would give eligible women health insurance longer, allowing them to continue treatment for any known health conditions. Women also could obtain treatment for any other conditions that may develop, such as diabetes or cancer.

Protecting continuity of care also would allow women to have one difference between viagra and cialis fewer transition in the tumultuous time of the first year after delivery and bolster their ability to have the continued support of their medical team. Extending postpartum Medicaid coverage for a year would align mothersâ care with that of their infants, who have guaranteed Medicaid coverage for the first year of their lives. This improvement might also decrease the likelihood the mother would need to seek emergency care (and face that extra expense) as women probably could be cared for in outpatient offices and clinics rather than having to rush to the hospital with an emergency.It is for these reasons that the Texas Medical Association supports enactment of comprehensive health care coverage initiatives, including extending full Medicaid coverage for 12 months to postpartum women who otherwise lose coverage 60 days postpartum, as well as extending comprehensive coverage to low-income, uninsured, working-age adults.* Extending postpartum Medicaid coverage has wide support among many physicians, medical societies, and hospitals, including difference between viagra and cialis the Texas Pediatric Society, Texas Association of Obstetricians and Gynecologists, American Congress of Obstetricians and Gynecologists District XI (Texas), Texas Academy of Family Physicians, and Texas Hospital Association, along with numerous national societies. There also is bipartisan congressional support. By extending postpartum Medicaid coverage to a full year, we can better support the health of Texan mothers, infants, and families.

*As a result of federal public health emergency (PHE) erectile dysfunction treatment legislation, states must maintain Medicaid coverage for anyone enrolled in Medicaid on or difference between viagra and cialis after March 18, 2020, including postpartum women. This temporary coverage extension is currently set to expire in June 2021, but will renew with every extension of the PHE.Shao-Chee SimEpiscopal Health FoundationDuring the erectile dysfunction treatment cialis, a time when our personal and community health should take center stage, Texans have been skipping or delaying medical care. Thatâs according to the Episcopal Health Foundationâs (EHFâs) Texas erectile dysfunction treatment Survey report released late last year. This finding is significant because delay or avoidance of medical care difference between viagra and cialis might increase Texansâ risk of serious illness or death due to preventable or treatable health conditions.This EHF study from August-September 2020 backs the results of two earlier national reports. The Kaiser Family Foundation (KFF) Health Tracking Poll in May 2020 found that close to half of adults said they or someone in their household postponed or skipped medical care due to the cialis.

The Centers for Disease Control and Prevention estimated 41% of Americans delayed or avoided seeking medical care as of June. Both reports documented the impact of difference between viagra and cialis the cialis on Americansâ seeking of medical care early in the cialis. The EHF survey is the first-ever statewide survey to capture erectile dysfunction treatmentâs influence on Texansâ medical care-seeking behavior (See the EHF reportâs methodology.) What does the EHF erectile dysfunction treatment Survey find?. More than one-third of Texans (36%) say they or someone in their household have skipped or postponed some type of medical treatment because of erectile dysfunction treatment. One-third of Texans skipped or postponed preventive care like wellness visits, cancer screenings, blood difference between viagra and cialis pressure and cholesterol tests, drugs/alcohol counseling, and treatments.

A small percentage also sidestepped diagnostic care like tests, office visits, and procedures needed to diagnose or monitor a disease. Make no mistake, 36% is a big percentage of people not going to the doctor when they should. The survey also revealed difference between viagra and cialis other troubling patterns. Almost three-quarters of respondents skipped or postponed both regular check-ups and dental check-ups as part of their preventive care. Nearly one-third (30%) put off preventive screenings and immunizations for their child.

Nearly the same amount of people (28%) missed or put off seeing their difference between viagra and cialis physician for chronic, ongoing conditions. While the survey shows smaller groups of Texans are neglecting more serious medical procedures like surgery (17%) and cancer treatment (4%), delaying care for chronic conditions can be dangerous. Do race/ethnicity, household income, and educational level matter in explaining Texansâ medical care-seeking behavior during the cialis?. Yes, apparently people of different incomes and race/ethnicity adopted different habits about seeking health care during the cialis difference between viagra and cialis. For example, Hispanic Texans were more likely to say they skipped or postponed cancer treatments than white Texans (9% vs.

3%). (The number of responses from Black Texans was too small to ensure statistical accuracy.) EHF difference between viagra and cialis also found that households with annual income less than $75,000 are more likely to skip or delay doctor visits for chronic conditions such as diabetes and high blood pressure than households with higher income (34% vs. 21%). Texans with less than a college degree are more likely to skip or postpone doctor visits for chronic conditions than their counterparts with a college degree or more (34% vs. 17%).

(See Tables One, Two, and Three for details.)So what does this tell us about the health of Texans?. As the cialis continues, it is disconcerting that six months after the cialis started, more than one-third of Texans were still skipping or delaying medical care, and 70% of those who skipped medical care were putting off their medical and dental check-ups or exams. Some ethnic minorities have been more likely to skip or postpone cancer treatments, and Texans with fewer resources and less education are more likely to delay doctor visits for their chronic conditions. We already knew that avoiding preventive care and delaying addressing health issues might lead to bigger, more serious health problems in the future. That is why it is important to conduct further research to better understand the underlying reasons why Texans have been avoiding medical care and to study whether and in what ways telehealth/telemedicine can address these medical care needs.

The cialis has caused tremendous disruptions in our society. Knowing the enormous health, economic, and social costs of continuing to defer medical care, the survey findings serve as an important reminder for policymakers, regulators, medical professionals, and public health communities to develop policies and programs that encourage Texans to seek appropriate and timely medical care. If Texans prioritize our general health needs as we fight to avoid erectile dysfunction treatment (by socially distancing, wearing masks, and washing hands frequently), we not only boost the overall health of our community but also we avoid suffering other health problems as the number of erectile dysfunction treatment cases in the state continues to increase.Table One. Type of Medical Care Skipped or Delayed by Texans Due to erectile dysfunction treatment by Race/Ethnicity Total White Hispanic Black Skipped or postponed regular check-ups of exams 69% 66% 70% 77% Skipped or postponed dental check-ups of exams 70% 68% 73% 65% Preventative screenings such as mammograms, colonoscopies, or other screenings 38% 41% 37% 31% Doctor visits for chronic conditions such as diabetes and high blood conditions 28% 29% 29% 25% Doctor visits for symptoms you were experiencing 39% 37% 44% 43% Reproductive health care visits 20% 18% 23% 15% Immunizations for your child or other child wellness visits 30% 23% 30% 28% Mental health care 19% 22% 17% 12% Physical therapy or rehabilitation care 17% 14% 21% 16% Surgery 17% 16% 18% 11% Cancer treatments* 4% 3% 9% 1% *Denotes statistically significant difference between Hispanic Texans and White Texans at p<.05Table Two. Type of Medical Care Skipped or Delayed by Texans Due to erectile dysfunction treatment by Household Income Total Under $75K $75K + Skipped or postponed regular check-ups of exams 69% 71% 70% Skipped or postponed dental check-ups of exams 70% 69% 71% Preventative screenings such as mammograms, colonoscopies, or other screenings 38% 37% 39% Doctor visits for chronic conditions such as diabetes and high blood conditions* 28% 34% 21% Doctor visits for symptoms you were experiencing 39% 43% 38% Reproductive health care visits 20% 33% 29% Immunizations for your child or other child wellness visits 30% 26% 16% Mental health care 19% 19% 15% Physical therapy or rehabilitation care 17% 18% 15% Surgery 17% 19% 16% Cancer treatments 4% 5% 4% *Denotes statistically significant difference between Households with income less than $75K and households with income more than $75K at p<.05.Table Three.

