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If the New York Times or the Las Vegas Review-Journal or Scientific American publishes a false statement that hurts buy zithromax with prescription someone's reputation, that person http://taettag.pressesite.dk/buy-generic-zithromax/ can sue the publication. If such defamation appears on Facebook or Twitter, however, they can't. The reason. Section 230 buy zithromax with prescription of the federal Communications Decency Act.

Signed into law in 1996, it states that online platforms—a category that includes enormously rich and powerful tech companies such as Facebook and Google, as well as smaller and less influential blog networks, forums and social media start-ups—are not considered “publishers.” You can sue the person who created the video or post or tweet but not the company that hosted it. The law was designed to protect Internet companies, many in their infancy at the time, from legal actions that could have held back their ability to innovate and grow. But today immunity from consequences has also allowed buy zithromax with prescription hate speech, harassment and misinformation to flourish. In a belated effort to deal with those problems, the biggest platforms now attempt to flag or ban what they feel are objectionable content generated by users.

This often infuriates those whose posts or tweets have been singled out, who complain their freedom of speech is being suppressed. Last October the buy zithromax with prescription U.S. Senate Committee on Commerce, Science and Transportation held a hearing about how to modify the law. But high-handed changes often don't consider all consequences—and that can lead to real danger.

Prime examples are 2018's Fight Online Sex Trafficking and buy zithromax with prescription Stop Enabling Sex Traffickers Acts (FOSTA-SESTA). These laws removed Section 230's protections for content that advertises prostitution, in an effort to stop victims of sex trafficking from being bought and sold online. The idea was to use potential legal liability to force platforms to remove content that encouraged such crimes. In practice, sites that lacked the resources to patrol users' activity ended up banning legitimate pages where illegal content had appeared in the past, deleting large swaths of material or shutting down entirely buy zithromax with prescription.

The purge kicked consensual sex workers out of online spaces they had used to find clients and assess any risk of harm before agreeing to in-person meetings. Without the ability to screen clients online, prostitution can be extremely dangerous. One 2017 paper, updated in 2019, suggests that in cities where the online classified ad service Craigslist allowed erotic listings, the buy zithromax with prescription overall female homicide rate dropped by 10 to 17 percent. Although other researchers have contested the link between online advertising and greater safety, consensual sex workers have reported negative effects as a result of FOSTA-SESTA.

Joe Biden and Donald Trump have both called for outright repeal of Section 230. Others in Congress are proposing less radical changes, offering bills such buy zithromax with prescription as the Platform Accountability and Consumer Transparency (PACT) Act, which would require social media companies to disclose their moderation practices to show they are not arbitrary and to promptly take down content that a court deems illegal. The stricter takedown standard would favor wealthy companies such as Facebook, which can afford to employ armies of moderators and lawyers, and disfavor start-ups—just the problem Section 230 was meant to prevent. In addition, as they did in response to the laws intended to curtail sex trafficking, smaller platforms are likely to increase overly broad censorship of users to avoid legal challenges.

As digital-rights group the Electronic Frontier Foundation (EFF) points out, hobbling Section 230 could have a chilling effect on free speech online and make it much more difficult for new competitors to challenge the dominance of big tech buy zithromax with prescription. The EFF is not the only voice picking holes in legislation like the PACT Act. Academics and other technology advocacy groups have offered measured critiques of the bill and proposed their own solutions for strategically modifying Section 230. One of buy zithromax with prescription their suggestions is to ensure the bill would apply only to platforms that host users directly—not to the companies providing background support for functions such as Internet access and payment processing—to protect the larger infrastructure of the Internet from legal liability.

Another idea is to improve users' ability to flag problematic content by working with legal authorities to develop a standardized reporting process that any platform could apply. Input from experts like these—not just from billionaire CEOs such as Facebook's Mark Zuckerberg and Twitter's Jack Dorsey, the usual suspects when hearings are convened on Capitol Hill—is crucial to craft nuanced legislation that will give online platforms incentives to protect users from harassment and to suppress malicious content without unduly compromising free speech. If that happens, we might get Internet regulation right..

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Highlights and updates buy zithromax Tennessee exchange overviewTennessee is among the states that have done the least to preserve the Affordable Care Act’s gains.Tennessee has buy zithromax pill a federally run exchange, so enrollees use HealthCare.gov to sign up for exchange plans. During the first five weeks of open enrollment for 2021 coverage (through December 5, 2020), 87,930 people had made plan selections through the Tennessee marketplace. At that point, there were still buy zithromax pill 10 days remaining in the open enrollment period.

Enrollment always increases towards the end of the enrollment window, and HealthCare.gov will process auto-renewals after December 15, for people with existing coverage who don’t return to the exchange to pick a new plan or manually renew their coverage for 2021.Last year, total enrollment during the open enrollment period for 202 coverage (including auto-renewals) reached 200,445 people. That was down from 221,553 people who had enrolled buy zithromax pill the year before, for 2019 coverage.Tennessee continues to refuse federal funding to expand its Medicaid program to cover low-income adults in the state (13 other states have also refused to expand their Medicaid programs, although some of them will expand coverage, either fully or partially, by mid-2021). As a result, there are an estimated 117,000 people in the coverage gap in Tennessee — ineligible for Medicaid, but also ineligible for premium subsidies in the exchange because their income is too low.Insurer participation in Tennessee’s exchange has been fairly volatile over the years, but there are six insurers offering plans for 2021, up from five in 2020 (UnitedHealthcare joined the exchange for 2021, after previously only offering coverage in 2016.

United’s plans buy zithromax pill are available in much of the central and western parts of the state for 2021). Although their coverage areas don’t all overlap, most Tennessee residents have a choice of insurers for 2021, as much of the state has at least three participating exchange insurers.Family and Children’s Service is the Tennessee Navigator organization, and brokers certified with the exchange can be found here.How are insurance premiums in Tennessee changing for 2021?. Insurers had to submit rate filings in Tennessee buy zithromax pill by July 15, 2020.

Some of the rates were approved as-filed, but the Tennessee Department of Commerce and Insurance worked with some of the insurers to reduce their proposed rates for 2021, with revised rate filings submitted by some insurers in August. By the time the rate review process was complete, the following average rate changes were approved for 2021 for the state’s individual market insurers:Blue Cross Blue Shield of Tennessee. Average premium increase of 9.8 percent (BCBSTN had initially proposed buy zithromax pill an average rate increase of 12.9 percent).

BCBSTN’s filing cover letter notes that they have about 93,000 members, although another area of the filing indicates 97,222 members. SERFF filing buy zithromax pill number. BCTN-132455585Cigna.

Average premium decrease of 6.1 percent buy zithromax pill (Cigna’s filing notes that they expect the buy antibiotics zithromax to increase their costs by about 1 percent in 2021, so the rate increase would be more significant without buy antibiotics as a factor). Cigna has 64,230 members. SERFF filing number buy zithromax pill.

CCGH-132359549Oscar. Average premium increase of 9.9 percent (Oscar had initially proposed an average rate increase of 12.4 percent). Oscar has buy zithromax pill 7,704 members.

SERFF filing number. OHIN-132442088Bright. Average premium increase of 3 percent (Bright’s filing notes that the average rate increase would have been larger — at about 4.2 percent — without the buy antibiotics zithromax.

Other insurers in other states have also predicted reduced overall costs in 2021 due to buy antibiotics’s reduction in non-emergency medical services) Bright has 26,746 members. SERFF filing number. BRHP-132308159Celtic/Ambetter.

Average premium decrease of 2.5 percent (Celtic had initially proposed an average premium decrease of 0.3 percent, but the approved decrease ended up being more substantial). Celtic has 10,716 members, and has expanded into the Jackson and Tri-City areas for 2021. SERFF filing number.

CELT-132409373UnitedHealthcare. New to the market for 2021, so no applicable rate change (UHC previously offered coverage in the Tennessee exchange in 2016. The insurer is also rejoining the exchange in Maryland for 2021).

UnitedHealthcare plans to offer coverage in all counties in rating areas 3, 4, 5, 6, and 8 (Figure 13 on this page shows the rating areas in map format. UHC’s plans will be available in southern/central and western Tennessee). UHC’s filing does not include a specific rate adjustment for buy antibiotics factors, but notes that they may revise this as the summer continues and more data become available.

SERFF filing number. UHLC-132400597In Tennessee, each insurer filed a separate form to detail the anticipated impact of buy antibiotics on 2021 claims costs. Where they had data and projections available, insurers broke it down into cost changes (either an increase or a decrease) associated with pent-up demand for elective services that were postponed this year, the cost of a buy antibiotics treatment, the cost of treating members who are diagnosed with buy antibiotics, and the cost changes associated with the transition of people from the employer-sponsored market to the individual market (ie, there are expected to be more people purchasing coverage in the individual market for 2021, due to job losses amid the buy antibiotics zithromax).

Premiums in the Tennessee exchange started out as some of the lowest in the country in 2014, but increased rapidly in the subsequent years. As of 2020, the average full-price premium in Tennessee’s exchange is $641/month. That’s higher than the $595/month average across the 38 states that use HealthCare.gov.

But 86 percent of Tennessee’s exchange enrollees are receiving premium subsidies in 2020, and their after-subsidy premiums average $145/month — which is exactly the same as the after-subsidy average premium across those 38 states. Here’s a summary of how full-price rates have changed in Tennessee’s exchange over the years (keeping in mind that premium subsidies are designed to keep pace with full-price premiums, so they have grown over time as well):2014. In 2014 Tennessee had among the lowest overall average rates in the country for individual market health plans.

That was the first year that ACA-compliant plans were available, and rates were essentially educated actuarial guesses, since there was no claims experience on which to base them.2015. Average rate increase of 12.5 percent (another analysis indicated a 9 percent increase for a 40-year-old non-smoker). This included an average rate increase of 19 percent for BCBSTN, 7.5 percent for Cigna, and 14.4 percent for Humana.

Tennessee was one of just eight states in a PricewaterhouseCooper analysis with double-digit average rate increases for 2015. But because Tennessee had rates so much lower than the national average in 2014, their rates were still much lower than most states in 2015, even after the rate hikes. A Kaiser Family Foundation analysis of benchmark plan (second-lowest-cost silver plan) premium changes in major metropolitan areas in all 50 states found that the Nashville area still has the fifth-lowest average benchmark premium in the country in 2015, even after an increase of nearly 8 percent.2016.

Average increase of 28.2 percent. Average premium increases ranged from just 0.4 percent for Cigna to more than 36 percent for Blue Cross Blue Shield of Tennessee (BCBSTN had 70 percent of the market share). The overall increase was substantial, but it essentially just brought Tennessee’s lower-than-average rates more in line with rates in the rest of the country.

Community Health Alliance had initially proposed a rate increase of nearly 45 percent, but the CO-OP ended up shutting down at the end of 2015, so that rate increase was not applicable.2017. Average rate increase of 56 percent. The average rate increases ranged from 44.3 percent for Humana, to 62 percent for BCBSTN.Tennessee’s individual market rate increase was roughly tied with Minnesota’s for 2017, and both states trailed only Oklahoma, which had the highest weighted average increase for 2017.Cigna and Humana had originally filed average rate increases of 23 percent and 29 percent, respectively.

But in early August 2016, regulators in Tennessee agreed to allow the carriers to refile new rates, after both carriers had told the state that the rates they had originally filed wouldn’t be adequate to cover claims costs. Several carriers across the country made headlines in August and September with announcements that they would exit the exchanges at the end of 2016, but UnitedHealthcare was the only insurer to exit the Tennessee exchange altogether. The fact that regulators in Tennessee allowed new rates to be filed helped to keep the carriers in the market, but it also resulted in more significant premium hikes for 2017.

Carriers had asked to refile rates for 2016 during the summer of 2015, but state regulators would not allow them to do so. For 2017, regulators softened their stance in an effort to keep Cigna and Humana in the marketplace.2018. Average rate increase of 28.5 percent.

BCBSTN increased average premiums by 21.4 percent. Cigna increased average premiums by 36.5 percent. Silver plans became disproportionately expensive in 2018 in Tennessee (driving a significant chunk of the overall rate increase), as the Trump administration eliminated funding for cost-sharing reductions (CSRs).

Although the official notice of the funding cut didn’t come until mid-October, TDCI confirmed in September that the additional premiums necessary to cover CSR in 2018 had already been added to silver plan rates for 2018 (pre-emptively, but presciently, since the funding was cut off by the federal government a few weeks later). The higher premiums for silver plans resulted in even larger premium subsidies for 2018. So although the federal government is no longer directly reimbursing insurers for the cost of CSR, they are indirectly continuing to fund CSR, via larger premium subsidies.TDCI published a document showing average premiums for 35-year-olds and 55-year-olds in each rating area of the state, but most enrollees pay far lower premiums, as their premiums subsidies cover a large portion of the premiums.Blue Cross Blue Shield of Tennessee issued a press release in June 2017, going into great detail about their proposed rate increase for 2018.

Their actuarial memo in their rate filing indicated that their average proposed rate increase was 21.4 percent, but that the majority of that was due to concerns that the Trump Administration wouldn’t continue to enforce the individual mandate, and the uncertainty surrounding ongoing funding for cost-sharing reductions (CSR).The press release from Blue Cross Blue Shield of Tennessee noted that of the 21.4 percent rate increase they proposed (which was later approved by TDCI), 14 percentage points were due to the possible lack of funding for cost-sharing subsidies, and 7 percentage points were due to concerns that the individual mandate wouldn’t be well enforced, resulting in a sicker risk pool (healthy people are the ones likely to drop coverage if the mandate isn’t enforced. Sick people will maintain their coverage regardless). So the rate increase for 2018 would apparently have been just 0.4 percent if it weren’t for the Trump administration’s refusal to commit to funding cost-sharing reductions and enforcing the individual mandate.

Instead, BCBSTN proposed an average rate increase of 21.4 percent, and state regulators had no choice but to approve it.Cigna noted that 14.1 percentage points of their rate increase was due to the fact that the Trump Administration had not committed to funding cost-sharing subsidies.2019. Average rate decrease of 12.4 percent. But the average benchmark plan premium decreased by 26 percent in 2019, which was the largest percentage decrease in the nation.

The average, across all states, was a 1.5 percent decrease. Premium subsidies are based on the cost of the benchmark plan, so subsidies decreased by a larger margin than average premiums.In August 2018, the Tennessee Insurance Department announced approved 2019 rate changes, including rate decreases for Blue Cross Blue Shield and Cigna, which had the bulk of the state’s individual market enrollees:Blue Cross Blue Shield of Tennessee. Average premium decrease of 14.9 percent (113,000 membes)Cigna.

Average premium decrease of 12.8 percent (75,568 members)Oscar. Average increase of 7.2 percent to 10.84 percent (14,107 members)Bright. New to the marketCeltic.

New to the market 2020. Average rate decrease of about 1.1 percent. But benchmark premiums dropped by 7 percent, leading to some people paying higher after-subsidy premiums for their coverage in 2020.

In 2019, when Bright and Celtic joined the marketplace in Tennessee and Cigna and Oscar expanded their coverage areas, benchmark premiums decreased much more significantly than overall average premiums, resulting in smaller premium subsidies. So 2020 was the second year in a row that subsidy amounts dropped by more than the average premium amounts in Tennessee’s exchange (which could partially explain the decrease in enrollment since 2018. Plans become less affordable when subsidies decrease by more than average premiums).Tennessee’s exchange insurers implemented the following average rate changes for 2020:Blue Cross Blue Shield of Tennessee.

Average premium increase of 1.4 percentCigna. Average premium decrease of 5.7 percentOscar. Average premium decrease of 8.3 percentBright.

Average premium increase of 2.93 percentCeltic. Average premium decrease of 1.6 percent Enrollment in Tennessee’s exchange. 2014 through 2020As has been the case in the majority of states that use HealthCare.gov, enrollment in Tennessee’s exchange peaked in 2016, and has declined each year since then.2014.

The first open enrollment period, for 2014 coverage, was six months long and had an additional extension tacked onto the end. By April 19, 2014, total enrollment in the Tennessee exchange stood at 151,352 people.2015. Enrollment grew significantly the next year, with 231,440 people enrolling through the exchange during the open enrollment period for 2015 coverage.2016.

Enrollment peaked in the third year, with 268,867 people enrolling through the exchange in Tennessee.2017. President Trump took office just days before the end of the open enrollment period for 2017 coverage, and immediately cut HealthCare.gov’s marketing campaign. 2017 rates were also sharply higher for people who didn’t qualify for premium subsidies.

So it wasn’t surprising that enrollment dropped to 234,125 people.2018. The Trump Administration reduced the marketing and outreach budget for HealthCare.gov, rates again increased sharply for people who didn’t qualify for premium subsidies (due mostly to uncertainty over the future of the individual mandate and the Trump Administration’s decision to cut off funding for cost-sharing reductions), and open enrollment was only half as long as it had been the year before (Nov 1 to Dec 15, which is the schedule that’s currently being used). So again, it wasn’t surprising that enrollment decreased, with 228,646 people buying plans during open enrollment.2019.

Although rates decreased for 2019, they’re still quite high for people who don’t qualify for premium subsidies. The GOP tax bill ended the individual mandate penalty at the end of 2018, and the Trump Administration has made it easier for people to opt for coverage under short-term health plans instead of ACA-compliant plans. So enrollment dropped again during the open enrollment period for 2019 coverage, with 221,553 people buying plans.2020.

Enrollment stood at 200,445 at the end of the open enrollment period for 2020 coverage. As noted above, benchmark premiums decreased more significantly than overall average premiums in Tennessee’s exchange, making after-subsidy premiums less affordable for many enrollees.Which insurers offer coverage in Tennessee's exchange?. There are six insurers offering coverage in Tennessee’s exchange in 2021, up from just three in 2018.

Here’s a summary of how insurer participation in the state’s exchange has changed over the years.2014. When the exchanges launched for 2014, plans were available in Tennessee’s exchange from Blue Cross Blue Shield of Tennessee, Community Health Alliance (an ACA-created CO-OP), Cigna, and Humana, although only BCBSTN offered plans statewide.2015. Time/Assurant joined the Tennessee exchange statewide in 2015, bringing the total number of participating insurers to five.2016.

Four insurers offered plans. BCBSTN, Cigna, Humana, and UnitedHealthcare. UnitedHealthcare was new to the exchange for 2016, and according to Kaiser Family Foundation’s analysis, UnitedHeathcare offered at least one of the two lowest-priced silver plans in the exchange in 73 of Tennessee’s 95 counties in 2016.

But Assurant and Community Health Alliance both stopped selling plans at the end of 2015. The CO-OP’s demise was due in part to the severe shortfall in federal risk corridor funding, although the CO-OP had stopped selling 2015 plans as of January 15, 2015, noting that they had already met their enrollment goal for the year. Community Health Alliance had planned to begin selling plans again during the 2016 open enrollment, but instead they ceased operations altogether at the end of 2015, leaving 27,000 enrollees who needed to select new coverage for 2016 from a different carrier.2017.

Plans were available from Humana, Cigna, and BCBSTN. Like Assurant’s brief stint in the exchange, UnitedHealthcare’s participation was also short-lived, as they exited the entire individual market in Tennessee at the end of 2016. The Department of Commerce and Insurance confirmed that the exit applied to both the exchange (UnitedHealthcare Insurance Company) and off-exchange (UnitedHealthcare Life Insurance Company).

The state reported that 40,879 people needed to secure new coverage for 2017 as a result of United’s exit (the large majority of these enrollees had their directory United coverage through the exchange). 2017 was also the first year that BCBSTN opted not to offer statewide coverage. As of 2017, BCBSTN stopped offering coverage in the metro areas of Knoxville, Nashville, and Memphis, which are the three largest metropolitan areas in the state.Blue Cross Blue Shield of Tennessee had the lion’s share of the Tennessee exchange market in 2016, covering almost 69 percent of the enrollees.

Because of BCBST’s exit from the three metropolitan areas, approximately 52,000 people in Nashville, 31,000 people in Knoxville, and 29,000 in Memphis had to switch to a different plan for 2017. So although there were three insurers offering plans in Tennessee’s exchange for 2017, residents in 73 of the state’s 95 counties had only one carrier option in the exchange. Cigna offered coverage in the Memphis and Nashville areas.

Humana offered coverage in the Memphis, Nashville, and Knoxville areas, and BCBSTN offered coverage in the rest of the state.2018. There was quite a bit of upheaval in the Tennessee exchange for 2018, in terms of insurer participation. Humana stopped offering individual market coverage in any states at the end of 2017.

Humana’s exit meant that residents in the Knoxville area were facing the possibility of having no exchange insurers at all in 2018. Humana insured about 40,000 people in the Knoxville area, and about 79,000 people across all three metropolitan areas in the state. State regulators scrambled to reach a solution, and succeeded.

In May 2017, Blue Cross Blue Shield of Tennessee agreed to once again offer coverage in 2018 in the Knoxville area in order to ensure that all areas of the state would have insurance plans available in the exchange.While it initially appeared that there would only be two insurers in the Tennessee exchange for 2019, Oscar Health’s entry to the market meant that three insurers offered plans:Cigna’s plans were available in a total of 22 counties in Memphis, Nashville, and the Tri-City area (the eight eastern-most counties in the state), just as they were in 2017.BCBS of Tennessee had plans available everywhere except Memphis and Nashville. They continued to offer coverage in the non-metro areas of the state where they offered plans in 2017, and expanded back into the Knoxville area.Oscar Health has plans available in nine counties in the Nashville area.Nashville and the Tri-City areas were the only parts of the state where enrollees had a choice between two insurers, with both BCBSTN and Cigna offering plans in the Tri-City area, and Oscar and Cigna offering plans in the Nashville area.Tennessee Insurance Commissioner, Julie Mix McPeak, expressed satisfaction that all areas of the state would have at least one insurer offering coverage in the exchange in 2018, but she reiterated how the uncertainty caused by the Trump Administration and Congress was damaging the individual health insurance market, noting that “the uncertainty about the future of the exchange, cost-sharing reduction payments, and enforcement of the individual mandate will likely increase carrier rate requests by 15 to 20 percent above what they would have otherwise filed. I share consumers’ frustrations about federal uncertainty and how that is impacting their ability to afford insurance.”2019.

Bright Health joined the Tennessee exchange for 2019, offering coverage in 16 counties in the Knoxville area, nine counties in the Nashville area, and five counties in the Memphis area.Celtic (Centene) also joined the Tennessee exchange for 2019, with plans available in Memphis and Chattanooga. Much of the state had multiple carrier options for 2019 coverage:Nashville. Oscar, Cigna, BrightKnoxville.

BCBSTN, Bright, and CignaMemphis. Bright, Oscar, Cigna, and CelticTri-City area. BCBSTN and CignaChattanooga area.

Celtic and BCBSTN2020. Tennessee continues to have five exchange insurers in 2020, but three have larger coverage areas. Blue Cross Blue Shield of Tennessee came back to the Memphis and Nashville areas for 2020.

Celtic expanded into the Nashville and Knoxville areas, and Cigna expanded into the Chattanooga and Jackson areas.2021. UnitedHealthcare rejoined the exchange in Tennessee for 2021, after leaving at the end of 2016. That brings the state to six insurers.

UnitedHealthcare’s plans are available in all counties in rating areas 3, 4, 5, 6, and 8 (southern/central and western Tennessee). Tennessee Insurance Commissioner’s reform proposalsJulie Mix McPeak was the Insurance Commissioner for Tennessee from 2011 through mid-2019, and also served as the President of the National Association of Insurance Commissioners. In February 2017, Mix McPeak spoke before the Senate Committee on Health, Education, Labor, &.

Pensions, presenting her recommendations for health care reform. Among her proposals were:Allowing states to define essential health benefits, rather than requiring all plans sold in every state to conform to the ACA’s essential health benefits (this has been part of most of the GOP proposals to repeal or change the ACA, although it has not been implemented. As of 2019, essential health benefits are still defined at the federal level).Relaxing the age band ratio from the 3:1 level set by the ACA, to a 5:1 or 6:1 cap.

The ACA limits premiums for older enrollees to no more than three times those of younger enrollees. Mix McPeak suggested that insurers should be able to charge older enrollees five or six times as much as younger enrollees, in an effort to reduce premiums for younger enrollees and incentivize them to enroll (this is another provision that was included in most of the GOP efforts to repeal or change the ACA in 2017, but none of those efforts were successful. It’s worth noting that adjusting the age rating bands would result in lower premiums for younger people, but markedly higher premiums for older people.

