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Can’t see the audio where can i buy renova over the counter player?. Click here to listen on SoundCloud where can i buy renova over the counter. For the first time in a long time, there is some good news about the skin care renova.

Although cases continue to climb, fewer people where can i buy renova over the counter seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform where can i buy renova over the counter community service in order to keep their Medicaid health benefits.

The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.Among the takeaways from this week’s podcast:Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence where can i buy renova over the counter of skin care s, but early experiences seem to show that there has been little transmission among young kids in classrooms.Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as where can i buy renova over the counter unions representing teachers and other employees, are more likely to be calling for continued online learning.California, which had a strong resurgence of the renova during the summer, is seeing signs of success in fighting back.

The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect where can i buy renova over the counter the renova to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths.

They also where can i buy renova over the counter fear the administration’s focus on restoring normalcy would by default move in this direction.Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to skin care products or the lack of other health care by people who could not or did not seek treatments because they were frightened by the renova.With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled where can i buy renova over the counter that decision, abortion policies would likely fall back to individual states.

A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:Julie Rovner. Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and where can i buy renova over the counter The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica ContreraMargot Sanger-Katz. The Hill’s “Republicans where can i buy renova over the counter.

Supreme Court Won’t Toss ObamaCare,” by Peter SullivanPaige Winfield Cunningham. The Wall Street Journal’s “Some California Hospitals Refused skin care products Transfers for Financial where can i buy renova over the counter Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela HernandezAlice Miranda Ollstein. ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten BergTo hear all our podcasts, click here.And subscribe to What the Health?.

on iTunes, Stitcher, Google Play, Spotify, or Pocket where can i buy renova over the counter Casts. Related Topics California Courts Medicaid Multimedia Public Health States Abortion Children's Health skin care products KHN's 'What The Health?. ' Podcasts Trump AdministrationSACRAMENTO, Calif where can i buy renova over the counter.

€” In an election year dominated by where can i buy renova over the counter a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure could cost the state roughly $7.8 billion over about 30 years, according to an estimate from the nonpartisan state Legislative Analyst’s Office.In 2004, voters approved Proposition 71, a $3 billion bond, to be repaid with interest over 30 years. The measure got the state agency up and running and was designed to seed research.During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could where can i buy renova over the counter reap millions in royalties from new treatments.

Email Sign-Up Subscribe to KHN’s free Morning Briefing. Yet most of those ambitions remain unfulfilled.“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about where can i buy renova over the counter how quickly research would yield cures. €œYou can’t rush this kind of work.”So advocates are back after 16 years for more research money, and to increase the size of the state agency.Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.When the first bond measure was adopted in 2004, the George W.

Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell where can i buy renova over the counter. Human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.But where can i buy renova over the counter advocates for Proposition 14 say the ability to do that research is still tenuous.

In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut where can i buy renova over the counter off those funds once again.The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM where can i buy renova over the counter board member who does not support the new bond measure.

He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. €œIt undermines people’s where can i buy renova over the counter trust in science,” Darnovsky said. €œNo one can promise cures, and nobody should.”Robert Klein, a real estate developer who wrote both ballot measures, disagrees.

He was where can i buy renova over the counter inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.“What are you going to do where can i buy renova over the counter if this doesn’t pass?. Tell those people we’re sorry, but we’re not going to do this?.

€ Klein where can i buy renova over the counter said. €œThe thought of other children needlessly dying is unbearable.”Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.“The promise was that it would pay for itself and it hasn’t,” Sheehy said. €œWe can’t really afford it, and this is the worst way to pay where can i buy renova over the counter for it.”Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money.

Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to where can i buy renova over the counter Weissman at Stanford for research.That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion.

Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.“Gilead will make far more than where can i buy renova over the counter that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks where can i buy renova over the counter promising — and ultimately reap the profits.Case in point. Fedratinib, one of the two FDA-approved drugs funded partly by CIRM, can cost about $20,000 for 120 capsules, according to GoodRx.“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public.

In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.But in practice, the regulations have never really been tested.Proposition where can i buy renova over the counter 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits where can i buy renova over the counter drug companies.

Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from where can i buy renova over the counter the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said.

€œBut at the end of the day, they’re only as good as people being able to access them affordably.” This KHN story first published on California Healthline, a service of where can i buy renova over the counter the California Health Care Foundation. Rachel where can i buy renova over the counter Bluth. rbluth@kff.org, @RachelHBluth Related Topics California Elections States PropositionsIf we really want to stem the spread of the skin care as winter looms and we wait for a treatment, here’s an idea.

The government should pay bars, many restaurants and event venues to close for where can i buy renova over the counter some months.That may sound radical, but it makes scientific sense and even has a political precedent. We pay farmers not to cultivate some fields (in theory, at least, to protect the environment), so why not compensate owners to shut their indoor venues (to protect public health)?. In the past nine months, we’ve learned a lot where can i buy renova over the counter about this particular skin care and how it’s most likely to spread.

Drinking establishments and indoor event venues have emerged as ideal environments for transmission. And there’s good scientific logic to explain that.renovaes are not villains who go after their prey where can i buy renova over the counter. They’re passive where can i buy renova over the counter opportunists.

Some spread through food or when left on surfaces. Others, like this skin care, can be transmitted through tiny droplets that can linger in the air after an infected person coughs, talks where can i buy renova over the counter or breathes. The renova spreads most easily indoors and particularly in crowded, poorly ventilated places.More important, people can be infectious while their bodies are incubating this renova for a couple of days before they develop symptoms, or even if they never develop symptoms at all.

So you might go to a bar or a wedding feeling top-notch, or just where can i buy renova over the counter maybe a little off. Drink, kiss and dance till you drop. Then you wake up where can i buy renova over the counter the next morning feeling awful.

It’s not just a hangover. It’s skin care products where can i buy renova over the counter. Email Sign-Up Subscribe where can i buy renova over the counter to KHN’s free Morning Briefing.

That explains why this renova is exceedingly contracted at “superspreader” events. (More so than the flu, according to the Centers for Disease Control and where can i buy renova over the counter Prevention.) A person who is shedding a good deal of the renova still feels well enough to hang out in a tight (likely indoor) space where people mingle boisterously with others they don’t know or don’t see often. And they can’t wear masks, because they’re drinking.No wonder bars are a problem.In scientific parlance, the skin care is more of a “heterogeneous” than a homogeneous spreader, according to Bjarke Frost Nielsen, a researcher at the Niels Bohr Institute at the University of Copenhagen.

Along with his colleague Kim Sneppen, he uses mathematical modeling to study the pattern of the spread of the renova where can i buy renova over the counter. That heterogeneous spread means that it tends to expand in burst-like outbreaks, often centered on a meeting place — a hot spot — rather than oozing slowly across a country.There is some good news in this finding, Nielsen told me. €œYou can close down certain types of gatherings and where can i buy renova over the counter a few types of places and tamp down the majority of the spread of the disease.

And you can carry on with the rest as pretty normal.”Back when we knew where can i buy renova over the counter little about the novel skin care, the government responded with a hammer. The Paycheck Protection Program treated all small businesses equally, providing them with loans to shut down so long as they paid their employees. Now we can use more delicate instruments.Food and clothing stores — indeed, most any kind of shop — can function safely with masking and attention where can i buy renova over the counter to distancing and sanitizing.

We don’t go to these places to chat, and we can all wear masks inside them. Factories and assembly lines can protect workers where can i buy renova over the counter with masking and spacing. Schools can do the same for students.Even movie theaters can arguably safely operate with masked patrons, quality ventilation systems and spacing between viewers or viewing groups.

They just won’t be able to sell as many seats.But bars and restaurants that depend on where can i buy renova over the counter packed indoor dining and concert halls with dance floors?. Most are attractive for exactly the reasons that make them such petri dishes for the skin care — the crowding, the drinking, the carousing with new, different people.That’s why some bar and restaurant owners say they would welcome a program that compensated them to shut their doors this winter. Peter Kurzweg, who co-owns three of what he calls “drink forward” establishments in Pittsburgh that used to have bustling happy hours, says that “bars and restaurants are unique in that to be really safe, they have to mitigate to a point that it’s not a where can i buy renova over the counter bar or restaurant experience anymore.”He and his partners have so far weathered the renova with outdoor seating on the sidewalk and in an alley.

They have where can i buy renova over the counter taken advantage of government loan programs. They have invested in tents and heaters and encouraged patrons to “lean in” to having fun outside. But as where can i buy renova over the counter fall turns to winter in Pittsburgh, he knows it won’t last.

€œI walk around saying, ‘Winter is coming. Winter is coming.’ We where can i buy renova over the counter need to do everything we can to survive.”Some states have allowed restaurants to open indoors at 25% or 50% capacity — indeed, that is permitted now in Pittsburgh. But Kurzweg has not done so, because he doesn’t feel it’s safe.

Anyway, he added, “No bar or restaurant can make it at that capacity where can i buy renova over the counter — on the best days in normal years, our profit margin is 10%.”Some very spacious high-end restaurants, and those in temperate climates, might be able to make it work. Most can’t.Bars and other venues that depend on drinks are where can i buy renova over the counter not essential services. We want them to survive so that in the future we can enjoy them.

So why not pay owners who cannot keep their businesses afloat safely this skin care products-tainted year an average of their normal monthly income to shut down for some months? where can i buy renova over the counter. They would keep paying their employees and help break the chain of skin care transmission. Maybe we could get creative and ask them to use their kitchens to help feed Americans who are going hungry.With bars closed, you could still drink and socialize with smaller groups of people at home where can i buy renova over the counter or outdoors, when the weather allows it.

That may not be quite as much fun, but nothing is much fun while the skin care is around. Elisabeth Rosenthal where can i buy renova over the counter. erosenthal@kff.org, @rosenthalhealth Related Topics Public Health skin care products treatmentsThis story also ran on NPR. This story can be republished for free (details). Facing a renova, record unemployment and unknown future costs for skin care products treatments, health insurers selling Affordable Care Act plans to individuals reacted by lowering rates in some areas and, overall, issuing only modest premium increases for 2021.“What’s been fascinating is that carriers in general are not projecting much impact from the renova for their 2021 premium rates,” said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.That’s good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces.

The federal market, which serves 36 states, opens for 2021 where can i buy renova over the counter enrollment Nov. 1, with where can i buy renova over the counter sign-up season ending Dec. 15.

Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.Here are a few where can i buy renova over the counter things to know about 2021 coverage:It might cost about the same this year — or even less.Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.“It’s the third year in a row with premiums staying pretty stable,” said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. €œWe’ve seen modest rate changes and influx of new insurers.”That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.Those increases priced out some enrollees, particularly people who don’t qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his ACASignups.net website, follows premium changes based on filings with where can i buy renova over the counter state regulators.

Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers’ requested rates, the percentage is lower, at 0.4%.Another where can i buy renova over the counter study, by KFF, of preliminary premiums filed this summer had similar findings. Premium changes in 2021 would be modest, only a few percentage points up or down.

(KHN is an where can i buy renova over the counter editorially independent program of KFF.) Don't Miss A Story Subscribe to KHN’s free Weekly Edition newsletter. It’s still worth it to shop around.Actuaries and other experts say premiums vary by state or region — even by insurer — for a number where can i buy renova over the counter of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.Because subsidies are tied to each region’s benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)Switching to the benchmark plan can help consumers maintain how much they spend in premiums.Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses.

€œThey might where can i buy renova over the counter be eligible for a bigger” subsidy, said Myra Simon, executive director of commercial policies for America’s Health Insurance Plans, the industry lobbying group.Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, where can i buy renova over the counter consumers should check whether the doctors and hospitals they want to use are included in the plan’s network.Premiums are just one part of the equation.

Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.“We encourage people to consider all their options,” said Simon.What’s behind the variation.Enrollees in some states next year will see premium decreases, according to Gaba’s website. Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland’s is where can i buy renova over the counter down almost 12%. At the same time, Indiana’s average is up 10% where can i buy renova over the counter.

And Kentucky is up 5%.Both Maine and Maryland attribute the decrease to state programs that provide reinsurance payments to health insurers to help offset high-cost medical claims.In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to where can i buy renova over the counter spend at least 80% of revenue on direct medical care. If insurers don’t meet that standard, they must issue rebates to policyholders.

Many insurers were already on the hook to return where can i buy renova over the counter money in 2020 for previous years.Most insurers did not cite additional skin care products treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.Indeed, many insurers in the second quarter posted record profits.“Some of them thought, ‘We’re going to make more than we thought this year in profits, so let’s not be aggressive with pricing next year,’” said Donna Novak, a member of the American Academy of Actuaries’ Individual and Small Group Markets Committee.A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminated by the Trump administration effective for 2021.Your choice of insurers may have widened.More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.“Insurers are seeing a profit or potential for it,” said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.Insurers, he said, like the way the ACA is working.“People on TV who say it’s not working, where can i buy renova over the counter they don’t know what they’re talking about,” said Dodd.

€œIt’s working well [for insurers] and every year it gets better.”New stuff in some states, including a public option.Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal healthcare.gov, which now covers 36 states.Lawmakers in those states said running their own marketplaces gives them more control and may save them money over time.In 19 Washington state counties, insurers are offering “public option plans,” which have all the standard benefits, including lower deductibles, and must meet additional quality standards.As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an where can i buy renova over the counter average of 160% of what Medicare would pay for the same services.When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.But three are more where can i buy renova over the counter expensive.The state’s marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during skin care products to a lack of incentives to get providers to participate.It could also just be normal first-year jitters.“It’s Year One.

As with any market entry strategy, people are pretty conservative,” said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange. Julie Appleby where can i buy renova over the counter. jappleby@kff.org, @Julie_Appleby Related Topics Insurance Uninsured skin care products Obamacare Plans Open EnrollmentAbout HealthBent KHN's chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years, offers insight and analysis of policies and politics in her regular HealthBent columns.Send questions to jrovner@kff.org.

This story also ran on The BMJ. This story can be republished for free (details). If Joe Biden wins the presidency in November, health is where can i buy renova over the counter likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.Barring something truly unforeseen, it’s fairly certain that on Jan. 20 the where can i buy renova over the counter U.S.

Will still be in the grip of the skin care renova — and the economic where can i buy renova over the counter dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009. A Democratic administration replacing a Republican one in the where can i buy renova over the counter midst of a national crisis.Obama had only a financial crisis to deal with.

Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He’s also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was where can i buy renova over the counter taking office.But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the renova and economic crisis before he can turn to some of the big health changes he’s promised, such as expanding the reach of the Affordable Care Act, creating a “public option” that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.Still, no matter what the partisan makeup of Congress, “priority one is to get the skin care products response going,” said Len Nichols, a professor of health policy at George Mason University.

Email where can i buy renova over the counter Sign-Up Subscribe to KHN’s free Morning Briefing. Biden’s skin care products plan includes taking major responsibility for the renova back from the states. His federal response would include more money where can i buy renova over the counter for, and coordination of, testing and contact tracing.

Ensuring adequate protective equipment for where can i buy renova over the counter health professionals. And assuring the public that new treatments and treatments will be based on science, not politics.In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government’s top infectious disease expert, who where can i buy renova over the counter has been derided by President Donald Trump.

€œDr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad,” says Biden’s website.Biden’s skin care products plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the renova and more financial aid for workers, where can i buy renova over the counter families and small businesses.“If we’ve learned anything, it is that the health sector and the economy are not two separate spheres. They are connected,” said Nichols.

€œI think health care and the economy are complementary and will be for the foreseeable future.”Assuming Biden gets beyond the renova and recession, he could move onto some of his bigger health promises, where can i buy renova over the counter including expanding eligibility for Medicare, creating a “public option” health plan and boosting premium subsidies for the ACA.Biden took heat throughout the primaries for his “moderate” approach to improving health insurance access and costs, compared with the “Medicare for All” plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and where can i buy renova over the counter Elizabeth Warren (D-Mass.). But that doesn’t mean his far less sweeping approach would be easy to get through Congress.“There’s a really big difference when you’re running the government than when you’re running for office,” said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.Many of Biden’s proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010.

Conservative Democratic senators objected to the plan.“We pushed,” Obama said in a recent interview where can i buy renova over the counter on the podcast “Pod Save America,” talking about the public option. €œI needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, ‘I’m not voting for a public option.’”Mendelson said where can i buy renova over the counter another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option “are not well-defined, and there are many different theories of what it should be and where it should be fielded.

There’s no common vision about what it really means.”The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. €œMore than half these where can i buy renova over the counter people have commercial insurance,” he said. €œWhat will happen to them?.

€Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he’s reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or “surprise” medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. €œIt would be a big statement,” she said. €œWhoever wins would then have the wind at their back.”But even those issues have a way of getting complicated.

Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats’ preferred ways of doing that. By allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.As always, even when health is at the top of the agenda, it proves difficult to address.

Julie Rovner. jrovner@kff.org, @jrovner Related Topics Elections HealthBent Medicare The Health Law skin care products U.S. Congress.

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It creates mobility and functional changes that make it painful for patients to use their hands or walk. Some of these changes are irreversible.Psoriatic arthritis is tough to treat.“There is a clear need for better treatments using alternative approaches renova black toilet paper case study to joint inflammation,” said Sam T. Hwang, professor and chair of dermatology at UC Davis and senior author of the study. Understanding the mechanism behind renova black toilet paper case study joint inflammationChemokines are small molecules with a critical role in the body’s response to inflammation and .

They help guide the migration of immune cells to the site of injury or trauma. Chemokines need receptors to function. One specific chemokine receptor is CCR6.The researchers assessed the role of CCR6 and its binding partner CC chemokine ligand renova black toilet paper case study 20 (CCL20) in inflammation linked to psoriatic arthritis and psoriasis. They looked at the potential of the CCR6/CCL20 combo as an effective therapeutic target.They measured the CCR6 and the CCL20 levels in the joint fluid and tendon tissues of patients with psoriatic arthritis.

CCR6 is a critical agent for the migration of T cells – a type of white blood cells - renova black toilet paper case study in skin psoriasis. The new study showed that CCR6 plays a similar role in joint inflammation. The team also found that CCL20 is present at very high levels in inflamed joint fluid.“We observed a significant increase of both CCR6 and CCL20 in the connective tissue of mice with psoriasis and psoriatic arthritis,” Hwang noted. €œThis high presence was also confirmed in inflamed human tendon biopsies.”The presence of CCL20 at the site of the inflammation makes it a renova black toilet paper case study very attractive target for arthritis therapy.The connective tissue linking tendons and ligaments with the bones is called the enthesis.

It is an important site of inflammation in psoriatic arthritis. The study found that entheses are distinct locations which CCR6+ T cells appear to locate and, therefore, cause inflammation.“It is critical to identify the specific tissues where inflammation in the joints renova black toilet paper case study first occurs before it spreads and damages the cartilage and the bone,” Hwang said.Blocking the function of the CCR6 chemokineThe researchers tested the ability of a novel engineered protein- known as CCL20 locked dimer (CCL20LD)- in blocking the CCR6 function in a mouse model with psoriatic arthritis. The protein profoundly reduced both skin and joint inflammation by shutting the CCR6’s power to attract T cells.“The success of CCL2OLD in blocking CCR6 function in a mouse model shows potential for treating psoriatic arthritis in humans,” Hwang said. €œDefinitely, this requires more testing and clinical trials to explore its effectiveness and safety.”The study was published in the journal Arthritis &.

Rheumatology.###Co-authors on this study renova black toilet paper case study are Zhenrui Shi at University of California, Davis and Sun Yat-sen University, China. Neal Millar, Emma Garcia-Melchor, Flavia Sunzini and Moeed Akbar at the University of Glasgow. Xuesong Wu, renova black toilet paper case study Mimi Nguyen, Douglas Rowland, Machelle Wilson, Mindy Huynh and Timothy Law at the University of California, Davis. Anthony Getschman and Brian Volkman at the Medical College of Wisconsin.

Smriti Kundu Raychaudhuri and Siba P. Raychaudhuri at the University of California School of Medicine, Davis, and VA Medical Center Sacramento.This study was supported by a Pfizer ASPIRE award and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (ROI_AR063091_01A1), a renova black toilet paper case study Translational Research Grant from the National Psoriasis Foundation, a New Investigator award from the National Psoriasis Foundation, a Small Business Innovation Research grant (1R43AR074363-01), a grant from National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (UL1 TR001860), a fellowship grant from Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and a Medical Research Council, UK (MR/R020515/1). Hwang is a holder on the patent for CCL20LD and has an unpaid role as medical director at XLock Biosciences, which produces the protein.Shi et al. (2021).

Targeting the CCR6/CCL20 axis in entheseal and cutaneous Inflammation, Arthritis &. Rheumatology, DOI:10.1002/art.41882.[embedded content]This video is best viewed in Chrome, Firefox or Safari.The newest employee at UC Davis Children’s Hospital doesn’t wear scrubs or use a stethoscope. He comes to work with a wet nose and a wagging tail to do a job only a canine can!. Facility Dog Daniels works in the Pediatric Intensive Care Unit (PICU) to help calm, comfort and motivate young patients going through medical procedures and long hospital stays.