Type of Medical Care Skipped or Delayed by Texans Due to erectile dysfunction treatment by Educational Level Total Less than college College+ Skipped or postponed regular check-ups of exams 69% 68% 73% Skipped or postponed dental check-ups of exams 70% 68% 72% Preventative screenings such as mammograms, colonoscopies, or other screenings 38% 36% 42% Doctor visits for chronic conditions such as diabetes and high blood conditions* 28% 34% 17% Doctor visits for symptoms you were experiencing 39% 43% 33% Reproductive health care visits 20% 18% 25% Immunizations for your child or other child wellness visits 30% 31% 29% Mental health care 19% 17% 23% Physical therapy or rehabilitation care 17% 19% 14% Surgery 17% 18% 16% Cancer treatments 4% 6% 2% *Denotes statistically significant difference between Texans with less than a college degree and Texans with a college degree at p<.05..

During the pregnancy, women see the physician more frequently than at any other time of a typical healthy personâs life. Visits ramp up near the end of pregnancy, as physicians who provide obstetrical care and their medical teams are looking for any condition that may affect the mother or an infant and might change their recommendation about the babyâs delivery. After delivery, the postpartum period is a where can i get cialis time of potential vulnerability for the new mother.

As every parent knows, the arrival of a newborn, no matter how loved, means many sleepless nights, new stress, and relationship challenges. But this period is especially dangerous for those who might have unstable insurance coverage or who are uninsured. Even before where can i get cialis the cialis, one-quarter of Texas women of reproductive age lacked health insurance.

Without coverage, women are less likely to access primary, specialty, and preventive care services to be healthy, increasing the risk of preventable issues and tragedies.Following childbirth, postpartum women need ongoing treatment for any underlying chronic health conditions, such as hypertension or diabetes, or to treat complications that might arise in the following year, some of which are life-threatening if untreated. These complications include severe postpartum depression and heart disease. In addition, healthy pregnancies do not begin at conception, but well where can i get cialis before.

Once a woman becomes pregnant, an obstetrician-gynecologist or family physician caring for her cannot undo cumulative years of poor health stemming from little or no care prior to getting pregnant. For example, if a woman has had uncontrolled diabetes, this can increase the risk of birth defects in the infant and the risk of complications. One example is shoulder dystocia (a condition when one or both of a babyâs shoulders where can i get cialis get caught inside the motherâs pelvis during labor).

Nearly one-third of new mothersâ deaths occur 60 days or more postpartum â the same time many low-income women lose their pregnancy-related Medicaid coverage. Among Black women, the numbers are far worse. Black women where can i get cialis account for 31% of maternal deaths but only 11% of births.

As tragic as maternal deaths are, they are only one part of the story. For every woman who dies in conjunction with having a baby, 50 to 100 women suffer a severe illness or complication, often with lasting consequences. According to the American College of Obstetricians and Gynecologists, nearly seven in 10 women report at least one physical problem in the first year after delivery, and one in nine women may experience where can i get cialis symptoms of postpartum depression.

Extending womenâs Medicaid coverage for a full year after they have their baby would prolong their care to help address and resolve these complications.Fortunately, the Healthy Texas Women (HTW) program â and the new Healthy Texas Women Plus program â help fill the coverage gap by providing low-income women preventive and basic primary care before and after pregnancy as well as some specialty services for the 12 months following delivery. HTW Plus, launched in September 2020, builds on HTW by providing one year of limited specialty care coverage for the three conditions and illnesses most likely to contribute to maternal mortality or morbidity. Postpartum depression, which one in eight where can i get cialis women develop.

Cardiovascular and other coronary conditions. And substance abuse disorders. However, these programs do not provide comprehensive coverage like Medicaid does, meaning women with complex medical where can i get cialis needs will not have coverage for all the services they need.

Extending postpartum Medicaid coverage would give eligible women health insurance longer, allowing them to continue treatment for any known health conditions. Women also could obtain treatment for any other conditions that may develop, such as diabetes or cancer. Protecting continuity where can i get cialis of care also would allow women to have one fewer transition in the tumultuous time of the first year after delivery and bolster their ability to have the continued support of their medical team.

Extending postpartum Medicaid coverage for a year would align mothersâ care with that of their infants, who have guaranteed Medicaid coverage for the first year of their lives. This improvement might also decrease the likelihood the mother would need to seek emergency care (and face that extra expense) as women probably could be cared for in outpatient offices and clinics rather than having to rush to the hospital with an emergency.It is for these reasons that the Texas Medical Association supports enactment of comprehensive health care coverage initiatives, including extending full Medicaid coverage for 12 months to postpartum women who otherwise lose coverage 60 days postpartum, as well as extending comprehensive coverage to low-income, uninsured, working-age adults.* Extending postpartum Medicaid coverage has wide support where can i get cialis among many physicians, medical societies, and hospitals, including the Texas Pediatric Society, Texas Association of Obstetricians and Gynecologists, American Congress of Obstetricians and Gynecologists District XI (Texas), Texas Academy of Family Physicians, and Texas Hospital Association, along with numerous national societies. There also is bipartisan congressional support.

By extending postpartum Medicaid coverage to a full year, we can better support the health of Texan mothers, infants, and families. *As a result of federal public health emergency (PHE) erectile dysfunction treatment legislation, states must maintain Medicaid coverage for anyone enrolled in Medicaid on or after March 18, where can i get cialis 2020, including postpartum women. This temporary coverage extension is currently set to expire in June 2021, but will renew with every extension of the PHE.Shao-Chee SimEpiscopal Health FoundationDuring the erectile dysfunction treatment cialis, a time when our personal and community health should take center stage, Texans have been skipping or delaying medical care.

Thatâs according to the Episcopal Health Foundationâs (EHFâs) Texas erectile dysfunction treatment Survey report released late last year. This finding is significant because delay or avoidance of medical care might increase where can i get cialis Texansâ risk of serious illness or death due to preventable or treatable health conditions.This EHF study from August-September 2020 backs the results of two earlier national reports. The Kaiser Family Foundation (KFF) Health Tracking Poll in May 2020 found that close to half of adults said they or someone in their household postponed or skipped medical care due to the cialis.

The Centers for Disease Control and Prevention estimated 41% of Americans delayed or avoided seeking medical care as of June. Both reports where can i get cialis documented the impact of the cialis on Americansâ seeking of medical care early in the cialis. The EHF survey is the first-ever statewide survey to capture erectile dysfunction treatmentâs influence on Texansâ medical care-seeking behavior (See the EHF reportâs methodology.) What does the EHF erectile dysfunction treatment Survey find?.

More than one-third of Texans (36%) say they or someone in their household have skipped or postponed some type of medical treatment because of erectile dysfunction treatment. One-third of Texans skipped or postponed preventive care like wellness visits, cancer screenings, blood pressure where can i get cialis and cholesterol tests, drugs/alcohol counseling, and treatments. A small percentage also sidestepped diagnostic care like tests, office visits, and procedures needed to diagnose or monitor a disease.

Make no mistake, 36% is a big percentage of people not going to the doctor when they should. The survey where can i get cialis also revealed other troubling patterns. Almost three-quarters of respondents skipped or postponed both regular check-ups and dental check-ups as part of their preventive care.

Nearly one-third (30%) put off preventive screenings and immunizations for their child. Nearly the where can i get cialis same amount of people (28%) missed or put off seeing their physician for chronic, ongoing conditions. While the survey shows smaller groups of Texans are neglecting more serious medical procedures like surgery (17%) and cancer treatment (4%), delaying care for chronic conditions can be dangerous.