For those who receive premium subsidies, the subsidies would grow to offset the increase. But for those who don’t get subsidies, coverage could become unaffordable).Tighter restrictions and increased verification of eligibility for special enrollment periods (HHS finalized a market stabilization rule in April 2017 that included increased eligibility verification, and restrictions such as limiting enrollees’ ability to use a special enrollment period to switch to a plan at a different metal level).Reducing the current 90-day grace period for people with premium subsidies down to a 30-day grace period (the market stabilization rule kept the 90-day grace period, but allows insurers to apply new enrollment premiums to past-due balances from the previous 12 months if the person seeks to re-enroll after losing coverage for non-payment of premium).Senator Alexander. 2017 legislation to protect bare counties, and a plea for CSR fundingIn 2017, the U.S.

Senators from Tennessee, Lamar Alexander and Bob Corker, both Republicans, introduced legislation (S.761, the Health Care Options Act of 2017) that would allow people in counties without any participating exchange insurers to use ACA subsidies for off-exchange plans. That scenario has never come to pass, but there were concerns at that point that some areas of the country, including the Knoxville, Tennessee area, might not have had any ACA-compliant plans available.Senator Alexander also, notably, stated in early 2017 that Congress or the Trump administration should commit to funding cost-sharing reductions (CSRs) through 2019, in an effort to stabilize the individual health insurance market. CSRs lower out-of-pocket costs for low-income exchange enrollees who pick silver plans, and 57 percent of Tennessee exchange enrollees have plans that include CSRs in 2017.CSR funding was ultimately eliminated by the Trump administration in October 2017, but the uncertainty (during the rate filing season of spring/summer 2017) around whether or not the funding would continue resulted in premium proposals for 2018 that were higher than they would otherwise have been.

Without a federal commitment to fund CSR, Tennessee Insurance Commissioner, Julie Mix McPeak estimated that premiums in Tennessee would be 15 to 20 percent higher than they would otherwise have been in 2018.Senator Alexander joined forces with Senator Patty Murray (D, Washington) in an effort to pass bipartisan legislation aimed at stabilizing the individual insurance markets nationwide, with a proposal that included CSR funding. However, Republican leadership in the Senate opted to push forward on their efforts to repeal the ACA (via the Graham-Cassidy legislation) and pulled the plug on Alexander and Murray’s bipartisan approach in September 2017.In the announcement about the approved rates for 2018, Mix McPeak said “I’m disappointed by yesterday’s announcement out of Washington [about Alexander and Murray’s bipartisan approach being abandoned by Senate leadership]. While Tennessee is supportive of long-term strategies such as the Graham-Cassidy Amendment introduced in Congress, I appreciate the diligent efforts of Senators Lamar Alexander and Patty Murray to find common ground in providing more immediate stabilization in the marketplace.

Instead, it appears more likely that Tennesseans must prepare themselves for a round of actuarially justified rates for 2018 that are far higher than could be necessary as a result of uncertainty in Washington.” Farm Bureau plans aren’t compliance with the ACA, but they’re still allowed to be sold in TennesseeAs of 2017, there were about 73,000 people in Tennessee who were covered under Farm Bureau plans that aren’t ACA-compliant. About 50,000 of those were grandfathered plans, but the rest are medically underwritten “traditional” plans that are still available for purchase. Medical underwriting means that the insurer uses the applicant’s medical history to determine whether to offer coverage and at what price.

That practice is no longer allowed under the ACA – on or off-exchange – for any plans that are considered individual major medical health insurance.But in Tennessee, the state doesn’t consider Farm Bureau to be a licensed health insurer. That’s been the case for more than two decades – Farm Bureau plans operate outside of the regulatory structure imposed by the state (and the ACA) on health insurers. As a result, Farm Bureau’s “traditional” plans, which are less expensive than regular health insurance but only available to healthy people, are being sold to healthy people in Tennessee, effectively removing them from the ACA-compliant risk pool.People who enroll in Farm Bureau’s “traditional” plans are not in compliance with the ACA’s individual mandate, so from 2014 through 2018, they were assessed a penalty for being uninsured unless they were exempt from the individual mandate (this is the same as the rule that required people with short-term health insurance to pay the individual mandate penalty.

Just like the Tennessee Farm Bureau “traditional” plans, short-term health insurance is not regulated by the ACA). But the individual mandate penalty no longer applies in 2019 and future years, so there is no longer a penalty for relying on a Farm Bureau plan.Farm Bureau’s plans are not as robust as regular health insurance, and aren’t helpful for people with pre-existing conditions. But the fact that Tennessee has allowed them to continue to be sold outside the scope of the state’s insurance regulations could be part of the reason the state has a risk pool in the ACA-compliant market that’s sicker than most states.Iowa has decided to follow Tennessee’s lead, enacting legislation in 2018 that allows Farm Bureau to partner with Wellmark to offer non-ACA-compliant plans in Iowa.BCBSTN losses pre-2017 and rate hike request – some backgroundDuring open enrollment for 2016 coverage, 166,425 exchange enrollees (62 percent of the total) signed up with Blue Cross Blue Shield of Tennessee for 2016.

This was an increase of 16 percent over BCBSTN’s exchange enrollment in 2015, despite the fact that the carrier raised its premiums by an average of 36 percent for 2016. The remaining 38 percent of the exchange enrollees selected plans from Humana, Cigna, and United Healthcare.Blue Cross Blue Shield of Tennessee had the lowest priced plans in the Tennessee exchange — and the nation — in 2014. Although BCBSTN’s average rate increase was 19 percent for 2015 and 36 percent for 2016 (and their competitors had significantly smaller rate hikes), they still had among the lowest premiums in many areas of Tennessee in 2016.

In the Memphis area, a search on Healthcare.gov indicated that the five least expensive bronze plans and the four least expensive silver plans were all offered by BCBSTN in 2016. Their lower premiums and brand-name recognition likely played a role in their outsized market share. But because enrollees have been sicker than expected, the carrier lost $300 million during 2014 and 2015, and projected total losses to reach $500 million by the end of 2016.

Losses of that magnitude are not sustainable.In order to continue working towards long-term sustainability in the ACA-compliant individual market, BCBSTN had indicated earlier in 2016 that they were expecting to propose significant rate increases for 2017, although the expectation in early 2016 was that the proposed rate increases for 2017 would be comparable to the 36 percent average increase that the carrier implemented for 2016. Ultimately, BCBSTN requested a much higher average increase – 62 percent – for 2017, and regulators approved it in order to keep the insurer in the marketplace.Joe Sullivan of The Knoxville Mercury tracked down some 2016 data that adds perspective to the rate changes for 2017, particularly in the Memphis and Nashville metropolitan areas, where Humana, Cigna, and BCBS all offered plans in the exchange in 2016:BCBS had two networks, and offered 10 silver PPO plans in Nashville and in Memphis in 2016. The plans included out-of-network coverage.

BCBST did not offer plans in either area in 2017.Humana had one silver PPO plan in Nashville and in Memphis.Cigna had three silver EPO plans in Nashville (no out-of-network coverage) and three silver PPO plans in Memphis.In Memphis, all three carriers offered silver PPO plans, and BCBS had the lowest prices (BCBST stopped offering coverage in Memphis in 2017).In Nashville, Cigna’s silver prices were lower than BCBS, but the Cigna plans were EPOs, without coverage for out-of-network care (BCBST stopped offering plans in Nashville in 2017).Grandmothered/Transitional health plansTennessee has allowed transitional (grandmothered) plans to remain in force, but the Tennessee Department of Commerce and Insurance confirmed in 2017 that they no longer had any grandmothered plans remaining in the individual market, as insurers had opted to end those plans and replace them with ACA-compliant plans instead.History of the Tennessee exchangeIn December 2012, then-Gov. Bill Haslam announced Tennessee would not develop its own health insurance exchange, citing a lack of information from the federal government.Prior to his 2012 announcement, Haslam had leaned toward a state-run exchange. He believed local state control was preferable and that the state could run the exchange more cost-effectively that the federal government.However, Republican legislators opposed the exchange, Tea Party supporters staged repeated protests, and Tennessee eventually ended up with an exchange run by HHS.Tennessee health insurance exchange linksHealthCare.gov800-318-2596State Exchange Profile.

TennesseeThe Henry J. Kaiser Family Foundation overview of Tennessee’s progress toward creating a state health insurance exchange.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.Key takeawaysNearly 4.3 million people in Texas have Medicare plans, but that’s only a little more than 14 percent of the state’s population.Nearly 43% Texas Medicare beneficiaries had Medicare Advantage plans (or other private Medicare plans, including Medicare Cost plans) as of 2020. Medicare Advantage plan availability ranges from eight plans to 60 plans, depending on the county.In Texas, 70 insurers offer Medigap plans and more than 873,000 Texas residents are enrolled in Medigap plans. Medigap insurers in Texas are required to offer at least Medigap Plan A to disabled beneficiaries under the age of 65.Premiums for stand-alone Part D prescription plans in Texas range from about $7 to $155 per month for 2021 coverage.

1.65 million Texas Medicare beneficiaries have stand-alone Part D plans, plus 1.54 million with Part D integrated with Medicare Advantage.Per-enrollee Original Medicare spending in Texas is the second-highest in the nation (Louisiana is the only state where average per-beneficiary spending is higher).Extended enrollment opportunity for Texas residents affected by 2020 tropical stormsThe regular annual open enrollment period for 2021 Medicare Advantage and Part D plans ended on December 7. But Texas residents who live in counties affected by tropical storms Marco and Laura have additional time to enroll in a Part D or Advantage plan for 2021. This window in Texas continues until December 31, 2020 (four calendar months after the tropical storm disaster incident in Texas).This extended enrollment opportunity applies to people who live in the counties in eastern Texas where FEMA declared a disaster, as well as those who live elsewhere but rely on a friend or family member for assistance with the enrollment process, and that person lives in one of the affected counties.

If you’re eligible for the enrollment period extension and you sign up for a Part D or Medicare Advantage plan by December 31, your new coverage will take effect January 1, the same as it would have if you’d enrolled by December 7. Medicare enrollment in TexasThe number of Medicare beneficiaries in Texas stood at 4,292,236 as of October 2020. Only Florida and California have more residents enrolled in Medicare.CMS has extended Medicare open enrollment through December 31 in 54 Texas counties in response to the natural disasters in 2020.But only a little more than 14 percent of Texas residents are enrolled in Medicare, compared with almost 19 percent of the United States population enrolled in Medicare.

Texas has among the youngest populations in the country, and since most people become eligible for Medicare enrollment when they turn 65, the state’s lower median age results in a smaller percentage of its residents filing for Medicare benefits.Although most people become eligible for Medicare coverage enrollment when they turn 65, Medicare also provides coverage for people under age 65. Those who have been receiving disability benefits for 24 months, have ALS, or have end-stage renal disease are eligible for Medicare. Fifteen percent of all Medicare beneficiaries in Texas — and nationwide — are under the age of 65.Medicare health insurance optionsIn most areas of the country, Medicare beneficiaries can choose Original Medicare or a Medicare Advantage plan.Original Medicare is provided directly by the federal government and includes Medicare Parts A and B.

Medicare Part A, also called hospital insurance, helps to pay for inpatient stays at a hospital, skilled nursing facility, or hospice center. Part B, also called medical insurance, helps pay for outpatient care like physician services, kidney dialysis, preventive care, durable medical equipment, etc.Medicare Advantage plans are administered by private insurance companies that have contracts with the federal government. Medicare Advantage plans include all of the benefits of Original Medicare (albeit with different cost-sharing, as the plans set their own deductibles, coinsurance, and copays, within the limits established by the federal government), and they typically have additional benefits, such coverage for prescription drugs, dental, and vision.

But provider networks are often limited with Medicare Advantage plans, and out-of-pocket costs are typically higher than a person would have if they opted for Original Medicare plus a Medigap plan. In short, there are pros and cons either way, and no one-size-fits-all solution. Medicare Advantage in TexasMedicare Advantage plans are available in all 254 counties in Texas in 2021, but plan availability ranges from as few as nine plans some of the state’s service areas to as many as 90 plans for sale in Harris County.A little more than a third of Texas Medicare beneficiares — just slightly more than the national average — were enrolled in private Medicare plans in 2018.

These were mostly Medicare Advantage plans, but some residents in Texas have Medicare Cost plans, which are another form of private coverage. By late 2020, however, the share of Texas Medicare beneficiaries enrolled in private plans had grown to more than 43 percent. The other 57 percent of Medicare beneficiaries in Texas were enrolled in Original Medicare instead.Medicare beneficiaries can switch between Medicare Advantage enrollment and Original Medicare (and can add or drop a Medicare Part D prescription plan) during the Medicare annual election period, which runs from October 15 to December 7 each year.

Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.Medigap in TexasMore than half of Original Medicare beneficiaries have supplemental coverage provided by an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans) are designed to pay some or all of the out-of-pocket costs (deductibles and coinsurance) that enrollees would otherwise have to pay themselves. Since Original Medicare does not include a cap on out-of-pocket costs, most enrollees maintain some form of supplemental coverage, and Medigap plans are one way to do this.According to an AHIP analysis, there were 873,514 Texas Medicare beneficiaries with Medigap coverage as of 2018.There are 70 insurers licensed to sell Medigap plans in Texas.Although Medigap plans are sold by private insurers, the plans are standardized under federal rules.

There are ten different plan designs (differentiated by letters, A through N), and the benefits offered by a particular plan (Plan A, Plan F, etc.) are the same from one insurer to another.Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue. This window starts when a person is at least 65 and enrolled in Medicare Part B (you have to be enrolled in both Part A and Part B to buy a Medigap plan).Although disabled Americans under the age of 65 are eligible for Medicare, federal rules do not guarantee access to Medigap plans for people who are under 65.

But the majority of the states — including Texas — have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Texas law requires Medigap insurers to offer at least Medigap Plan A to disabled enrollees under age 65, during the six-month period that begins when they’re enrolled in Medicare Part B. Medigap Plan A is the least comprehensive of the Medigap plans, but it will cover the 20 percent Part B coinsurance that the enrollee would othewise have to pay out-of-pocket.Disabled Medicare beneficiaries under the age of 65 have another six-month Medigap open enrollment period when they turn 65.

At that point, they have access to any of the available Medigap plans, at the standard premiums that apply to people who are enrolling in Medicare due to turning 65 (premiums are generally significantly higher for Medicare beneficiaries under age 65, since their disabilities result in more costly medical care).Medicare Advantage plans are available to anyone eligible for Medicare, except people with end-stage renal disease (starting in 2021, this limitation will no longer apply. People with ESRD will be able to enroll in Medicare Advantage plans). So unless they have ESRD, Texas Medicare beneficiaries under the age of 65 can choose a Medicare Advantage plan instead of Medigap Plan A.

Medicare Advantage plans do have a cap on out-of-pocket costs, but they also tend to have limited provider networks, which is an important consideration for people with serious health issues.Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those regulations don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months, if you didn’t have at least six months of continuous coverage prior to your enrollment. And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the insurer can look back at your medical history in determining whether to accept your application, and at what premium.

Texas Medicare Part DOriginal Medicare does not cover the cost of outpatient prescription drugs. As noted above, more than half of Original Medicare beneficiaries have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage. But Medicare beneficiaries who don’t have drug coverage through Medicaid or an employer-sponsored plan need to obtain Medicare Part D prescription coverage (prior to 2006, some Medigap plans included prescription coverage.

People who still have those plans can keep them, but they have not been for sale since the end of 2005).Part D coverage can be purchased as a stand-alone plan, or as part of a Medicare Advantage plan that includes Part D prescription drug coverage.In Texas, there are 35 stand-alone Medicare Part D plans for sale for 2021, with premiums that range from about $7 to $155/month.As of late 2020, there were 1.65 million Medicare beneficiaries in Texas with stand-alone Medicare Part D plans. An additional 1.54 million Texas residents had Medicare Part D coverage integrated with their Medicare Advantage plans.Medicare Part D enrollment follows the same schedule as Medicare Advantage. Beneficiaries can enroll in Medicare Part D plans when they’re first eligible for Medicare, and there’s also an annual enrollment window (October 15 to December 7) when people can enroll or switch to a different plan.

Medicare spending in TexasIn 2018, Original Medicare’s per-beneficiary spending in Texas averaged $11,627, which was 15 percent higher than the $10,096 national average. Texas had the second-highest average per-beneficiary costs in the country. Only Louisiana had higher average costs.

That’s based on data that were standardized to eliminate regional differences in payment rates, but it did not include costs for Medicare Advantage.How does Medicaid provide financial assistance to Medicare beneficiaries in Texas?. Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesn’t cover – such as long-term care.Our guide to financial assistance for Medicare enrollees in Texas includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.Helpful resources for Texas Medicare beneficiaries and their caregiversNeed help with your Medicare application in Texas, or have questions about Medicare eligibility in Texas?. These resources provide free assistance and information.The Health Information, Counseling, and Advocacy Program (HICAP), with any questions related to Medicare coverage in Texas.

Visit the website or call 1-800-252-9240.The Texas Department of Insurance has a resources page for Texas residents with Medicare coverage.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..

Highlights and updates Tennessee exchange overviewTennessee is among buy zithromax with prescription the states that have done the least to preserve the Affordable Care Act’s gains.Tennessee has a federally run exchange, so enrollees use HealthCare.gov to sign up for exchange plans. During the first five weeks of open enrollment for 2021 coverage (through December 5, 2020), 87,930 people had made plan selections through the Tennessee marketplace. At that point, buy zithromax with prescription there were still 10 days remaining in the open enrollment period. Enrollment always increases towards the end of the enrollment window, and HealthCare.gov will process auto-renewals after December 15, for people with existing coverage who don’t return to the exchange to pick a new plan or manually renew their coverage for 2021.Last year, total enrollment during the open enrollment period for 202 coverage (including auto-renewals) reached 200,445 people. That was down from 221,553 people who had enrolled the year before, for 2019 coverage.Tennessee continues to refuse federal funding to expand its Medicaid program to cover low-income adults in the state (13 other states buy zithromax with prescription have also refused to expand their Medicaid programs, although some of them will expand coverage, either fully or partially, by mid-2021).

As a result, there are an estimated 117,000 people in the coverage gap in Tennessee — ineligible for Medicaid, but also ineligible for premium subsidies in the exchange because their income is too low.Insurer participation in Tennessee’s exchange has been fairly volatile over the years, but there are six insurers offering plans for 2021, up from five in 2020 (UnitedHealthcare joined the exchange for 2021, after previously only offering coverage in 2016. United’s plans buy zithromax with prescription are available in much of the central and western parts of the state for 2021). Although their coverage areas don’t all overlap, most Tennessee residents have a choice of insurers for 2021, as much of the state has at least three participating exchange insurers.Family and Children’s Service is the Tennessee Navigator organization, and brokers certified with the exchange can be found here.How are insurance premiums in Tennessee changing for 2021?. Insurers had to submit rate buy zithromax with prescription filings in Tennessee by July 15, 2020. Some of the rates were approved as-filed, but the Tennessee Department of Commerce and Insurance worked with some of the insurers to reduce their proposed rates for 2021, with revised rate filings submitted by some insurers in August.

By the time the rate review process was complete, the following average rate changes were approved for 2021 for the state’s individual market insurers:Blue Cross Blue Shield of Tennessee. Average premium increase of 9.8 percent (BCBSTN had initially proposed an buy zithromax with prescription average rate increase of 12.9 percent). BCBSTN’s filing cover letter notes that they have about 93,000 members, although another area of the filing indicates 97,222 members. SERFF filing buy zithromax with prescription number. BCTN-132455585Cigna.

Average premium decrease of 6.1 percent (Cigna’s filing notes that they expect the buy zithromax with prescription buy antibiotics zithromax to increase their costs by about 1 percent in 2021, so the rate increase would be more significant without buy antibiotics as a factor). Cigna has 64,230 members. SERFF filing buy zithromax with prescription number. CCGH-132359549Oscar. Average premium increase of 9.9 percent (Oscar had initially proposed an average rate increase of 12.4 percent).

Oscar has 7,704 members buy zithromax with prescription. SERFF filing number. OHIN-132442088Bright. Average premium increase of 3 percent (Bright’s filing notes that the average rate increase would have been larger — at about 4.2 percent — without the buy antibiotics zithromax. Other insurers in other states have also predicted reduced overall costs in 2021 due to buy antibiotics’s reduction in non-emergency medical services) Bright has 26,746 members.

SERFF filing number. BRHP-132308159Celtic/Ambetter. Average premium decrease of 2.5 percent (Celtic had initially proposed an average premium decrease of 0.3 percent, but the approved decrease ended up being more substantial). Celtic has 10,716 members, and has expanded into the Jackson and Tri-City areas for 2021. SERFF filing number.

CELT-132409373UnitedHealthcare. New to the market for 2021, so no applicable rate change (UHC previously offered coverage in the Tennessee exchange in 2016. The insurer is also rejoining the exchange in Maryland for 2021). UnitedHealthcare plans to offer coverage in all counties in rating areas 3, 4, 5, 6, and 8 (Figure 13 on this page shows the rating areas in map format. UHC’s plans will be available in southern/central and western Tennessee).

UHC’s filing does not include a specific rate adjustment for buy antibiotics factors, but notes that they may revise this as the summer continues and more data become available. SERFF filing number. UHLC-132400597In Tennessee, each insurer filed a separate form to detail the anticipated impact of buy antibiotics on 2021 claims costs. Where they had data and projections available, insurers broke it down into cost changes (either an increase or a decrease) associated with pent-up demand for elective services that were postponed this year, the cost of a buy antibiotics treatment, the cost of treating members who are diagnosed with buy antibiotics, and the cost changes associated with the transition of people from the employer-sponsored market to the individual market (ie, there are expected to be more people purchasing coverage in the individual market for 2021, due to job losses amid the buy antibiotics zithromax). Premiums in the Tennessee exchange started out as some of the lowest in the country in 2014, but increased rapidly in the subsequent years.

As of 2020, the average full-price premium in Tennessee’s exchange is $641/month. That’s higher than the $595/month average across the 38 states that use HealthCare.gov. But 86 percent of Tennessee’s exchange enrollees are receiving premium subsidies in 2020, and their after-subsidy premiums average $145/month — which is exactly the same as the after-subsidy average premium across those 38 states. Here’s a summary of how full-price rates have changed in Tennessee’s exchange over the years (keeping in mind that premium subsidies are designed to keep pace with full-price premiums, so they have grown over time as well):2014. In 2014 Tennessee had among the lowest overall average rates in the country for individual market health plans.

That was the first year that ACA-compliant plans were available, and rates were essentially educated actuarial guesses, since there was no claims experience on which to base them.2015. Average rate increase of 12.5 percent (another analysis indicated a 9 percent increase for a 40-year-old non-smoker). This included an average rate increase of 19 percent for BCBSTN, 7.5 percent for Cigna, and 14.4 percent for Humana. Tennessee was one of just eight states in a PricewaterhouseCooper analysis with double-digit average rate increases for 2015. But because Tennessee had rates so much lower than the national average in 2014, their rates were still much lower than most states in 2015, even after the rate hikes.

A Kaiser Family Foundation analysis of benchmark plan (second-lowest-cost silver plan) premium changes in major metropolitan areas in all 50 states found that the Nashville area still has the fifth-lowest average benchmark premium in the country in 2015, even after an increase of nearly 8 percent.2016. Average increase of 28.2 percent. Average premium increases ranged from just 0.4 percent for Cigna to more than 36 percent for Blue Cross Blue Shield of Tennessee (BCBSTN had 70 percent of the market share). The overall increase was substantial, but it essentially just brought Tennessee’s lower-than-average rates more in line with rates in the rest of the country. Community Health Alliance had initially proposed a rate increase of nearly 45 percent, but the CO-OP ended up shutting down at the end of 2015, so that rate increase was not applicable.2017.

Average rate increase of 56 percent. The average rate increases ranged from 44.3 percent for Humana, to 62 percent for BCBSTN.Tennessee’s individual market rate increase was roughly tied with Minnesota’s for 2017, and both states trailed only Oklahoma, which had the highest weighted average increase for 2017.Cigna and Humana had originally filed average rate increases of 23 percent and 29 percent, respectively. But in early August 2016, regulators in Tennessee agreed to allow the carriers to refile new rates, after both carriers had told the state that the rates they had originally filed wouldn’t be adequate to cover claims costs. Several carriers across the country made headlines in August and September with announcements that they would exit the exchanges at the end of 2016, but UnitedHealthcare was the only insurer to exit the Tennessee exchange altogether. The fact that regulators in Tennessee allowed new rates to be filed helped to keep the carriers in the market, but it also resulted in more significant premium hikes for 2017.

Carriers had asked to refile rates for 2016 during the summer of 2015, but state regulators would not allow them to do so. For 2017, regulators softened their stance in an effort to keep Cigna and Humana in the marketplace.2018. Average rate increase of 28.5 percent. BCBSTN increased average premiums by 21.4 percent. Cigna increased average premiums by 36.5 percent.