Daniels joins a patient in the PICU playroom at UC Davis Children’s Hospital.Daniels with his handler, Kristen Cady, who is a child life specialist who works in the UC Davis Pediatric and Cardiac Intensive Care Unit (PICU/PCICU).Daniels was provided free of charge by Canine Companions, a national nonprofit that provides expertly trained service dogs to adults, children and veterans with disabilities, and to professionals working in medical, rehabilitation, physical therapy and other settings. Daniels joins three other Canine Companions facility dogs who work at UC Davis Children’s Hospital— Huggie, Paloma and ZeeBee. Facility Dog Daniels, a two-year old yellow Labrador Retriever, knows more than 40 commands. His training enables him to calm and motivate young patients who face big challenges.

Daniels and his handler, Child Life Specialist Kristen Cady, graduated from Canine Companions intensive Team Training course in April. Since then, they’ve brought love and light to hospitalized children. Daniels’ sweet personality and calm demeanor are perfect for the PICU. He is always willing to lean in for a hug and is very gentle when he climbs in bed for cuddles.

€œDaniels has been a wonderful addition to the PICU!. We’ve had some great interactions and I am sure there will be many more to come,” Cady said. Recently, Daniels and Cady partnered with the UC Davis physical therapy team to support a child who hesitated to get up and move around. But after a game of ‘hide and seek’ with Daniels, the boy moved more confidently and wanted to take charge of walking his new four-legged friend.

Daniels joins a patient in the PICU playroom at UC Davis Children’s Hospital.“By the end, he was smiling and interacting with Daniels, his nurse and myself,” Cady said. Daniels also provides procedural support, helping children to cope successfully through what can be quite stressful experiences. He also supports parents, offering comfort as they await their child’s return from a surgery or begin to process a new diagnosis. €œThe presence of Daniels has brought moments of joy and stress relief for the PICU staff, and we are excited about all of the ways he will continue to benefit our entire unit.

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An international team of researchers, led Propecia discount by UC Davis Health, has developed a where can i buy renova over the counter new therapeutic approach to treating psoriatic arthritis, a chronic inflammatory disease affecting the joints. Using a novel chemical blocker targeting chemokine proteins, the researchers were able to significantly reduce skin and joint inflammation in a mouse model with psoriasis and psoriatic arthritis. What is where can i buy renova over the counter psoriatic arthritis?. Psoriatic arthritis affects up to a third of patients with psoriasis, an auto-immune skin inflammation. It creates mobility and functional changes that make it painful for patients to use their hands or walk.

Some of these changes are where can i buy renova over the counter irreversible.Psoriatic arthritis is tough to treat.“There is a clear need for better treatments using alternative approaches to joint inflammation,” said Sam T. Hwang, professor and chair of dermatology at UC Davis and senior author of the study. Understanding the mechanism behind joint inflammationChemokines are where can i buy renova over the counter small molecules with a critical role in the body’s response to inflammation and . They help guide the migration of immune cells to the site of injury or trauma. Chemokines need receptors to function.

One specific chemokine receptor is CCR6.The researchers assessed the role of CCR6 and its binding partner CC chemokine ligand 20 (CCL20) where can i buy renova over the counter in inflammation linked to psoriatic arthritis and psoriasis. They looked at the potential of the CCR6/CCL20 combo as an effective therapeutic target.They measured the CCR6 and the CCL20 levels in the joint fluid and tendon tissues of patients with psoriatic arthritis. CCR6 is a critical agent for where can i buy renova over the counter the migration of T cells – a type of white blood cells - in skin psoriasis. The new study showed that CCR6 plays a similar role in joint inflammation. The team also found that CCL20 is present at very high levels in inflamed joint fluid.“We observed a significant increase of both CCR6 and CCL20 in the connective tissue of mice with psoriasis and psoriatic arthritis,” Hwang noted.

€œThis high presence was also confirmed in inflamed human tendon biopsies.”The presence of CCL20 at the site of the inflammation makes it a very attractive target for where can i buy renova over the counter arthritis therapy.The connective tissue linking tendons and ligaments with the bones is called the enthesis. It is an important site of inflammation in psoriatic arthritis. The study found that entheses are distinct locations which CCR6+ T cells appear to locate and, therefore, cause inflammation.“It is critical to identify the specific tissues where inflammation in the joints first occurs before it spreads and damages the cartilage and the bone,” Hwang said.Blocking the function of the CCR6 chemokineThe researchers tested where can i buy renova over the counter the ability of a novel engineered protein- known as CCL20 locked dimer (CCL20LD)- in blocking the CCR6 function in a mouse model with psoriatic arthritis. The protein profoundly reduced both skin and joint inflammation by shutting the CCR6’s power to attract T cells.“The success of CCL2OLD in blocking CCR6 function in a mouse model shows potential for treating psoriatic arthritis in humans,” Hwang said. €œDefinitely, this requires more testing and clinical trials to explore its effectiveness and safety.”The study was published in the journal Arthritis &.

Rheumatology.###Co-authors on where can i buy renova over the counter this study are Zhenrui Shi at University of California, Davis and Sun Yat-sen University, China. Neal Millar, Emma Garcia-Melchor, Flavia Sunzini and Moeed Akbar at the University of Glasgow. Xuesong Wu, Mimi Nguyen, Douglas Rowland, Machelle where can i buy renova over the counter Wilson, Mindy Huynh and Timothy Law at the University of California, Davis. Anthony Getschman and Brian Volkman at the Medical College of Wisconsin. Smriti Kundu Raychaudhuri and Siba P.

Raychaudhuri at the University of California School of Medicine, Davis, and VA Medical Center Sacramento.This study was supported by a Pfizer ASPIRE award and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (ROI_AR063091_01A1), a Translational Research Grant from the National Psoriasis Foundation, where can i buy renova over the counter a New Investigator award from the National Psoriasis Foundation, a Small Business Innovation Research grant (1R43AR074363-01), a grant from National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (UL1 TR001860), a fellowship grant from Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and a Medical Research Council, UK (MR/R020515/1). Hwang is a holder on the patent for CCL20LD and has an unpaid role as medical director at XLock Biosciences, which produces the protein.Shi et al. (2021). Targeting the CCR6/CCL20 axis in entheseal and cutaneous Inflammation, Arthritis &. Rheumatology, DOI:10.1002/art.41882.[embedded content]This video is best viewed in Chrome, Firefox or Safari.The newest employee at UC Davis Children’s Hospital doesn’t wear scrubs or use a stethoscope.

He comes to work with a wet nose and a wagging tail to do a job only a canine can!. Facility Dog Daniels works in the Pediatric Intensive Care Unit (PICU) to help calm, comfort and motivate young patients going through medical procedures and long hospital stays. Daniels joins a patient in the PICU playroom at UC Davis Children’s Hospital.Daniels with his handler, Kristen Cady, who is a child life specialist who works in the UC Davis Pediatric and Cardiac Intensive Care Unit (PICU/PCICU).Daniels was provided free of charge by Canine Companions, a national nonprofit that provides expertly trained service dogs to adults, children and veterans with disabilities, and to professionals working in medical, rehabilitation, physical therapy and other settings. Daniels joins three other Canine Companions facility dogs who work at UC Davis Children’s Hospital— Huggie, Paloma and ZeeBee. Facility Dog Daniels, a two-year old yellow Labrador Retriever, knows more than 40 commands.

His training enables him to calm and motivate young patients who face big challenges. Daniels and his handler, Child Life Specialist Kristen Cady, graduated from Canine Companions intensive Team Training course in April. Since then, they’ve brought love and light to hospitalized children. Daniels’ sweet personality and calm demeanor are perfect for the PICU. He is always willing to lean in for a hug and is very gentle when he climbs in bed for cuddles.

€œDaniels has been a wonderful addition to the PICU!. We’ve had some great interactions and I am sure there will be many more to come,” Cady said. Recently, Daniels and Cady partnered with the UC Davis physical therapy team to support a child who hesitated to get up and move around. But after a game of ‘hide and seek’ with Daniels, the boy moved more confidently and wanted to take charge of walking his new four-legged friend. Daniels joins a patient in the PICU playroom at UC Davis Children’s Hospital.“By the end, he was smiling and interacting with Daniels, his nurse and myself,” Cady said.

Daniels also provides procedural support, helping children to cope successfully through what can be quite stressful experiences. He also supports parents, offering comfort as they await their child’s return from a surgery or begin to process a new diagnosis. €œThe presence of Daniels has brought moments of joy and stress relief for the PICU staff, and we are excited about all of the ways he will continue to benefit our entire unit. Daniels has already made such an impact at the hospital, and we can’t wait to see all he does in the future!. € Cady said..

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The Centers http://www.ec-eckbolsheim.ac-strasbourg.fr/?page_id=162 for renova worldwide products Medicare &. Medicaid Services (CMS) and Mathematica released a fifth and final toolkit and two case studies to highlight strategies that Accountable Care Organizations (ACOs) and End-Stage Renal Disease Seamless Care Organizations (ESCOs) use to improve quality of care, lower health care costs, and enhance beneficiaries’ experience. Mathematica completed this work as part of a contract with CMS.CMS and Mathematica conducted focus groups with representatives from 13 ACOs participating in the Medicare Shared Savings Program and the Next Generation ACO Model to identify strategies for providing value-based care. With insights gained through these focus renova discount groups and other CMS-sponsored events, CMS’s ACO Learning System team developed the renova worldwide products Operational Elements Toolkit.

The toolkit presents fundamental strategies that Medicare ACOs use to begin or refine operations and considers approaches to meet the following objectives. Establishing strategic partnerships to strengthen or expand an organization Understanding beneficiaries’ care needs and preferences Harnessing data to improve performance and support quality reportingThe Operational Elements Toolkit is part of a broader series of resources that explores how ACOs and ESCOs provide value-based care. CMS and Mathematica added to these resources with two new case studies that highlight the following strategies.

The Centers where can i buy renova over the counter for Medicare &. Medicaid Services (CMS) and Mathematica released a fifth and final toolkit and two case studies to highlight strategies that Accountable Care Organizations (ACOs) and End-Stage Renal Disease Seamless Care Organizations (ESCOs) use to improve quality of care, lower health care costs, and enhance beneficiaries’ experience. Mathematica completed this work as part of a contract with CMS.CMS and Mathematica conducted focus groups with representatives from 13 ACOs participating in the Medicare Shared Savings Program and the Next Generation ACO Model to identify strategies for providing value-based care. With insights gained through these focus groups and other CMS-sponsored where can i buy renova over the counter events, CMS’s ACO Learning System team developed the Operational Elements Toolkit. The toolkit presents fundamental strategies that Medicare ACOs use to begin or refine operations and considers approaches to meet the following objectives.

Establishing strategic partnerships to strengthen or expand an organization Understanding beneficiaries’ care needs and preferences Harnessing data to improve performance and support quality reportingThe Operational Elements Toolkit is part of a broader series of resources that explores how ACOs and ESCOs provide value-based care. CMS and Mathematica added to these resources with two new case studies that highlight the following strategies.

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How to cite this how can i buy renova article:Singh renova zero pods amazon OP. Comprehensive Mental Health Action Plan 2013–2030. We must rise to the challenge renova zero pods amazon. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development.