Do race/ethnicity, household income, and educational level matter in explaining Texansâ medical care-seeking behavior during the cialis?. Yes, apparently people of different incomes and race/ethnicity adopted different habits about seeking where can i get cialis health care during the cialis. For example, Hispanic Texans were more likely to say they skipped or postponed cancer treatments than white Texans (9% vs.

3%). (The number of responses from Black Texans was too small to ensure statistical accuracy.) EHF also found that households with annual income less than $75,000 are more likely to skip or delay doctor visits for chronic conditions such as diabetes and high blood pressure than households with higher income (34% vs where can i get cialis. 21%).

Texans with less than a college degree are more likely to skip or postpone doctor visits for chronic conditions than their counterparts with a college degree or more (34% vs. 17%). (See Tables One, Two, and Three for details.)So what does this tell us about the health of Texans?.

As the cialis continues, it is disconcerting that six months after the cialis started, more than one-third of Texans were still skipping or delaying medical care, and 70% of those who skipped medical care were putting off their medical and dental check-ups or exams. Some ethnic minorities have been more likely to skip or postpone cancer treatments, and Texans with fewer resources and less education are more likely to delay doctor visits for their chronic conditions. We already knew that avoiding preventive care and delaying addressing health issues might lead to bigger, more serious health problems in the future.

That is why it is important to conduct further research to better understand the underlying reasons why Texans have been avoiding medical care and to study whether and in what ways telehealth/telemedicine can address these medical care needs. The cialis has caused tremendous disruptions in our society. Knowing the enormous health, economic, and social costs of continuing to defer medical care, the survey findings serve as an important reminder for policymakers, regulators, medical professionals, and public health communities to develop policies and programs that encourage Texans to seek appropriate and timely medical care.

If Texans prioritize our general health needs as we fight to avoid erectile dysfunction treatment (by socially distancing, wearing masks, and washing hands frequently), we not only boost the overall health of our community but also we avoid suffering other health problems as the number of erectile dysfunction treatment cases in the state continues to increase.Table One. Type of Medical Care Skipped or Delayed by Texans Due to erectile dysfunction treatment by Race/Ethnicity Total White Hispanic Black Skipped or postponed regular check-ups of exams 69% 66% 70% 77% Skipped or postponed dental check-ups of exams 70% 68% 73% 65% Preventative screenings such as mammograms, colonoscopies, or other screenings 38% 41% 37% 31% Doctor visits for chronic conditions such as diabetes and high blood conditions 28% 29% 29% 25% Doctor visits for symptoms you were experiencing 39% 37% 44% 43% Reproductive health care visits 20% 18% 23% 15% Immunizations for your child or other child wellness visits 30% 23% 30% 28% Mental health care 19% 22% 17% 12% Physical therapy or rehabilitation care 17% 14% 21% 16% Surgery 17% 16% 18% 11% Cancer treatments* 4% 3% 9% 1% *Denotes statistically significant difference between Hispanic Texans and White Texans at p<.05Table Two. Type of Medical Care Skipped or Delayed by Texans Due to erectile dysfunction treatment by Household Income Total Under $75K $75K + Skipped or postponed regular check-ups of exams 69% 71% 70% Skipped or postponed dental check-ups of exams 70% 69% 71% Preventative screenings such as mammograms, colonoscopies, or other screenings 38% 37% 39% Doctor visits for chronic conditions such as diabetes and high blood conditions* 28% 34% 21% Doctor visits for symptoms you were experiencing 39% 43% 38% Reproductive health care visits 20% 33% 29% Immunizations for your child or other child wellness visits 30% 26% 16% Mental health care 19% 19% 15% Physical therapy or rehabilitation care 17% 18% 15% Surgery 17% 19% 16% Cancer treatments 4% 5% 4% *Denotes statistically significant difference between Households with income less than $75K and households with income more than $75K at p<.05.Table Three.

Benefits of daily cialis

He focused his eyes on me to verify that I http://nickfarnell.ca/where-to-get-zithromax-pills/ pose benefits of daily cialis no danger. If I had fetched my cell phone to snap a photo, he would have disappeared. I chose to enjoy the view, savoring the moment as if the deer were a transient piece of music. In such instances, rare beauty benefits of daily cialis cannot be documented or else it disappears.

This left no way for me to share my rare experience with my family. Past generations may have witnessed phenomena that were never documented in a scientific way. Is it benefits of daily cialis possible that we missed important scientific clues from the past?. Science relies on reproducibility of results, but we might need to wait a long time before rare events will repeat.

Let us consider a particular example. Suppose the solar system had been visited by benefits of daily cialis technological equipment from an extraterrestrial civilization a few million years agoâhardly impossible since the age of the Milky Way galaxy is a million times longer than our recorded history. If we found a photo album with high-resolution images from that time, we would have an affirmative answer to Enrico Fermiâs paradox. ÂWhere is everybody?.

Â But the absence of that evidence doesnât mean the benefits of daily cialis answer is negative. If a tree falls in the forest and there is nobody around to hear it, does it make a sound?. One remedy is to search for surprising events in the long history of Earth. For example, two billion years after the benefits of daily cialis Earth formed, the oxygen level in the atmosphere rose for an unknown reason, enabling the complex life that currently thrives on Earth.

Even more surprisingly, intelligent life appeared abruptly in the last one thousandth of the Earthâs history. Both events probably have a natural origin, but other explanations are possible. A better approach is to search the sky for technological relics from distant civilizations benefits of daily cialis. The newly announced Galileo Project aims to image objects near Earth whose nature is unknown, such as unidentified aerial phenomena (UAP) or anomalous interstellar objects like âOumuamua.

It makes little sense to do otherwise. Choosing not to look through the windows doesnât mean your neighbors arenât benefits of daily cialis there. A common mistake is to assume that our environment was choreographed with us in mind. Instead, we might just be spectators of a play designed for other actors, just as I was in the natural environment of the Adirondack deer.

Any technological equipment that the Galileo Project finds could have been sent millions benefits of daily cialis of years ago, long before humans existed. The probes could have been sent towards Earth as a habitable destination on its own merit. The Galileo Project will ignore objects that are of most interest to national security, such as drones or airplanes which are human-made. Instead, it will focus on the âotherâ category in the UAP report that was delivered to benefits of daily cialis Congress on June 25, 2021.

To justify my engagement in the Galileo Project as part of my day job at Harvard University, I explained that it will assemble and interpret data from telescopes. Rather than focusing on distant objects as astronomers often do, our research team will track nearby objects that move fast on the sky. There is no minimum distance for benefits of daily cialis an object to be considered astronomical, especially if it originated from outside the solar system before arriving to our vicinity. The thousands of supporting e-mails I received in the days following the announcement of the Galileo Project show unequivocally that the idea of imaging the unknown inspires people.

Bringing the study to the mainstream of astronomy will attract new funds and talent to science. There is no downside to seeking evidence benefits of daily cialis. It is a win-win proposition that will teach us something new. Even if âOumuamua is a natural object, like a never-seen-before hydrogen iceberg, we will learn that there must be nurseries of interstellar objects that are very different from the solar system.

In leading the Galileo Project, I act as former farm boy who has preserved his benefits of daily cialis childhood curiosity. I understand the pushback from those who do not share my perspective, but cherish the company of like-minded explorers and donors. The Galileo Project is a fishing expedition. We use hooks in the benefits of daily cialis form of telescopes without assuming what they might catch.

The fundamental innovation is that we chose to look through telescopes for answers. This is the biggest lesson we learned from Galileo Galileiâs debate with the philosophers who refused to look through his telescope. Recently, a philosopher published an benefits of daily cialis article that uses philosophical reasoning to argue that âOumuamua could not have been technological in origin. This suggests that looking through telescopes for answers is not as trivial as it may seem four centuries after Galileo.