Silver plans became disproportionately expensive in 2018 in Tennessee (driving a significant chunk of the overall rate increase), as the Trump administration eliminated funding for cost-sharing reductions (CSRs). Although the official notice of the funding cut didn’t come until mid-October, TDCI confirmed in September that the additional premiums necessary to cover CSR in 2018 had already been added to silver plan rates for 2018 (pre-emptively, but presciently, since the funding was cut off by the federal government a few weeks later). The higher premiums for silver plans resulted in even larger premium subsidies for 2018. So although the federal government is no longer directly reimbursing insurers for the cost of CSR, they are indirectly continuing to fund CSR, via larger premium subsidies.TDCI published a document showing average premiums for 35-year-olds and 55-year-olds in each rating area of the state, but most enrollees pay far lower premiums, as their premiums subsidies cover a large portion of the premiums.Blue Cross Blue Shield of Tennessee issued a press release in June 2017, going into great detail about their proposed rate increase for 2018. Their actuarial memo in their rate filing indicated that their average proposed rate increase was 21.4 percent, but that the majority of that was due to concerns that the Trump Administration wouldn’t continue to enforce the individual mandate, and the uncertainty surrounding ongoing funding for cost-sharing reductions (CSR).The press release from Blue Cross Blue Shield of Tennessee noted that of the 21.4 percent rate increase they proposed (which was later approved by TDCI), 14 percentage points were due to the possible lack of funding for cost-sharing subsidies, and 7 percentage points were due to concerns that the individual mandate wouldn’t be well enforced, resulting in a sicker risk pool (healthy people are the ones likely to drop coverage if the mandate isn’t enforced.

Sick people will maintain their coverage regardless). So the rate increase for 2018 would apparently have been just 0.4 percent if it weren’t for the Trump administration’s refusal to commit to funding cost-sharing reductions and enforcing the individual mandate. Instead, BCBSTN proposed an average rate increase of 21.4 percent, and state regulators had no choice but to approve it.Cigna noted that 14.1 percentage points of their rate increase was due to the fact that the Trump Administration had not committed to funding cost-sharing subsidies.2019. Average rate decrease of 12.4 percent. But the average benchmark plan premium decreased by 26 percent in 2019, which was the largest percentage decrease in the nation.

The average, across all states, was a 1.5 percent decrease. Premium subsidies are based on the cost of the benchmark plan, so subsidies decreased by a larger margin than average premiums.In August 2018, the Tennessee Insurance Department announced approved 2019 rate changes, including rate decreases for Blue Cross Blue Shield and Cigna, which had the bulk of the state’s individual market enrollees:Blue Cross Blue Shield of Tennessee. Average premium decrease of 14.9 percent (113,000 membes)Cigna. Average premium decrease of 12.8 percent (75,568 members)Oscar. Average increase of 7.2 percent to 10.84 percent (14,107 members)Bright.

New to the marketCeltic. New to the market 2020. Average rate decrease of about 1.1 percent. But benchmark premiums dropped by 7 percent, leading to some people paying higher after-subsidy premiums for their coverage in 2020. In 2019, when Bright and Celtic joined the marketplace in Tennessee and Cigna and Oscar expanded their coverage areas, benchmark premiums decreased much more significantly than overall average premiums, resulting in smaller premium subsidies.

So 2020 was the second year in a row that subsidy amounts dropped by more than the average premium amounts in Tennessee’s exchange (which could partially explain the decrease in enrollment since 2018. Plans become less affordable when subsidies decrease by more than average premiums).Tennessee’s exchange insurers implemented the following average rate changes for 2020:Blue Cross Blue Shield of Tennessee. Average premium increase of 1.4 percentCigna. Average premium decrease of 5.7 percentOscar. Average premium decrease of 8.3 percentBright.

Average premium increase of 2.93 percentCeltic. Average premium decrease of 1.6 percent Enrollment in Tennessee’s exchange. 2014 through 2020As has been the case in the majority of states that use HealthCare.gov, enrollment in Tennessee’s exchange peaked in 2016, and has declined each year since then.2014. The first open enrollment period, for 2014 coverage, was six months long and had an additional extension tacked onto the end. By April 19, 2014, total enrollment in the Tennessee exchange stood at 151,352 people.2015.

Enrollment grew significantly the next year, with 231,440 people enrolling through the exchange during the open enrollment period for 2015 coverage.2016. Enrollment peaked in the third year, with 268,867 people enrolling through the exchange in Tennessee.2017. President Trump took office just days before the end of the open enrollment period for 2017 coverage, and immediately cut HealthCare.gov’s marketing campaign. 2017 rates were also sharply higher for people who didn’t qualify for premium subsidies. So it wasn’t surprising that enrollment dropped to 234,125 people.2018.

The Trump Administration reduced the marketing and outreach budget for HealthCare.gov, rates again increased sharply for people who didn’t qualify for premium subsidies (due mostly to uncertainty over the future of the individual mandate and the Trump Administration’s decision to cut off funding for cost-sharing reductions), and open enrollment was only half as long as it had been the year before (Nov 1 to Dec 15, which is the schedule that’s currently being used). So again, it wasn’t surprising that enrollment decreased, with 228,646 people buying plans during open enrollment.2019. Although rates decreased for 2019, they’re still quite high for people who don’t qualify for premium subsidies. The GOP tax bill ended the individual mandate penalty at the end of 2018, and the Trump Administration has made it easier for people to opt for coverage under short-term health plans instead of ACA-compliant plans. So enrollment dropped again during the open enrollment period for 2019 coverage, with 221,553 people buying plans.2020.

Enrollment stood at 200,445 at the end of the open enrollment period for 2020 coverage. As noted above, benchmark premiums decreased more significantly than overall average premiums in Tennessee’s exchange, making after-subsidy premiums less affordable for many enrollees.Which insurers offer coverage in Tennessee's exchange?. There are six insurers offering coverage in Tennessee’s exchange in 2021, up from just three in 2018. Here’s a summary of how insurer participation in the state’s exchange has changed over the years.2014. When the exchanges launched for 2014, plans were available in Tennessee’s exchange from Blue Cross Blue Shield of Tennessee, Community Health Alliance (an ACA-created CO-OP), Cigna, and Humana, although only BCBSTN offered plans statewide.2015.

Time/Assurant joined the Tennessee exchange statewide in 2015, bringing the total number of participating insurers to five.2016. Four insurers offered plans. BCBSTN, Cigna, Humana, and UnitedHealthcare. UnitedHealthcare was new to the exchange for 2016, and according to Kaiser Family Foundation’s analysis, UnitedHeathcare offered at least one of the two lowest-priced silver plans in the exchange in 73 of Tennessee’s 95 counties in 2016. But Assurant and Community Health Alliance both stopped selling plans at the end of 2015.

The CO-OP’s demise was due in part to the severe shortfall in federal risk corridor funding, although the CO-OP had stopped selling 2015 plans as of January 15, 2015, noting that they had already met their enrollment goal for the year. Community Health Alliance had planned to begin selling plans again during the 2016 open enrollment, but instead they ceased operations altogether at the end of 2015, leaving 27,000 enrollees who needed to select new coverage for 2016 from a different carrier.2017. Plans were available from Humana, Cigna, and BCBSTN. Like Assurant’s brief stint in the exchange, UnitedHealthcare’s participation was also short-lived, as they exited the entire individual market in Tennessee at the end of 2016. The Department of Commerce and Insurance confirmed that the exit applied to both the exchange (UnitedHealthcare Insurance Company) and off-exchange (UnitedHealthcare Life Insurance Company).

The state reported that 40,879 people needed to secure new coverage for 2017 as a result of United’s exit (the large majority of these enrollees had their United coverage through the exchange). 2017 was also the first year that BCBSTN opted not to offer statewide coverage. As of 2017, BCBSTN stopped offering coverage in the metro areas of Knoxville, Nashville, and Memphis, which are the three largest metropolitan areas in the state.Blue Cross Blue Shield of Tennessee had the lion’s share of the Tennessee exchange market in 2016, covering almost 69 percent of the enrollees. Because of BCBST’s exit from the three metropolitan areas, approximately 52,000 people in Nashville, 31,000 people in Knoxville, and 29,000 in Memphis had to switch to a different plan for 2017. So although there were three insurers offering plans in Tennessee’s exchange for 2017, residents in 73 of the state’s 95 counties had only one carrier option in the exchange.

Cigna offered coverage in the Memphis and Nashville areas. Humana offered coverage in the Memphis, Nashville, and Knoxville areas, and BCBSTN offered coverage in the rest of the state.2018. There was quite a bit of upheaval in the Tennessee exchange for 2018, in terms of insurer participation. Humana stopped offering individual market coverage in any states at the end of 2017. Humana’s exit meant that residents in the Knoxville area were facing the possibility of having no exchange insurers at all in 2018.

Humana insured about 40,000 people in the Knoxville area, and about 79,000 people across all three metropolitan areas in the state. State regulators scrambled to reach a solution, and succeeded. In May 2017, Blue Cross Blue Shield of Tennessee agreed to once again offer coverage in 2018 in the Knoxville area in order to ensure that all areas of the state would have insurance plans available in the exchange.While it initially appeared that there would only be two insurers in the Tennessee exchange for 2019, Oscar Health’s entry to the market meant that three insurers offered plans:Cigna’s plans were available in a total of 22 counties in Memphis, Nashville, and the Tri-City area (the eight eastern-most counties in the state), just as they were in 2017.BCBS of Tennessee had plans available everywhere except Memphis and Nashville. They continued to offer coverage in the non-metro areas of the state where they offered plans in 2017, and expanded back into the Knoxville area.Oscar Health has plans available in nine counties in the Nashville area.Nashville and the Tri-City areas were the only parts of the state where enrollees had a choice between two insurers, with both BCBSTN and Cigna offering plans in the Tri-City area, and Oscar and Cigna offering plans in the Nashville area.Tennessee Insurance Commissioner, Julie Mix McPeak, expressed satisfaction that all areas of the state would have at least one insurer offering coverage in the exchange in 2018, but she reiterated how the uncertainty caused by the Trump Administration and Congress was damaging the individual health insurance market, noting that “the uncertainty about the future of the exchange, cost-sharing reduction payments, and enforcement of the individual mandate will likely increase carrier rate requests by 15 to 20 percent above what they would have otherwise filed. I share consumers’ frustrations about federal uncertainty and how that is impacting their ability to afford insurance.”2019.

Bright Health joined the Tennessee exchange for 2019, offering coverage in 16 counties in the Knoxville area, nine counties in the Nashville area, and five counties in the Memphis area.Celtic (Centene) also joined the Tennessee exchange for 2019, with plans available in Memphis and Chattanooga. Much of the state had multiple carrier options for 2019 coverage:Nashville. Oscar, Cigna, BrightKnoxville. BCBSTN, Bright, and CignaMemphis. Bright, Oscar, Cigna, and CelticTri-City area.

BCBSTN and CignaChattanooga area. Celtic and BCBSTN2020. Tennessee continues to have five exchange insurers in 2020, but three have larger coverage areas. Blue Cross Blue Shield of Tennessee came back to the Memphis and Nashville areas for 2020. Celtic expanded into the Nashville and Knoxville areas, and Cigna expanded into the Chattanooga and Jackson areas.2021.

UnitedHealthcare rejoined the exchange in Tennessee for 2021, after leaving at the end of 2016. That brings the state to six insurers. UnitedHealthcare’s plans are available in all counties in rating areas 3, 4, 5, 6, and 8 (southern/central and western Tennessee). Tennessee Insurance Commissioner’s reform proposalsJulie Mix McPeak was the Insurance Commissioner for Tennessee from 2011 through mid-2019, and also served as the President of the National Association of Insurance Commissioners. In February 2017, Mix McPeak spoke before the Senate Committee on Health, Education, Labor, &.

Pensions, presenting her recommendations for health care reform. Among her proposals were:Allowing states to define essential health benefits, rather than requiring all plans sold in every state to conform to the ACA’s essential health benefits (this has been part of most of the GOP proposals to repeal or change the ACA, although it has not been implemented. As of 2019, essential health benefits are still defined at the federal level).Relaxing the age band ratio from the 3:1 level set by the ACA, to a 5:1 or 6:1 cap. The ACA limits premiums for older enrollees to no more than three times those of younger enrollees. Mix McPeak suggested that insurers should be able to charge older enrollees five or six times as much as younger enrollees, in an effort to reduce premiums for younger enrollees and incentivize them to enroll (this is another provision that was included in most of the GOP efforts to repeal or change the ACA in 2017, but none of those efforts were successful.

It’s worth noting that adjusting the age rating bands would result in lower premiums for younger people, but markedly higher premiums for older people. For those who receive premium subsidies, the subsidies would grow to offset the increase. But for those who don’t get subsidies, coverage could become unaffordable).Tighter restrictions and increased verification of eligibility for special enrollment periods (HHS finalized a market stabilization rule in April 2017 that included increased eligibility verification, and restrictions such as limiting enrollees’ ability to use a special enrollment period to switch to a plan at a different metal level).Reducing the current 90-day grace period for people with premium subsidies down to a 30-day grace period (the market stabilization rule kept the 90-day grace period, but allows insurers to apply new enrollment premiums to past-due balances from the previous 12 months if the person seeks to re-enroll after losing coverage for non-payment of premium).Senator Alexander. 2017 legislation to protect bare counties, and a plea for CSR fundingIn 2017, the U.S. Senators from Tennessee, Lamar Alexander and Bob Corker, both Republicans, introduced legislation (S.761, the Health Care Options Act of 2017) that would allow people in counties without any participating exchange insurers to use ACA subsidies for off-exchange plans.

That scenario has never come to pass, but there were concerns at that point that some areas of the country, including the Knoxville, Tennessee area, might not have had any ACA-compliant plans available.Senator Alexander also, notably, stated in early 2017 that Congress or the Trump administration should commit to funding cost-sharing reductions (CSRs) through 2019, in an effort to stabilize the individual health insurance market. CSRs lower out-of-pocket costs for low-income exchange enrollees who pick silver plans, and 57 percent of Tennessee exchange enrollees have plans that include CSRs in 2017.CSR funding was ultimately eliminated by the Trump administration in October 2017, but the uncertainty (during the rate filing season of spring/summer 2017) around whether or not the funding would continue resulted in premium proposals for 2018 that were higher than they would otherwise have been. Without a federal commitment to fund CSR, Tennessee Insurance Commissioner, Julie Mix McPeak estimated that premiums in Tennessee would be 15 to 20 percent higher than they would otherwise have been in 2018.Senator Alexander joined forces with Senator Patty Murray (D, Washington) in an effort to pass bipartisan legislation aimed at stabilizing the individual insurance markets nationwide, with a proposal that included CSR funding. However, Republican leadership in the Senate opted to push forward on their efforts to repeal the ACA (via the Graham-Cassidy legislation) and pulled the plug on Alexander and Murray’s bipartisan approach in September 2017.In the announcement about the approved rates for 2018, Mix McPeak said “I’m disappointed by yesterday’s announcement out of Washington [about Alexander and Murray’s bipartisan approach being abandoned by Senate leadership]. While Tennessee is supportive of long-term strategies such as the Graham-Cassidy Amendment introduced in Congress, I appreciate the diligent efforts of Senators Lamar Alexander and Patty Murray to find common ground in providing more immediate stabilization in the marketplace.

Instead, it appears more likely that Tennesseans must prepare themselves for a round of actuarially justified rates for 2018 that are far higher than could be necessary as a result of uncertainty in Washington.” Farm Bureau plans aren’t compliance with the ACA, but they’re still allowed to be sold in TennesseeAs of 2017, there were about 73,000 people in Tennessee who were covered under Farm Bureau plans that aren’t ACA-compliant. About 50,000 of those were grandfathered plans, but the rest are medically underwritten “traditional” plans that are still available for purchase. Medical underwriting means that the insurer uses the applicant’s medical history to determine whether to offer coverage and at what price. That practice is no longer allowed under the ACA – on or off-exchange – for any plans that are considered individual major medical health insurance.But in Tennessee, the state doesn’t consider Farm Bureau to be a licensed health insurer. That’s been the case for more than two decades – Farm Bureau plans operate outside of the regulatory structure imposed by the state (and the ACA) on health insurers.

As a result, Farm Bureau’s “traditional” plans, which are less expensive than regular health insurance but only available to healthy people, are being sold to healthy people in Tennessee, effectively removing them from the ACA-compliant risk pool.People who enroll in Farm Bureau’s “traditional” plans are not in compliance with the ACA’s individual mandate, so from 2014 through 2018, they were assessed a penalty for being uninsured unless they were exempt from the individual mandate (this is the same as the rule that required people with short-term health insurance to pay the individual mandate penalty. Just like the Tennessee Farm Bureau “traditional” plans, short-term health insurance is not regulated by the ACA). But the individual mandate penalty no longer applies in 2019 and future years, so there is no longer a penalty for relying on a Farm Bureau plan.Farm Bureau’s plans are not as robust as regular health insurance, and aren’t helpful for people with pre-existing conditions. But the fact that Tennessee has allowed them to continue to be sold outside the scope of the state’s insurance regulations could be part of the reason the state has a risk pool in the ACA-compliant market that’s sicker than most states.Iowa has decided to follow Tennessee’s lead, enacting legislation in 2018 that allows Farm Bureau to partner with Wellmark to offer non-ACA-compliant plans in Iowa.BCBSTN losses pre-2017 and rate hike request – some backgroundDuring open enrollment for 2016 coverage, 166,425 exchange enrollees (62 percent of the total) signed up with Blue Cross Blue Shield of Tennessee for 2016. This was an increase of 16 percent over BCBSTN’s exchange enrollment in 2015, despite the fact that the carrier raised its premiums by an average of 36 percent for 2016.

The remaining 38 percent of the exchange enrollees selected plans from Humana, Cigna, and United Healthcare.Blue Cross Blue Shield of Tennessee had the lowest priced plans in the Tennessee exchange — and the nation — in 2014. Although BCBSTN’s average rate increase was 19 percent for 2015 and 36 percent for 2016 (and their competitors had significantly smaller rate hikes), they still had among the lowest premiums in many areas of Tennessee in 2016. In the Memphis area, a search on Healthcare.gov indicated that the five least expensive bronze plans and the four least expensive silver plans were all offered by BCBSTN in 2016. Their lower premiums and brand-name recognition likely played a role in their outsized market share. But because enrollees have been sicker than expected, the carrier lost $300 million during 2014 and 2015, and projected total losses to reach $500 million by the end of 2016.

Losses of that magnitude are not sustainable.In order to continue working towards long-term sustainability in the ACA-compliant individual market, BCBSTN had indicated earlier in 2016 that they were expecting to propose significant rate increases for 2017, although the expectation in early 2016 was that the proposed rate increases for 2017 would be comparable to the 36 percent average increase that the carrier implemented for 2016. Ultimately, BCBSTN requested a much higher average increase – 62 percent – for 2017, and regulators approved it in order to keep the insurer in the marketplace.Joe Sullivan of The Knoxville Mercury tracked down some 2016 data that adds perspective to the rate changes for 2017, particularly in the Memphis and Nashville metropolitan areas, where Humana, Cigna, and BCBS all offered plans in the exchange in 2016:BCBS had two networks, and offered 10 silver PPO plans in Nashville and in Memphis in 2016. The plans included out-of-network coverage. BCBST did not offer plans in either area in 2017.Humana had one silver PPO plan in Nashville and in Memphis.Cigna had three silver EPO plans in Nashville (no out-of-network coverage) and three silver PPO plans in Memphis.In Memphis, all three carriers offered silver PPO plans, and BCBS had the lowest prices (BCBST stopped offering coverage in Memphis in 2017).In Nashville, Cigna’s silver prices were lower than BCBS, but the Cigna plans were EPOs, without coverage for out-of-network care (BCBST stopped offering plans in Nashville in 2017).Grandmothered/Transitional health plansTennessee has allowed transitional (grandmothered) plans to remain in force, but the Tennessee Department of Commerce and Insurance confirmed in 2017 that they no longer had any grandmothered plans remaining in the individual market, as insurers had opted to end those plans and replace them with ACA-compliant plans instead.History of the Tennessee exchangeIn December 2012, then-Gov. Bill Haslam announced Tennessee would not develop its own health insurance exchange, citing a lack of information from the federal government.Prior to his 2012 announcement, Haslam had leaned toward a state-run exchange.

He believed local state control was preferable and that the state could run the exchange more cost-effectively that the federal government.However, Republican legislators opposed the exchange, Tea Party supporters staged repeated protests, and Tennessee eventually ended up with an exchange run by HHS.Tennessee health insurance exchange linksHealthCare.gov800-318-2596State Exchange Profile. TennesseeThe Henry J. Kaiser Family Foundation overview of Tennessee’s progress toward creating a state health insurance exchange.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.Key takeawaysNearly 4.3 million people in Texas have Medicare plans, but that’s only a little more than 14 percent of the state’s population.Nearly 43% Texas Medicare beneficiaries had Medicare Advantage plans (or other private Medicare plans, including Medicare Cost plans) as of 2020.

Medicare Advantage plan availability ranges from eight plans to 60 plans, depending on the county.In Texas, 70 insurers offer Medigap plans and more than 873,000 Texas residents are enrolled in Medigap plans. Medigap insurers in Texas are required to offer at least Medigap Plan A to disabled beneficiaries under the age of 65.Premiums for stand-alone Part D prescription plans in Texas range from about $7 to $155 per month for 2021 coverage. 1.65 million Texas Medicare beneficiaries have stand-alone Part D plans, plus 1.54 million with Part D integrated with Medicare Advantage.Per-enrollee Original Medicare spending in Texas is the second-highest in the nation (Louisiana is the only state where average per-beneficiary spending is higher).Extended enrollment opportunity for Texas residents affected by 2020 tropical stormsThe regular annual open enrollment period for 2021 Medicare Advantage and Part D plans ended on December 7. But Texas residents who live in counties affected by tropical storms Marco and Laura have additional time to enroll in a Part D or Advantage plan for 2021. This window in Texas continues until December 31, 2020 (four calendar months after the tropical storm disaster incident in Texas).This extended enrollment opportunity applies to people who live in the counties in eastern Texas where FEMA declared a disaster, as well as those who live elsewhere but rely on a friend or family member for assistance with the enrollment process, and that person lives in one of the affected counties.

If you’re eligible for the enrollment period extension and you sign up for a Part D or Medicare Advantage plan by December 31, your new coverage will take effect January 1, the same as it would have if you’d enrolled by December 7. Medicare enrollment in TexasThe number of Medicare beneficiaries in Texas stood at 4,292,236 as of October 2020. Only Florida and California have more residents enrolled in Medicare.CMS has extended Medicare open enrollment through December 31 in 54 Texas counties in response to the natural disasters in 2020.But only a little more than 14 percent of Texas residents are enrolled in Medicare, compared with almost 19 percent of the United States population enrolled in Medicare. Texas has among the youngest populations in the country, and since most people become eligible for Medicare enrollment when they turn 65, the state’s lower median age results in a smaller percentage of its residents filing for Medicare benefits.Although most people become eligible for Medicare coverage enrollment when they turn 65, Medicare also provides coverage for people under age 65. Those who have been receiving disability benefits for 24 months, have ALS, or have end-stage renal disease are eligible for Medicare.

Fifteen percent of all Medicare beneficiaries in Texas — and nationwide — are under the age of 65.Medicare health insurance optionsIn most areas of the country, Medicare beneficiaries can choose Original Medicare or a Medicare Advantage plan.Original Medicare is provided directly by the federal government and includes Medicare Parts A and B. Medicare Part A, also called hospital insurance, helps to pay for inpatient stays at a hospital, skilled nursing facility, or hospice center. Part B, also called medical insurance, helps pay for outpatient care like physician services, kidney dialysis, preventive care, durable medical equipment, etc.Medicare Advantage plans are administered by private insurance companies that have contracts with the federal government. Medicare Advantage plans include all of the benefits of Original Medicare (albeit with different cost-sharing, as the plans set their own deductibles, coinsurance, and copays, within the limits established by the federal government), and they typically have additional benefits, such coverage for prescription drugs, dental, and vision. But provider networks are often limited with Medicare Advantage plans, and out-of-pocket costs are typically higher than a person would have if they opted for Original Medicare plus a Medigap plan.

In short, there are pros and cons either way, and no one-size-fits-all solution. Medicare Advantage in TexasMedicare Advantage plans are available in all 254 counties in Texas in 2021, but plan availability ranges from as few as nine plans some of the state’s service areas to as many as 90 plans for sale in Harris County.A little more than a third of Texas Medicare beneficiares — just slightly more than the national average — were enrolled in private Medicare plans in 2018. These were mostly Medicare Advantage plans, but some residents in Texas have Medicare Cost plans, which are another form of private coverage. By late 2020, however, the share of Texas Medicare beneficiaries enrolled in private plans had grown to more than 43 percent. The other 57 percent of Medicare beneficiaries in Texas were enrolled in Original Medicare instead.Medicare beneficiaries can switch between Medicare Advantage enrollment and Original Medicare (and can add or drop a Medicare Part D prescription plan) during the Medicare annual election period, which runs from October 15 to December 7 each year.

Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31.Medigap in TexasMore than half of Original Medicare beneficiaries have supplemental coverage provided by an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans) are designed to pay some or all of the out-of-pocket costs (deductibles and coinsurance) that enrollees would otherwise have to pay themselves. Since Original Medicare does not include a cap on out-of-pocket costs, most enrollees maintain some form of supplemental coverage, and Medigap plans are one way to do this.According to an AHIP analysis, there were 873,514 Texas Medicare beneficiaries with Medigap coverage as of 2018.There are 70 insurers licensed to sell Medigap plans in Texas.Although Medigap plans are sold by private insurers, the plans are standardized under federal rules. There are ten different plan designs (differentiated by letters, A through N), and the benefits offered by a particular plan (Plan A, Plan F, etc.) are the same from one insurer to another.Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue.

This window starts when a person is at least 65 and enrolled in Medicare Part B (you have to be enrolled in both Part A and Part B to buy a Medigap plan).Although disabled Americans under the age of 65 are eligible for Medicare, federal rules do not guarantee access to Medigap plans for people who are under 65. But the majority of the states — including Texas — have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Texas law requires Medigap insurers to offer at least Medigap Plan A to disabled enrollees under age 65, during the six-month period that begins when they’re enrolled in Medicare Part B. Medigap Plan A is the least comprehensive of the Medigap plans, but it will cover the 20 percent Part B coinsurance that the enrollee would othewise have to pay out-of-pocket.Disabled Medicare beneficiaries under the age of 65 have another six-month Medigap open enrollment period when they turn 65. At that point, they have access to any of the available Medigap plans, at the standard premiums that apply to people who are enrolling in Medicare due to turning 65 (premiums are generally significantly higher for Medicare beneficiaries under age 65, since their disabilities result in more costly medical care).Medicare Advantage plans are available to anyone eligible for Medicare, except people with end-stage renal disease (starting in 2021, this limitation will no longer apply.

People with ESRD will be able to enroll in Medicare Advantage plans). So unless they have ESRD, Texas Medicare beneficiaries under the age of 65 can choose a Medicare Advantage plan instead of Medigap Plan A. Medicare Advantage plans do have a cap on out-of-pocket costs, but they also tend to have limited provider networks, which is an important consideration for people with serious health issues.Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those regulations don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months, if you didn’t have at least six months of continuous coverage prior to your enrollment. And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the insurer can look back at your medical history in determining whether to accept your application, and at what premium.

Texas Medicare Part DOriginal Medicare does not cover the cost of outpatient prescription drugs. As noted above, more than half of Original Medicare beneficiaries have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage. But Medicare beneficiaries who don’t have drug coverage through Medicaid or an employer-sponsored plan need to obtain Medicare Part D prescription coverage (prior to 2006, some Medigap plans included prescription coverage. People who still have those plans can keep them, but they have not been for sale since the end of 2005).Part D coverage can be purchased as a stand-alone plan, or as part of a Medicare Advantage plan that includes Part D prescription drug coverage.In Texas, there are 35 stand-alone Medicare Part D plans for sale for 2021, with premiums that range from about $7 to $155/month.As of late 2020, there were 1.65 million Medicare beneficiaries in Texas with stand-alone Medicare Part D plans. An additional 1.54 million Texas residents had Medicare Part D coverage integrated with their Medicare Advantage plans.Medicare Part D enrollment follows the same schedule as Medicare Advantage.

Beneficiaries can enroll in Medicare Part D plans when they’re first eligible for Medicare, and there’s also an annual enrollment window (October 15 to December 7) when people can enroll or switch to a different plan. Medicare spending in TexasIn 2018, Original Medicare’s per-beneficiary spending in Texas averaged $11,627, which was 15 percent higher than the $10,096 national average. Texas had the second-highest average per-beneficiary costs in the country. Only Louisiana had higher average costs. That’s based on data that were standardized to eliminate regional differences in payment rates, but it did not include costs for Medicare Advantage.How does Medicaid provide financial assistance to Medicare beneficiaries in Texas?.

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums and services Medicare doesn’t cover – such as long-term care.Our guide to financial assistance for Medicare enrollees in Texas includes overviews of these benefits, including Medicare Savings Programs, long-term care coverage, and eligibility guidelines for assistance.Helpful resources for Texas Medicare beneficiaries and their caregiversNeed help with your Medicare application in Texas, or have questions about Medicare eligibility in Texas?. These resources provide free assistance and information.The Health Information, Counseling, and Advocacy Program (HICAP), with any questions related to Medicare coverage in Texas. Visit the website or call 1-800-252-9240.The Texas Department of Insurance has a resources page for Texas residents with Medicare coverage.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..

What may interact with Zithromax?

  • antacids
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Restrictions for religious gatherings and gyms will be eased under relaxed buy antibiotics safety rules what are xanax zithromax and zocor zithromax for sale cheap announced today. From Friday 23 October what are xanax zithromax and zocor. Religious gatherings/places of worship (excluding weddings and funerals) can have up to 300 people, subject to a buy antibiotics safety plan gyms will only be required to have a buy antibiotics safety marshal if there are more than 20 people in the gym at one time.Treasurer Dominic Perrottet said as the NSW Government eases restrictions the community should continue to be buy antibiotics Safe.“Our aim is to provide as many opportunities as we can for organisations and the community to carry on with their work and lives as much as possible,” Mr Perrottet said.“We want to keep moving forward but for that strategy to be successful we need everyone to follow the buy antibiotics Safety Plans.”Minister for Health Brad Hazzard thanked religious leaders and the community for their ongoing support of the efforts to control buy antibiotics. €œThe impact of buy antibiotics is being felt right across the community but the further easing of restrictions to allow 300 people at religious gatherings is another cautious step towards a ‘buy antibiotics-normal’ life,” Mr Hazzard said.“buy antibiotics is still lurking amongst us what are xanax zithromax and zocor so I urge all leaders to continue encouraging everyone at their religious gatherings and places of worship to comply with the health advice to keep themselves and others safe.”Religious gatherings exclude weddings and funerals.

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Health Minister Brad Hazzard said the NSW Government invests millions of dollars in services and infrastructure across the state to ensure regional communities can access the best health care possible.“Echuca, on the Victorian side of the border, and Moama, on the NSW side, are in a similar situation to Albury-Wodonga. These border towns identify as single communities, with residents crossing the border daily to access services,” Mr Hazzard said.“This new centre will provide patients in cross-border communities with world-class, critical cancer services and treatments right on their doorstep.”Echuca Regional Health Chief Executive Nick Bush thanked the NSW Government what are xanax zithromax and zocor for its $1 million commitment. €œWe appreciate the support of the NSW Government of the Echuca-Moama and surrounding what are xanax zithromax and zocor community. It is very exciting to see the project progressing.

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Restrictions for religious gatherings and gyms will be eased under relaxed buy antibiotics safety rules buy zithromax with prescription announced today. From Friday 23 October buy zithromax with prescription. Religious gatherings/places of worship (excluding weddings and funerals) can have up to 300 people, subject to a buy antibiotics safety plan gyms will only be required to have a buy antibiotics safety marshal if there are more than 20 people in the gym at one time.Treasurer Dominic Perrottet said as the NSW Government eases restrictions the community should continue to be buy antibiotics Safe.“Our aim is to provide as many opportunities as we can for organisations and the community to carry on with their work and lives as much as possible,” Mr Perrottet said.“We want to keep moving forward but for that strategy to be successful we need everyone to follow the buy antibiotics Safety Plans.”Minister for Health Brad Hazzard thanked religious leaders and the community for their ongoing support of the efforts to control buy antibiotics.

€œThe impact of buy antibiotics is being felt right buy zithromax with prescription across the community but the further easing of restrictions to allow 300 people at religious gatherings is another cautious step towards a ‘buy antibiotics-normal’ life,” Mr Hazzard said.“buy antibiotics is still lurking amongst us so I urge all leaders to continue encouraging everyone at their religious gatherings and places of worship to comply with the health advice to keep themselves and others safe.”Religious gatherings exclude weddings and funerals. However, from 1 December, the number buy zithromax with prescription of people who can attend weddings will be lifted to 300 people subject to the four square metre rule indoors and two square metre rule outdoors. People attending a religious service will be required to provide their name and contact details when they enter so they can be used for contact tracing.

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These border towns identify as single communities, with residents crossing the border daily to access services,” Mr Hazzard said.“This new centre will provide buy zithromax with prescription patients in cross-border communities with world-class, critical cancer services and treatments right on their doorstep.”Echuca Regional Health Chief Executive Nick Bush thanked the NSW Government for its $1 million commitment. €œWe appreciate the support of the NSW Government of the Echuca-Moama and surrounding community buy zithromax with prescription. It is very exciting to see the project progressing.

The purpose-built facility will give patients the best care in a wonderful, new buy zithromax with prescription centre in our community.”NSW and Victoria have a long-standing agreement for cross-border health care. In 2020/2021, NSW will reimburse about $63 million to Victoria, on top of the buy zithromax with prescription $120 million NSW Health provides to Albury-Wodonga Health for NSW residents.Planning is underway for the centre, which will provide access to haematologists, medical oncologists, nephrologists and radiation oncologists for more than 1,200 patients each year. Murrumbidgee Local Health District provides a cancer diagnosis service at Deniliquin Hospital, and there are plans to recruit and train staff in oncology.​.

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A study published today by researchers at the National Institutes of Health revealed that about half of individuals who said they don’t want to receive secondary genomic findings changed their mind after their healthcare provider gave them more zithromax 500mg 3 days detailed information http://tracedwithpurpose.org/buy-ventolin-uk/. The paper, published in Genomics in Medicine, examines people's attitudes about receiving secondary genomic findings related to treatable or preventable diseases. The study was led by scientists at the National Human Genome Research Institute (NHGRI) and the National Institute of Environmental Health Sciences (NIEHS), both zithromax 500mg 3 days part of NIH. Your browser does not support the video tag. Animation of patient filling out an zithromax 500mg 3 days informed consent form and checking the "YES" checkboxes for both Expected Outcome and Secondary Findings.

Credit. Ernesto del Aguila III, NHGRI. With the broader adoption of genome sequencing in clinical zithromax 500mg 3 days care, researchers and the bioethics community are considering options for how to navigate the discovery of secondary genomic findings. Secondary findings that come out of genome sequencing reflect information that is separate from the primary reason for an individual's medical care or participation in a study. For example, the genomic data of a patient who undergoes genome sequencing to address an autoimmune problem might reveal genomic variants that are associated with a heightened zithromax 500mg 3 days risk for breast cancer.

Based on the American College of Medical Genetics and Genomics recommendations in 2021, individuals who have their genomes sequenced for a clinical reason should also be screened for genomic variants in 73 genes, including BRCA1 and BRCA2, both of which are linked to an increased risk of breast and ovarian cancer. All 59 genes are associated zithromax 500mg 3 days with treatable or potentially severe diseases. Proponents of a person’s right to not know their secondary genomic findings have argued that, to maintain autonomy, individuals should have the opportunity to decide whether to be provided information about genomic variants in these additional genes. "Because these genomic findings can have life-saving implications, we wanted to ask the question. Are people really understanding zithromax 500mg 3 days what they are saying no to?.

If they get more context, or a second opportunity to decide, do they change their mind?. " said Benjamin Berkman, J.D., M.P.H., deputy director of the NHGRI Bioethics zithromax 500mg 3 days Core and senior author on the study. The research group worked with participants from the Environmental Polymorphisms Registry, an NIEHS study examining how genetic and environmental factors influence human health. Out of 8,843 zithromax 500mg 3 days participants, 8,678 elected to receive secondary genomic findings, while 165 opted out. Researchers assessed those 165 individuals to determine how strongly and consistently they maintained their "right not to know" decision.

The researchers wanted to determine whether providing additional information to people about their genomic variants influenced their decision and to better understand why some people still refused their secondary genomic findings after they received the additional information. Following the intervention, the researchers found that the 165 people sorted into two zithromax 500mg 3 days groups. "reversible refusers" who switched their decision to accept to know their secondary genomic findings and "persistent refusers" who still refused. Because these genomic findings can have life-saving implications, zithromax 500mg 3 days we wanted to ask the question. Are people really understanding what they are saying no to?.

If they get more context, or a second opportunity to decide, do they change zithromax 500mg 3 days their mind?. "It is worth noting that nearly three-quarters of reversible refusers thought they had originally agreed to receive secondary genomic findings," said Will Schupmann, a doctoral candidate at UCLA and first author on the study. "This means that we should be skeptical about whether checkbox choices are accurately capturing people’s preferences.” Based on the results, the researchers question whether healthcare providers should ask people who have their genome sequenced if they want to receive clinically important secondary genomic findings. Investigators argue that enough data supports a default practice of returning zithromax 500mg 3 days secondary genomic findings without first asking participants if they would like to receive them. But research studies should create a system that also allows people who do not want to know their secondary genomic findings to opt out.

The researchers suggest zithromax 500mg 3 days that if healthcare providers actively seek their patients’ preferences to know or not know about their secondary genomic findings, the providers should give the individuals multiple opportunities to make and revise their choice. "The right not to know has been a contentious topic in the genomics research community, but we believe that our real-world data can help move the field towards a new policy consensus," said Berkman. Researchers at the NIH Department of Bioethics, NIEHS, Harvard University and zithromax 500mg 3 days Social &. Scientific Systems collaborated on the study.NIH research could lead to new treatment strategies for stomach cancer Glucocorticoids and androgens promote a healthy stomach pit by inhibiting inflammation, left, while their absence promotes inflammation and SPEM seen in a diseased pit, right. SPEM glands are also much larger than healthy stomach glands.

(Photo courtesy of Jonathan Busada, Ph.D./NIEHS) Scientists at the National Institutes of Health determined zithromax 500mg 3 days that stomach inflammation is regulated differently in male and female mice after finding that androgens, or male sex hormones, play a critical role in preventing inflammation in the stomach. The finding suggests that physicians could consider treating male patients with stomach inflammation differently than female patients with the same condition. The study was published in Gastroenterology.Researchers at NIH’s National Institute of Environmental Health zithromax 500mg 3 days Sciences (NIEHS) made the discovery after removing adrenal glands from mice of both sexes. Adrenal glands produce glucocorticoids, hormones that have several functions, one of them being suppressing inflammation. With no glucocorticoids, the female mice soon developed zithromax 500mg 3 days stomach inflammation.

The males did not. However, after removing androgens from the males, they exhibited the same stomach inflammation seen in the females."The fact that androgens are regulating inflammation is a novel idea," said co-corresponding author John Cidlowski, Ph.D., deputy chief of the NIEHS Laboratory of Signal Transduction and head of the Molecular Endocrinology Group. "Along with glucocorticoids, androgens offer a new way to control immune function in humans."While this study provides insight into how inflammation is being regulated in males, Cidlowski said zithromax 500mg 3 days additional research is underway to understand the process in females. The scientist handling this phase of research is co-corresponding author Jonathan Busada, Ph.D., assistant professor at West Virginia University School of Medicine in Morgantown. When Busada started the project several years ago, he was a postdoctoral fellow working in Cidlowski’s group.Whether inflammation is inside the stomach or zithromax 500mg 3 days elsewhere in the body, Busada said rates of chronic inflammatory and autoimmune diseases vary depending on sex.

He said eight out of 10 individuals with autoimmune disease are women, and his long-term goal is to figure out how glucocorticoids and androgens affect stomach cancer, which is induced by chronic inflammation.The current research focused on stomach glands called pits, which are embedded in the lining of the stomach.Busada said the study showed that glucocorticoids and androgens act like brake pedals on the immune system and are essential for regulating stomach inflammation. In his analogy, zithromax 500mg 3 days glucocorticoids are the primary brakes and androgens are the emergency brakes."Females only have one layer of protection, so if you remove glucocorticoids, they develop stomach inflammation and a pre-cancerous condition in the stomach called spasmolytic polypeptide-expressing metaplasia (SPEM)," Busada said. "Males have redundancy built in, so if something cuts the glucocorticoid brake line, it is okay, because the androgens can pick up the slack."The research also offered a possible mechanism — or biological process — behind this phenomenon. In healthy stomach glands, the presence of glucocorticoids and androgens inhibit special immune cells called type 2 innate lymphoid cells (ILC2s). But in diseased stomach glands, the zithromax 500mg 3 days hormones are missing.

As a result, ILC2s may act like a fire alarm, directing other immune cells called macrophages to promote inflammation and damage gastric glands leading to SPEM and ultimately cancer."ILC2s are the only immune cells that contain androgen receptors and could be a potential therapeutic target," Cidlowski said.This press release describes a basic research finding. Basic research increases our understanding of human behavior zithromax 500mg 3 days and biology, which is foundational to advancing new and better ways to prevent, diagnose, and treat disease. Science is an unpredictable and incremental process — each research advance builds on past discoveries, often in unexpected ways. Most clinical advances would not be possible without zithromax 500mg 3 days the knowledge of fundamental basic research. To learn more about basic research, visit Basic Research – Digital Media Kit.Grant Numbers:ZIAES090057Fi2GM123974P20GM103434P20GM121322U54GM104942P30GM103488 Reference.

Busada JT, Peterson KN, Khadka S, Xu, X, Oakley RH, Cook DN, Cidlowski JA. 2021. Glucocorticoids and androgens protect from gastric metaplasia by suppressing group 2 innate lymphoid cell activation. Gastroenterology. Doi.

10.1053/j.gastro.2021.04.075 [Online 7 May 2021]..

A study published today by researchers at the National Institutes of Health revealed that about buy zithromax with prescription half Continue of individuals who said they don’t want to receive secondary genomic findings changed their mind after their healthcare provider gave them more detailed information. The paper, published in Genomics in Medicine, examines people's attitudes about receiving secondary genomic findings related to treatable or preventable diseases. The study was led by buy zithromax with prescription scientists at the National Human Genome Research Institute (NHGRI) and the National Institute of Environmental Health Sciences (NIEHS), both part of NIH. Your browser does not support the video tag. Animation of buy zithromax with prescription patient filling out an informed consent form and checking the "YES" checkboxes for both Expected Outcome and Secondary Findings.

Credit. Ernesto del Aguila III, NHGRI. With the broader adoption of genome sequencing in clinical care, researchers and the bioethics buy zithromax with prescription community are considering options for how to navigate the discovery of secondary genomic findings. Secondary findings that come out of genome sequencing reflect information that is separate from the primary reason for an individual's medical care or participation in a study. For example, the genomic data of a patient who undergoes genome sequencing to address an autoimmune problem might reveal buy zithromax with prescription genomic variants that are associated with a heightened risk for breast cancer.

Based on the American College of Medical Genetics and Genomics recommendations in 2021, individuals who have their genomes sequenced for a clinical reason should also be screened for genomic variants in 73 genes, including BRCA1 and BRCA2, both of which are linked to an increased risk of breast and ovarian cancer. All 59 genes buy zithromax with prescription are associated with treatable or potentially severe diseases. Proponents of a person’s right to not know their secondary genomic findings have argued that, to maintain autonomy, individuals should have the opportunity to decide whether to be provided information about genomic variants in these additional genes. "Because these genomic findings can have life-saving implications, we wanted to ask the question. Are people really understanding what they buy zithromax with prescription are saying no to?.

If they get more context, or a second opportunity to decide, do they change their mind?. " said Benjamin Berkman, J.D., M.P.H., deputy director of the NHGRI Bioethics Core and senior buy zithromax with prescription author on the study. The research group worked with participants from the Environmental Polymorphisms Registry, an NIEHS study examining how genetic and environmental factors influence human health. Out of buy zithromax with prescription 8,843 participants, 8,678 elected to receive secondary genomic findings, while 165 opted out. Researchers assessed those 165 individuals to determine how strongly and consistently they maintained their "right not to know" decision.

The researchers wanted to determine whether providing additional information to people about their genomic variants influenced their decision and to better understand why some people still refused their secondary genomic findings after they received the additional information. Following the intervention, the researchers found that the 165 people sorted buy zithromax with prescription into two groups. "reversible refusers" who switched their decision to accept to know their secondary genomic findings and "persistent refusers" who still refused. Because these buy zithromax with prescription genomic findings can have life-saving implications, we wanted to ask the question. Are people really understanding what they are saying no to?.

If they get more context, or a second opportunity buy zithromax with prescription to decide, do they change their mind?. "It is worth noting that nearly three-quarters of reversible refusers thought they had originally agreed to receive secondary genomic findings," said Will Schupmann, a doctoral candidate at UCLA and first author on the study. "This means that we should be skeptical about whether checkbox choices are accurately capturing people’s preferences.” Based on the results, the researchers question whether healthcare providers should ask people who have their genome sequenced if they want to receive clinically important secondary genomic findings. Investigators argue that buy zithromax with prescription enough data supports a default practice of returning secondary genomic findings without first asking participants if they would like to receive them. But research studies should create a system that also allows people who do not want to know their secondary genomic findings to opt out.

The researchers suggest that if healthcare providers actively seek their patients’ preferences to know or not know about their secondary genomic findings, the providers should give the individuals multiple opportunities to make and revise their buy zithromax with prescription choice. "The right not to know has been a contentious topic in the genomics research community, but we believe that our real-world data can help move the field towards a new policy consensus," said Berkman. Researchers at the NIH Department of Bioethics, NIEHS, Harvard University and Social & buy zithromax with prescription. Scientific Systems collaborated on the study.NIH research could lead to new treatment strategies for stomach cancer Glucocorticoids and androgens promote a healthy stomach pit by inhibiting inflammation, left, while their absence promotes inflammation and SPEM seen in a diseased pit, right. SPEM glands are also much larger than healthy stomach glands.

(Photo courtesy of Jonathan Busada, Ph.D./NIEHS) Scientists at the buy zithromax with prescription National Institutes of Health determined that stomach inflammation is regulated differently in male and female mice after finding that androgens, or male sex hormones, play a critical role in preventing inflammation in the stomach. The finding suggests that physicians could consider treating male patients with stomach inflammation differently than female patients with the same condition. The study was published in Gastroenterology.Researchers at NIH’s National Institute of Environmental buy zithromax with prescription Health Sciences (NIEHS) made the discovery after removing adrenal glands from mice of both sexes. Adrenal glands produce glucocorticoids, hormones that have several functions, one of them being suppressing inflammation. With no glucocorticoids, the female mice soon developed stomach inflammation buy zithromax with prescription.

The males did not. However, after removing androgens from the males, they exhibited the same stomach inflammation seen in the females."The fact that androgens are regulating inflammation is a novel idea," said co-corresponding author John Cidlowski, Ph.D., deputy chief of the NIEHS Laboratory of Signal Transduction and head of the Molecular Endocrinology Group. "Along with glucocorticoids, androgens offer a new way to control immune function in humans."While this study provides insight into how inflammation is being regulated in males, Cidlowski said additional research is underway to buy zithromax with prescription understand the process in females. The scientist handling this phase of research is co-corresponding author Jonathan Busada, Ph.D., assistant professor at West Virginia University School of Medicine in Morgantown. When Busada started the project several years ago, he was a postdoctoral fellow working in Cidlowski’s group.Whether inflammation is inside the stomach or elsewhere in the body, buy zithromax with prescription Busada said rates of chronic inflammatory and autoimmune diseases vary depending on sex.

He said eight out of 10 individuals with autoimmune disease are women, and his long-term goal is to figure out how glucocorticoids and androgens affect stomach cancer, which is induced by chronic inflammation.The current research focused on stomach glands called pits, which are embedded in the lining of the stomach.Busada said the study showed that glucocorticoids and androgens act like brake pedals on the immune system and are essential for regulating stomach inflammation. In his analogy, glucocorticoids are the primary brakes and buy zithromax with prescription androgens are the emergency brakes."Females only have one layer of protection, so if you remove glucocorticoids, they develop stomach inflammation and a pre-cancerous condition in the stomach called spasmolytic polypeptide-expressing metaplasia (SPEM)," Busada said. "Males have redundancy built in, so if something cuts the glucocorticoid brake line, it is okay, because the androgens can pick up the slack."The research also offered a possible mechanism — or biological process — behind this phenomenon. In healthy stomach glands, the presence of glucocorticoids and androgens inhibit special immune cells called type 2 innate lymphoid cells (ILC2s). But in buy zithromax with prescription diseased stomach glands, the hormones are missing.