Further, in September 2021, the 74th World Health Assembly renova zero pods amazon accepted the updates to the action plan, including updates to the target options for indicators and implementation. This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target renova zero pods amazon 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing.

It is renova zero pods amazon an opportunity for us to expand psychiatry by being involved in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health Action renova zero pods amazon Plan 2013-2020. Geneva.

World Health renova zero pods amazon Organization. 2013. 2.World renova zero pods amazon Health Organization. Comprehensive Mental Health Action Plan 2013-2030.

Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background.

Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim.

This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods. This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy.

The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results.

Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS.

Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 23];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?.

2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare.

The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded.

As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence.

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment.

Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated.

Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1].

The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058).

This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1.

Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4.

Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress.

This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.

Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics http://www.col-gerstheim.ac-strasbourg.fr/?p=3155.

CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations.

Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.

Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution.

Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective.

Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.

3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ.

An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment. A review with special emphasis on alcoholism.

Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study.

Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?.

Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy.

J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61.

13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3. 14.Krebs D.

Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles.

Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis.

Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda.

Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?.

Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48.

22.Miller PA, Eisenberg N. The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al.

Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders.

Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL.

A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism.

Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84.

31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70. 32.Cook S, Heather N, McCambridge J.

Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How to cite where can i buy renova over the counter this article:Singh how to get a renova prescription from your doctor OP. Comprehensive Mental Health Action Plan 2013–2030. We must rise where can i buy renova over the counter to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development.

Further, in September 2021, the 74th World Health Assembly accepted the updates to the action plan, including updates to where can i buy renova over the counter the target options for indicators and implementation. This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries where can i buy renova over the counter. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing.

It is an opportunity for us to expand psychiatry by being involved where can i buy renova over the counter in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health Action Plan where can i buy renova over the counter 2013-2020. Geneva.

World Health Organization where can i buy renova over the counter. 2013. 2.World where can i buy renova over the counter Health Organization. Comprehensive Mental Health Action Plan 2013-2030.

Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background.

Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim.

This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods. This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy.

The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results.

Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS.

Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 23];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?.

2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare.

The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded.

As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence.

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment.

Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated.

Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1].

The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058).

This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1.

Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4.

Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress.

This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.

Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social renova tretinoin cream 0.02 buy situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics.

CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations.

Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.

Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution.

Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective.

Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.

3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ.

An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment. A review with special emphasis on alcoholism.

Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study.

Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?.

Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy.

J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61.

13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3. 14.Krebs D.

Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles.

Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis.

Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda.

Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?.

Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48.

22.Miller PA, Eisenberg N. The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al.

Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders.

Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL.

A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism.

Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84.

31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70. 32.Cook S, Heather N, McCambridge J.

Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How to use renova zero

By means of concurrent publication in American Journal of Kidney Diseases (AJKD) and Journal of the American Society of Nephrology (JASN), we present the interim report of a joint task force established by the National how to use renova zero Kidney Foundation and the American Society of Nephrology read what he said to reconsider inclusion of race in the estimation of GFR. This report comes at a time in the United States when the enormous and disproportionate burden of illness and death from skin care disease 2019 within minority communities, as well as police violence against Black Americans, has laid bare the racial inequities in health and wellbeing in our society. Kidney disease and its complications play a prominent role in this excess burden of illness, motivating the creation of this joint task force.For nephrologists, how to use renova zero eGFR is a critical workhorse, a starting point for much of what we do.

Diagnosis, prognostication, treatment options, and the use of medications all hinge on eGFR. We all know, of course, there is much more to kidney function than fiation, but when we ask about a how to use renova zero patient’s kidney function, it is shorthand for wanting to know the eGFR. So, getting it right—having reliable and consistent estimates—is critical to the effective practice of nephrology and all of medicine.

Further, understanding the how to use renova zero epidemiology of kidney disease, tracking disparities and inequities, and selecting participants for inclusion in clinical trials all depend on estimating GFR accurately and consistently.The task force’s interim report1 documents a process being undertaken with extraordinary care and thoroughness. The task force has laid out a planned course of action with three phases, this being the culmination of phase 1. It has articulated a core set of principles to be used in the how to use renova zero subsequent stages, compiled a summary of much of the relevant evidence base, and established stakeholder input, particularly that of patients.

Mindful of the potential unintended consequences of precipitous changes in methods to estimate GFR, the task force has deferred its recommendations until its inclusive and deliberative processes are completed. The editorial teams of the two journals decided to take the unusual step of jointly publishing this report, reflecting our assessment how to use renova zero of the importance of the task force’s work.The starting point for considering the inclusion of race in eGFR estimation must be what is best for our patients—people with kidney disease or at risk of kidney disease. The disproportionate burden of kidney disease among Black people in the United States2 and their inequitable access to care, including transplantation, must be addressed3.

The burden on Black Americans has been known for decades. It is not simply or how to use renova zero even principally a reflection of biologic differences. Rather, deep inequities in the social determinants of health and structural racism in the delivery of health care are eroding the wellbeing of our minority communities, compounding the overall societal effects of racism on the lives of Black Americans.4,5As editors we recognize that journals have participated in the dissemination and perpetuation of science that casts race as a biologic construct.

Much is how to use renova zero being written about how race is a flawed concept, a societal construct that oversimplifies and at times distorts.6,7 The editorial teams of both JASN and AJKD are committed to re-examining our own roles and the language we use to talk about these problems—an essential step, we believe, if we are going to participate effectively in the eradication of unacceptable health disparities. As journal editors, we recognize published research that has emphasized race as a biologic construct has contributed to a failure to address core problems.Journals play an important and privileged role in the dissemination of science, and we feel a deep responsibility not only to inform our readers of these problems but also to participate in a more informed discussion of racism. This is a start, we suggest, in the pursuit how to use renova zero of effective interventions that will lessen race-based disparities in health.

It includes being more cognizant of how reporting of science can perpetuate racism. In this spirit, we are grateful for the opportunity how to use renova zero to promote and disseminate the work of the task force.The task force is examining the full potential effect of removing race from eGFR expressions, both the desirable benefits and the unintended consequences. Their deliberations are focusing on how best to optimize GFR estimation for all racial and ethnic groups, while limiting any potential unintended consequences.

Although the steps undertaken by the task force may produce recommendations more slowly than some would like, we applaud its deliberative approach and have confidence it will promote improvement in the health status of the patients we serve.We eagerly await the recommendations of the task force but call upon the kidney medicine community to show as much resolve to mitigate the influence of the broad array of factors leading to racial disparities as is now being brought to the effort to reassess the use of race how to use renova zero in the calculation of eGFR. This important work on GFR estimation should serve as a starting point to robustly address and reverse the unacceptable excessive burden of kidney disease in people within racial minority communities, a sentiment resonant with the task force’s aspiration “that the community of healthcare professionals, scientists, medical educators, students, health professionals in training, and patients to join in the larger, comprehensive effort needed to address the entire spectrum of kidney health to eliminate health disparities.”DisclosuresH.I. Feldman reports consultancy agreements from DLA Piper, LLP, InMed, Inc., how to use renova zero Kyowa Hakko Kirin Co.

Ltd. (ongoing). Receiving honoraria from Rogosin Institute (invited how to use renova zero speaker).

Being the Steering Committee Chair of NIH-NIDDK’s Chronic Renal Insufficiency Cohort Study. Being a member of the National Kidney Foundation (NKF) Scientific how to use renova zero Advisory Board. And receiving funding from the NKF to support his role as AJKD Editor-in-Chief.

J.P. Briggs serves as a scientific advisor to the Executive Director of Patient Centered Outcomes Research Institute and reports having other interests/relationships including PCORI—Interim Executive Director from November 2019 through April 2020, and JASN Editor-in-Chief.FundingNone.FootnotesThis article is being published concurrently in the Journal of the American Society of Nephrology and American Journal of Kidney Diseases. The articles are identical except for stylistic changes in keeping with each journal’s style.

Either of these versions may be used in citing this article.Published online ahead of print. Publication date available at www.jasn.org.See related article, “Reassessing the Inclusion of Race in Diagnosing Kidney Diseases. An Interim Report from the NKF-ASN Task Force,” on pages 1305–1317.Copyright © 2021 by the American Society of Nephrology and the National Kidney Foundation, Inc.

By means of concurrent publication in American Journal of Kidney Diseases (AJKD) and Journal of the American Society of Nephrology (JASN), we present the interim report of a joint task force established by the National Kidney where can i buy renova over the counter Foundation and the American Society More about of Nephrology to reconsider inclusion of race in the estimation of GFR. This report comes at a time in the United States when the enormous and disproportionate burden of illness and death from skin care disease 2019 within minority communities, as well as police violence against Black Americans, has laid bare the racial inequities in health and wellbeing in our society. Kidney disease and its complications play a prominent role in this excess burden of illness, motivating the creation of this joint task force.For nephrologists, eGFR is a critical workhorse, a starting point for much of what we where can i buy renova over the counter do. Diagnosis, prognostication, treatment options, and the use of medications all hinge on eGFR. We all know, where can i buy renova over the counter of course, there is much more to kidney function than fiation, but when we ask about a patient’s kidney function, it is shorthand for wanting to know the eGFR.

So, getting it right—having reliable and consistent estimates—is critical to the effective practice of nephrology and all of medicine. Further, understanding the epidemiology of kidney disease, tracking disparities and inequities, and selecting participants where can i buy renova over the counter for inclusion in clinical trials all depend on estimating GFR accurately and consistently.The task force’s interim report1 documents a process being undertaken with extraordinary care and thoroughness. The task force has laid out a planned course of action with three phases, this being the culmination of phase 1. It has articulated a core set of principles to be used in the subsequent stages, compiled a summary of much where can i buy renova over the counter of the relevant evidence base, and established stakeholder input, particularly that of patients. Mindful of the potential unintended consequences of precipitous changes in methods to estimate GFR, the task force has deferred its recommendations until its inclusive and deliberative processes are completed.

The editorial teams of the two journals decided where can i buy renova over the counter to take the unusual step of jointly publishing this report, reflecting our assessment of the importance of the task force’s work.The starting point for considering the inclusion of race in eGFR estimation must be what is best for our patients—people with kidney disease or at risk of kidney disease. The disproportionate burden of kidney disease among Black people in the United States2 and their inequitable access to care, including transplantation, must be addressed3. The burden on Black Americans has been known for decades. It is not simply or even where can i buy renova over the counter principally a reflection of biologic differences. Rather, deep inequities in the social determinants of health and structural racism in the delivery of health care are eroding the wellbeing of our minority communities, compounding the overall societal effects of racism on the lives of Black Americans.4,5As editors we recognize that journals have participated in the dissemination and perpetuation of science that casts race as a biologic construct.