This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American.Some gestures can benefits of daily cialis be understood almost anywhere. Pointing to direct someoneâs attention, for instance. New research shows that certain vocalizations can also be iconic and recognizable to people around the worldâeven when a speaker is not simply imitating a well-known sound.

These findings, published in Scientific Reports, may help explain the rise of modern spoken language benefits of daily cialis. In 2015 language researchers challenged some English speakers to make up sounds representing various basic concepts (âsleep,â âchild,â âmeat,â ârock,â and more). When other English speakers listened to these sounds and tried matching them to concepts, they were largely successful. But âwe wanted to be benefits of daily cialis able to show that these vocalizations are understandable across cultures,â says study co-author and University of Birmingham cognitive scientist Marcus Perlman.

Credit. Amanda MontaÃ±ez. Source. ÂNovel Vocalizations Are Understood across Cultures,â by Aleksandra Cwiek et al., in Scientific Reports, Vol.

11. May 12, 2021 So Perlman and his colleagues conducted online and in-person experiments in seven countries, from Morocco to Brazil. They recruited more than 900 participants, who spoke a total of 28 languages, to listen to the best-understood vocalizations from the 2015 investigation and select matching concepts from a set of words or images. Vocalizations that evoked well-known soundsâfor example, dripping waterâperformed best.

But many others were also understood at rates significantly above chance across all languages tested, the team found. ÂThere is a notable degree of success outside of just onomatopoeia,â Perlman says. This is likely because certain acoustic patterns are universal, the team suggests. For example, short and basic sounds often convey the concept of âone,â and repeated sounds are typically associated with âmany.â Likewise, low-pitched sounds accompany something big, and high-pitched sounds convey small size.

These findings of âiconicâ sounds could help scientists understand how human ancestors started using rich acoustic communication, says co-author Aleksandra Äwiek, a linguist at the Leibniz-Center General Linguistics in Berlin. The human voice, she says, might âafford enough iconicity to get language off the ground.â University of TÃ¼bingen linguist Matthias Urban, who was not involved in the research, agrees. ÂItâs unclear how words came into being in the first place,â he says. Iconic vocalizations are âpotentially one pathway that could have been involved.âThe famous opening words, âIt was the best of times, it was the worst of times,â of Charles Dickens' 1859 novel A Tale of Two Cities referred to the period of French Revolution.

But he could equally well have been describing his contemporary Charles Darwinâs experience with his theory of evolution by natural selection. Darwin was born at the best of times in 1809 when conditions were highly conducive for his theory to flourish, but he died in 1882 at the worst of times because there was a real danger that it might soon be killed off. Darwin's nemesis was the eminent physicist Lord Kelvin, and the weapon used against him was the age of the Earth. Various theories of evolution predated Darwin, but whatever version one favored, one thing was clear.

It needed a very long time for its consequences to work itself out. Precisely how long was hard to pin down, but it was believed to require tens or hundreds of millions of years. From 1650 on, the dominant theory about the age of the Earth, based on the work of Bishop Ussher, Isaac Newton and many other scholars who used various textual sources, was that it was about 6,000 years. Theories of geology and biology had to accommodate themselves to this short timeframe.

The geological theory known as catastrophism postulated that major features such as the Grand Canyon, Himalayas, etc. Had emerged as a result of sudden and violent upheavals. When it came to biological diversity, the idea of special creation, that organisms were immutable and had been specially designed to fit the biological niches in which they found themselves, was the prevailing view. Such a short window of time would have made it impossible for anyone to credibly propose the emergence of new species by a process of slow evolution.

But around 1785, ideas of the age of the Earth began to undergo a radical change as geologists and paleontologists started using the features of the Earth itself, such as erosion, sedimentation and the layers of strata and the fossils embedded in them, to estimate its age. The theory of uniformitarianism, that major geological features were caused by the very slow accumulation of tiny changes, gained ground, culminating in Charles Lyellâs epic three-volume work Principles of Geology in 1830 that cemented the idea that the Earth had been around for hundreds of millions of years and possibly much longer, so long that it seemed impossible to fix an actual age. Darwin was also a keen student of geology and was familiar with Lyell's work (they later became close friends) and had the first two volumes of his book with him as he made his five-year voyage around the globe on the HMS Beagle during 1831â1836, where the ideas for his theory of evolution germinated as he observed the patterns of species in the various locations that he visited. Darwin knew from his work with pigeons that even deliberately breeding for specific characteristics took a long time to produce them.

But how much time was necessary?. He felt that it required at least hundreds of millions of years. The work of Lyell and other geologists gave him the luxury of assuming that sufficient time existed for natural selection to do its work. Darwin also came of age at a time when the idea that species were immutable had begun to crumble.

While Darwin was taught and accepted the still dominant special creation theory, he was also familiar with the general idea of evolution. His own grandfather Erasmus Darwin had in 1794 published a book Zoonomia that explored protoevolutionary ideas. Jean-Baptiste Lamarck had published his own model of how evolution worked in 1802. The various models proposed for the mechanism of evolution, such as Lamarckian evolution, orthogenesis and use-disuse, all implied some level of teleology.

That there was a directionality inherent in the process. The extremely long window of time opened up by the new geology allowed Darwin and his co-creator Alfred Russell Wallace, working independently, to develop the central new insight of natural selection that differed from other models of evolution by showing how diversity could arise naturally by a process of Malthusian population selection pressures, without any kind of mystical agency directing the process towards any specific ends. Their theory held that evolution was contingency-driven in that how organisms evolved depended on chance factors and a changing environment, which suggested that if we ran the clock again, we could get very different outcomes in which human beings might never appear. Their work was first presented in a joint paper in 1858.

Darwin's major work On the Origin of Species, published a year later, was a closely argued compilation of a massive amount of evidence that helped establish evolution as a fact. The radical change in the status of human beings implied by their model, from being specially created in the image of God to just another accidental byproduct of the evolutionary process just like all other species, was an immediate source of controversy because it challenged a key religious tenet that human beings were special. This was why natural selection aroused such opposition even while evolution was accepted. Many scientists of that time were religious and believed in theistic evolution that said that a supernatural agency was guiding the process to produce the desired ends.

While all models of evolution required long times, natural selection required much longer times than any guided selection process. Hence the younger the age of the Earth, the more likely it was that natural selection could not be the mechanism. Physicists, led by the eminent Kelvin, himself a theistic evolutionist, were leaders of the charge for a young Earth, though it must be emphasized that âyoungâ at that time meant around 100 million years or less. Even religious scientists had abandoned the idea of the Earth being just 6,000 years old.

Beginning around 1860, Kelvin and other physicists started estimating the ages of the Earth and sun using the nebular hypothesis proposed around 1750 by Immanuel Kant and Pierre-Simon Laplace. This model treated the Earth and the sun as starting as rotating clouds of particles that coalesced under gravity to form molten balls, with the Earth subsequently solidifying and cooling. Kelvin used the laws of thermodynamics and other physics principles to arrive at estimates of 20â400 million years. By 1879 the upper limit had been lowered to about 100 million years for the Earth and an even shorter upper limit of 20 million years for the Sun, much less than the 200 million years or so believed to be required for natural selection to work.

Since physics was considered to be the most rigorous of the sciences, things looked bad for natural selection. When Darwin died in 1882, he was mourned as a great scientist who had radically changed our understanding of how the vast diversity of organisms we see around us came about, dethroning the idea that they were immutable. But because of the shrinking age of the Earth, he died with a major cloud hanging over his mechanism of natural selection. Darwin's final words on the topic, written in 1880 just two years before his death, expressed a plaintive hope that future developments might reconcile the needs of natural selection with physics calculations.