As a result, ILC2s may act like a fire alarm, directing other immune cells called macrophages to promote inflammation and damage gastric glands leading to SPEM and ultimately cancer."ILC2s are the only immune cells that contain androgen receptors and could be a potential therapeutic target," Cidlowski said.This press release describes a basic research finding. Basic research increases our understanding of human behavior and biology, which is foundational to buy zithromax with prescription advancing new and better ways to prevent, diagnose, and treat disease. Science is an unpredictable and incremental process — each research advance builds on past discoveries, often in unexpected ways. Most clinical advances would not be possible without the knowledge buy zithromax with prescription of fundamental basic research. To learn more about basic research, visit Basic Research – Digital Media Kit.Grant Numbers:ZIAES090057Fi2GM123974P20GM103434P20GM121322U54GM104942P30GM103488 Reference.

Busada JT, Peterson KN, Khadka S, Xu, X, Oakley RH, Cook DN, Cidlowski JA. 2021. Glucocorticoids and androgens protect from gastric metaplasia by suppressing group 2 innate lymphoid cell activation. Gastroenterology. Doi.

10.1053/j.gastro.2021.04.075 [Online 7 May 2021]..

Zithromax and alcohol

Patients are Zithromax cost without insurance more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter.1 2 For several decades, a hallmark of surgical quality and zithromax and alcohol safety has been the use of checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have been or will be performed. The most widely used approach globally is the Surgical Safety Checklist (SSC) recommended by the WHO.3 It is divided into preinduction (or sign in, consisting of seven items performed by anaesthesia and nursing), preincision (timeout, 10 items performed by the entire team) and postsurgery (sign out, five items by the entire team).4 5 Most hospitals in the developed world perform the SSC zithromax and alcohol or an equivalent timeout prior to surgical incision. However, preinduction briefings, and postcase debriefings in particular, are much less commonly performed.6 7There are widely disseminated arguments recommending the use of checklists in healthcare8 but also recognised limitations.9 Checklist-based preincision timeouts appear to improve surgical outcomes in many settings,4 5 yet, in other hospitals, the introduction of the SSC failed to improve outcomes.10 Like all tools or processes intended to improve safety, ineffective implementation will reduce the desired benefits.

For example, there is appreciable evidence zithromax and alcohol showing that surgical teams skip or do not meaningfully respond to timeout checklist items.11 12 Even with a robust implementation, effectiveness can be weakened by contextual factors, failure of leadership or deficient safety culture.Despite numerous studies, gaps in the evidence to guide optimal checklist use persist. For example, we do not know whether checklist-based timeouts only decrease the occurrence of the undesirable events targeted by the checklist or, as many hypothesise, whether their use also facilitates teamwork and interprofessional communication. Although there is increasing guidance on how to optimally implement checklists at the local level, many questions remain.13 Moreover, we still do not understand the circumstances in which checklist use facilitates the detection, reporting and correction of errors.In this issue of the journal, Muensterer and colleagues14 describe a clever study in which the attending surgeon intentionally introduced errors during the preincision timeout while a medical student in zithromax and alcohol the operating theatre surreptitiously noted whether the error was detected and reported by one or more members of the surgical team.

If the error was not verbalised, the attending surgeon corrected the error before the timeout was complete. The single error embedded in each of zithromax and alcohol 120 of 1800 paediatric operations was randomly chosen from among wrong patient name, age, gender, allergy or surgical procedure, side or site. Overall, only about half (65.

54%) of zithromax and alcohol all errors were detected and reported by a team member prior to surgeon correction. Of these, errors were most commonly reported by the anaesthesiologist (64%) and almost never by residents in training (6%) or medical students (1%).This study also has important limitations. Because the investigators were leading the timeouts as part of a research study, adherence to all of zithromax and alcohol the checklist items was reportedly 100%.

Yet, few organisations consistently attain timeout adherence above 90%.11 Since you are less likely to catch an error if you do not address that item during the timeout, in institutions with lower adherence, the proportion of missed errors may be even higher.The authors, with input from their institutional review board, designed the study to be feasible and compliant with established human subjects protection principles. As such, the attending surgeon always corrected zithromax and alcohol the error after the anaesthesiologist’s component of the timeout but before the nurses’ component. By excluding the part of the timeout when the nurses address their checklist items (eg, instruments are sterile,) followed by a final opportunity as the timeout ends to note any errors or concerns, the study may have underestimated the rate of error reporting.Because the study did not query team members individually after the timeout, we also do not know how many errors were detected but not annunciated.

For example, recognised errors that were zithromax and alcohol attributed to ‘misspeaking’ and/or had no clinical significance may not have been verbally challenged. Moreover, as is discussed by the authors, there was an unequivocal hierarchy effect—individuals with the least ‘power’ (ie, low in hierarchy within the current healthcare culture) were the least likely to report the error.This study highlights two important safety relevant questions on which I will elaborate. First, why and how should we change healthcare zithromax and alcohol culture to facilitate ‘speaking up’?.

Second, how can we best design and implement checklists and other safety interventions to yield more consistent and sustained clinician behaviour change?. The continued problem of hierarchical culture in healthcareThe significant influence of hierarchy on the incidence of error reporting in Muensterer et al’s14 study is consistent with substantial prior evidence that lower hierarchy clinical providers are less likely to ‘speak up’, even when they are aware of major safety violations.15–17Failure of a subordinate copilot to challenge or speak up to the captain in the 1977 Tenerife disaster was the impetus for the aviation industry’s adoption of crew resource management (CRM) zithromax and alcohol. Healthcare team-training initiatives like the Agency for Healthcare Research and Quality’s TeamSTEPPS now include tools such as the ‘two-challenge rule’ and emphasise speaking up.18 Flattened hierarchies and reliance on expertise rather than seniority, especially during crisis or stress, are an integral component of high-reliability organisations.

In contrast, the persistent hierarchical culture zithromax and alcohol of healthcare is anathema to positive safety attitudes and behaviours. This is particularly problematic in operating theatres where surgeons view themselves as ‘captain of the ship’ and where uncivil behaviour is tolerated.19 The insidious effects of hierarchy will impair effectiveness of checklist use and predispose to safety issues in all aspects of routine and emergency care.20 While team-oriented training designed to enhance the ability of lower hierarchy clinicians to ‘speak up’ can be effective,21 22 evidence to guide the design and implementation of these interventions is still sparse. Single training exposures have zithromax and alcohol generally had limited effects,17 23 in part likely due to inadequate ‘potency’ to achieve the desired effect24 in a clinical environment contaminated by the hierarchical culture and in part because most interventions have focused on ‘assertiveness’ training for the less powerful members of the team rather than, or in addition to, sensitivity or receptivity training of the most powerful (eg, surgical attendings).17Discussions of power hierarchy to date have largely focused on clinicians’ professional roles (ie, nurse vs physician) and level of experience (eg, resident vs attending).

Even with two attending physicians, for example, a surgeon and anaesthesiologist, power dynamics can degrade communication and decrease team performance. In a multicentre study of experienced zithromax and alcohol anaesthesiologists managing simulated crisis events, the anaesthesiologists’ failure to challenge the surgeon to initiate life-saving interventions (eg, to open the abdomen in the presence of an enlarging retroperitoneal haematoma during laparoscopic surgery, or to halt surgery to cardiovert an unstable patient) was associated with lower overall scenario performance scores as determined by trained blinded anaesthesiologist video raters.25In fact, hierarchy is much more complex and this may explain in part the variable and generally weak results seen in ‘speaking up’ intervention studies to date. When considering hierarchical effects on communication assertiveness, one must also consider individual characteristics including gender, race/ethnicity, language, personal cultural background and personality, as well as the personality of those in higher power roles, microclimate factors of the team and care unit, and overall organisational culture.17 22 An interesting direction for future study is the facilitation of more positive communication (eg, expressions of gratitude or encouragement).26In a single-site intervention study to improve the quality of handovers from anaesthesia professionals to postanaesthesia care unit (PACU) nurses,27 simulation-based training emphasised specific dyadic communication behaviours—assertiveness for the nurses when their needs were not being met and ‘sensitivity’ (or receptiveness) for the anaesthesia professionals when the nurses raised concerns.

In poststudy interviews, this behavioural focus was considered an important contributor to the resulting sustained improvement in the quality of actual handovers zithromax and alcohol. As part of this study, we explicitly taught participants to CUSS. CUSS is a graduated approach to zithromax and alcohol facilitate speaking up.

The acronym stands for ‘I’m Concerned’, ‘I’m Uncomfortable’, ‘This is a Safety issue’ and ‘Stop!. €™. The intended learners were taught these ‘triggers’ for eliciting desired behaviours (ie, to stop what they are doing and have a conversation with the initiator) and this approach creates an environment where the initiating individual can receive support from others who overhear the conversation—‘Doctor, I hear that Maria is CUSSing at you?.

How can I help to resolve this situation?. €™ Such a graded assertiveness approach to ‘stop the line’, developed in other industries, is increasingly being used throughout healthcare.28Designing and implementing more effective safety tools and processesSSCs are just one tool used to advance overall perioperative system safety. Similarly, in commercial aviation, checklists are one tool used as part of CRM to assure operational safety.

CRM is a philosophy or construct that includes explicit values and principles, procedures supported by purpose-designed checklists and other tools, and regularly scheduled mandatory simulation-based training and assessment that together contribute to an existing safety culture in pilots and across the organisation.29 CRM and most of the existing aviation safety system were iteratively designed by pilots (the front-line workers) in collaboration with other stakeholders (including regulators). Healthcare must employ similar human-centred design approaches to re-engineer our safety systems.For commercial aviation to be completely safe, no planes would fly. Similarly, safety will never be the foremost system objective in healthcare.

The primary goal is to efficiently deliver cost-effective care. Instead, in any high-consequence industry, safety is a desirable by-product (an ‘emergent feature’) of a system designed to achieve primary operational goals. In healthcare, sick patients must be treated and there is inherent risk in doing so.30 Achieving societally acceptable levels of safety will stem from a deliberately designed system founded on a strong safety culture and truly committed leadership.With this as background, it is not surprising that so many hospitals struggle to garner reliable and sustained benefit from the use of checklists and other safety tools.

To understand what is required, I would like to draw parallels with anaesthesiology’s experience of implementing another type of checklist.The Food and Drug Administration Anesthesia Machine Pre-Use ChecklistThe earliest checklist used in healthcare to reduce adverse events is the anaesthesia equipment preuse checklist, developed in 1987 by the US Food and Drug Administration (FDA) in collaboration with the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.31 After more than three decades of use, lessons learnt from the use of the FDA checklist parallel more recent experiences with SSCs, and are instructive to a more general understanding of the role of safety tools in healthcare (see table 1).View this table:Table 1 Lessons learnt from 30 years of personal experience with and reflection about the Anesthesia Equipment Pre-Use Checklist*A checklist alone is insufficient to achieve optimal resultsHospitals that get the best results from an SSC implementation are often well-resourced organisations that already have safety-oriented committed leadership, a strong safety culture, educated and engaged front-line clinicians and an established track record of successfully implementing other safety interventions.32 That said, any hospital, given adequate commitment, resources and expertise, can implement an SSC or other substantive safety intervention successfully. In doing so, it will educate and engage its workers, improve its safety culture and set the stage for further safety and quality improvements.A multimodal approach to safety interventions is more effective. Hospitals that were able to successfully implement all three components of the SSC saw greater reductions in postoperative complications.33 Similarly, the combination of the SSC with a complementary approach that more fully addresses preoperative and postoperative issues, the Surgical Patient Safety System, was associated with better postoperative outcomes than use of the WHO SSC alone.34 The most effective interventions are those that are based on an integrated conceptual framework and follow human factor principles, especially when the safety goals are multiple or diverse.35In our PACU handover improvement project mentioned earlier,27 the multimodal intervention produced a fourfold improvement in observed clinician behaviours (ie, conduct of actual handovers) that was sustained for at least 3 years after the intervention ceased.

The project began by getting perioperative leadership buy-in, conducting observations of the current handover process and engaging front-line clinicians in all phases of study development. The criteria for an ‘acceptable handover’ were chosen by an independent team of clinicians. Front-line clinicians first completed a multimedia introductory webinar that included key principles and a knowledge assessment.

To attend the 2-hour simulation training session, both anaesthesia professionals and PACU nurses were relieved from regular clinical duties (a strong message that this was an organisational priority). A custom patient-specific electronic form was available at every bedside in the PACU to reinforce the training during actual handovers. Performance feedback was provided to individuals, units and perioperative leadership.

The number of components needed for successful safety interventions will depend on the behaviour change desired, the existing safety culture, current experience and expertise of the intended end users and the priority articulated by organisational leaders. Regardless, design and implementation must be based on a solid conceptual framework, consider the full life-cycle of the intervention (from conceptualisation to obsolescence) and employ human factors engineering and implementation science principles and tools.13ConclusionChecklists and other safety tools are potentially valuable tools to advance perioperative safety. However, when used in isolation or implemented incorrectly, checklists have significant limitations.

Safety initiatives that take a systems-oriented multimodal approach to design and implementation can, with organisational leadership and determination, produce both targeted and more general safety improvement.Ethics statementsPatient consent for publicationNot required.Many patients admitted to hospital require venous access to infuse medications and fluids. The most commonly used device, the peripheral venous catheter, ranges from 2.5 to 4.5 cm in length, and is typically used for less than 5 days. The midline, a relatively newer peripheral venous catheter, is up to 20 cm in length, but does not reach the central veins, and may be used for up to 2 weeks.

A peripherally inserted central venous catheter (PICC) is a longer catheter that is placed in one of the arm veins and extends to reach the central veins. The PICC is used for longer periods of time compared with peripheral intravenous devices, and initially gained popularity as a convenient vascular access device used in the outpatient and home settings. Its premise has been to provide access that lasts for weeks, that is fairly safe and easily manageable.

Patients often require central venous access when hospitalised, with more than half of patients in intensive care, and up to 20% in those cared for in the non-intensive care wards.1 Common indications for PICC use in the acute care setting include the requirement for multiple and frequent infusions (eg, antibiotics, parenteral nutrition), the administration of medications incompatible with peripheral infusion, invasive haemodynamic monitoring in critically ill patients, very poor venous access and frequent need for blood draws.2 Specially trained healthcare workers place PICCs, often nurses from a vascular access team (VAT), or interventional radiologists. The VAT is comprised of skilled nurses, with either medical/surgical, emergency department or intensive care unit backgrounds. Contrary to other healthcare workers that place PICCs, the VAT’s primary function is to place PICCs, and optimise the infusion delivery, through a safe and effective process.

Its scope includes assessment for need, peripheral and central device insertion, monitoring of use and removal.3In their study of five hospitals within the Veterans Administration (VA) healthcare systems in the USA, Krein et al4 underscore the importance of a formal VAT to formulate and implement explicit appropriateness criteria, ensure timely insertion and safe management and direct patient education around PICC use. They found that team structures supporting line placement vary across hospitals from a dedicated team, to individual nurses trained in placement, to hospitals where only interventional radiologists insert PICCs. The presence of a VAT was associated with more defined criteria for PICC use, but a recurrent theme was inadequate interdisciplinary dialogue.

Although qualitative data were gathered at five VA hospitals only, the study’s findings reflect the variation in PICC placement and use, whether in academic or community, small or large hospitals.An important factor in variation in the approach to PICC line placement and management is the availability of resources and expertise at the hospital site. For example, if healthcare workers have suboptimal skills to place peripheral venous catheters, including midlines,5 clinicians may resort to ordering more PICCs unnecessarily to fill that void. Furthermore, as revealed in Krein’s study, a hospital that does not have the expertise to learn about alternative devices, such as those with lower risks and shorter dwell times (eg, midlines), may resort to using more PICCs than necessary.

Similarly, hospitals without clinicians skilled or comfortable placing other central lines6 may rely more on using PICCs. In addition, the lack of an available VAT to place PICCs using uasound guidance may result in more referrals to interventional radiology for placement, potentially exposing the patient to avoidable radiation during fluoroscopy.7We propose an approach to improve the appropriate and safe use of PICCs by focusing on three elements that address the findings by Krein and colleagues. Establishing a structure powered by a VAT.

Anchoring a standardised process for line selection, insertion and care. And promoting adoption by engagement with the key stakeholders.Establishing a structure to support placement and management of PICCs depends on whether the number of devices placed is enough to support the creation of a dedicated vascular access programme. Leadership plays a critical role to invest the resources for a functional VAT, understanding the financial and quality benefits associated.8 Not realising its value, hospital leaders may view the VAT as a non-revenue-generating service, putting it at risk when considering cost reduction strategies.

The value of the VAT expands from mitigating preventable events (eg, deep venous thrombosis, ) to enhancing patient experience (eg, less attempts to place a peripheral device).9 In addition, better outcomes help curb the financial risks (eg, hospital-acquired condition penalties)8 and improve hospital ratings. The VAT’s role encompasses placing PICCs and guaranteeing the proper selection of the intravascular device and its appropriate use.2The second element involves standardising processes for line selection and care, regardless of who is taking care of the device. Implementing policies to address indications, placement and maintenance and using standardised kits help minimise variation.

The creation of policies should be achieved through a multidisciplinary approach with VAT, nurses and physicians. The VAT can act as the ‘gate keeper’ evaluating whether the reason for PICC placement is aligned with indications. In addition, the VAT plays a critical role supporting nurses’ competencies for venous catheter use (eg, aseptic access and maintenance, addressing complications and mitigating risk)10 to reduce mechanical11 and infectious complications.12 The VAT performs regular rounds to mitigate process gaps (eg, dressing site intactness) and to identify complications (eg, PICC site erythema or drainage, arm swelling), and provides timely feedback on clinical performance.

The VAT can also serve as subject matter experts to the ordering physicians for the appropriate device type, based on vessel size and indications for use, how many lumens, site selection and a de-escalation plan for the patient prior to discharge. It also provides services should a device-related complication occur (eg, clotting), and works with clinicians to remedy the issue and salvage the device, thereby preventing a patient from losing their vascular access and/or having to replace it.The last element, and perhaps most significant, is to enhance the adoption of best practices through a partnership with the key stakeholders. PICC-associated outcomes are not only owned by the VAT, rather it is the responsibility of the clinicians, physicians and nurses to achieve those goals (table 1).

Physicians are an essential stakeholder group to engage as they are the ones responsible for ordering the PICC. An identified physician champion who partners and empowers the VAT will help resolve any barriers and be a liaison with the local physician community.13 The ideal physician champion should have the respect of peers, understand process optimisation and promote quality improvement. They need to be well versed on the appropriate indications for PICC use, the associated complications and risks and alternatives to the device.

The physician champion engages the leaders of the key disciplines responsible for requesting a PICC, educating them on the appropriate indications for use, the outcomes associated with PICC use, inviting them to be partners and responding to any of their concerns.View this table:Table 1 Disciplines and their support to mitigate PICC harmWhat about the key physician disciplines to engage?. Physicians can play an active role in enhancing PICC use through avoiding the unnecessary use of infusions. The consultation of infectious diseases specialists for intravenous antibiotic use appropriateness has been associated with less PICC use and lower complications.14 Similarly, having a surgeon support the decision for whether enteral or parenteral nutrition is needed will help reduce unnecessary device use.15 Disciplines like hospitalists or general internists care for a large number of patients and often order PICCs for venous access,16 while nephrologists may advocate avoiding the use of PICCs in the chronic kidney disease population in an effort for vein preservation.17 In hospitals with teaching programmes, the VAT and its physician champion may educate physicians in training on device choice, placement and duration of use, and address with their faculty competencies for line management.18 Engaging these disciplines, elucidating the indications for appropriate use and providing feedback and local data on the potential harm ensure accountability and further attention to PICC safety.In summary, the PICC is one of the primary solutions to achieve vascular access.

With up to one in five patients at risk for developing complications,19 it is incumbent on us to ensure that these devices are properly used and maintained. Identifying and overcoming system barriers are key to delivering sustainable safe outcomes. As a first step, clinical and administrative leaders, realising the financial and quality benefits, need to support the structure reflected by the VAT to enhance PICC care.

Second, the VAT must partner with disciplines (particularly nursing) to promote and ensure adequate competencies for placement and maintenance. Finally, clinical disciplines caring for the patient should instil a collaborative environment for better decision-making on when central access is required, and what device provides the safest and most effective delivery of care.Ethics statementsPatient consent for publicationNot required..

Patients are more likely to experience preventable harm during perioperative care than in any other type of healthcare encounter.1 2 For several decades, a hallmark of surgical quality and safety has been the use of checklists to prevent errors (eg, wrong site surgery) and assure that key tasks have buy zithromax with prescription been or will be performed. The most widely used approach globally is the Surgical Safety buy zithromax with prescription Checklist (SSC) recommended by the WHO.3 It is divided into preinduction (or sign in, consisting of seven items performed by anaesthesia and nursing), preincision (timeout, 10 items performed by the entire team) and postsurgery (sign out, five items by the entire team).4 5 Most hospitals in the developed world perform the SSC or an equivalent timeout prior to surgical incision. However, preinduction briefings, and postcase debriefings in particular, are much less commonly performed.6 7There are widely disseminated arguments recommending the use of checklists in healthcare8 but also recognised limitations.9 Checklist-based preincision timeouts appear to improve surgical outcomes in many settings,4 5 yet, in other hospitals, the introduction of the SSC failed to improve outcomes.10 Like all tools or processes intended to improve safety, ineffective implementation will reduce the desired benefits.

For example, there is appreciable evidence showing that surgical teams skip or do not meaningfully respond to timeout checklist items.11 12 Even with a robust implementation, effectiveness can be weakened by contextual factors, failure of leadership buy zithromax with prescription or deficient safety culture.Despite numerous studies, gaps in the evidence to guide optimal checklist use persist. For example, we do not know whether checklist-based timeouts only decrease the occurrence of the undesirable events targeted by the checklist or, as many hypothesise, whether their use also facilitates teamwork and interprofessional communication. Although there is increasing guidance on how to optimally implement checklists at the local level, many questions remain.13 Moreover, we still do buy zithromax with prescription not understand the circumstances in which checklist use facilitates the detection, reporting and correction of errors.In this issue of the journal, Muensterer and colleagues14 describe a clever study in which the attending surgeon intentionally introduced errors during the preincision timeout while a medical student in the operating theatre surreptitiously noted whether the error was detected and reported by one or more members of the surgical team.

If the error was not verbalised, the attending surgeon corrected the error before the timeout was complete. The single error embedded in each of buy zithromax with prescription 120 of 1800 paediatric operations was randomly chosen from among wrong patient name, age, gender, allergy or surgical procedure, side or site. Overall, only about half (65.

54%) of all errors were detected buy zithromax with prescription and reported by a team member prior to surgeon correction. Of these, errors were most commonly reported by the anaesthesiologist (64%) and almost never by residents in training (6%) or medical students (1%).This study also has important limitations. Because the investigators were leading the timeouts as part of a research study, adherence to all of the checklist buy zithromax with prescription items was reportedly 100%.

Yet, few organisations consistently attain timeout adherence above 90%.11 Since you are less likely to catch an error if you do not address that item during the timeout, in institutions with lower adherence, the proportion of missed errors may be even higher.The authors, with input from their institutional review board, designed the study to be feasible and compliant with established human subjects protection principles. As such, the buy zithromax with prescription attending surgeon always corrected the error after the anaesthesiologist’s component of the timeout but before the nurses’ component. By excluding the part of the timeout when the nurses address their checklist items (eg, instruments are sterile,) followed by a final opportunity as the timeout ends to note any errors or concerns, the study may have underestimated the rate of error reporting.Because the study did not query team members individually after the timeout, we also do not know how many errors were detected but not annunciated.

For example, recognised errors that were attributed to ‘misspeaking’ buy zithromax with prescription and/or had no clinical significance may not have been verbally challenged. Moreover, as is discussed by the authors, there was an unequivocal hierarchy effect—individuals with the least ‘power’ (ie, low in hierarchy within the current healthcare culture) were the least likely to report the error.This study highlights two important safety relevant questions on which I will elaborate. First, why and how should we change healthcare culture to facilitate ‘speaking up’? buy zithromax with prescription.

Second, how can we best design and implement checklists and other safety interventions to yield more consistent and sustained clinician behaviour change?. The continued problem of hierarchical culture in healthcareThe significant influence of hierarchy on the incidence of error reporting in Muensterer et al’s14 study is consistent with substantial prior evidence that lower hierarchy clinical providers are less likely to ‘speak up’, even buy zithromax with prescription when they are aware of major safety violations.15–17Failure of a subordinate copilot to challenge or speak up to the captain in the 1977 Tenerife disaster was the impetus for the aviation industry’s adoption of crew resource management (CRM). Healthcare team-training initiatives like the Agency for Healthcare Research and Quality’s TeamSTEPPS now include tools such as the ‘two-challenge rule’ and emphasise speaking up.18 Flattened hierarchies and reliance on expertise rather than seniority, especially during crisis or stress, are an integral component of high-reliability organisations.