Much is being written about how race is a flawed concept, where can i buy renova over the counter a societal construct that oversimplifies and at times distorts.6,7 The editorial teams of both JASN and AJKD are committed to re-examining our own roles and the language we use to talk about these problems—an essential step, we believe, if we are going to participate effectively in the eradication of unacceptable health disparities. As journal editors, we recognize published research that has emphasized race as a biologic construct has contributed to a failure to address core problems.Journals play an important and privileged role in the dissemination of science, and we feel a deep responsibility not only to inform our readers of these problems but also to participate in a more informed discussion of racism. This is a start, we suggest, in the pursuit of effective interventions that will lessen race-based disparities in where can i buy renova over the counter health. It includes being more cognizant of how reporting of science can perpetuate racism. In this spirit, we are grateful for the opportunity to promote and disseminate the work of the task where can i buy renova over the counter force.The task force is examining the full potential effect of removing race from eGFR expressions, both the desirable benefits and the unintended consequences.

Their deliberations are focusing on how best to optimize GFR estimation for all racial and ethnic groups, while limiting any potential unintended consequences. Although the steps undertaken by the task force may produce recommendations more slowly than some would like, we applaud its deliberative approach and have confidence it will promote improvement in the health status of the patients we serve.We eagerly await the recommendations of the task force but call upon the kidney medicine community to show as much resolve to mitigate the influence of the broad array of factors leading to racial disparities as is now being brought to where can i buy renova over the counter the effort to reassess the use of race in the calculation of eGFR. This important work on GFR estimation should serve as a starting point to robustly address and reverse the unacceptable excessive burden of kidney disease in people within racial minority communities, a sentiment resonant with the task force’s aspiration “that the community of healthcare professionals, scientists, medical educators, students, health professionals in training, and patients to join in the larger, comprehensive effort needed to address the entire spectrum of kidney health to eliminate health disparities.”DisclosuresH.I. Feldman reports consultancy agreements from DLA Piper, LLP, InMed, Inc., where can i buy renova over the counter Kyowa Hakko Kirin Co. Ltd.

(ongoing). Receiving honoraria from where can i buy renova over the counter Rogosin Institute (invited speaker). Being the Steering Committee Chair of NIH-NIDDK’s Chronic Renal Insufficiency Cohort Study. Being a member of the National Kidney Foundation (NKF) Scientific where can i buy renova over the counter Advisory Board. And receiving funding from the NKF to support his role as AJKD Editor-in-Chief.

J.P. Briggs serves as a scientific advisor to the Executive Director of Patient Centered Outcomes Research Institute and reports having other interests/relationships including PCORI—Interim Executive Director from November 2019 through April 2020, and JASN Editor-in-Chief.FundingNone.FootnotesThis article is being published concurrently in the Journal of the American Society of Nephrology and American Journal of Kidney Diseases. The articles are identical except for stylistic changes in keeping with each journal’s style. Either of these versions may be used in citing this article.Published online ahead of print. Publication date available at www.jasn.org.See related article, “Reassessing the Inclusion of Race in Diagnosing Kidney Diseases.

An Interim Report from the NKF-ASN Task Force,” on pages 1305–1317.Copyright © 2021 by the American Society of Nephrology and the National Kidney Foundation, Inc. All rights reserved..

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Fortunately, the ARP’s enhanced subsidies will still be in effect in 2022 http://www.ec-cath-hilsenheim.site.ac-strasbourg.fr/ECOLE/?page_id=179 – and possibly longer, if Congress can agree on timberland pro renova professional an extension. That means subsidies will continue to be larger than they used to be, and more widely available, including to households earning more than 400% of the poverty level. For 2022 individual/family coverage, we’re seeing some wide variation in proposed and finalized rate changes across the country. Average rates will decrease in some areas and increase in timberland pro renova professional others, with modest single-digit rate changes in most places. (Since the ARP has eliminated the income cap for subsidy eligibility for 2021 and 2022, few enrollees will see these rate changes reflected in their actual premiums, since most enrollees get premium subsidies.

But rate changes do affect the size of the subsidy amount, and that can result in changes for after-subsidy premiums, as explained below.) Increased insurer participation in marketplaces continues But we’re also seeing widespread continuation of the increasing insurer participation trend that’s been ongoing since 2019. In 2017 timberland pro renova professional and 2018, insurers fled the ACA’s exchanges – or even the entire individual/family market. But that started to turn around in 2019, and insurer participation increased again in 2020 and 2021. For 2022, that trend is continuing. Some big-name insurers that previously scaled back their marketplace participation are rejoining timberland pro renova professional various marketplaces, and some smaller regional insurers are joining marketplaces or expanding their existing footprints.

Where are new carriers entering ACA’s marketplace for 2022?. Here’s a summary of some of the major individual/family insurers that are entering new markets for 2022. Aetna CVS Health is joining the marketplace in Arizona, Florida, Georgia, Missouri, Nevada, North Carolina, Virginia, and timberland pro renova professional Texas. Friday Health Plans is joining the marketplace in Oklahoma and Georgia, and possibly North Carolina. Bright Healthcare is joining the marketplace in California, Texas, and Georgia.

UnitedHealthcare is joining the marketplace in Alabama, timberland pro renova professional Texas and Georgia. Oscar Health is joining the marketplace in Arkansas, Illinois, and Nebraska. Cigna is joining the marketplace in Georgia. Moda is joining the marketplace in Texas timberland pro renova professional. US Health and Life is joining the marketplace in Indiana.

Hometown Health Plan is joining the marketplace in Nevada. Innovation Health Plan is joining the marketplace timberland pro renova professional in Virginia. ConnectiCare Insurance Company is joining the marketplace in Connecticut. More carriers = more plan options … That’s in addition to numerous coverage area expansions by existing marketplace insurers in many states. Based on the rate filings that we’ve analyzed thus far, we anticipate that many – if not most timberland pro renova professional – marketplace enrollees will have more plan options available for 2022 than they had this year.

One of the goals of the ACA was to increase competition in the individual health insurance market. The exchanges are set up to facilitate that, with enrollees able to compare options from all of the participating insurers and select the plan that best fits their needs. From that perspective, increasing insurer participation and competition in the exchange is good timberland pro renova professional. And it does give people more plans from which to choose, which can also be a good thing. But too many choices can overwhelm applicants and result in poor decision making.

€¦ and a new carrier could also affect premium subsidies In addition to delivering more plan options, carriers expanding into an area might also affect timberland pro renova professional premium subsidies in that area. How much effect will depend on how the new plans are priced in comparison with the existing plans – keeping in mind that rates change each year on January 1 regardless of whether any new insurers are entering the market. Premium subsidy amounts are based on the cost of the benchmark plan in each area. But since that timberland pro renova professional just refers to the second-lowest-cost Silver plan, it’s not necessarily the same plan from one year to the next. If a new insurer enters the market with low-priced plans, the insurer may undercut the current benchmark and take over the second-lowest-cost spot.

If the premium is lower than the benchmark plan’s price would otherwise have been, the result is smaller premium subsidies for everyone in that area. For people in that area who prefer to keep their existing plan (as opposed to switching to the new lower-cost options), this can result in an increase in after-subsidy premiums, timberland pro renova professional since the subsidies are smaller than they would otherwise have been. We can see an example of this in the Phoenix area in 2019 and 2020, when new insurers entered the market with lower-priced plans that reduced the size of premium subsidies in the area. To clarify, anything that reduces the cost of the benchmark premium will result in smaller subsidies. This can be a new lower-cost insurer entering the timberland pro renova professional market, or existing insurers reducing their rates.

An example of this can be seen in how after-subsidy premiums increased for many of Colorado’s exchange enrollees in 2020, when the state’s new reinsurance program reduced average pre-subsidy premiums by about 20%. The reduction helped unsubsidized enrollees (mostly those with incomes over the limit for subsidy eligibility, which has been removed at least through 2022) but resulted in higher net premiums for many enrollees who qualified for subsidies. Although the vast majority of exchange enrollees do qualify for premium subsidies (especially now that the American Rescue Plan has eliminated the “subsidy cliff” for 2021 and timberland pro renova professional 2022) some enrollees do not. For these enrollees, the introduction of a new insurer simply broadens their plan options, and does not affect their premiums unless they choose to switch to the new plan. And of course, if the new insurer has plans that are priced higher than the existing benchmark plan, the carrier’s entry will not affect net premiums paid by subsidized enrollees.

Plan to compare your coverage options during open enrollment It will be several weeks before all the details are clear in terms timberland pro renova professional of rate changes and plan availability for 2022 coverage. But it appears that the trend of increasing competition in the exchanges will continue. And although the American Rescue Plan’s enhanced subsidy structure will still be in place in 2022 – making subsidies larger and more widely available than they would otherwise have been – it’s still possible for a new insurer to disrupt the market and end up adjusting the size of premium subsidies in a given area. Open enrollment for timberland pro renova professional 2022 coverage will begin November 1. Actively comparing your options during open enrollment is always the best approach, and that’s especially true if a new insurer will be offering plans in your area.

Letting your current plan auto-renew without comparison shopping is never in your best interest. If a new insurer is joining the marketplace, you may find that its plans are a perfect fit for your timberland pro renova professional needs. Or you might find that your best option is to switch to a different plan because your after-subsidy premiums are increasing due to the new insurer undercutting the price of the current benchmark plan. Switching plans might be a non-starter due to your provider network or drug formulary needs, but you won’t know for sure until you consider the various options that are available to you. Ask a professional how a new carrier could impact your coverage We have an overview timberland pro renova professional of factors to keep in mind when you’re choosing a health plan, but it’s also worthwhile to seek out professional advice.

Enrollment assistance is available from brokers, enrollment counselors, and Navigators. Brokers are licensed and regulated by state insurance departments, and must also have certification from the exchange in order to help people enroll in health plans offered through the exchange. Training and testing are necessary in order to obtain the license and certification, and brokers must also complete ongoing continuing timberland pro renova professional education in order to maintain their credentials. Broker training encompasses a wide range of topics, including ethics, fraud prevention, evolving insurance laws and regulations, and health plan details. The training and regulatory oversight make brokers a reliable source of information and assistance with initial plan selections and enrollments as well as future issues that might arise as the health plan is utilized.

Navigators should be much more widely available this fall, as the Biden administration has allocated $80 million for this year’s Navigator grants in timberland pro renova professional the states that use HealthCare.gov. (The previous high was $63 million in 2016. The Trump administration subsequently reduced it to $36 million in 2017 and to $10 million each year from 2018 through 2020.) The Biden administration has also proposed a return to expanded duties for Navigators, which would provide consumers with increased access to post-enrollment assistance with their coverage. In short, enrollment assistance timberland pro renova professional should be widely available this fall, and it’s in your best interest to use it. A recent report from Young Invincibles highlights the myriad ways that enrollment assisters help consumers – it’s more than just picking a plan.