ÂWith respect to the lapse of time not having been sufficient since our planet was consolidated for the assumed amount of organic change, and this objection, as urged by [Lord Kelvin], is probably one of the gravest as yet advanced, I can only say, firstly that we do not know at what rate species change as measured in years, and secondly that many philosophers are not yet willing to admit that we know enough of the constitution of the universe and of the interior of our globe to speculate with safety on its past duration.â It turned out Darwin was prescient that improved knowledge of the interior of the Earth might change the calculations in his favor, but at the time he seemed to be grasping at straws. In fact, in the near term the problem got even worse because Kelvin and others produced new calculations that resulted in the age of the Earth being reduced even more, so that by 1895 the consensus physics view was that the age of the planet lay in the range 20â40 million years. Natural selection appeared to be doomed. But physicists were now encountering stiffer opposition from other disciplines.

Geologists were adamant that their models based on the accumulating evidence on sedimentation and erosion, while not as rigorous as the physics models, were well enough established that they were confident of their lower limit of 100 million years. Paleontologists were also arguing that the fossil record was not consistent with the physicistsâ shorter ages. Both groups argued that the physicists must have gone awry somewhere, even if they could not point out the specific flaws. Beginning in 1895, this impasse began to be broken when physicist John Perry, a former assistant of Kelvin's, challenged the latter's assumption that the Earth was a rigid and homogeneous body, saying there was little evidence to support it.

By introducing inhomogeneity and convective flow in the Earthâs interior, he found that Kelvinâs estimates for the age of the Earth could change by as much as a factor as 100, shifting the upper limit into the billions of years. Other physicists also chimed in with similar upward shifts, and this encouraged geologists, paleontologists and biologists to ignore the physicists' arguments for a young Earth. It was the discovery of radioactivity that decisively changed the picture. It led to an entirely new way of measuring the age of the Earth, by allowing scientists to calculate the ages of rocks.

Since the oldest rock that could be found set a lower limit for the age of the Earth, the race was on to find older and older rocks using this method. Records fell rapidly, leading to ages of 141 million years by 1905, 1.64 billion years by 1911, 1.9 billion years by 1935, 3.35 billion years by 1947, and to 4.5 billion years by 1953, which is where the current consensus lies. When Kelvin died in 1907 at the age of 83, it was not clear if he had accepted that his estimates were no longer valid. But Darwin's hope that Kelvin would be proven wrong, and that eventually it would be shown that sufficient time existed for natural selection to work, was realized, 30 years after Darwinâs death.

His theory now has all the time it needs. This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American.Edited by Dava Sobel First it fell just fell at my feet no wind no squirrel or bird to give it a push a green green pine cone with brown accents heavy with sealed overlapping rounded rhomboid structures in spirals I have to restrain myself from seeing here the condensed aromatic hydrocarbons I leave it on a plate and look on the web for the names of cone parts names are important even if my last name changed three times what I learn is that I have a female cone that the plates are scales and that each comes in two types bract or seed I think I am seeing seed scales in formation tightly fitting each scale at its center begins to ooze ever-so-slowly a tiny pitch droplet a spiral of spherical diamonds now I know it's pitch and not sap because it is damn sticky I can't get it off my fingers we enter the world of science dealing with the world of words and the world of things being farmed and manufactured and sold sap is not pitch which is not resin-resin and rosin and turpentine and pine tar what's in it for plants is not what's in it for us see water-based sap gets molecule A from site B to C in the inner tree while pitch is an organic soup moving in its own pipelines near the bark ready to flow out if bark or wood is damaged to push out with some force an insect to seal in time forming a solid resin odoriferous to repel insects that might enter the damage or attract some others and we thought we humans made things complicated damned chemist in me can't stop wondering what smells what makes things sticky it's terpenes oligomers of isoprene with appropriate names monoterpenes like pinene and diterpenoid resin acids like abietic acid I could tell you how they're made in pine or the lab and before long we have the whole lovable interconnected and thoroughly messy world meanwhile the cone rests oozing gently maybe the small globules of pitch are a survival strategy to be pollinated by any pollen from male cones that might be left over vain hope wrong season no males and the premature cone begins to darken to brown waiting for dispersal. Don't let me get started on acorns.Toward the end of my senior year at Dartmouth, I watched my peers line up in front of the Career Services building.

Waiting for their interviews for corporate jobs, all seemed to be dressed the sameâthe men wearing navy jackets, the women dark dresses. I thought back to my first day on campus four years earlier when we all wore different colors and dreamed of different futures. It was as if our education, instead of enhancing our individualities and imaginations, had reduced them to sameness. It was not a unique scene.

All over the world, formal education supplies the economy with workers who will increase productivity. Its purpose is to fuel the economic machine rather than to alter its inner workings. But this machine now threatens our very survival. If the entire world reaches the levels of consumption seen in high-income countries today, weâll need multiple planet Earths to supply the resources.

The absurd idea of infinite growth within a finite territory is at the heart of our economic system. To keep this machine running, formal education generates ever more efficient âhuman capital.â Increasing productivity metricsâsuch as revenue per employee or return on investmentârather than the individuality of students, drive our civilizationâs approach to schooling our young people. Whereas the Sustainable Development Goals call for turning education into a force for sustainability, the opposite is often true. The ways Western societies have come to think about education undermine our ability to deal with the environmental crisis.

To get through this crisis, we need to cultivate our imagination, not undermine it. Growing up, none of my schooling fostered my ability to imagine a world different from what I saw around me. As a child in 1990s Slovakia, I had to memorize textbooks word by word. Decades later, as an education researcher, I see children elsewhere going through the sameâa chorus of Indian pupils repeating the sentences written by their teacher on the blackboard, a South African child yelled at by the teacher for failing to reproduce exactly the content of the textbook.

Rote learning, discouraging individuality and instilling docility in children are still at the root of what it means to be educated across much of the world. Many experts agree that we need to move away from such approaches to education. But the suppression of childrenâs imagination doesnât take place only in underresourced communities or outmoded education systems. The issue is obscured but even more pernicious in âeliteâ institutions that tout âcritical thinking.â Save for a few wise mentors, hardly anyone encouraged me to imagine an alternative future for the world throughout my Ivy League undergraduate years and my Oxbridge graduate years.

These institutions want to see their graduates succeed, and success is too often about maintaining current structuresânot about reimagining their foundations. In recent years, we have witnessed efforts towards standardizing curricula across the globe. Such reforms bring Western notions of educational success to the rest of the world. Driven by the OECDâs standardized tests, which rank education systems, countries focus on improving quantifiable outcomes such as literacy and numeracy.

Winning the competition for the most efficient educational system today means having the most efficient workforce and growing the national economy faster tomorrow. Our standardized, metric-driven, âefficientâ education systems essentially shape children in the image of artificial intelligence (AI). The perfect âworker,â AI continually improves its own productivity but doesnât challenge the larger structures within which it operates. It is one of the great paradoxes of our time that we invest so much into building supercomputers while marginalizing the imaginative potential of millions of human brains.

Our focus on technological solutions to our civilizationâs challenges is driving our approach to education. More students at British universities are studying science, technology, engineering and mathematics (STEM) than ever before, including a 400 percent increase in enrollment in AI courses over the last 10 years. Compared to STEM, social sciences and humanities are often underfunded and seen as inferior by policy makers and the public alike. But this approach is counterproductive because non-STEM subjects are crucial to fostering our ability to reimagine the world.

We even put our hope in solving the environmental crisis on AI. We use machine learning to optimize energy networks, track land use through satellite imagery and predict extreme weather. But AI, like our other technologies, can only treat the symptoms of the environmental crisis, not the causes. These lie in our arrogance and lack of sensitivity to our impact on the planet.