In contrast, the persistent hierarchical culture of healthcare is buy zithromax with prescription anathema to positive safety attitudes and behaviours. This is particularly problematic in operating theatres where surgeons view themselves as ‘captain of the ship’ and where uncivil behaviour is tolerated.19 The insidious effects of hierarchy will impair effectiveness of checklist use and predispose to safety issues in all aspects of routine and emergency care.20 While team-oriented training designed to enhance the ability of lower hierarchy clinicians to ‘speak up’ can be effective,21 22 evidence to guide the design and implementation of these interventions is still sparse. Single training exposures have generally had limited effects,17 23 in part likely due to inadequate ‘potency’ to achieve the desired effect24 in a clinical environment contaminated by the hierarchical culture and in part because most interventions have focused on ‘assertiveness’ training for the less powerful members of the team rather than, or in addition to, sensitivity or receptivity training of the most powerful (eg, surgical attendings).17Discussions of power hierarchy to date buy zithromax with prescription have largely focused on clinicians’ professional roles (ie, nurse vs physician) and level of experience (eg, resident vs attending).

Even with two attending physicians, for example, a surgeon and anaesthesiologist, power dynamics can degrade communication and decrease team performance. In a multicentre study of experienced anaesthesiologists managing simulated crisis events, the anaesthesiologists’ failure to challenge the surgeon to initiate life-saving interventions (eg, to open the abdomen in the presence of an enlarging retroperitoneal haematoma during laparoscopic surgery, or to halt surgery to cardiovert an unstable patient) was buy zithromax with prescription associated with lower overall scenario performance scores as determined by trained blinded anaesthesiologist video raters.25In fact, hierarchy is much more complex and this may explain in part the variable and generally weak results seen in ‘speaking up’ intervention studies to date. When considering hierarchical effects on communication assertiveness, one must also consider individual characteristics including gender, race/ethnicity, language, personal cultural background and personality, as well as the personality of those in higher power roles, microclimate factors of the team and care unit, and overall organisational culture.17 22 An interesting direction for future study is the facilitation of more positive communication (eg, expressions of gratitude or encouragement).26In a single-site intervention study to improve the quality of handovers from anaesthesia professionals to postanaesthesia care unit (PACU) nurses,27 simulation-based training emphasised specific dyadic communication behaviours—assertiveness for the nurses when their needs were not being met and ‘sensitivity’ (or receptiveness) for the anaesthesia professionals when the nurses raised concerns.

In poststudy interviews, this behavioural focus was considered an important contributor to the resulting sustained improvement in the quality buy zithromax with prescription of actual handovers. As part of this study, we explicitly taught participants to CUSS. CUSS is a graduated approach buy zithromax with prescription to facilitate speaking up.

The acronym stands for ‘I’m Concerned’, ‘I’m Uncomfortable’, ‘This is a Safety issue’ and ‘Stop!. €™. The intended learners were taught these ‘triggers’ for eliciting desired behaviours (ie, to stop what they are doing and have a conversation with the initiator) and this approach creates an environment where the initiating individual can receive support from others who overhear the conversation—‘Doctor, I hear that Maria is CUSSing at you?.

How can I help to resolve this situation?. €™ Such a graded assertiveness approach to ‘stop the line’, developed in other industries, is increasingly being used throughout healthcare.28Designing and implementing more effective safety tools and processesSSCs are just one tool used to advance overall perioperative system safety. Similarly, in commercial aviation, checklists are one tool used as part of CRM to assure operational safety.

CRM is a philosophy or construct that includes explicit values and principles, procedures supported by purpose-designed checklists and other tools, and regularly scheduled mandatory simulation-based training and assessment that together contribute to an existing safety culture in pilots and across the organisation.29 CRM and most of the existing aviation safety system were iteratively designed by pilots (the front-line workers) in collaboration with other stakeholders (including regulators). Healthcare must employ similar human-centred design approaches to re-engineer our safety systems.For commercial aviation to be completely safe, no planes would fly. Similarly, safety will never be the foremost system objective in healthcare.

The primary goal is to efficiently deliver cost-effective care. Instead, in any high-consequence industry, safety is a desirable by-product (an ‘emergent feature’) of a system designed to achieve primary operational goals. In healthcare, sick patients must be treated and there is inherent risk in doing so.30 Achieving societally acceptable levels of safety will stem from a deliberately designed system founded on a strong safety culture and truly committed leadership.With this as background, it is not surprising that so many hospitals struggle to garner reliable and sustained benefit from the use of checklists and other safety tools.

To understand what is required, I would like to draw parallels with anaesthesiology’s experience of implementing another type of checklist.The Food and Drug Administration Anesthesia Machine Pre-Use ChecklistThe earliest checklist used in healthcare to reduce adverse events is the anaesthesia equipment preuse checklist, developed in 1987 by the US Food and Drug Administration (FDA) in collaboration with the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.31 After more than three decades of use, lessons learnt from the use of the FDA checklist parallel more recent experiences with SSCs, and are instructive to a more general understanding of the role of safety tools in healthcare (see table 1).View this table:Table 1 Lessons learnt from 30 years of personal experience with and reflection about the Anesthesia Equipment Pre-Use Checklist*A checklist alone is insufficient to achieve optimal resultsHospitals that get the best results from an SSC implementation are often well-resourced organisations that already have safety-oriented committed leadership, a strong safety culture, educated and engaged front-line clinicians and an established track record of successfully implementing other safety interventions.32 That said, any hospital, given adequate commitment, resources and expertise, can implement an SSC or other substantive safety intervention successfully. In doing so, it will educate and engage its workers, improve its safety culture and set the stage for further safety and quality improvements.A multimodal approach to safety interventions is more effective. Hospitals that were able to successfully implement all three components of the SSC saw greater reductions in postoperative complications.33 Similarly, the combination of the SSC with a complementary approach that more fully addresses preoperative and postoperative issues, the Surgical Patient Safety System, was associated with better postoperative outcomes than use of the WHO SSC alone.34 The most effective interventions are those that are based on an integrated conceptual framework and follow human factor principles, especially when the safety goals are multiple or diverse.35In our PACU handover improvement project mentioned earlier,27 the multimodal intervention produced a fourfold improvement in observed clinician behaviours (ie, conduct of actual handovers) that was sustained for at least 3 years after the intervention ceased.

The project began by getting perioperative leadership buy-in, conducting observations of the current handover process and engaging front-line clinicians in all phases of study development. The criteria for an ‘acceptable handover’ were chosen by an independent team of clinicians. Front-line clinicians first completed a multimedia introductory webinar that included key principles and a knowledge assessment.

To attend the 2-hour simulation training session, both anaesthesia professionals and PACU nurses were relieved from regular clinical duties (a strong message that this was an organisational priority). A custom patient-specific electronic form was available at every bedside in the PACU to reinforce the training during actual handovers. Performance feedback was provided to individuals, units and perioperative leadership.

The number of components needed for successful safety interventions will depend on the behaviour change desired, the existing safety culture, current experience and expertise of the intended end users and the priority articulated by organisational leaders. Regardless, design and implementation must be based on a solid conceptual framework, consider the full life-cycle of the intervention (from conceptualisation to obsolescence) and employ human factors engineering and implementation science principles and tools.13ConclusionChecklists and other safety tools are potentially valuable tools to advance perioperative safety. However, when used in isolation or implemented incorrectly, checklists have significant limitations.

Safety initiatives that take a systems-oriented multimodal approach to design and implementation can, with organisational leadership and determination, produce both targeted and more general safety improvement.Ethics statementsPatient consent for publicationNot required.Many patients admitted to hospital require venous access to infuse medications and fluids. The most commonly used device, the peripheral venous catheter, ranges from 2.5 to 4.5 cm in length, and is typically used for less than 5 days. The midline, a relatively newer peripheral venous catheter, is up to 20 cm in length, but does not reach the central veins, and may be used for up to 2 weeks.

A peripherally inserted central venous catheter (PICC) is a longer catheter that is placed in one of the arm veins and extends to reach the central veins. The PICC is used for longer periods of time compared with peripheral intravenous devices, and initially gained popularity as a convenient vascular access device used in the outpatient and home settings. Its premise has been to provide access that lasts for weeks, that is fairly safe and easily manageable.

Patients often require central venous access when hospitalised, with more than half of patients in intensive care, and up to 20% in those cared for in the non-intensive care wards.1 Common indications for PICC use in the acute care setting include the requirement for multiple and frequent infusions (eg, antibiotics, parenteral nutrition), the administration of medications incompatible with peripheral infusion, invasive haemodynamic monitoring in critically ill patients, very poor venous access and frequent need for blood draws.2 Specially trained healthcare workers place PICCs, often nurses from a vascular access team (VAT), or interventional radiologists. The VAT is comprised of skilled nurses, with either medical/surgical, emergency department or intensive care unit backgrounds. Contrary to other healthcare workers that place PICCs, the VAT’s primary function is to place PICCs, and optimise the infusion delivery, through a safe and effective process.

Its scope includes assessment for need, peripheral and central device insertion, monitoring of use and removal.3In their study of five hospitals within the Veterans Administration (VA) healthcare systems in the USA, Krein et al4 underscore the importance of a formal VAT to formulate and implement explicit appropriateness criteria, ensure timely insertion and safe management and direct patient education around PICC use. They found that team structures supporting line placement vary across hospitals from a dedicated team, to individual nurses trained in placement, to hospitals where only interventional radiologists insert PICCs. The presence of a VAT was associated with more defined criteria for PICC use, but a recurrent theme was inadequate interdisciplinary dialogue.

Although qualitative data were gathered at five VA hospitals only, the study’s findings reflect the variation in PICC placement and use, whether in academic or community, small or large hospitals.An important factor in variation in the approach to PICC line placement and management is the availability of resources and expertise at the hospital site. For example, if healthcare workers have suboptimal skills to place peripheral venous catheters, including midlines,5 clinicians may resort to ordering more PICCs unnecessarily to fill that void. Furthermore, as revealed in Krein’s study, a hospital that does not have the expertise to learn about alternative devices, such as those with lower risks and shorter dwell times (eg, midlines), may resort to using more PICCs than necessary.

Similarly, hospitals without clinicians skilled or comfortable placing other central lines6 may rely more on using PICCs. In addition, the lack of an available VAT to place PICCs using uasound guidance may result in more referrals to interventional radiology for placement, potentially exposing the patient to avoidable radiation during fluoroscopy.7We propose an approach to improve the appropriate and safe use of PICCs by focusing on three elements that address the findings by Krein and colleagues. Establishing a structure powered by a VAT.

Anchoring a standardised process for line selection, insertion and care. And promoting adoption by engagement with the key stakeholders.Establishing a structure to support placement and management of PICCs depends on whether the number of devices placed is enough to support the creation of a dedicated vascular access programme. Leadership plays a critical role to invest the resources for a functional VAT, understanding the financial and quality benefits associated.8 Not realising its value, hospital leaders may view the VAT as a non-revenue-generating service, putting it at risk when considering cost reduction strategies.

The value of the VAT expands from mitigating preventable events (eg, deep venous thrombosis, ) to enhancing patient experience (eg, less attempts to place a peripheral device).9 In addition, better outcomes help curb the financial risks (eg, hospital-acquired condition penalties)8 and improve hospital ratings. The VAT’s role encompasses placing PICCs and guaranteeing the proper selection of the intravascular device and its appropriate use.2The second element involves standardising processes for line selection and care, regardless of who is taking care of the device. Implementing policies to address indications, placement and maintenance and using standardised kits help minimise variation.

The creation of policies should be achieved through a multidisciplinary approach with VAT, nurses and physicians. The VAT can act as the ‘gate keeper’ evaluating whether the reason for PICC placement is aligned with indications. In addition, the VAT plays a critical role supporting nurses’ competencies for venous catheter use (eg, aseptic access and maintenance, addressing complications and mitigating risk)10 to reduce mechanical11 and infectious complications.12 The VAT performs regular rounds to mitigate process gaps (eg, dressing site intactness) and to identify complications (eg, PICC site erythema or drainage, arm swelling), and provides timely feedback on clinical performance.

The VAT can also serve as subject matter experts to the ordering physicians for the appropriate device type, based on vessel size and indications for use, how many lumens, site selection and a de-escalation plan for the patient prior to discharge. It also provides services should a device-related complication occur (eg, clotting), and works with clinicians to remedy the issue and salvage the device, thereby preventing a patient from losing their vascular access and/or having to replace it.The last element, and perhaps most significant, is to enhance the adoption of best practices through a partnership with the key stakeholders. PICC-associated outcomes are not only owned by the VAT, rather it is the responsibility of the clinicians, physicians and nurses to achieve those goals (table 1).

Physicians are an essential stakeholder group to engage as they are the ones responsible for ordering the PICC. An identified physician champion who partners and empowers the VAT will help resolve any barriers and be a liaison with the local physician community.13 The ideal physician champion should have the respect of peers, understand process optimisation and promote quality improvement. They need to be well versed on the appropriate indications for PICC use, the associated complications and risks and alternatives to the device.

The physician champion engages the leaders of the key disciplines responsible for requesting a PICC, educating them on the appropriate indications for use, the outcomes associated with PICC use, inviting them to be partners and responding to any of their concerns.View this table:Table 1 Disciplines and their support to mitigate PICC harmWhat about the key physician disciplines to engage?. Physicians can play an active role in enhancing PICC use through avoiding the unnecessary use of infusions. The consultation of infectious diseases specialists for intravenous antibiotic use appropriateness has been associated with less PICC use and lower complications.14 Similarly, having a surgeon support the decision for whether enteral or parenteral nutrition is needed will help reduce unnecessary device use.15 Disciplines like hospitalists or general internists care for a large number of patients and often order PICCs for venous access,16 while nephrologists may advocate avoiding the use of PICCs in the chronic kidney disease population in an effort for vein preservation.17 In hospitals with teaching programmes, the VAT and its physician champion may educate physicians in training on device choice, placement and duration of use, and address with their faculty competencies for line management.18 Engaging these disciplines, elucidating the indications for appropriate use and providing feedback and local data on the potential harm ensure accountability and further attention to PICC safety.In summary, the PICC is one of the primary solutions to achieve vascular access.

With up to one in five patients at risk for developing complications,19 it is incumbent on us to ensure that these devices are properly used and maintained. Identifying and overcoming system barriers are key to delivering sustainable safe outcomes. As a first step, clinical and administrative leaders, realising the financial and quality benefits, need to support the structure reflected by the VAT to enhance PICC care.

Second, the VAT must partner with disciplines (particularly nursing) to promote and ensure adequate competencies for placement and maintenance. Finally, clinical disciplines caring for the patient should instil a collaborative environment for better decision-making on when central access is required, and what device provides the safest and most effective delivery of care.Ethics statementsPatient consent for publicationNot required..

Does zithromax cure uti

Citizen Science Salon is a partnership does zithromax cure uti between Discover and SciStarter.org. The future of individualized medicine may depend on an army of one million volunteers. And scientists want you to get does zithromax cure uti involved. Researchers with the National Institutes of Health are recruiting citizen scientists to enlist in a study of unprecedented scope and depth. The program, called All of Us, promises to take personal data does zithromax cure uti from a diverse cross-section of volunteers and turn it into groundbreaking insights about the complex roles our genes, lifestyles and environments play in our health.

€œBy studying people longitudinally over time, we’re able to see diseases arise,” says Sheri Schully, the All of Us program’s acting chief medical and scientific officer.In return for completing surveys and offering up biological samples, the program will send participants personalized results about everything from their ancestry to their genetic predisposition for certain diseases. It’s also free to does zithromax cure uti join. And last month, All of Us sent participants back the first set of genetic results. Take Part does zithromax cure uti. Join the National Institutes of Health’s All of Us Program‘The Right Treatment at the Right Time’In January of 2015, President Barack Obama stood in front of the country during the State of the Union and offered a bold vision for accelerating research.

A research program then called the Precision Medicine Initiative would recruit at least one million people from across the United States and study them, leading to rapid advances in drug discovery and customized treatments for patients based on personal data.“I want the country that eliminated polio and mapped the human genome to lead a new era of medicine — one that delivers the right treatment at the right time,” Obama told the nation. He added that the project could bring us closer to curing diseases like cancer and diabetes, does zithromax cure uti while offering people access to personal information that could help them stay healthy. Five years later, NIH has already enrolled hundreds of thousands of participants, and last month, those volunteers started receiving the first results from their genetic samples. But the does zithromax cure uti project still has a long way to go to reach one million people. And with the approach of Citizen Science Month in April, they’re calling on volunteers from around the country to get involved in not only All of Us, but also a group of featured citizen science projects and events produced with global and national partners like SciStarter, Arizona State University, Science Friday and National Geographic.

€œThe power of citizen science is the massive impact that is made by everyday people, individually and collectively,” says Darlene Cavalier, founder of SciStarter and a professor of practice at the School for the Future does zithromax cure uti of Innovation in Society at Arizona State University. €œOnline and virtual events during Citizen Science Month will help introduce thousands of people to citizen science and help them find ways to act upon issues they are curious or concerned about, individually or as a community.”The NIH has now enrolled hundreds of thousands of volunteers, and participants have now started to receive the first results from their genetic samples. (Credit. All of Us/NIH)Kickstarting Precision MedicineParticipants with All of Us start by taking a survey about their lifestyle, family history and more. Then, they can agree to share their health records with researchers and offer up blood and urine samples, as well as physical measurements like height, weight and heart rate.

Participants can even share daily personal health data from smart devices like a Fitbit. The data is stripped of all personal identifiers, but this granular level of detail, when monitored over time, can give researchers a real-time look at the ways diseases arise. It’s all part of what researchers call precision medicine. Precision medicine stands in contrast to the current one-size-fits-all approach to disease treatment used by doctors around the world. But if medical professionals could better understand their patients at an individual level, doctors could predict the best possible treatment for a particular disease.

€œ[Precision medicine] is understanding what a person is experiencing and what’s going on inside and outside their body in relation to disease,” Schully says. €œIt’s really evaluating a person holistically. What are they eating?. What’s their lifestyle like?. And what kind of job do they have?.

Precision medicine to us doesn't just mean targeted treatment, it means targeted prevention.”A Holistic Look at buy antibiotics’s ImpactResearchers are already studying the database. And it’s even giving them new insights into buy antibiotics. Back before the zithromax started, All of Us was enrolling about 3,000 people every week. Eventually, the antibiotics forced them to temporarily pause that enrollment. But when researchers went back and studied the 24,000 blood samples they’d collected between late 2019 and early 2020, they found some surprises.

At the time, researchers didn’t know buy antibiotics was spreading in communities around the country. Yet a significant number of the blood samples All of Us collected showed signs of buy antibiotics antibodies, meaning that the disease was spreading in many states well before health officials realized. Researchers with the project recently published those results in the New England Journal of Medicine. Meanwhile, All of Us has also been asking participants about buy antibiotics symptoms via a survey sent out last May. The survey included broad buy antibiotics-related questions, including inquiries about people’s mental well-being and whether they’d lost their job.

The initial results of that work were released to researchers in December, and they offer a detailed look at how buy antibiotics is affecting families and communities. Among other things, All of Us heard back that people are suffering long-term heart defects and breathing effects, problems that medical professionals have seen elsewhere. Armed with this data, the program hopes they can monitor these lingering health problems over time. It’s a sort of holistic look that has been part of the program’s mission since the start. An All of Us staff member measures a participant’s height.

(Credit. All of Us/NH)A Truly Diverse DatasetOther large projects have collected genetic databases aimed at advancing disease diagnosis and treatment, but All of Us stands out for its staggering size and its mission. Researchers aren’t just studying people’s DNA, All of Us is putting its participants at the epicenter of their program. The community helps make decisions, with volunteers even sitting on governing boards, deciding how data can be used. If that aim wasn’t lofty enough, All of Us is also after a diverse cross-section of the American public, including people from diverse ethnic and economic backgrounds, as well as a mix of rural and urban residents.

That’s something other studies have long struggled with. The project’s leaders say that most of modern medicine has been biased toward studying people with European ancestry, leaving other segments of the population underrepresented in research. And as an incentive to get one million people involved, the project will also share genetic information with its participants, including things like ancestry and whether they’re at an increased risk for disease. €œNever before have we really put the participant at the center of the study and really valued the back and forth, giving them what matters to them,” Schully says. €œWe really want to be a catalyst for change in how things are done in science.”Insights into Disease PredispositionIn December, they started returning those first individual ancestry and genetic trait results to volunteers.

€œParticipants are our most important partners in this effort, and we know many of them are eager to get their genetic results and learn about the science they’re making possible,” All of Us chief executive officer Josh Denny said in an announcement. €œWe’re working to provide that valuable information in a responsible way.”Later this year, All of Us plans to start telling interested participants about how their DNA could affect their body’s response to certain drugs, or even about genes that could increase their risk of a variety of diseases like cancer. Those results will be paired with counseling to help people understand the implications of their DNA profile. And, like everything with the program, the personal data will be tightly protected. €œIt's a huge milestone for our project,” Schully says.

€œReturning results on this level has never been done before.”And people who get involved throughout the year — including during Citizen Science Month — can look forward to learning more about their family’s ancestry and genetic predispositions. Citizen Science Month is all about turning curiosity into impact, and what better way than with a project that could help you better understand yourself while helping researchers better understand human health at large?. You can join the All of Us program by visiting joinallofus.org/nlm.Your digestive system plays host to a mind-boggling 100 trillion microbes — microscopic pinch-hitters that allow you to absorb energy from your food and churn out compounds like serotonin, which affect your mental well-being. While some of these microbes take up residence in your gut from birth, others emerge or wane depending on the lifestyle choices you make.New research suggests that if you exercise, take antidepressants or use cannabis, your gut-bacterial balance may shift profoundly. But scientists still face a so-called black box conundrum.

They’re not always sure what biological processes cause these microbial shifts or how the shifts affect other body functions. Planned larger-scale studies promise to deepen experts’ understanding of the bacterial changes your daily habits usher in, as well as the long-term health implications.Exercise to ColonizeNot only does regular exercise boost your overall well-being, it also swells the ranks of gut bacteria that promote a healthy metabolism, says Satu Pekkala, a bacteriologist at Finland’s University of Jyväskylä. In a 2018 study, Pekkala and his colleagues recruited 17 overweight women who participated in three endurance exercise sessions each week for six weeks. The women rode an exercise bike that adjusted workout intensity so that riders stayed at about 85% of their maximum heart rate.The team had participants collect stool samples before and after the six-week training period, then sequenced DNA from these samples to detect changes in the women’s gut bacteria. After the training regimen, the women had higher levels of gut bacteria from the genus Akkermansia — a bacterial group tied to improved metabolic function — than they had before.

They also had lower levels of Proteobacteria, a genus linked to inflammation in the body.Pekkala has secured approval to conduct another study that examines bacteria-produced molecules to explore what biological role Akkermansia and Proteobacteria might play in the gut — and how Akkermansia abundance might affect the body’s ability to burn fat stores. €œNot everybody loses fat mass even if they exercise,” Pekkala says. €œIt’s important to know how the metabolic functions [of gut bacteria] affect fat loss.” The Cannabis ConnectionPlenty of research shows that marijuana compounds reduce disease-related inflammation, and, according to a 2019 study, these compounds’ effects on gut bacteria might explain some of their anti-inflammatory properties.In exploring possible treatments for Multiple Sclerosis (MS), University of South Carolina researchers treated mice that had a similar condition with molecules like delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD).The mice showed fewer signs of inflammation after the cannabis treatment — and an analysis showed that gut-bacterial shifts were likely responsible, at least in part. Before treatment, the mice had high levels of the bacterial species Akkermansia muciniphila, which produces compounds called lipopolysaccharides that are linked to brain inflammation. After treatment, mice had lower levels of this species in their guts and lower levels of lipopolysaccharides in their brains.

Future studies may show whether cannabis can spur similar gut-bacterial and brain changes in humans with MS.Gut CheckAn antidepressant that millions of Americans take may alter their gut-bacterial mix as well as their mental outlook, University of California-Los Angeles researchers say. In a 2019 study, the UCLA team added fluoxetine (Prozac) to a tube with a common gut bacterial species called Turicibacter sanguinis, which normally tells intestinal cells to produce more serotonin — a neurotransmitter that affects mood. After the team put in fluoxetine, the bacteria transported less serotonin than it had before. Further experiments showed that mice dosed with fluoxetine had lower gut levels of Turicibacter than other mice.These results suggest that Turicibacter populations fluctuate in the presence of drugs like fluoxetine that modify serotonin levels. Next, the UCLA team plans to tease out the molecular mechanisms that reveal just how fluoxetine affects certain gut bacteria — and how that might influence the way the drug works in the brain and the rest of the body.