Regardless of where you seek assistance, it won’t cost you anything – and a broker, Navigator, or enrollment counselor will be able to help you determine the impact of any new insurers that will be offering plans in your area for 2022, and help you make sense of the options available to you. Louise Norris is an individual health insurance timberland pro renova professional broker who has been writing about health 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 exchange updates are regularly cited by media who cover health reform and by other health insurance experts.In eleven of the twelve states that have so far refused to enact the Affordable Care Act’s expansion of Medicaid eligibility (which the Supreme Court made optional for states in 2012), there’s good news and bad news for people who are seeking health insurance for 2022 and don’t earn a lot of income. The good news is that skin care products relief legislation signed by President Biden in March of this year, the American timberland pro renova professional Rescue Plan Act, vastly improved subsidies in the ACA private plan marketplace.

Comprehensive coverage – a Silver plan with strong cost-sharing reductions – is now free to many low-income Americans, and heavily subsidized for people who earn a bit more. The bad news is that in states that have refused to enact the Medicaid expansion, the government still offers no help to people who report household incomes below the poverty line. ACA’s coverage gap The ACA’s creators intended for people in this income category to get Medicaid, but governors and legislators in the timberland pro renova professional twelve “nonexpansion” states said no – even though the federal government foots 90% of the cost. More than 2 million low-income adults in these states are in the ACA’s coverage gap – eligible neither for Medicaid nor for help paying for coverage in the ACA private plan marketplace. The remaining non-expansion states (excluding Wisconsin, which has no coverage gap,* and Missouri, where expansion is imminent) are as follows.

Alabama Florida Georgia Kansas Mississippi North Carolina South timberland pro renova professional Carolina South Dakota Tennessee Texas Wyoming The minimum income to qualify for subsidized marketplace coverage in “nonexpansion” states is 100% of the federal poverty level (FPL). For enrollment in 2022, the cutoffs are as follows. (They are slightly lower for those still seeking coverage for the remainder of 2021.) Persons in family/household 100% FPL (minimum to qualify for coverage) 1 $12,880 2 $17,420 3 $21,960 4 $26,500 A Silver plan with strong cost-sharing reduction is free to enrollees with incomes between 100% FPL and 150% FPL. (In 2022, that’s $19,230 for an individual, $39,750 for a family of four.) timberland pro renova professional At 150-200% FPL, Silver coverage costs no more than 2% of income. At incomes above 200% FPL, the percentage of income required for a benchmark Silver plan rises with income to a maximum of 8.5% of income.

But again, in non-expansion states, subsidies are not available to people in households with incomes below 100% FPL. Stumbling blind into the coverage gap The application for coverage on HealthCare.gov – the federal marketplace for health coverage used by all of timberland pro renova professional the non-expansion states (and 24 other states) – does not highlight the minimum income required for coverage. As a result, many low-income applicants who might expect to get federal aid find themselves confronted with a choice of plans quoted at full, unsubsidized cost – an average of $452 per month per adult for benchmark Silver coverage, unaffordable for almost all low-income enrollees. Very few low-income enrollees know about the minimum income requirement, or know that their state legislatures and governors have denied them the Medicaid coverage that the ACA’s creators intended for them. Many who work uncertain hours, or are self-employed, or do seasonal work, may not recognize how many variables go into their estimate of annual household income, which determines the size of subsidy – or whether a subsidy timberland pro renova professional is available at all.

For applicants with incomes near the federal poverty line, knowing the stakes – that good coverage is free just above the 100% FPL threshold, and unaffordable just below that threshold – can make the difference between coverage and no coverage. For anyone not on a fixed salary, a good-faith estimate of next year’s income allows for some wiggle room. Many applicants may miss including allowable income sources, or fail to take fluctuations in their income into account, or otherwise miss the opportunity to claim a timberland pro renova professional qualifying income. A budget resolution introduced last week by Sen. Bernie Sanders proposes to create a new federal program that would offer insurance to people in this “coverage gap.” But with Democrats holding narrow majorities in both houses of Congress, their ability to create such a program is at best uncertain.

Even if they do, it timberland pro renova professional likely won’t go into effect in 2022. Open enrollment for 2022 in non-expansion states begins on November 1 and HHS has proposed an end date of January 15. For those still seeking coverage in 2021, an emergency special enrollment period open to all who lack coverage ends soon – on August 15. After that date, you need a qualifying “life change” to get coverage for timberland pro renova professional the remainder of 2021. Six tactics for avoiding the coverage gap Here is a checklist of strategies that may help you achieve eligibility for subsidized ACA coverage.

1. Know the eligibility timberland pro renova professional cutoff. As noted above, to qualify for subsidized coverage, an applicant must estimate an annual income for the coming year that’s above 100% of the Federal Poverty Level ($12,880 for an individual, $17,420 for a couple, etc. In 2022 get renova. See the list above.) This point can’t be emphasized enough, according to Shelli Quenga, Director of Programs at the Palmetto Project, a nonprofit health insurance brokerage in South Carolina.

“You need to know what timberland pro renova professional amount you’re shooting for,” Quenga says. €œYou need to know where that line is. HealthCare.gov does not tell you.” Jennifer Chumbley Hogue, CEO of KG Health Insurance in Murphy Texas, is equally emphatic on this point. €œIf somebody calls me and they’re timberland pro renova professional on the bubble, I tell them. €˜the state of Texas did not expand Medicaid.

That means, if you cannot project $13,000 of income, you do not get any help. So let timberland pro renova professional me ask you. Do you think you’re going to make $13,000 in 2021?. €™â€ 2. Use gross timberland pro renova professional income, not net.

Many applicants don’t recognize these terms, which denote income before and after taxes. Gross income, which the application requires, is basically the largest number on the pay stub or tax form. 3. Consider earning more income if necessary. When clients’ estimates fall short, Quenga will ask them what they can do to hit the target.

€œI’ll say, ‘Can you think of something you can do that’s going to earn you another $150 a month?. Bake cakes?. Clean houses?. Mow grass?. Do some babysitting?.

Provide some care to a nearby elderly person?. €™â€ Extra income of this sort can be entered on the application as self-employment, with wage income entered elsewhere. 4. Recognize uncertainty. The marketplace application for coverage provides a box to check “if you think your income will be difficult to predict.” That’s the case for many people – especially at low wages.

If it’s hard to forecast how many hours you’ll work per week, how much you’ll make per hour (tips or overtime may make this variable), or how much work you’ll get if you’re self-employed, keep the eligibility threshold in mind as you estimate these factors. 5. Count everyone’s income. Household income includes income earned by everyone included in your tax return, including those who are not seeking coverage. Hogue cites the case of a woman in her early 60s whose husband is on Medicare and Social Security.

€œIf your spouse is getting Social Security income, don’t forget to include it,” she says. That also holds for pensions, retirement accounts, and alimony (if awarded before 2019). 6. Consider how to count. The application allows you to estimate income on an hourly, weekly, twice-monthly, monthly or annual basis – and, if your income changes during the year, it invites you to estimate a different income for next year than for the current year.

This flexibility allows you to take account of factors described below. You can view the application on the HealthCare.gov site here. The income questions are on page 3. Note that the form recognizes the uncertainty involved in forecasting future income. Considerations for individuals earning an hourly wage If your income estimate is based on an hourly wage, consider the following questions.

Is the amount you and other workers in your household earned in the current month (or on the pay stubs you’re looking at) representative of what you are likely to earn throughout the year?. If you or a household member are a seasonal worker, have you fully accounted for that person’s likely full-year income?. Do you work more hours or earn more tips during the holiday season (or at other times of the year?. ) Have you fully accounted for that?. Does anyone in the household take on a second job or temp job during the holiday season (or other season)?.

Have you included that income?. Do you sometimes get paid overtime?. Do the pay stubs you’re using to estimate income reflect that?. Do you have reason to anticipate a raise in the coming year?. (For example, Florida will raise the state minimum wage to $10 per hour in September 2021, and to $11 per hour in September 2022).

If so, estimate your income on the basis of future pay rates. Many who report income on an hourly wage basis work uneven and uncertain schedules. If a single person is unsure how many hours per week they’re likely to work, “I often tell them to put down 30 hours,” says Hogue – an amount that generally will qualify a solo applicant for coverage at an hourly wage of $8.50 or higher. Strategies for the self-employed Many of the low-income clients served by the Palmetto Project are self-employed, Quenga says. €œCharleston is a huge destination wedding site.

We have a lot of wedding planners, DJs, photographers, videographers.” Estimating next-year income is especially difficult if you’re self-employed, Quenga notes. And for the self-employed, “Your projected income is your best guess of what you hope to earn.” She notes that the self-employed are generally oriented toward minimizing their income for tax purposes. For the health insurance application, they have to reverse that mindset. Considerations when estimating your income for 2022 When you apply for coverage for 2022 (or the remainder of 2021), you may have your 2020 tax return to refer to, as well as well as pay stubs for at least 10 months’ income in 2021. If the totals for 2020 or 2021 are below the eligibility cutoff, that’s not necessarily going to be true in the year following.

When estimating income in this case, consider these questions. Were your hours cut because of the renova?. Regardless, can you realistically expect to work more hours in 2022 (or the remainder of 2021)?. These questions apply to everyone in your household – that is, all who file taxes together and earn any income. If so, you can estimate a higher income for the coming year in good faith.

Should you check off allowable tax deductions?. The health insurance application asks about tax deductions that, if taken, reduce your gross income. The application points out that reporting these deductions “could make the cost of health coverage a little lower.” That’s true – if your income is above 150% FPL (Coverage is free up to that threshold.) But if your income hovers near 100% FPL, these deductions could put your income below that threshold and disqualify you from subsidized coverage. The deductions listed on the application are those taken for interest paid on student loans, tuition and fees, retirement plan contributions, and alimony paid. If your income is near the cutoff, “do not check off a deduction that will put you under 100% FPL,” says Hogue.

If you were unemployed in any part of 2021 The American Rescue Plan provides free marketplace coverage in 2021 for any applicant who received any unemployment insurance income at any point in the year. After the emergency special enrollment period (SEP) ends on August 15, you will need to apply for a personal SEP to access this benefit – and do so within 60 days of having lost employer-sponsored coverage or experienced another qualifying life event. This particular benefit is not available in 2022. What if your income estimate turns out to be higher than what you actually earn?. Low-income applicants may worry that they will owe large sums of money if their income estimate proves inaccurate.

While those who underestimate their income do have to pay back a portion of their subsidy at tax time, that is not the case for those who overestimate income (in fact, if over-estimators pay any premium at all, they will get a partial refund). If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant’s income estimate is made with “intentional or reckless disregard for the facts.” Your income estimate has to be good faith. You can’t make stuff up. But within the range of the realistically probable, you have leeway. €œSuppose you mow grass for a living, and there was a drought,” Quenga posits.