We canât outsource to computers the solutions to the flaws in our politics and culture that underpin the environmental crisis. Throughout history, achievers of great change have relied on their imaginations to address fundamental flaws in society. In my country of birth, Czechoslovakia, dissidents against Communism kept their dreams of democracy alive for decades by imagining different futures. In South Africa under apartheid, Nelson Mandelaâs followers had to be radical in their imagination to create a vision of a fairer society.

Imagining democracy when living under a totalitarian regime isnât that different from imagining degrowth when living in a world of infinite growth. The kind of intelligence Nelson Mandela and VÃ¡clav Havel possessed was not artificial. The ability to reimagine the future and disrupt the status quo remains a distinctly human quality. Unlike AI, children are naturally imaginative and question the premises of society.

In my research, I have observed that younger children are often the most radical in imagining different futures. As they get older, their imagination tends to become more generic, mimicking mainstream narratives of technological progress. As long as our imagination is curtailed, ideas like degrowth or intergenerational justice remain fringe and sound utopian to many. Cultivating imagination means learning from historyâs disrupters who made the allegedly impossible palatable.

It means moving away from our standardized curricula, quantifiable metrics and authoritarian pedagogies. Instead of dismissing âchildishâ ideas about the worldâs future, it means seeing inspiration in childrenâs imaginations. In an education system that celebrates imagination, arts and creativity are as important as math and science. Teachers develop and act on their own pedagogical philosophies.

Children define success for themselves. Idealism coexists with pragmatism. Expressing opinions and taking political action are goals of education, not distractions from it. Some of these ideas have already inspired educational projects around the worldâsuch as forest schools in Europe, jeevanshalas (schools of life) in India or Schumacher College in the U.K.âbut these are the exceptions.

The environmental crisis is not a crisis of technology or science, it is a crisis of imagination. If we let children be our guides, we might just be able to imagine our way to survival. This is an opinion and analysis article.

And out there I saw where can i get cialis unexpectedly a beautiful young deer near a lake. He focused his eyes on me to verify that I pose no danger. If I had fetched my cell phone to snap a photo, he would have disappeared. I chose to enjoy the view, where can i get cialis savoring the moment as if the deer were a transient piece of music.

In such instances, rare beauty cannot be documented or else it disappears. This left no way for me to share my rare experience with my family. Past generations where can i get cialis may have witnessed phenomena that were never documented in a scientific way. Is it possible that we missed important scientific clues from the past?.

Science relies on reproducibility of results, but we might need to wait a long time before rare events will repeat. Let us consider a where can i get cialis particular example. Suppose the solar system had been visited by technological equipment from an extraterrestrial civilization a few million years agoâhardly impossible since the age of the Milky Way galaxy is a million times longer than our recorded history. If we found a photo album with high-resolution images from that time, we would have an affirmative answer to Enrico Fermiâs paradox.

ÂWhere is everybody? where can i get cialis. Â But the absence of that evidence doesnât mean the answer is negative. If a tree falls in the forest and there is nobody around to hear it, does it make a sound?. One remedy is to search where can i get cialis for surprising events in the long history of Earth.

For example, two billion years after the Earth formed, the oxygen level in the atmosphere rose for an unknown reason, enabling the complex life that currently thrives on Earth. Even more surprisingly, intelligent life appeared abruptly in the last one thousandth of the Earthâs history. Both events probably have a natural origin, but other where can i get cialis explanations are possible. A better approach is to search the sky for technological relics from distant civilizations.

The newly announced Galileo Project aims to image objects near Earth whose nature is unknown, such as unidentified aerial phenomena (UAP) or anomalous interstellar objects like âOumuamua. It makes where can i get cialis little sense to do otherwise. Choosing not to look through the windows doesnât mean your neighbors arenât there. A common mistake is to assume that our environment was choreographed with us in mind.

Instead, we might just be spectators of a play designed for other actors, just as I was in the natural environment of the Adirondack deer where can i get cialis. Any technological equipment that the Galileo Project finds could have been sent millions of years ago, long before humans existed. The probes could have been sent towards Earth as a habitable destination on its own merit. The Galileo Project will ignore objects that are where can i get cialis of most interest to national security, such as drones or airplanes which are human-made.

Instead, it will focus on the âotherâ category in the UAP report that was delivered to Congress on June 25, 2021. To justify my engagement in the Galileo Project as part of my day job at Harvard University, I explained that it will assemble and interpret data from telescopes. Rather than focusing on distant objects as astronomers often do, our research team will track nearby objects that move fast on where can i get cialis the sky. There is no minimum distance for an object to be considered astronomical, especially if it originated from outside the solar system before arriving to our vicinity.

The thousands of supporting e-mails I received in the days following the announcement of the Galileo Project show unequivocally that the idea of imaging the unknown inspires people. Bringing the study to the mainstream of astronomy will attract new funds and talent to science where can i get cialis. There is no downside to seeking evidence. It is a win-win proposition that will teach us something new.

Even if âOumuamua is a natural object, like a never-seen-before hydrogen iceberg, we will learn that there where can i get cialis must be nurseries of interstellar objects that are very different from the solar system. In leading the Galileo Project, I act as former farm boy who has preserved his childhood curiosity. I understand the pushback from those who do not share my perspective, but cherish the company of like-minded explorers and donors. The Galileo where can i get cialis Project is a fishing expedition.

We use hooks in the form of telescopes without assuming what they might catch. The fundamental innovation is that we chose to look through telescopes for answers. This is the biggest lesson we learned from Galileo Galileiâs debate with where can i get cialis the philosophers who refused to look through his telescope. Recently, a philosopher published an article that uses philosophical reasoning to argue that âOumuamua could not have been technological in origin.

This suggests that looking through telescopes for answers is not as trivial as it may seem four centuries after Galileo. This is an opinion and analysis where can i get cialis article. The views expressed by the author or authors are not necessarily those of Scientific American.Some gestures can be understood almost anywhere. Pointing to direct someoneâs attention, for instance.

New research shows that certain where can i get cialis vocalizations can also be iconic and recognizable to people around the worldâeven when a speaker is not simply imitating a well-known sound. These findings, published in Scientific Reports, may help explain the rise of modern spoken language. In 2015 language researchers challenged some English speakers to make up sounds representing various basic concepts (âsleep,â âchild,â âmeat,â ârock,â and more). When other English speakers listened to these where can i get cialis sounds and tried matching them to concepts, they were largely successful.

But âwe wanted to be able to show that these vocalizations are understandable across cultures,â says study co-author and University of Birmingham cognitive scientist Marcus Perlman. Credit. Amanda MontaÃ±ez where can i get cialis. Source.

ÂNovel Vocalizations Are Understood across Cultures,â by Aleksandra Cwiek et al., in Scientific Reports, Vol. 11. May 12, 2021 So Perlman and his colleagues conducted online and in-person experiments in seven countries, from Morocco to Brazil. They recruited more than 900 participants, who spoke a total of 28 languages, to listen to the best-understood vocalizations from the 2015 investigation and select matching concepts from a set of words or images.

Vocalizations that evoked well-known soundsâfor example, dripping waterâperformed best. But many others were also understood at rates significantly above chance across all languages tested, the team found. ÂThere is a notable degree of success outside of just onomatopoeia,â Perlman says. This is likely because certain acoustic patterns are universal, the team suggests.

For example, short and basic sounds often convey the concept of âone,â and repeated sounds are typically associated with âmany.â Likewise, low-pitched sounds accompany something big, and high-pitched sounds convey small size. These findings of âiconicâ sounds could help scientists understand how human ancestors started using rich acoustic communication, says co-author Aleksandra Äwiek, a linguist at the Leibniz-Center General Linguistics in Berlin. The human voice, she says, might âafford enough iconicity to get language off the ground.â University of TÃ¼bingen linguist Matthias Urban, who was not involved in the research, agrees. ÂItâs unclear how words came into being in the first place,â he says.