€œThere’s variation in how effective fluoxetine is for different people,” says UCLA microbiologist Jonathan Lynch. €œSomething like the interaction with the microbiome might be mediating that.”Future studies of these gut-brain interactions could allow a personalized-medicine approach that identifies people who are good candidates to respond to drugs like fluoxetine, Lynch says. Someday, based on your gut microbe profile, doctors might be able to tell you which antidepressants will work for you and which ones you shouldn’t even try.This article contains affiliate links to products. Discover may receive a commission for purchases made through these links. CBD enthusiasts know that the best CBD oil is made with naturally grown hemp.

It has accurate labeling, comes with a certificate of analysis, and the companies that make it are absolutely transparent.But let’s face it, we all need a little something extra after the year that we’ve had. The changes and challenges that came with 2020 mean that we are all looking for companies and products that offer more than just what it takes to get by. CBD oils are no exception. We know you want CBD oils that are made by companies that aim to support you in your mission to thrive. Not just survive.In addition to creating the best CBD oils you can find, the companies mentioned here are doing their part to make the world a better place.This year, we have selected CBD oils that are made by great, tried-and-true classic companies that you have probably heard of over and over again.

However, we are also focusing on including oils from companies that are doing great things. You may have never heard of some of the CBD oils listed here, but you will by the end of 2021. They are quickly rising to the top, working hard to give back to their communities and the environment, and many are owed by women and people of color. When you purchase one of the best 25 CBD oils for 2021, you are making a sound investment in supporting your wellness and the world around you. Every CBD oil listed here is made with pure quality ingredients, and they are backed by the integrity of companies that care.We’ve also made sure to include some excellent bargains here too, because who doesn’t love a great deal?.

You don’t have to break the bank to get high-quality CBD oil, you just need to know where to shop.Best Overall CBD Oil1. Penguin’s Broad Spectrum CBD OilExcellent ValuePenguin CBD oil may be one of the newer kids on the block, but this company wins our pick for best all-around CBD oil because of its commitment to your wellness and the environment.Fortunately, the care for these two things goes hand-in-hand, with sustainable farming practices that result in a CBD oil that you can count on every single day.Need a morning boost?. Penguin CBD’s broad-spectrum CBD has all the benefits of additional cannabinoids found in the hemp plant, with all the THC removed.Tired of the typical mid-afternoon blahs?. Give yourself a lift with Penguin’s citrus-flavored CBD. Ready to relax after a long day?.

Squeeze a dropperful of Penguin’s mint-flavored CBD into your chamomile tea to unwind before bed.The variety of flavors and concentrations is one of our favorite things about Penguin’s CBD oil. Choose from five flavors and four strengths at prices you can afford. If you need help choosing your next purchase, Penguin’s customer support line has real people on the other end. Just send them an email, and they are ready to make sure you are totally confident and satisfied with your selection.The cheerful packaging and adorable mascot are just a hint at what’s to come when you try Penguin CBD.In addition to everything Penguin does to support the environment and your wellness, the company also supports our military personnel by offering a discount on the products they need to maintain their health. Penguin CBD is a company that cares about everyone equally, which is why it’s at the top of our list for 2021.Best Full-Spectrum CBD Oil2.

Verma FarmsOne of the top brands in CBD out, Verma Farms has been winning awards left and right for the past couple of years, with 2021 as no exception.What Verma does well provides a solution that helps set the standard for how CBD oils should go. Starting out with very intent-driven oils like Focus, Chill, and Boost, they began diversifying their lineup to include more fruit-flavored varieties as well, such as Lemon Lime, Pineapple, Strawberry, Watermelon, Mango, and Peach. As all of them use natural, vegan ingredients, they’ve stripped down their offering to host only the standards but doing it well, sourcing all their oil’s materials from inside the US.An overall great brand, Verma Farms is an easy number one for any CBD fan out there, no matter how much they’ve done.3. NuLeaf Naturals Full-Spectrum CBD OilYou may have never heard of NuLeaf Naturals before, but this company has been perfecting its full-spectrum CBD oil since the early days. NuLeaf makes only one concentration of CBD oil, and it is not flavored.

However, you can order it in a number of different sizes. You no longer have to worry about running out before the month is out when you can order bottles as large as 3.38 ounces!. NuLeaf takes the importance of wellness seriously, and it makes sure that those who need the support of CBD most get it. It offers deep discounts to frontline workers, military personnel, teachers, students, people on long-term disability, lower-income households and more. 4.

Charlotte’s Web Original FormulaExcellent ValueA classic CBD oil that helped fuel the beginning of an industry, Charlotte’s Web’s Original Formula CBD oil was formulated out of a passion to help others. Every CBD enthusiast should give this whole-plant formula a try. Gently extracted with alcohol, the original formula intends to keep all the healthy properties in the hemp plant and packs them into a full spectrum oil you can take every day.We love that Charlotte’s Web keeps getting better, too. The company just earned a B Corp certification, meaning it is recognized as a leader in its concern for its customers, its employees, the environment, and its level of transparency. 5.

Spruce Maximum Potency CBD TinctureWe love Spruce’s Maximum Potency 2,400 mg Tincture because it is made by a family-owned company that cares deeply about helping its customers maintain their health and wellness.You’ll sometimes even see the Spencer family packing shipments themselves, working hard to get the CBD you love delivered to your door as quickly as possible.The hemp used is grown on family-owned farms, and is extracted using Kentucky moonshine (don’t worry, all traces are gone by the time the finished product is bottled). The result is a formula Spruce is proud of.The company boasts a full-spectrum CBD oil that has a high concentration of all the beneficial cannabinoids found in hemp, with a very low concentration of THC.Best CBD Oil for Giving Back to the Community6. Endoca THC-Free Chocolate Mint CBD OilExcellent ValueThis is one of Endoca's first flavored CBD oils, and it has one of the highest concentrations available today. Free of THC, the super-strength CBD oil is also super affordable. It has 5 mg of CBD per drop, and 150 mg per dropperful.The Endoca Foundation was developed in order to spread its mission for wellness around the world, and people with disabilities and those who live in low-income households can now benefit from a 50 percent discount on CBD products that help maintain your health.In addition to the discount program for customers in need, Endoca has established programs that are committed to helping people obtain nutritional wellness.7.

Lazarus Naturals 1:1 CBG. CBD TinctureExcellent ValueLazarus Naturals is an employee-owned company that is committed to keeping the benefits of hemp affordable, effective, safe, and all-natural.When you’re looking for an energizing kick, this CBG/CBD tincture is just the thing you need. CBG is another cannabinoid found in hemp and combining it with CBD is thought to have additional wellness effects.The prices at Lazarus Naturals are already low, but the company offers a support discount program for those who are disabled, or who live in households with low incomes. People who qualify get a full 60 percent off on the CBD products they need.8. Flora’s Mercantile CBD Isolate TinctureExcellent ValueWith 2,000 mg of CBD isolate in a 30 mL bottle, Flora’s Mercantile CBD Isolate Drops are some of the most potent, pure CBD oil drops you can find.

Owner and founder, Chris Bedrosian has committed to sharing her profits throughout the buy antibiotics crisis, by giving away this particular formula to anyone who can prove they are employed as a nurse, or any other hospital or frontline worker. When times get tough, Flora’s Mercantile steps up and offers the kind of support we all need right now. You can also find relaxing teas that are made with different botanical ingredients including hemp, and everything the company makes is “tested, trusted, and guaranteed.”Best CBD With a Kick9. Bluebird Botanicals Uplift CBG + CBD OilBluebird Botanicals is another one of the classic trailblazing companies on our list. This company was founded with the mission of bringing us all into a closer relationship with the earth, ourselves, and each other, through its products.The company’s latest energizing formula—a combination of CBG in addition to CBD—is meant to give you that extra boost in your day.

Bluebird is a B Corp certified company, and its concern for the environment and community are apparent in everything it does. Its products are certified as being glyphosate-free, they all have a Leaping Bunny certification, and everything the company makes is vegan as well. 10. Medterra’s Ultra Broad Spectrum CBD OilExcellent ValueMedterra makes some of the best CBD oil on the market, and at great prices. Functionality and affordability are the key with Medterra’s Ultra Broad Spectrum CBD Oil, which is what we love about it.This is one of the best broad-spectrum formulas we’ve seen.

The Ultra Broad Spectrum™ oil has all the benefits of a whole-plant extract, with all the THC removed. Medterra is conscientious and careful in everything it makes, while supplying excellent variety to keep its shoppers coming back. It also offers discounts to people in the military and those who have a disability.Best CBD Oil from Companies Owned by People of Color11. Brown Girl Jane Balance Wellness DropsExcellent ValueBrown Girl Jane is dedicated to supporting the wellness of Black women everywhere, and a portion of the revenue from each purchase you make goes to this end. The company is owned by Black women who are respected leaders in their communities and committed to contributing to the diversification of the hemp and CBD industries.The quality hemp used to make the company’s Balance oil is grown in the United States, and Brown Girl Jane pledges to make only the best CBD oil and other products.12.

Buena Botanicals CBD ElixirThe pair of set sisters who founded Buena Botanicals wanted to “create a business seeded in our common passion for holistic healing, community, self-determination, plant medicine, and love for Mama Earth.”That’s exactly what has come through with this company’s products, and supporting this company is supporting the community it aims to create as well. With Buena Botanicals, you don’t have to worry about getting too much CBD at a time, because its concentrations are a little on the lower side, just right for beginners.13. Lion X Wellness CBD IsolateWe don’t have many CBD isolates on our list, but we think this one is pretty great. It’s an oil you can take every day, and its flavor is light and mild.Nico Marley (yes, related to Bob Marley) started this CBD company with a goal to "heal our communities through their mind, body, and soul."All of Lion X’s products are vegan friendly, made with natural sustainable ingredients, and you can count on them to be made in the United States. 14.

Noirebud Balance DropsCarolyn Gray founded Noirebud to pay homage to Black communities and offer a luxury brand that everyone can trust. Noirebud products are all-natural and vegan, and these Balance Drops are a perfect way to inspire some much-needed you-time.Take a moment to stop worrying about everyone else’s problems and get yourself the wellness you deserve.Best CBD Oil from Women-Owned Companies15. Kat’s Naturals Kat’s Craft Collection Full-Spectrum CBD OilThis company has helped farmers transform their tobacco fields into hemp fields, employed people from its own backyard, and expanded access to a variety of wellness products to satisfied customers all over the globe.Kat’s Naturals have been focused on helping its local Tennessee community thrive since its beginnings, and now you can reap the benefits in this limited-edition CBD oil.Kat’s Craft Collection is described as “hemp in a bottle,” with all the supportive components of the Tennessee-1 strain of locally grown hemp. It comes in a gorgeous bottle hand-designed by a local Tennessee artist, and the 2000 mg of CBD is intended to last customers four months.16. Ohana Night Repair Face OilAll kinds of CBD oils are made for wellness from the inside out.

Ohana’s products are made for wellness to help you glow on the outside, too. The company’s integrity and quality start with the fact that it was founded by a woman who used CBD for support and maintenance as she dealt with multiple sclerosis.She wanted everyone to experience some of the same benefits she experienced, and that’s what inspired her to create a company that focused on skincare.The Night Repair Face Serum is one of our favorites because it has a relaxing lavender scent that’s perfect for when you’re headed off to bed. The serum does its work overnight, keeping your skin fresh and moisturized while you rest. 17. Onyx + Rose Pure Bloom Chocolate Coconut Broad-Spectrum CBD OilExcellent ValueWe love this picture-perfect CBD oil brand not only because it’s completely Instagram-ready, but also because of its unique, delicious flavors that were made with both your wellness and your delight in mind.This woman-owned company focuses on creating sustainable products with high-quality hemp.

Its broad-spectrum CBD formulas also contain CBG, CBN, and CBC, and they are completely free of THC.The company also offers a full-spectrum CBD oil as well as other products, and the prices are just as pretty as the packaging. 18. Joy Organics Organic Full Spectrum CBD Oil TinctureJoy Organics was founded by Joy Smith and her family, and they still run the company today. Joy Organics is one of the most trusted companies out there. It is easy to see why they have this reputation, given their high level of transparency and clear focus on quality.It can be exceptionally challenging to get an organic certification for CBD products, but Joy has made the investment in order to show its customers just how much it cares.All of this company’s certified organic products have met stringent USDA guidelines for all of the ingredients used to make them.

They are cruelty-free and Hemp Roundtable certified as well. 19. Sisters of the Valley CBD Infused OilSisters of the Valley CBD is one of the most unique CBD companies out there, and its CBD infused oil is one of the few products on the market today differentiating CBD oil from CBD tinctures.The company offers both, but be warned if you intend to try their tinctures. They are made with alcohol and can have quite a bite.The CBD-infused oil is made from hemp grown on the farm owned by the Sisters, and they hand-process their products after a full-moon blessing. Each order is blessed before it is shipped as well.Best CBD Oil for the Planet20.

Plant People Drops+ Starter SetPlant People has been expanding its inventory and improving its products since it was founded by two friends who found the supportive properties of CBD to be essential to their wellbeing. We are having such a hard time selecting our favorite of this company’s CBD products, that we decided to recommend the starter set. It’s a perfect opportunity to sample each of the favorite CBD oils from Plant People, and to figure out which one is your favorite, too. In this set, you get a sample-sized bottle of the formulas dedicated to mind, body, and relief.In addition to making some of the most conscientious CBD products on the planet, Plant People has demonstrated its care for the environment through partnering with the non-profit organization American Forests to plant a tree for every purchase made.21. Søjen Refocus OilSøjen wants to support you in your wellness journey wherever you are, and the company is dedicated to helping everyone have access to opportunities for better self-care.Refocus Oil contains a special blend of French peppermint oil, copaiba oil and hemp extract.

You can purchase it on its own, or as part of a package that includes a yoga mat and virtual yoga lessons. Every time someone buys the package, a portion of the proceeds goes to helping kids in NYC public schools receive a yoga mat and virtual lessons as well. In addition to Søjen’s contribution to the community, the company also pledges to leave a negative carbon footprint by funding reforestation projects all over the world. Best USDA Certified Organic CBD Oil22. Elixinol Organic Balance TinctureElixinol has been around for a long time, but it has stayed low-key.

Instead of spending mega-dollars on advertising, it has let its products speak for themselves. The Organic Balance CBD oil is just right for people just getting started with CBD, because its dose is pretty low. It is USDA-certified organic, too, which means that it has passed some of the most stringent agricultural and processing guidelines in the world.Elixinol has also been a sponsor to the Realm of Caring, a non-profit dedicated to conducting research, and providing advocacy and access to CBD, for families who have suffered from physical disabilities and illnesses. 23. Cornbread Hemp’s Distilled CBD OilCornbread Hemp’s Distilled CBD Oil is meant for energizing daytime use.

If you are looking for a product that is intended to support relaxation, we recommend also giving this company’s whole plant extract a try. This is another of the few CBD products that is USDA-certified as being organic, and the company’s level of conscientiousness goes far beyond the ecosystem.Cornbread Hemp is dedicated to donating $10,000 to the Last Prisoner Project in 2021. So when you make a purchase from this company, some of your dollars go to restorative justice. Best CBD Oil for Pets24. Green Gorilla Pure CBD Oil for Dogs and PetsWe haven’t forgotten about your beloved furry friends.

Pets will love the olive oil base, which is meant to be gentle on their stomachs. This CBD-infused oil for dogs and pets from Green Gorilla is a product you know you can trust, because its certified organic ingredients are accurately labeled at just the right dose.With 300 mg of CBD in a convenient spray-bottle, you can give this product to your pets in their water, on their food, or right into their mouths.Green Gorilla was also dedicated to giving back at the beginning of the zithromax, by giving first responders a free bottle of CBD for every bottle their customers had purchased.25. Honest Paws Extra Strength CBD Oil for DogsThis extra strength CBD oil for dogs is formulated to be safe for your bigger pooches that need a little extra love.Honest Paws specializes in making products your pets will love. This company has quite the variety when it comes to balms, treats, oils, and shampoos for all your four-legged family members.A Few Notes to Keep in Mind as You ShopAs you set about your CBD oil shopping in 2021, remember that you never have to settle for less than the best when it comes to supporting and maintaining your own wellness. Not only are there CBD oil companies out there making amazing and innovative products, you can most definitely find a company that aligns with your values as well.Whether you are concerned about the environment or social justice, there is something in the CBD industry for you.And you don’t have to bust the bank to get the wellness you deserve.

While CBD prices can vary wildly, you can find a product that meets your needs without costing a fortune. Why do CBD prices vary so much?. There are plenty of reasons that CBD from one company may cost one price, and something that seems exactly the same from a different company costs a drastically different amount.One thing to keep in mind is that while some products cost more because a manufacturer is using more expensive products or has invested more in production costs, price does not necessarily indicate quality.Sometimes CBD companies are more concerned with profits than customers, and they may be inflating the price unreasonably. Other CBD companies may import the hemp used to make their CBD. The expense related to importing raw materials can lead to a higher-priced finished product.Sometimes, however, the higher price is justified.

When a company invests a significant amount in developing superior products, its products may be a little more expensive. Companies that have gone through the USDA organic certification process, or companies that use premium ingredients are good examples of companies that have justifiably higher prices. How to Compare the Cost of Your CBDThere are so many different types of CBD oil out there, and they come in different bottle sizes and concentrations. This makes it difficult to compare one product to another, but it’s nothing a little simple math can’t fix.You want to look at how much a product costs per milligram of CBD it contains. The easiest example to give would be to compare the cost of a 1000 mg bottle of CBD to a 750 mg bottle of CBD.

(These are not intended to reflect an actual product, but to illustrate an example):1000 mg of CBD $100$100/1000 mgCBD costs $0.10/mg750 mg of CBD $55$55/750 mgCBD costs $0.07/mgYou can use this technique even if you are comparing the price of two completely different products, and it is a way to figure out which formats are most cost-effective.Keep in mind that the formula may influence the cost of a CBD product as well. CBD oils that are made with CBD isolate are generally less expensive than oils that are made with a broad or full-spectrum formula. What’s the Difference Between CBD Formulas?. When you are looking for the right CBD for your needs, it's best to keep the difference between the formulas in mind.CBD Isolate contains only CBD. There are no other cannabinoids present, and it is the least likely formula to contain traces of THC as well.Full-Spectrum CBD is also commonly referred to as whole plant extract.

This means that the process makes use of all the beneficial cannabinoids found in the hemp plant including THC (the intoxicating substance found in cannabis plants). Full-Spectrum CBD may contain anywhere between zero THC, and 0.3 percent THC.Hemp is federally legal, and adults 21 and over have a right to choose whether they want to use CBD that contains up to 0.3 percent THC, as long as it was derived from hemp. Broad Spectrum CBD is the best of both worlds. It contains all the beneficial cannabinoids found in the hemp plant, minus the THC. In addition to CBD, broad-spectrum CBD may contain CBG, CBN, and CBC, as well as terpenes and other molecules.Is CBD Legal?.

CBD was made federally legal by the Farm Bill (also known as the Agricultural Improvement Act) of 2018. It was this bill that officially took hemp off the list of controlled substances. States are able to create their own laws surrounding hemp and its derivatives, and some may restrict who can purchase and possess CBD, THC concentrations, and formats. It’s a good idea to always check the laws in your state before making any new purchases.How Do I Know if My CBD is Accurately Labeled?. You should always be on the lookout for a certificate of analysis that goes with your product.

This provides confirmation that your CBD oil has been lab-tested, that it is free of contaminants and toxins, and that it has the advertised concentration of cannabinoids.If the company you are shopping with does not display a certificate of analysis on its website, you should still be able to request one by contacting customer service. If you don’t get a response, steer away from the company..

Citizen Science Salon is a partnership between Discover and buy zithromax with prescription link SciStarter.org. The future of individualized medicine may depend on an army of one million volunteers. And scientists want buy zithromax with prescription you to get involved. Researchers with the National Institutes of Health are recruiting citizen scientists to enlist in a study of unprecedented scope and depth. The program, called All of Us, promises to take personal data from a diverse cross-section of volunteers and turn it into groundbreaking insights about the buy zithromax with prescription complex roles our genes, lifestyles and environments play in our health.

€œBy studying people longitudinally over time, we’re able to see diseases arise,” says Sheri Schully, the All of Us program’s acting chief medical and scientific officer.In return for completing surveys and offering up biological samples, the program will send participants personalized results about everything from their ancestry to their genetic predisposition for certain diseases. It’s also buy zithromax with prescription free to join. And last month, All of Us sent participants back the first set of genetic results. Take Part buy zithromax with prescription. Join the National Institutes of Health’s All of Us Program‘The Right Treatment at the Right Time’In January of 2015, President Barack Obama stood in front of the country during the State of the Union and offered a bold vision for accelerating research.

A research program then called the Precision Medicine Initiative would recruit at least one million people from across the United States and study them, leading to rapid advances in drug discovery and customized treatments for patients based on personal data.“I want the country that eliminated polio and mapped the human genome to lead a new era of medicine — one that delivers the right treatment at the right time,” Obama told the nation. He added that the project could bring us closer to curing diseases buy zithromax with prescription like cancer and diabetes, while offering people access to personal information that could help them stay healthy. Five years later, NIH has already enrolled hundreds of thousands of participants, and last month, those volunteers started receiving the first results from their genetic samples. But the project still has a long way to go to reach buy zithromax with prescription one million people. And with the approach of Citizen Science Month in April, they’re calling on volunteers from around the country to get involved in not only All of Us, but also a group of featured citizen science projects and events produced with global and national partners like SciStarter, Arizona State University, Science Friday and National Geographic.

€œThe power of buy zithromax with prescription citizen science is the massive impact that is made by everyday people, individually and collectively,” says Darlene Cavalier, founder of SciStarter and a professor of practice at the School for the Future of Innovation in Society at Arizona State University. €œOnline and virtual events during Citizen Science Month will help introduce thousands of people to citizen science and help them find ways to act upon issues they are curious or concerned about, individually or as a community.”The NIH has now enrolled hundreds of thousands of volunteers, and participants have now started to receive the first results from their genetic samples. (Credit. All of Us/NIH)Kickstarting Precision MedicineParticipants with All of Us start by taking a survey about their lifestyle, family history and more. Then, they can agree to share their health records with researchers and offer up blood and urine samples, as well as physical measurements like height, weight and heart rate.

Participants can even share daily personal health data from smart devices like a Fitbit. The data is stripped of all personal identifiers, but this granular level of detail, when monitored over time, can give researchers a real-time look at the ways diseases arise. It’s all part of what researchers call precision medicine. Precision medicine stands in contrast to the current one-size-fits-all approach to disease treatment used by doctors around the world. But if medical professionals could better understand their patients at an individual level, doctors could predict the best possible treatment for a particular disease.

€œ[Precision medicine] is understanding what a person is experiencing and what’s going on inside and outside their body in relation to disease,” Schully says. €œIt’s really evaluating a person holistically. What are they eating?. What’s their lifestyle like?. And what kind of job do they have?.

Precision medicine to us doesn't just mean targeted treatment, it means targeted prevention.”A Holistic Look at buy antibiotics’s ImpactResearchers are already studying the database. And it’s even giving them new insights into buy antibiotics. Back before the zithromax started, All of Us was enrolling about 3,000 people every week. Eventually, the antibiotics forced them to temporarily pause that enrollment. But when researchers went back and studied the 24,000 blood samples they’d collected between late 2019 and early 2020, they found some surprises.

At the time, researchers didn’t know buy antibiotics was spreading in communities around the country. Yet a significant number of the blood samples All of Us collected showed signs of buy antibiotics antibodies, meaning that the disease was spreading in many states well before health officials realized. Researchers with the project recently published those results in the New England Journal of Medicine. Meanwhile, All of Us has also been asking participants about buy antibiotics symptoms via a survey sent out last May. The survey included broad buy antibiotics-related questions, including inquiries about people’s mental well-being and whether they’d lost their job.

The initial results of that work were released to researchers in December, and they offer a detailed look at how buy antibiotics is affecting families and communities. Among other things, All of Us heard back that people are suffering long-term heart defects and breathing effects, problems that medical professionals have seen elsewhere. Armed with this data, the program hopes they can monitor these lingering health problems over time. It’s a sort of holistic look that has been part of the program’s mission since the start. An All of Us staff member measures a participant’s height.