€œYou can’t control that. There is no penalty if you don’t end up hitting your target.” Who’s checking your income anyway?. The ACA exchanges do check applicants’ income estimates against data sources such as employer records. In 2019, the Trump administration implemented a rule requiring the ACA exchanges to demand income documentation from applicants who claimed an income above 100% FPL if “trusted data sources” indicated an income below the threshold. If the enrollee failed to provide the documentation, the federal subsidy would be cut off, and the enrollee would likely lose coverage due to the unaffordability of the unsubsidized premiums.

But that rule was challenged in court, and in March 2021 a federal court ordered the Department of Health and Human Services (HHS) to rescind it. HHS responded promptly, rescinding the documentation requirement this past May. HHS did warn that its computer systems could not be retooled instantly, so that for some time, a request for income documentation would be sent in this situation. But HHS added that it would send a follow-up communication to the enrollee, saying that documentation was not required. The ACA’s creators did not intend to shut poor Americans out of its benefits.

But governors and state legislatures that refuse to enact the ACA Medicaid expansion do willfully perpetuate the coverage gap. Low-income people in non-expansion states should use every tool available to produce a good faith income estimate that will give them access to quality government-subsidized health insurance. * * * * States that enact the ACA Medicaid expansion offer Medicaid to all legally present adults with household incomes up to 138% FPL. Wisconsin, uniquely, offers Medicaid to adults with incomes up to 100% FPL – which is also the bottom threshold for subsidy eligibility in the private plan marketplace. No one, therefore, is excluded from aid on the basis of income.

Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic.

Now, as we approach ACA’s annual open enrollment period, it’s a good time to look ahead to where can i buy renova over the counter what renova for sale online we can expect to happen with 2022 coverage. Fortunately, the ARP’s enhanced subsidies will still be in effect in 2022 – and possibly longer, if Congress can agree on an extension. That means subsidies will continue to be larger than they used to be, and more widely available, including to households earning more than 400% of the poverty level. For 2022 individual/family coverage, we’re seeing some wide variation where can i buy renova over the counter in proposed and finalized rate changes across the country. Average rates will decrease in some areas and increase in others, with modest single-digit rate changes in most places.

(Since the ARP has eliminated the income cap for subsidy eligibility for 2021 and 2022, few enrollees will see these rate changes reflected in their actual premiums, since most enrollees get premium subsidies. But rate changes do affect the size of the subsidy amount, and that can result in changes for after-subsidy premiums, as explained below.) Increased insurer participation in marketplaces continues But we’re also seeing widespread continuation of the increasing insurer participation trend that’s been where can i buy renova over the counter ongoing since 2019. In 2017 and 2018, insurers fled the ACA’s exchanges – or even the entire individual/family market. But that started to turn around in 2019, and insurer participation increased again in 2020 and 2021. For 2022, that where can i buy renova over the counter trend is continuing.

Some big-name insurers that previously scaled back their marketplace participation are rejoining various marketplaces, and some smaller regional insurers are joining marketplaces or expanding their existing footprints. Where are new carriers entering ACA’s marketplace for 2022?. Here’s a summary of some of the major individual/family insurers where can i buy renova over the counter that are entering new markets for 2022. Aetna CVS Health is joining the marketplace in Arizona, Florida, Georgia, Missouri, Nevada, North Carolina, Virginia, and Texas. Friday Health Plans is joining the marketplace in Oklahoma and Georgia, and possibly North Carolina.

Bright Healthcare is joining the marketplace in where can i buy renova over the counter California, Texas, and Georgia. UnitedHealthcare is joining the marketplace in Alabama, Texas and Georgia. Oscar Health is joining the marketplace in Arkansas, Illinois, and Nebraska. Cigna is joining the marketplace in where can i buy renova over the counter Georgia. Moda is joining the marketplace in Texas.

US Health and Life is joining the marketplace in Indiana. Hometown Health Plan is where can i buy renova over the counter joining the marketplace in Nevada. Innovation Health Plan is joining the marketplace in Virginia. ConnectiCare Insurance Company is joining the marketplace in Connecticut. More carriers = more plan options … That’s where can i buy renova over the counter in addition to numerous coverage area expansions by existing marketplace insurers in many states.

Based on the rate filings that we’ve analyzed thus far, we anticipate that many – if not most – marketplace enrollees will have more plan options available for 2022 than they had this year. One of the goals of the ACA was to increase competition in the individual health insurance market. The exchanges are set up to facilitate that, with enrollees able to compare options from all of the participating insurers and select the plan that best where can i buy renova over the counter fits their needs. From that perspective, increasing insurer participation and competition in the exchange is good. And it does give people more plans from which to choose, which can also be a good thing.

But too many choices can overwhelm applicants and result in poor decision making where can i buy renova over the counter. €¦ and a new carrier could also affect premium subsidies In addition to delivering more plan options, carriers expanding into an area might also affect premium subsidies in that area. How much effect will depend on how the new plans are priced in comparison with the existing plans – keeping in mind that rates change each year on January 1 regardless of whether any new insurers are entering the market. Premium subsidy where can i buy renova over the counter amounts are based on the cost of the benchmark plan in each area. But since that just refers to the second-lowest-cost Silver plan, it’s not necessarily the same plan from one year to the next.

If a new insurer enters the market with low-priced plans, the insurer may undercut the current benchmark and take over the second-lowest-cost spot. If the premium is lower than the benchmark plan’s price would otherwise have been, the result is smaller premium subsidies for everyone in that where can i buy renova over the counter area. For people in that area who prefer to keep their existing plan (as opposed to switching to the new lower-cost options), this can result in an increase in after-subsidy premiums, since the subsidies are smaller than they would otherwise have been. We can see an example of this in the Phoenix area in 2019 and 2020, when new insurers entered the market with lower-priced plans that reduced the size of premium subsidies in the area. To clarify, anything that reduces where can i buy renova over the counter the cost of the benchmark premium will result in smaller subsidies.

This can be a new lower-cost insurer entering the market, or existing insurers reducing their rates. An example of this can be seen in how after-subsidy premiums increased for many of Colorado’s exchange enrollees in 2020, when the state’s new reinsurance program reduced average pre-subsidy premiums by about 20%. The reduction helped unsubsidized enrollees (mostly those with incomes over the limit for subsidy eligibility, which has been removed at least through 2022) but resulted in higher net premiums for many where can i buy renova over the counter enrollees who qualified for subsidies. Although the vast majority of exchange enrollees do qualify for premium subsidies (especially now that the American Rescue Plan has eliminated the “subsidy cliff” for 2021 and 2022) some enrollees do not. For these enrollees, the introduction of a new insurer simply broadens their plan options, and does not affect their premiums unless they choose to switch to the new plan.

And of course, if the new insurer has plans that are priced higher than the existing benchmark plan, the carrier’s entry where can i buy renova over the counter will not affect net premiums paid by subsidized enrollees. Plan to compare your coverage options during open enrollment It will be several weeks before all the details are clear in terms of rate changes and plan availability for 2022 coverage. But it appears that the trend of increasing competition in the exchanges will continue. And although the American Rescue Plan’s enhanced subsidy structure will still be in place in 2022 – making where can i buy renova over the counter subsidies larger and more widely available than they would otherwise have been – it’s still possible for a new insurer to disrupt the market and end up adjusting the size of premium subsidies in a given area. Open enrollment for 2022 coverage will begin November 1.

Actively comparing your options during open enrollment is always the best approach, and that’s especially true if a new insurer will be offering plans in your area. Letting your current plan auto-renew without comparison where can i buy renova over the counter shopping is never in your best interest. If a new insurer is joining the marketplace, you may find that its plans are a perfect fit for your needs. Or you might find that your best option is to switch to a different plan because your after-subsidy premiums are increasing due to the new insurer undercutting the price of the current benchmark plan. Switching plans might be a non-starter due to your provider network or drug formulary needs, but you won’t know for sure until where can i buy renova over the counter you consider the various options that are available to you.

Ask a professional how a new carrier could impact your coverage We have an overview of factors to keep in mind when you’re choosing a health plan, but it’s also worthwhile to seek out professional advice. Enrollment assistance is available from brokers, enrollment counselors, and Navigators. Brokers are licensed and regulated by state insurance departments, and must also have certification from the exchange in order to help people enroll in health plans offered through the exchange where can i buy renova over the counter. Training and testing are necessary in order to obtain the license and certification, and brokers must also complete ongoing continuing education in order to maintain their credentials. Broker training encompasses a wide range of topics, including ethics, fraud prevention, evolving insurance laws and regulations, and health plan details.

The training and regulatory oversight make brokers a reliable source of information and assistance with initial plan selections and enrollments as well as future issues that might arise as the health plan where can i buy renova over the counter is utilized. Navigators should be much more widely available this fall, as the Biden administration has allocated $80 million for this year’s Navigator grants in the states that use HealthCare.gov. (The previous high was $63 million in 2016. The Trump administration subsequently reduced it to $36 million in 2017 and to $10 million each year from 2018 through 2020.) The Biden administration has also where can i buy renova over the counter proposed a return to expanded duties for Navigators, which would provide consumers with increased access to post-enrollment assistance with their coverage. In short, enrollment assistance should be widely available this fall, and it’s in your best interest to use it.

A recent report from Young Invincibles highlights the myriad ways that enrollment assisters help consumers – it’s more than just picking a plan. Regardless of where you seek assistance, it won’t cost you anything – and a broker, Navigator, or enrollment counselor will be able to help you determine the impact of any new insurers that will be offering plans where can i buy renova over the counter in your area for 2022, and help you make sense of the options available to you. Louise Norris is an individual health insurance broker who has been writing about health 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 exchange updates are regularly cited by media who cover health reform and by other health insurance experts.In eleven of the twelve states that have so far refused to enact the Affordable Care Act’s expansion of Medicaid eligibility (which the Supreme Court made optional for states in 2012), there’s good news and bad news for people who are seeking health insurance where can i buy renova over the counter for 2022 and don’t earn a lot of income.

The good news is that skin care products relief legislation signed by President Biden in March of this year, the American Rescue Plan Act, vastly improved subsidies in the ACA private plan marketplace. Comprehensive coverage – a Silver plan with strong cost-sharing reductions – is now free to many low-income Americans, and heavily subsidized for people who earn a bit more. The bad news is that in states that have refused to enact the Medicaid expansion, where can i buy renova over the counter the government still offers no help to people who report household incomes below the poverty line. ACA’s coverage gap The ACA’s creators intended for people in this income category to get Medicaid, but governors and legislators in the twelve “nonexpansion” states said no – even though the federal government foots 90% of the cost. More than 2 million low-income adults in these states are in the ACA’s coverage gap – eligible neither for Medicaid nor for help paying for coverage in the ACA private plan marketplace.