Iconic vocalizations are âpotentially one pathway that could have been involved.âThe famous opening words, âIt was the best of times, it was the worst of times,â of Charles Dickens' 1859 novel A Tale of Two Cities referred to the period of French Revolution. But he could equally well have been describing his contemporary Charles Darwinâs experience with his theory of evolution by natural selection. Darwin was born at the best of times in 1809 when conditions were highly conducive for his theory to flourish, but he died in 1882 at the worst of times because there was a real danger that it might soon be killed off. Darwin's nemesis was the eminent physicist Lord Kelvin, and the weapon used against him was the age of the Earth.

Various theories of evolution predated Darwin, but whatever version one favored, one thing was clear. It needed a very long time for its consequences to work itself out. Precisely how long was hard to pin down, but it was believed to require tens or hundreds of millions of years. From 1650 on, the dominant theory about the age of the Earth, based on the work of Bishop Ussher, Isaac Newton and many other scholars who used various textual sources, was that it was about 6,000 years.

Theories of geology and biology had to accommodate themselves to this short timeframe. The geological theory known as catastrophism postulated that major features such as the Grand Canyon, Himalayas, etc. Had emerged as a result of sudden and violent upheavals. When it came to biological diversity, the idea of special creation, that organisms were immutable and had been specially designed to fit the biological niches in which they found themselves, was the prevailing view.

Such a short window of time would have made it impossible for anyone to credibly propose the emergence of new species by a process of slow evolution. But around 1785, ideas of the age of the Earth began to undergo a radical change as geologists and paleontologists started using the features of the Earth itself, such as erosion, sedimentation and the layers of strata and the fossils embedded in them, to estimate its age. The theory of uniformitarianism, that major geological features were caused by the very slow accumulation of tiny changes, gained ground, culminating in Charles Lyellâs epic three-volume work Principles of Geology in 1830 that cemented the idea that the Earth had been around for hundreds of millions of years and possibly much longer, so long that it seemed impossible to fix an actual age. Darwin was also a keen student of geology and was familiar with Lyell's work (they later became close friends) and had the first two volumes of his book with him as he made his five-year voyage around the globe on the HMS Beagle during 1831â1836, where the ideas for his theory of evolution germinated as he observed the patterns of species in the various locations that he visited.

Darwin knew from his work with pigeons that even deliberately breeding for specific characteristics took a long time to produce them. But how much time was necessary?. He felt that it required at least hundreds of millions of years. The work of Lyell and other geologists gave him the luxury of assuming that sufficient time existed for natural selection to do its work.

Darwin also came of age at a time when the idea that species were immutable had begun to crumble. While Darwin was taught and accepted the still dominant special creation theory, he was also familiar with the general idea of evolution. His own grandfather Erasmus Darwin had in 1794 published a book Zoonomia that explored protoevolutionary ideas. Jean-Baptiste Lamarck had published his own model of how evolution worked in 1802.

The various models proposed for the mechanism of evolution, such as Lamarckian evolution, orthogenesis and use-disuse, all implied some level of teleology. That there was a directionality inherent in the process. The extremely long window of time opened up by the new geology allowed Darwin and his co-creator Alfred Russell Wallace, working independently, to develop the central new insight of natural selection that differed from other models of evolution by showing how diversity could arise naturally by a process of Malthusian population selection pressures, without any kind of mystical agency directing the process towards any specific ends. Their theory held that evolution was contingency-driven in that how organisms evolved depended on chance factors and a changing environment, which suggested that if we ran the clock again, we could get very different outcomes in which human beings might never appear.

Their work was first presented in a joint paper in 1858. Darwin's major work On the Origin of Species, published a year later, was a closely argued compilation of a massive amount of evidence that helped establish evolution as a fact. The radical change in the status of human beings implied by their model, from being specially created in the image of God to just another accidental byproduct of the evolutionary process just like all other species, was an immediate source of controversy because it challenged a key religious tenet that human beings were special. This was why natural selection aroused such opposition even while evolution was accepted.

Many scientists of that time were religious and believed in theistic evolution that said that a supernatural agency was guiding the process to produce the desired ends. While all models of evolution required long times, natural selection required much longer times than any guided selection process. Hence the younger the age of the Earth, the more likely it was that natural selection could not be the mechanism. Physicists, led by the eminent Kelvin, himself a theistic evolutionist, were leaders of the charge for a young Earth, though it must be emphasized that âyoungâ at that time meant around 100 million years or less.

Even religious scientists had abandoned the idea of the Earth being just 6,000 years old. Beginning around 1860, Kelvin and other physicists started estimating the ages of the Earth and sun using the nebular hypothesis proposed around 1750 by Immanuel Kant and Pierre-Simon Laplace. This model treated the Earth and the sun as starting as rotating clouds of particles that coalesced under gravity to form molten balls, with the Earth subsequently solidifying and cooling. Kelvin used the laws of thermodynamics and other physics principles to arrive at estimates of 20â400 million years.

By 1879 the upper limit had been lowered to about 100 million years for the Earth and an even shorter upper limit of 20 million years for the Sun, much less than the 200 million years or so believed to be required for natural selection to work. Since physics was considered to be the most rigorous of the sciences, things looked bad for natural selection. When Darwin died in 1882, he was mourned as a great scientist who had radically changed our understanding of how the vast diversity of organisms we see around us came about, dethroning the idea that they were immutable. But because of the shrinking age of the Earth, he died with a major cloud hanging over his mechanism of natural selection.

Darwin's final words on the topic, written in 1880 just two years before his death, expressed a plaintive hope that future developments might reconcile the needs of natural selection with physics calculations. ÂWith respect to the lapse of time not having been sufficient since our planet was consolidated for the assumed amount of organic change, and this objection, as urged by [Lord Kelvin], is probably one of the gravest as yet advanced, I can only say, firstly that we do not know at what rate species change as measured in years, and secondly that many philosophers are not yet willing to admit that we know enough of the constitution of the universe and of the interior of our globe to speculate with safety on its past duration.â It turned out Darwin was prescient that improved knowledge of the interior of the Earth might change the calculations in his favor, but at the time he seemed to be grasping at straws. In fact, in the near term the problem got even worse because Kelvin and others produced new calculations that resulted in the age of the Earth being reduced even more, so that by 1895 the consensus physics view was that the age of the planet lay in the range 20â40 million years. Natural selection appeared to be doomed.

But physicists were now encountering stiffer opposition from other disciplines. Geologists were adamant that their models based on the accumulating evidence on sedimentation and erosion, while not as rigorous as the physics models, were well enough established that they were confident of their lower limit of 100 million years. Paleontologists were also arguing that the fossil record was not consistent with the physicistsâ shorter ages. Both groups argued that the physicists must have gone awry somewhere, even if they could not point out the specific flaws.

Beginning in 1895, this impasse began to be broken when physicist John Perry, a former assistant of Kelvin's, challenged the latter's assumption that the Earth was a rigid and homogeneous body, saying there was little evidence to support it. By introducing inhomogeneity and convective flow in the Earthâs interior, he found that Kelvinâs estimates for the age of the Earth could change by as much as a factor as 100, shifting the upper limit into the billions of years. Other physicists also chimed in with similar upward shifts, and this encouraged geologists, paleontologists and biologists to ignore the physicists' arguments for a young Earth. It was the discovery of radioactivity that decisively changed the picture.

It led to an entirely new way of measuring the age of the Earth, by allowing scientists to calculate the ages of rocks. Since the oldest rock that could be found set a lower limit for the age of the Earth, the race was on to find older and older rocks using this method. Records fell rapidly, leading to ages of 141 million years by 1905, 1.64 billion years by 1911, 1.9 billion years by 1935, 3.35 billion years by 1947, and to 4.5 billion years by 1953, which is where the current consensus lies. When Kelvin died in 1907 at the age of 83, it was not clear if he had accepted that his estimates were no longer valid.

But Darwin's hope that Kelvin would be proven wrong, and that eventually it would be shown that sufficient time existed for natural selection to work, was realized, 30 years after Darwinâs death. His theory now has all the time it needs. This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American.Edited by Dava Sobel First it fell just fell at my feet no wind no squirrel or bird to give it a push a green green pine cone with brown accents heavy with sealed overlapping rounded rhomboid structures in spirals I have to restrain myself from seeing here the condensed aromatic hydrocarbons I leave it on a plate and look on the web for the names of cone parts names are important even if my last name changed three times what I learn is that I have a female cone that the plates are scales and that each comes in two types bract or seed I think I am seeing seed scales in formation tightly fitting each scale at its center begins to ooze ever-so-slowly a tiny pitch droplet a spiral of spherical diamonds now I know it's pitch and not sap because it is damn sticky I can't get it off my fingers we enter the world of science dealing with the world of words and the world of things being farmed and manufactured and sold sap is not pitch which is not resin-resin and rosin and turpentine and pine tar what's in it for plants is not what's in it for us see water-based sap gets molecule A from site B to C in the inner tree while pitch is an organic soup moving in its own pipelines near the bark ready to flow out if bark or wood is damaged to push out with some force an insect to seal in time forming a solid resin odoriferous to repel insects that might enter the damage or attract some others and we thought we humans made things complicated damned chemist in me can't stop wondering what smells what makes things sticky it's terpenes oligomers of isoprene with appropriate names monoterpenes like pinene and diterpenoid resin acids like abietic acid I could tell you how they're made in pine or the lab and before long we have the whole lovable interconnected and thoroughly messy world meanwhile the cone rests oozing gently maybe the small globules of pitch are a survival strategy to be pollinated by any pollen from male cones that might be left over vain hope wrong season no males and the premature cone begins to darken to brown waiting for dispersal.

Don't let me get started on acorns.Toward the end of my senior year at Dartmouth, I watched my peers line up in front of the Career Services building. Waiting for their interviews for corporate jobs, all seemed to be dressed the sameâthe men wearing navy jackets, the women dark dresses. I thought back to my first day on campus four years earlier when we all wore different colors and dreamed of different futures. It was as if our education, instead of enhancing our individualities and imaginations, had reduced them to sameness.

It was not a unique scene. All over the world, formal education supplies the economy with workers who will increase productivity. Its purpose is to fuel the economic machine rather than to alter its inner workings. But this machine now threatens our very survival.

If the entire world reaches the levels of consumption seen in high-income countries today, weâll need multiple planet Earths to supply the resources. The absurd idea of infinite growth within a finite territory is at the heart of our economic system. To keep this machine running, formal education generates ever more efficient âhuman capital.â Increasing productivity metricsâsuch as revenue per employee or return on investmentârather than the individuality of students, drive our civilizationâs approach to schooling our young people. Whereas the Sustainable Development Goals call for turning education into a force for sustainability, the opposite is often true.

The ways Western societies have come to think about education undermine our ability to deal with the environmental crisis. To get through this crisis, we need to cultivate our imagination, not undermine it. Growing up, none of my schooling fostered my ability to imagine a world different from what I saw around me. As a child in 1990s Slovakia, I had to memorize textbooks word by word.

Decades later, as an education researcher, I see children elsewhere going through the sameâa chorus of Indian pupils repeating the sentences written by their teacher on the blackboard, a South African child yelled at by the teacher for failing to reproduce exactly the content of the textbook. Rote learning, discouraging individuality and instilling docility in children are still at the root of what it means to be educated across much of the world. Many experts agree that we need to move away from such approaches to education. But the suppression of childrenâs imagination doesnât take place only in underresourced communities or outmoded education systems.

The issue is obscured but even more pernicious in âeliteâ institutions that tout âcritical thinking.â Save for a few wise mentors, hardly anyone encouraged me to imagine an alternative future for the world throughout my Ivy League undergraduate years and my Oxbridge graduate years. These institutions want to see their graduates succeed, and success is too often about maintaining current structuresânot about reimagining their foundations. In recent years, we have witnessed efforts towards standardizing curricula across the globe. Such reforms bring Western notions of educational success to the rest of the world.

Driven by the OECDâs standardized tests, which rank education systems, countries focus on improving quantifiable outcomes such as literacy and numeracy. Winning the competition for the most efficient educational system today means having the most efficient workforce and growing the national economy faster tomorrow. Our standardized, metric-driven, âefficientâ education systems essentially shape children in the image of artificial intelligence (AI). The perfect âworker,â AI continually improves its own productivity but doesnât challenge the larger structures within which it operates.

It is one of the great paradoxes of our time that we invest so much into building supercomputers while marginalizing the imaginative potential of millions of human brains. Our focus on technological solutions to our civilizationâs challenges is driving our approach to education. More students at British universities are studying science, technology, engineering and mathematics (STEM) than ever before, including a 400 percent increase in enrollment in AI courses over the last 10 years. Compared to STEM, social sciences and humanities are often underfunded and seen as inferior by policy makers and the public alike.

But this approach is counterproductive because non-STEM subjects are crucial to fostering our ability to reimagine the world. We even put our hope in solving the environmental crisis on AI. We use machine learning to optimize energy networks, track land use through satellite imagery and predict extreme weather. But AI, like our other technologies, can only treat the symptoms of the environmental crisis, not the causes.

These lie in our arrogance and lack of sensitivity to our impact on the planet. We canât outsource to computers the solutions to the flaws in our politics and culture that underpin the environmental crisis. Throughout history, achievers of great change have relied on their imaginations to address fundamental flaws in society. In my country of birth, Czechoslovakia, dissidents against Communism kept their dreams of democracy alive for decades by imagining different futures.

In South Africa under apartheid, Nelson Mandelaâs followers had to be radical in their imagination to create a vision of a fairer society. Imagining democracy when living under a totalitarian regime isnât that different from imagining degrowth when living in a world of infinite growth. The kind of intelligence Nelson Mandela and VÃ¡clav Havel possessed was not artificial. The ability to reimagine the future and disrupt the status quo remains a distinctly human quality.

Unlike AI, children are naturally imaginative and question the premises of society. In my research, I have observed that younger children are often the most radical in imagining different futures. As they get older, their imagination tends to become more generic, mimicking mainstream narratives of technological progress. As long as our imagination is curtailed, ideas like degrowth or intergenerational justice remain fringe and sound utopian to many.

Cultivating imagination means learning from historyâs disrupters who made the allegedly impossible palatable. It means moving away from our standardized curricula, quantifiable metrics and authoritarian pedagogies. Instead of dismissing âchildishâ ideas about the worldâs future, it means seeing inspiration in childrenâs imaginations. In an education system that celebrates imagination, arts and creativity are as important as math and science.

Teachers develop and act on their own pedagogical philosophies. Children define success for themselves. Idealism coexists with pragmatism. Expressing opinions and taking political action are goals of education, not distractions from it.

Some of these ideas have already inspired educational projects around the worldâsuch as forest schools in Europe, jeevanshalas (schools of life) in India or Schumacher College in the U.K.âbut these are the exceptions. The environmental crisis is not a crisis of technology or science, it is a crisis of imagination. If we let children be our guides, we might just be able to imagine our way to survival.