(Credit. All of Us/NH)A Truly Diverse DatasetOther large projects have collected genetic databases aimed at advancing disease diagnosis and treatment, but All of Us stands out for its staggering size and its mission. Researchers aren’t just studying people’s DNA, All of Us is putting its participants at the epicenter of their program. The community helps make decisions, with volunteers even sitting on governing boards, deciding how data can be used. If that aim wasn’t lofty enough, All of Us is also after a diverse cross-section of the American public, including people from diverse ethnic and economic backgrounds, as well as a mix of rural and urban residents.

That’s something other studies have long struggled with. The project’s leaders say that most of modern medicine has been biased toward studying people with European ancestry, leaving other segments of the population underrepresented in research. And as an incentive to get one million people involved, the project will also share genetic information with its participants, including things like ancestry and whether they’re at an increased risk for disease. €œNever before have we really put the participant at the center of the study and really valued the back and forth, giving them what matters to them,” Schully says. €œWe really want to be a catalyst for change in how things are done in science.”Insights into Disease PredispositionIn December, they started returning those first individual ancestry and genetic trait results to volunteers.

€œParticipants are our most important partners in this effort, and we know many of them are eager to get their genetic results and learn about the science they’re making possible,” All of Us chief executive officer Josh Denny said in an announcement. €œWe’re working to provide that valuable information in a responsible way.”Later this year, All of Us plans to start telling interested participants about how their DNA could affect their body’s response to certain drugs, or even about genes that could increase their risk of a variety of diseases like cancer. Those results will be paired with counseling to help people understand the implications of their DNA profile. And, like everything with the program, the personal data will be tightly protected. €œIt's a huge milestone for our project,” Schully says.

€œReturning results on this level has never been done before.”And people who get involved throughout the year — including during Citizen Science Month — can look forward to learning more about their family’s ancestry and genetic predispositions. Citizen Science Month is all about turning curiosity into impact, and what better way than with a project that could help you better understand yourself while helping researchers better understand human health at large?. You can join the All of Us program by visiting joinallofus.org/nlm.Your digestive system plays host to a mind-boggling 100 trillion microbes — microscopic pinch-hitters that allow you to absorb energy from your food and churn out compounds like serotonin, which affect your mental well-being. While some of these microbes take up residence in your gut from birth, others emerge or wane depending on the lifestyle choices you make.New research suggests that if you exercise, take antidepressants or use cannabis, your gut-bacterial balance may shift profoundly. But scientists still face a so-called black box conundrum.

They’re not always sure what biological processes cause these microbial shifts or how the shifts affect other body functions. Planned larger-scale studies promise to deepen experts’ understanding of the bacterial changes your daily habits usher in, as well as the long-term health implications.Exercise to ColonizeNot only does regular exercise boost your overall well-being, it also swells the ranks of gut bacteria that promote a healthy metabolism, says Satu Pekkala, a bacteriologist at Finland’s University of Jyväskylä. In a 2018 study, Pekkala and his colleagues recruited 17 overweight women who participated in three endurance exercise sessions each week for six weeks. The women rode an exercise bike that adjusted workout intensity so that riders stayed at about 85% of their maximum heart rate.The team had participants collect stool samples before and after the six-week training period, then sequenced DNA from these samples to detect changes in the women’s gut bacteria. After the training regimen, the women had higher levels of gut bacteria from the genus Akkermansia — a bacterial group tied to improved metabolic function — than they had before.

They also had lower levels of Proteobacteria, a genus linked to inflammation in the body.Pekkala has secured approval to conduct another study that examines bacteria-produced molecules to explore what biological role Akkermansia and Proteobacteria might play in the gut — and how Akkermansia abundance might affect the body’s ability to burn fat stores. €œNot everybody loses fat mass even if they exercise,” Pekkala says. €œIt’s important to know how the metabolic functions [of gut bacteria] affect fat loss.” The Cannabis ConnectionPlenty of research shows that marijuana compounds reduce disease-related inflammation, and, according to a 2019 study, these compounds’ effects on gut bacteria might explain some of their anti-inflammatory properties.In exploring possible treatments for Multiple Sclerosis (MS), University of South Carolina researchers treated mice that had a similar condition with molecules like delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD).The mice showed fewer signs of inflammation after the cannabis treatment — and an analysis showed that gut-bacterial shifts were likely responsible, at least in part. Before treatment, the mice had high levels of the bacterial species Akkermansia muciniphila, which produces compounds called lipopolysaccharides that are linked to brain inflammation. After treatment, mice had lower levels of this species in their guts and lower levels of lipopolysaccharides in their brains.

Future studies may show whether cannabis can spur similar gut-bacterial and brain changes in humans with MS.Gut CheckAn antidepressant that millions of Americans take may alter their gut-bacterial mix as well as their mental outlook, University of California-Los Angeles researchers say. In a 2019 study, the UCLA team added fluoxetine (Prozac) to a tube with a common gut bacterial species called Turicibacter sanguinis, which normally tells intestinal cells to produce more serotonin — a neurotransmitter that affects mood. After the team put in fluoxetine, the bacteria transported less serotonin than it had before. Further experiments showed that mice dosed with fluoxetine had lower gut levels of Turicibacter than other mice.These results suggest that Turicibacter populations fluctuate in the presence of drugs like fluoxetine that modify serotonin levels. Next, the UCLA team plans to tease out the molecular mechanisms that reveal just how fluoxetine affects certain gut bacteria — and how that might influence the way the drug works in the brain and the rest of the body.

€œThere’s variation in how effective fluoxetine is for different people,” says UCLA microbiologist Jonathan Lynch. €œSomething like the interaction with the microbiome might be mediating that.”Future studies of these gut-brain interactions could allow a personalized-medicine approach that identifies people who are good candidates to respond to drugs like fluoxetine, Lynch says. Someday, based on your gut microbe profile, doctors might be able to tell you which antidepressants will work for you and which ones you shouldn’t even try.This article contains affiliate links to products. Discover may receive a commission for purchases made through these links. CBD enthusiasts know that the best CBD oil is made with naturally grown hemp.

It has accurate labeling, comes with a certificate of analysis, and the companies that make it are absolutely transparent.But let’s face it, we all need a little something extra after the year that we’ve had. The changes and challenges that came with 2020 mean that we are all looking for companies and products that offer more than just what it takes to get by. CBD oils are no exception. We know you want CBD oils that are made by companies that aim to support you in your mission to thrive. Not just survive.In addition to creating the best CBD oils you can find, the companies mentioned here are doing their part to make the world a better place.This year, we have selected CBD oils that are made by great, tried-and-true classic companies that you have probably heard of over and over again.

However, we are also focusing on including oils from companies that are doing great things. You may have never heard of some of the CBD oils listed here, but you will by the end of 2021. They are quickly rising to the top, working hard to give back to their communities and the environment, and many are owed by women and people of color. When you purchase one of the best 25 CBD oils for 2021, you are making a sound investment in supporting your wellness and the world around you. Every CBD oil listed here is made with pure quality ingredients, and they are backed by the integrity of companies that care.We’ve also made sure to include some excellent bargains here too, because who doesn’t love a great deal?.

You don’t have to break the bank to get high-quality CBD oil, you just need to know where to shop.Best Overall CBD Oil1. Penguin’s Broad Spectrum CBD OilExcellent ValuePenguin CBD oil may be one of the newer kids on the block, but this company wins our pick for best all-around CBD oil because of its commitment to your wellness and the environment.Fortunately, the care for these two things goes hand-in-hand, with sustainable farming practices that result in a CBD oil that you can count on every single day.Need a morning boost?. Penguin CBD’s broad-spectrum CBD has all the benefits of additional cannabinoids found in the hemp plant, with all the THC removed.Tired of the typical mid-afternoon blahs?. Give yourself a lift with Penguin’s citrus-flavored CBD. Ready to relax after a long day?.

Squeeze a dropperful of Penguin’s mint-flavored CBD into your chamomile tea to unwind before bed.The variety of flavors and concentrations is one of our favorite things about Penguin’s CBD oil. Choose from five flavors and four strengths at prices you can afford. If you need help choosing your next purchase, Penguin’s customer support line has real people on the other end. Just send them an email, and they are ready to make sure you are totally confident and satisfied with your selection.The cheerful packaging and adorable mascot are just a hint at what’s to come when you try Penguin CBD.In addition to everything Penguin does to support the environment and your wellness, the company also supports our military personnel by offering a discount on the products they need to maintain their health. Penguin CBD is a company that cares about everyone equally, which is why it’s at the top of our list for 2021.Best Full-Spectrum CBD Oil2.

Verma FarmsOne of the top brands in CBD out, Verma Farms has been winning awards left and right for the past couple of years, with 2021 as no exception.What Verma does well provides a solution that helps set the standard for how CBD oils should go. Starting out with very intent-driven oils like Focus, Chill, and Boost, they began diversifying their lineup to include more fruit-flavored varieties as well, such as Lemon Lime, Pineapple, Strawberry, Watermelon, Mango, and Peach. As all of them use natural, vegan ingredients, they’ve stripped down their offering to host only the standards but doing it well, sourcing all their oil’s materials from inside the US.An overall great brand, Verma Farms is an easy number one for any CBD fan out there, no matter how much they’ve done.3. NuLeaf Naturals Full-Spectrum CBD OilYou may have never heard of NuLeaf Naturals before, but this company has been perfecting its full-spectrum CBD oil since the early days. NuLeaf makes only one concentration of CBD oil, and it is not flavored.

However, you can order it in a number of different sizes. You no longer have to worry about running out before the month is out when you can order bottles as large as 3.38 ounces!. NuLeaf takes the importance of wellness seriously, and it makes sure that those who need the support of CBD most get it. It offers deep discounts to frontline workers, military personnel, teachers, students, people on long-term disability, lower-income households and more. 4.

Charlotte’s Web Original FormulaExcellent ValueA classic CBD oil that helped fuel the beginning of an industry, Charlotte’s Web’s Original Formula CBD oil was formulated out of a passion to help others. Every CBD enthusiast should give this whole-plant formula a try. Gently extracted with alcohol, the original formula intends to keep all the healthy properties in the hemp plant and packs them into a full spectrum oil you can take every day.We love that Charlotte’s Web keeps getting better, too. The company just earned a B Corp certification, meaning it is recognized as a leader in its concern for its customers, its employees, the environment, and its level of transparency. 5.

Spruce Maximum Potency CBD TinctureWe love Spruce’s Maximum Potency 2,400 mg Tincture because it is made by a family-owned company that cares deeply about helping its customers maintain their health and wellness.You’ll sometimes even see the Spencer family packing shipments themselves, working hard to get the CBD you love delivered to your door as quickly as possible.The hemp used is grown on family-owned farms, and is extracted using Kentucky moonshine (don’t worry, all traces are gone by the time the finished product is bottled). The result is a formula Spruce is proud of.The company boasts a full-spectrum CBD oil that has a high concentration of all the beneficial cannabinoids found in hemp, with a very low concentration of THC.Best CBD Oil for Giving Back to the Community6. Endoca THC-Free Chocolate Mint CBD OilExcellent ValueThis is one of Endoca's first flavored CBD oils, and it has one of the highest concentrations available today. Free of THC, the super-strength CBD oil is also super affordable. It has 5 mg of CBD per drop, and 150 mg per dropperful.The Endoca Foundation was developed in order to spread its mission for wellness around the world, and people with disabilities and those who live in low-income households can now benefit from a 50 percent discount on CBD products that help maintain your health.In addition to the discount program for customers in need, Endoca has established programs that are committed to helping people obtain nutritional wellness.7.

Lazarus Naturals 1:1 CBG. CBD TinctureExcellent ValueLazarus Naturals is an employee-owned company that is committed to keeping the benefits of hemp affordable, effective, safe, and all-natural.When you’re looking for an energizing kick, this CBG/CBD tincture is just the thing you need. CBG is another cannabinoid found in hemp and combining it with CBD is thought to have additional wellness effects.The prices at Lazarus Naturals are already low, but the company offers a support discount program for those who are disabled, or who live in households with low incomes. People who qualify get a full 60 percent off on the CBD products they need.8. Flora’s Mercantile CBD Isolate TinctureExcellent ValueWith 2,000 mg of CBD isolate in a 30 mL bottle, Flora’s Mercantile CBD Isolate Drops are some of the most potent, pure CBD oil drops you can find.

Owner and founder, Chris Bedrosian has committed to sharing her profits throughout the buy antibiotics crisis, by giving away this particular formula to anyone who can prove they are employed as a nurse, or any other hospital or frontline worker. When times get tough, Flora’s Mercantile steps up and offers the kind of support we all need right now. You can also find relaxing teas that are made with different botanical ingredients including hemp, and everything the company makes is “tested, trusted, and guaranteed.”Best CBD With a Kick9. Bluebird Botanicals Uplift CBG + CBD OilBluebird Botanicals is another one of the classic trailblazing companies on our list. This company was founded with the mission of bringing us all into a closer relationship with the earth, ourselves, and each other, through its products.The company’s latest energizing formula—a combination of CBG in addition to CBD—is meant to give you that extra boost in your day.

Bluebird is a B Corp certified company, and its concern for the environment and community are apparent in everything it does. Its products are certified as being glyphosate-free, they all have a Leaping Bunny certification, and everything the company makes is vegan as well. 10. Medterra’s Ultra Broad Spectrum CBD OilExcellent ValueMedterra makes some of the best CBD oil on the market, and at great prices. Functionality and affordability are the key with Medterra’s Ultra Broad Spectrum CBD Oil, which is what we love about it.This is one of the best broad-spectrum formulas we’ve seen.

The Ultra Broad Spectrum™ oil has all the benefits of a whole-plant extract, with all the THC removed. Medterra is conscientious and careful in everything it makes, while supplying excellent variety to keep its shoppers coming back. It also offers discounts to people in the military and those who have a disability.Best CBD Oil from Companies Owned by People of Color11. Brown Girl Jane Balance Wellness DropsExcellent ValueBrown Girl Jane is dedicated to supporting the wellness of Black women everywhere, and a portion of the revenue from each purchase you make goes to this end. The company is owned by Black women who are respected leaders in their communities and committed to contributing to the diversification of the hemp and CBD industries.The quality hemp used to make the company’s Balance oil is grown in the United States, and Brown Girl Jane pledges to make only the best CBD oil and other products.12.

Buena Botanicals CBD ElixirThe pair of set sisters who founded Buena Botanicals wanted to “create a business seeded in our common passion for holistic healing, community, self-determination, plant medicine, and love for Mama Earth.”That’s exactly what has come through with this company’s products, and supporting this company is supporting the community it aims to create as well. With Buena Botanicals, you don’t have to worry about getting too much CBD at a time, because its concentrations are a little on the lower side, just right for beginners.13. Lion X Wellness CBD IsolateWe don’t have many CBD isolates on our list, but we think this one is pretty great. It’s an oil you can take every day, and its flavor is light and mild.Nico Marley (yes, related to Bob Marley) started this CBD company with a goal to "heal our communities through their mind, body, and soul."All of Lion X’s products are vegan friendly, made with natural sustainable ingredients, and you can count on them to be made in the United States. 14.

Noirebud Balance DropsCarolyn Gray founded Noirebud to pay homage to Black communities and offer a luxury brand that everyone can trust. Noirebud products are all-natural and vegan, and these Balance Drops are a perfect way to inspire some much-needed you-time.Take a moment to stop worrying about everyone else’s problems and get yourself the wellness you deserve.Best CBD Oil from Women-Owned Companies15. Kat’s Naturals Kat’s Craft Collection Full-Spectrum CBD OilThis company has helped farmers transform their tobacco fields into hemp fields, employed people from its own backyard, and expanded access to a variety of wellness products to satisfied customers all over the globe.Kat’s Naturals have been focused on helping its local Tennessee community thrive since its beginnings, and now you can reap the benefits in this limited-edition CBD oil.Kat’s Craft Collection is described as “hemp in a bottle,” with all the supportive components of the Tennessee-1 strain of locally grown hemp. It comes in a gorgeous bottle hand-designed by a local Tennessee artist, and the 2000 mg of CBD is intended to last customers four months.16. Ohana Night Repair Face OilAll kinds of CBD oils are made for wellness from the inside out.

Ohana’s products are made for wellness to help you glow on the outside, too. The company’s integrity and quality start with the fact that it was founded by a woman who used CBD for support and maintenance as she dealt with multiple sclerosis.She wanted everyone to experience some of the same benefits she experienced, and that’s what inspired her to create a company that focused on skincare.The Night Repair Face Serum is one of our favorites because it has a relaxing lavender scent that’s perfect for when you’re headed off to bed. The serum does its work overnight, keeping your skin fresh and moisturized while you rest. 17. Onyx + Rose Pure Bloom Chocolate Coconut Broad-Spectrum CBD OilExcellent ValueWe love this picture-perfect CBD oil brand not only because it’s completely Instagram-ready, but also because of its unique, delicious flavors that were made with both your wellness and your delight in mind.This woman-owned company focuses on creating sustainable products with high-quality hemp.

Its broad-spectrum CBD formulas also contain CBG, CBN, and CBC, and they are completely free of THC.The company also offers a full-spectrum CBD oil as well as other products, and the prices are just as pretty as the packaging. 18. Joy Organics Organic Full Spectrum CBD Oil TinctureJoy Organics was founded by Joy Smith and her family, and they still run the company today. Joy Organics is one of the most trusted companies out there. It is easy to see why they have this reputation, given their high level of transparency and clear focus on quality.It can be exceptionally challenging to get an organic certification for CBD products, but Joy has made the investment in order to show its customers just how much it cares.All of this company’s certified organic products have met stringent USDA guidelines for all of the ingredients used to make them.

They are cruelty-free and Hemp Roundtable certified as well. 19. Sisters of the Valley CBD Infused OilSisters of the Valley CBD is one of the most unique CBD companies out there, and its CBD infused oil is one of the few products on the market today differentiating CBD oil from CBD tinctures.The company offers both, but be warned if you intend to try their tinctures. They are made with alcohol and can have quite a bite.The CBD-infused oil is made from hemp grown on the farm owned by the Sisters, and they hand-process their products after a full-moon blessing. Each order is blessed before it is shipped as well.Best CBD Oil for the Planet20.

Plant People Drops+ Starter SetPlant People has been expanding its inventory and improving its products since it was founded by two friends who found the supportive properties of CBD to be essential to their wellbeing. We are having such a hard time selecting our favorite of this company’s CBD products, that we decided to recommend the starter set. It’s a perfect opportunity to sample each of the favorite CBD oils from Plant People, and to figure out which one is your favorite, too. In this set, you get a sample-sized bottle of the formulas dedicated to mind, body, and relief.In addition to making some of the most conscientious CBD products on the planet, Plant People has demonstrated its care for the environment through partnering with the non-profit organization American Forests to plant a tree for every purchase made.21. Søjen Refocus OilSøjen wants to support you in your wellness journey wherever you are, and the company is dedicated to helping everyone have access to opportunities for better self-care.Refocus Oil contains a special blend of French peppermint oil, copaiba oil and hemp extract.

You can purchase it on its own, or as part of a package that includes a yoga mat and virtual yoga lessons. Every time someone buys the package, a portion of the proceeds goes to helping kids in NYC public schools receive a yoga mat and virtual lessons as well. In addition to Søjen’s contribution to the community, the company also pledges to leave a negative carbon footprint by funding reforestation projects all over the world. Best USDA Certified Organic CBD Oil22. Elixinol Organic Balance TinctureElixinol has been around for a long time, but it has stayed low-key.

Instead of spending mega-dollars on advertising, it has let its products speak for themselves. The Organic Balance CBD oil is just right for people just getting started with CBD, because its dose is pretty low. It is USDA-certified organic, too, which means that it has passed some of the most stringent agricultural and processing guidelines in the world.Elixinol has also been a sponsor to the Realm of Caring, a non-profit dedicated to conducting research, and providing advocacy and access to CBD, for families who have suffered from physical disabilities and illnesses. 23. Cornbread Hemp’s Distilled CBD OilCornbread Hemp’s Distilled CBD Oil is meant for energizing daytime use.

If you are looking for a product that is intended to support relaxation, we recommend also giving this company’s whole plant extract a try. This is another of the few CBD products that is USDA-certified as being organic, and the company’s level of conscientiousness goes far beyond the ecosystem.Cornbread Hemp is dedicated to donating $10,000 to the Last Prisoner Project in 2021. So when you make a purchase from this company, some of your dollars go to restorative justice. Best CBD Oil for Pets24. Green Gorilla Pure CBD Oil for Dogs and PetsWe haven’t forgotten about your beloved furry friends.

Pets will love the olive oil base, which is meant to be gentle on their stomachs. This CBD-infused oil for dogs and pets from Green Gorilla is a product you know you can trust, because its certified organic ingredients are accurately labeled at just the right dose.With 300 mg of CBD in a convenient spray-bottle, you can give this product to your pets in their water, on their food, or right into their mouths.Green Gorilla was also dedicated to giving back at the beginning of the zithromax, by giving first responders a free bottle of CBD for every bottle their customers had purchased.25. Honest Paws Extra Strength CBD Oil for DogsThis extra strength CBD oil for dogs is formulated to be safe for your bigger pooches that need a little extra love.Honest Paws specializes in making products your pets will love. This company has quite the variety when it comes to balms, treats, oils, and shampoos for all your four-legged family members.A Few Notes to Keep in Mind as You ShopAs you set about your CBD oil shopping in 2021, remember that you never have to settle for less than the best when it comes to supporting and maintaining your own wellness. Not only are there CBD oil companies out there making amazing and innovative products, you can most definitely find a company that aligns with your values as well.Whether you are concerned about the environment or social justice, there is something in the CBD industry for you.And you don’t have to bust the bank to get the wellness you deserve.

While CBD prices can vary wildly, you can find a product that meets your needs without costing a fortune. Why do CBD prices vary so much?. There are plenty of reasons that CBD from one company may cost one price, and something that seems exactly the same from a different company costs a drastically different amount.One thing to keep in mind is that while some products cost more because a manufacturer is using more expensive products or has invested more in production costs, price does not necessarily indicate quality.Sometimes CBD companies are more concerned with profits than customers, and they may be inflating the price unreasonably. Other CBD companies may import the hemp used to make their CBD. The expense related to importing raw materials can lead to a higher-priced finished product.Sometimes, however, the higher price is justified.

When a company invests a significant amount in developing superior products, its products may be a little more expensive. Companies that have gone through the USDA organic certification process, or companies that use premium ingredients are good examples of companies that have justifiably higher prices. How to Compare the Cost of Your CBDThere are so many different types of CBD oil out there, and they come in different bottle sizes and concentrations. This makes it difficult to compare one product to another, but it’s nothing a little simple math can’t fix.You want to look at how much a product costs per milligram of CBD it contains. The easiest example to give would be to compare the cost of a 1000 mg bottle of CBD to a 750 mg bottle of CBD.

(These are not intended to reflect an actual product, but to illustrate an example):1000 mg of CBD $100$100/1000 mgCBD costs $0.10/mg750 mg of CBD $55$55/750 mgCBD costs $0.07/mgYou can use this technique even if you are comparing the price of two completely different products, and it is a way to figure out which formats are most cost-effective.Keep in mind that the formula may influence the cost of a CBD product as well. CBD oils that are made with CBD isolate are generally less expensive than oils that are made with a broad or full-spectrum formula. What’s the Difference Between CBD Formulas?. When you are looking for the right CBD for your needs, it's best to keep the difference between the formulas in mind.CBD Isolate contains only CBD. There are no other cannabinoids present, and it is the least likely formula to contain traces of THC as well.Full-Spectrum CBD is also commonly referred to as whole plant extract.

This means that the process makes use of all the beneficial cannabinoids found in the hemp plant including THC (the intoxicating substance found in cannabis plants). Full-Spectrum CBD may contain anywhere between zero THC, and 0.3 percent THC.Hemp is federally legal, and adults 21 and over have a right to choose whether they want to use CBD that contains up to 0.3 percent THC, as long as it was derived from hemp. Broad Spectrum CBD is the best of both worlds. It contains all the beneficial cannabinoids found in the hemp plant, minus the THC. In addition to CBD, broad-spectrum CBD may contain CBG, CBN, and CBC, as well as terpenes and other molecules.Is CBD Legal?.

CBD was made federally legal by the Farm Bill (also known as the Agricultural Improvement Act) of 2018. It was this bill that officially took hemp off the list of controlled substances. States are able to create their own laws surrounding hemp and its derivatives, and some may restrict who can purchase and possess CBD, THC concentrations, and formats. It’s a good idea to always check the laws in your state before making any new purchases.How Do I Know if My CBD is Accurately Labeled?. You should always be on the lookout for a certificate of analysis that goes with your product.

This provides confirmation that your CBD oil has been lab-tested, that it is free of contaminants and toxins, and that it has the advertised concentration of cannabinoids.If the company you are shopping with does not display a certificate of analysis on its website, you should still be able to request one by contacting customer service. If you don’t get a response, steer away from the company..

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