The remaining non-expansion states (excluding Wisconsin, where can i buy renova over the counter which has no coverage gap,* and Missouri, where expansion is imminent) are as follows. Alabama Florida Georgia Kansas Mississippi North Carolina South Carolina South Dakota Tennessee Texas Wyoming The minimum income to qualify for subsidized marketplace coverage in “nonexpansion” states is 100% of the federal poverty level (FPL). For enrollment in 2022, the cutoffs are as follows. (They are slightly lower for those still seeking coverage for the remainder of 2021.) Persons in family/household 100% where can i buy renova over the counter FPL (minimum to qualify for coverage) 1 $12,880 2 $17,420 3 $21,960 4 $26,500 A Silver plan with strong cost-sharing reduction is free to enrollees with incomes between 100% FPL and 150% FPL. (In 2022, that’s $19,230 for an individual, $39,750 for a family of four.) At 150-200% FPL, Silver coverage costs no more than 2% of income.

At incomes above 200% FPL, the percentage of income required for a benchmark Silver plan rises with income to a maximum of 8.5% of income. But again, in non-expansion states, subsidies are not available to people in households with incomes below 100% where can i buy renova over the counter FPL. Stumbling blind into the coverage gap The application for coverage on HealthCare.gov – the federal marketplace for health coverage used by all of the non-expansion states (and 24 other states) – does not highlight the minimum income required for coverage. As a result, many low-income applicants who might expect to get federal aid find themselves confronted with a choice of plans quoted at full, unsubsidized cost – an average of $452 per month per adult for benchmark Silver coverage, unaffordable for almost all low-income enrollees. Very few low-income enrollees know about the minimum income requirement, or know that their state where can i buy renova over the counter legislatures and governors have denied them the Medicaid coverage that the ACA’s creators intended for them.

Many who work uncertain hours, or are self-employed, or do seasonal work, may not recognize how many variables go into their estimate of annual household income, which determines the size of subsidy – or whether a subsidy is available at all. For applicants with incomes near the federal poverty line, knowing the stakes – that good coverage is free just above the 100% FPL threshold, and unaffordable just below that threshold – can make the difference between coverage and no coverage. For anyone not on a fixed salary, a good-faith estimate of next year’s income allows for some where can i buy renova over the counter wiggle room. Many applicants may miss including allowable income sources, or fail to take fluctuations in their income into account, or otherwise miss the opportunity to claim a qualifying income. A budget resolution introduced last week by Sen.

Bernie Sanders proposes to create a new federal program that would offer insurance to people in this “coverage gap.” But where can i buy renova over the counter with Democrats holding narrow majorities in both houses of Congress, their ability to create such a program is at best uncertain. Even if they do, it likely won’t go into effect in 2022. Open enrollment for 2022 in non-expansion states begins on November 1 and HHS has proposed an end date of January 15. For those still seeking coverage in 2021, where can i buy renova over the counter an emergency special enrollment period open to all who lack coverage ends soon – on August 15. After that date, you need a qualifying “life change” to get coverage for the remainder of 2021.

Six tactics for avoiding the coverage gap Here is a checklist of strategies that may help you achieve eligibility for subsidized ACA coverage. 1. Know the eligibility cutoff. As noted above, to qualify for subsidized coverage, an applicant must estimate an annual income for the coming year that’s above 100% of the Federal Poverty Level go to my site ($12,880 for an individual, $17,420 for a couple, etc. In 2022.

See the list above.) This point can’t be emphasized enough, according to Shelli Quenga, Director of Programs at the Palmetto Project, a nonprofit health insurance brokerage in South Carolina. “You need to know what amount you’re shooting for,” Quenga says. €œYou need to know where that line is. HealthCare.gov does not tell you.” Jennifer Chumbley Hogue, CEO of KG Health Insurance in Murphy Texas, is equally emphatic on this point. €œIf somebody calls me and they’re on the bubble, I tell them.

€˜the state of Texas did not expand Medicaid. That means, if you cannot project $13,000 of income, you do not get any help. So let me ask you. Do you think you’re going to make $13,000 in 2021?. €™â€ 2.

Use gross income, not net. Many applicants don’t recognize these terms, which denote income before and after taxes. Gross income, which the application requires, is basically the largest number on the pay stub or tax form. 3. Consider earning more income if necessary.

When clients’ estimates fall short, Quenga will ask them what they can do to hit the target. €œI’ll say, ‘Can you think of something you can do that’s going to earn you another $150 a month?. Bake cakes?. Clean houses?. Mow grass?.

Do some babysitting?. Provide some care to a nearby elderly person?. €™â€ Extra income of this sort can be entered on the application as self-employment, with wage income entered elsewhere. 4. Recognize uncertainty.

The marketplace application for coverage provides a box to check “if you think your income will be difficult to predict.” That’s the case for many people – especially at low wages. If it’s hard to forecast how many hours you’ll work per week, how much you’ll make per hour (tips or overtime may make this variable), or how much work you’ll get if you’re self-employed, keep the eligibility threshold in mind as you estimate these factors. 5. Count everyone’s income. Household income includes income earned by everyone included in your tax return, including those who are not seeking coverage.

Hogue cites the case of a woman in her early 60s whose husband is on Medicare and Social Security. €œIf your spouse is getting Social Security income, don’t forget to include it,” she says. That also holds for pensions, retirement accounts, and alimony (if awarded before 2019). 6. Consider how to count.

The application allows you to estimate income on an hourly, weekly, twice-monthly, monthly or annual basis – and, if your income changes during the year, it invites you to estimate a different income for next year than for the current year. This flexibility allows you to take account of factors described below. You can view the application on the HealthCare.gov site here. The income questions are on page 3. Note that the form recognizes the uncertainty involved in forecasting future income.

Considerations for individuals earning an hourly wage If your income estimate is based on an hourly wage, consider the following questions. Is the amount you and other workers in your household earned in the current month (or on the pay stubs you’re looking at) representative of what you are likely to earn throughout the year?. If you or a household member are a seasonal worker, have you fully accounted for that person’s likely full-year income?. Do you work more hours or earn more tips during the holiday season (or at other times of the year?. ) Have you fully accounted for that?.

Does anyone in the household take on a second job or temp job during the holiday season (or other season)?. Have you included that income?. Do you sometimes get paid overtime?. Do the pay stubs you’re using to estimate income reflect that?. Do you have reason to anticipate a raise in the coming year?.

(For example, Florida will raise the state minimum wage to $10 per hour in September 2021, and to $11 per hour in September 2022). If so, estimate your income on the basis of future pay rates. Many who report income on an hourly wage basis work uneven and uncertain schedules. If a single person is unsure how many hours per week they’re likely to work, “I often tell them to put down 30 hours,” says Hogue – an amount that generally will qualify a solo applicant for coverage at an hourly wage of $8.50 or higher. Strategies for the self-employed Many of the low-income clients served by the Palmetto Project are self-employed, Quenga says.

€œCharleston is a huge destination wedding site. We have a lot of wedding planners, DJs, photographers, videographers.” Estimating next-year income is especially difficult if you’re self-employed, Quenga notes. And for the self-employed, “Your projected income is your best guess of what you hope to earn.” She notes that the self-employed are generally oriented toward minimizing their income for tax purposes. For the health insurance application, they have to reverse that mindset. Considerations when estimating your income for 2022 When you apply for coverage for 2022 (or the remainder of 2021), you may have your 2020 tax return to refer to, as well as well as pay stubs for at least 10 months’ income in 2021.

If the totals for 2020 or 2021 are below the eligibility cutoff, that’s not necessarily going to be true in the year following. When estimating income in this case, consider these questions. Were your hours cut because of the renova?. Regardless, can you realistically expect to work more hours in 2022 (or the remainder of 2021)?. These questions apply to everyone in your household – that is, all who file taxes together and earn any income.

If so, you can estimate a higher income for the coming year in good faith. Should you check off allowable tax deductions?. The health insurance application asks about tax deductions that, if taken, reduce your gross income. The application points out that reporting these deductions “could make the cost of health coverage a little lower.” That’s true – if your income is above 150% FPL (Coverage is free up to that threshold.) But if your income hovers near 100% FPL, these deductions could put your income below that threshold and disqualify you from subsidized coverage. The deductions listed on the application are those taken for interest paid on student loans, tuition and fees, retirement plan contributions, and alimony paid.

If your income is near the cutoff, “do not check off a deduction that will put you under 100% FPL,” says Hogue. If you were unemployed in any part of 2021 The American Rescue Plan provides free marketplace coverage in 2021 for any applicant who received any unemployment insurance income at any point in the year. After the emergency special enrollment period (SEP) ends on August 15, you will need to apply for a personal SEP to access this benefit – and do so within 60 days of having lost employer-sponsored coverage or experienced another qualifying life event. This particular benefit is not available in 2022. What if your income estimate turns out to be higher than what you actually earn?.

Low-income applicants may worry that they will owe large sums of money if their income estimate proves inaccurate. While those who underestimate their income do have to pay back a portion of their subsidy at tax time, that is not the case for those who overestimate income (in fact, if over-estimators pay any premium at all, they will get a partial refund). If income for the year in question ultimately proves to fall below the 100% FPL threshold, there is no clawback of subsidies granted, unless the applicant’s income estimate is made with “intentional or reckless disregard for the facts.” Your income estimate has to be good faith. You can’t make stuff up. But within the range of the realistically probable, you have leeway.

€œSuppose you mow grass for a living, and there was a drought,” Quenga posits. €œYou can’t control that. There is no penalty if you don’t end up hitting your target.” Who’s checking your income anyway?. The ACA exchanges do check applicants’ income estimates against data sources such as employer records. In 2019, the Trump administration implemented a rule requiring the ACA exchanges to demand income documentation from applicants who claimed an income above 100% FPL if “trusted data sources” indicated an income below the threshold.

If the enrollee failed to provide the documentation, the federal subsidy would be cut off, and the enrollee would likely lose coverage due to the unaffordability of the unsubsidized premiums. But that rule was challenged in court, and in March 2021 a federal court ordered the Department of Health and Human Services (HHS) to rescind it. HHS responded promptly, rescinding the documentation requirement this past May. HHS did warn that its computer systems could not be retooled instantly, so that for some time, a request for income documentation would be sent in this situation. But HHS added that it would send a follow-up communication to the enrollee, saying that documentation was not required.

The ACA’s creators did not intend to shut poor Americans out of its benefits. But governors and state legislatures that refuse to enact the ACA Medicaid expansion do willfully perpetuate the coverage gap. Low-income people in non-expansion states should use every tool available to produce a good faith income estimate that will give them access to quality government-subsidized health insurance. * * * * States that enact the ACA Medicaid expansion offer Medicaid to all legally present adults with household incomes up to 138% FPL. Wisconsin, uniquely, offers Medicaid to adults with incomes up to 100% FPL – which is also the bottom threshold for subsidy eligibility in the private plan marketplace.

No one, therefore, is excluded from aid on the basis of income. Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid.